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People ask for a lactation consultant’s help for lots of different reasons. We often see people at one of the most difficult times in their lives. They might be damaged and in pain and feeling really desperate. Positioning and attachment problems are a common issue.

Sometimes we can see immediately how things could be improved and after just a few minutes, a mum might feel more comfortable. A look of relief passes across her face. I’ve had mums say things like, “This is the first time it’s ever felt like this.” Or they don’t even need to say anything as their stress just falls away.

Many many times, towards the end of one of these sessions (where I’m feeling really good about what I do and slightly smug), a mum then says, “But what would I do if I was feeding outside the house. How would this work if I wasn’t sitting here?”

She’s overcome an enormous obstacle and the next problem for her immediately pops into her head.

I see these comments as a positive. It suggests she feels like she’s making progress and feels her major difficulties are behind her but it does reveal just how the subject of breastfeeding outside the home nibbles at the mind of many new mums.

I think most of us know that mothers and babies are not allowed to be discriminated against on the grounds of breastfeeding. Their access to businesses and services is not allowed to be restricted. You are not allowed to ask them to move on or to stop. It's not complicated. It really isn't. The Equality Act 2010 protects mums in England and Wales. In Scotland, it is a criminal act to stop anyone breastfeeding up until the act of two: http://www.legislation.gov.uk/asp/2005/1/contents

But the law doesn’t automatically change how people feel.

The idea of breastfeeding in a public place feels scary when the whole breastfeeding things feels new and you are getting used to your body behaving unpredictably.

Are feelings based on reality? A Start4Life poll showed that 72% of the UK population ‘support’ breastfeeding in public. But yet a third of mums still feel uncomfortable.

Media love a story of a breastfeeding mum being harassed. And there’s no doubt that there ARE some poorly educated employees and members of the public sailing beyond the law and embarrassing themselves regularly. But these stories make headlines precisely because they are rare and juicy. If 72% support breastfeeding in public, a heck of a  lot more really aren’t that bothered. And I’ll bet in the tiny group that are bothered, most will mumble an internal dialogue that the mother doesn’t pick up on.

Yet it doesn’t stop it feeling scary even when we know the statistics.

In my years of breastfeeding, I have fed all around the world - on planes, trains, mountain-sides, cafes, doorsteps, bus stops - and not ONCE have I ever received a negative comment or glance or been asked to stop. The response has either been warm and supportive or indifferent. I have spoken to many experienced breastfeeding mums and breastfeeding counsellors and none of them have ever received a negative comment (and actually quite a few wish they had as they would have loved to have snapped something back).

Yet it doesn’t stop it feeling scary even when experienced breastfeeding mums tell you not to worry and in their experience everything is fine.

What might help?
Acknowledge what is the scary bit for YOU.

What is the thing that you are really really worried about?  Deep deep down. The thing that worries you won’t necessarily be the thing that worries your friend.

Are you worried about people seeing your breasts?
People seeing your new baby tummy?
People seeing milk dripping or spraying?
People seeing you in pain?
Not having your stuff with you?
Are you worried about people saying something negative?
Or about people looking?

Depending on what you worry is, you might address the problem differently.

What is the absolute worst thing that would happen in your worst nightmare? Imagine it. How is it likely to go?

For someone, it might be the middle aged bloke yelling across the room that it is disgusting that you are breastfeeding outside the home and he doesn’t want to see that. I think we all know that’s bloody unlikely to happen but what happens then in your nightmare? Does everyone rise out of their chairs with pitchforks and move towards you with threatening expressions on their faces?

Is that what happened in that internet story someone posted on your birth group? I bet actually someone came to the mum’s defence: the bloke on the train who protected her or the employees in the bowling alley who formed a line and threw the bloke out (and several of these videos are set up by actors to test public reaction and get a nice bit of internet clickbait by the way).
 
The new mum would have felt scared but she probably also felt protected by those around her and angry on behalf of her baby rather than upset.
 
If it’s more likely that you are worried about looks, don’t look around the room. Why should you? I remember when my own son was less than 6 months old and I was feeding him in a café in an unfamiliar town, I scanned the room before I started. I clocked a man across the room chatting to a friend and when I was feeding, I looked over again. Why did I do that? What on earth was I doing? Almost certainly giving off a nervous vibe which is the sort of vibe an unkind person might sometimes thrive on. As it happened, the café customer I had first clocked called across, “you’re alright love. Good on ya.” OK, that was pretty embarrassing too as it happens but I expect he had felt obliged because he sensed I was nervous.
 
I once spoke to a mum who took off her glasses when she fed to stop her being tempted to look around. It’s probably not going to help the breastfeeding if you’re nervous so just give your focus to your baby for that moment. They will latch on more easily and oxytocin is more likely to happen.
 
Is the scary thing actually about being outside of the house with a new baby? I think for many people the nightmare is not the pitchforks or a weird shouting person but it’s that you will have a crying screaming loud baby and you won’t be able to sort it out. They might get themselves in such a frazzle that they can’t even latch on. And then what would you do?

At home, you try some skin-to-skin or walk around for a bit and try another room. You are not disturbing anyone else unless you have thin walls and neighbours who are home.

But in a café there are people EVERYWHERE and VERY CLOSE. People wanting to relax and talk to others. People with their own stresses. And YOU are making so much noise.

I promise that everyone in that room is feeling sorry for you and wishing they could help. We are British and get embarrassed so our embarrassment and discomfort FOR you might look like edginess for other reasons but we really just wish we could help.

That’s not about breastfeeding really, it’s just about fear of loss of control.
The solution? Have a baby for longer. After a few more weeks and months, it feels easier. Babies still cry but you feel better about not being able to retain control.

Choose places to go where you know you could escape if you really needed to. Go with people who offer you emotional support.

Who you have with you when you breastfeed outside the home in the early days is really important.

Go to a café with your partner or your mum to practise. Meet your NCT group in a friendly library space and tell them if you are worried. The test of a great post-natal group is the one where you don’t have to pretend you are sailing through this parenting experience and you are allowed to say when you need help. See if you can find some friends that don’t always meet outside the home.

Being a new parent can feel like a constant cocktail party. Just when you feel least up to it, you are trying to develop new friendships and work out what place these new people will have in your lives. And your house is a complete heap too. Here’s another test of a post-natal group: people are OK to come to each other’s houses and sit on piles of washing and not care. It doesn’t always have to be Starbucks.

If you are in Starbucks, it’s not just who you are with, the way you breastfeed helps too.

I’ve met mums who say that they don’t want to use a cushion at home because they won’t have one when they are out and about. Sod that. If you want to use a cushion, use a cushion! Be as comfortable as you can for each breastfeed that you do. There’s no point in making strict rules about these things.

Babies change shape really quickly – all over their bodies. They get heavier and their heads move differently for starters. But WE change shape too. I’ve supported mums who find breastfeeding is getting trickier after a couple of weeks and it turns out that they were previously resting baby on their arms and THEN their arms were resting on their baby belly. When their belly started to go, their arms were doing more work and they started to get more tired.

If you find yourself loving your cushion at home, the idea of breastfeeding without it seems terrifying. Well, if you want to put in a plastic bag under the pram and take it out with you, who cares? Do it!

But you may find that other chair is a different height anyway? Perhaps it doesn’t work quite the same with your cushion? You may want to rethink. You could improvise with a rolled up jacket or even your change bag but I would try and develop a position where the baby’s weight is supported by your torso and not a cushion nor just your arms.

Have a look at Nancy Mohrbacher’s resources on Natural Breastfeeding. If you lean back a bit, a baby can be supported securely against your body and cushions and all the rest of it doesn’t matter. You don’t even need to do it in a sofa (though coffee shops are good at those). You can slouch in quite an upright chair but scooting your bottom forward and putting your leg out in front of you to support you.

Truthfully, the position you use in the corner café might not be super perfect. It might just be good enough.

It might seem tempting to take a bottle when you go out. Now that we have super dooper breast pumps and the bottles that ALL claim to be just like breastfeeding, that might seem appealing but it’s not quite so straightforward.

First off, if you are getting to grips with breastfeeding, let’s not give a baby a masterclass in bad latching. That bottle may claim to be like breastfeeding but which bit of breastfeeding did they pick? The tongue position? The need to elicit a letdown before milk starts to really flow? The way the milk gets gradually thicker and the letdowns come and go? The wide gape? Two of those if you are lucky. Some babies transfer between breast and bottle just fine but if you haven’t yet sorted your latch, it might be wise to hold off.

The other crucial thing is that even if your baby’s latch is fine and a bottle is less of a risk, even if you can easily transport breastmilk outside the home (and it is easy), what’s going to happen to your breasts if you don’t use them? In the early days, we’re going to be more sensitive to signals that reduce our milk supply if we go for several hours without removing milk. When our breasts become full and engorged, that sends messages to reduce production. We’re also vulnerable to getting blocked ducts and even developing mastitis. So realistically, you might have to pump around the same time you give your baby a bottle. I have yet to find someone who considers pumping milk in public to be easier (though plenty of exclusively pumping mums find a way to make it work).

We also need to bear in mind that for a breastfeeding baby, breastfeeding isn’t just about the milk. When you are out in the big wide world and you are very small and everything else seems very loud and big (and smells of coffee) being attached to mummy also brings calm and contentment.

And all of this is about your baby. They can‘t  stand up for themselves. They can’t write a rude comment on that article when someone makes a stupid comment about public breastfeeding. They can’t shout at the television when a daft celebrity makes a lazy statement. What would they say to you? What would they say when you were feeling nervous?

I doubt they would want you to feel stuck at home. They want to see the world too. They would want you to leave the house whenever you wanted to. But also not to feel that you HAD to.
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And they might thank you for helping to create a world where other women feel able to breastfeed in public. Every time you breastfeed outside the home, you make someone else feel that little bit better and normalise it for the next generation – for the little girl who may not have her own baby until 2040 and might not even remember that she saw you but it’s in her subconscious somewhere. For her partner who will support her. For the woman who is now going to breastfeed outside her home next week.
 
 
 
 
References:
https://www.gov.uk/government/news/new-mothers-are-anxious-about-breastfeeding-in-public
http://www.news.com.au/lifestyle/parenting/babies/hero-passenger-defends-breastfeeding-mother-from-abusive-man-on-london-train-video/news-story/33e4710b51374f3f60607ad1cf472e2a
http://www.mothering.com/articles/natural-breastfeeding/




 [U1]
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​http://www.theguardian.com/lifeandstyle/2016/feb/10/we-need-an-proper-strategy-in-the-uk-to-help-support-breastfeeding-mothers

by Emma Pickett, International Board Certified Lactation Consultant

My book is available now from Amazon.co.uk and from other retailers.

"You may be worried about breastfeeding and worried that it might ‘not work’. This is a common feeling when you live in a society where breastfeeding is often sabotaged by incorrect information, patchy support from a stretched health service and powerful messages from formula companies. But it’s not a feeling that is entirely logical. We are mammals. We get our name from the dangly milk-producing bits. It defines us. 

This book aims to make you as well-prepared as possible. I would like you to breastfeed for as long as you want to and as happily as possible. I want you to feel supported. 

Some of this new life with baby will be about flexibility, responsiveness and acceptance. If you are used to a world of schedules and decisions and goals, it may be a bit of a shock. Learn about human biology before you think it sounds a bit too scary! Babies are the products of millions of years of evolution, and we are too; if we can just tap into our instincts and trust them a little bit. 

Success comes when we tap into those instincts and when we know when to get help when our instincts aren’t answering all of our questions. 

Can everyone who wants to breastfeed make it work? No. Not everyone may be able to exclusively breastfeed due to medical issues. Most of these people can give their baby breastmilk, though, which the book also covers. (And let’s not start this journey by imagining you’ll be someone who won’t make it...!)"
http://www.amazon.co.uk/dp/B019JE5E44

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Forgive me for asking but...

Do you REALLY have low milk supply?

This is a very important place to start. Please bear with me. I don’t mean to doubt your situation and be annoying patronising lactation consultant woman but it’s crucial to note that the MAJORITY of new mothers who fear they have low milk supply DO NOT.

The majority of women who start to use formula because they worry they aren’t making enough or baby isn’t getting enough DO NOT HAVE A PROBLEM.

I cannot emphasise this enough. 

Every day mothers panic and end breastfeeding or start using formula and there is not an underlying problem with their milk supply. But of course – once they start using formula without correct support, they often will start to send signals to their breasts to really reduce supply.

· You do not have low milk supply just because your baby won’t go the X number of hours between feeds that the book on your coffee table tells you they should. Or your mother-in-law. Or the X number of hours your friend’s baby is going between feeds.

 A normal happy healthy baby who has a gorgeous mummy with a normal healthy milk supply might get hungry an hour after the last feed, or 90 minutes, or 45 minutes or two hours. They might be cluster feeding and hardly want to come off the breast at all. They might be having a growth spurt and feed every hour for a day.

·You do not have low milk supply because your breasts have stopped leaking. Some mothers leak less than others. MOST mothers notice that leaking reduces at the weeks go by and the teeny tiny sphincter muscles responsible tighten.

· You do not have low milk supply because your breasts feel softer than they used to. The excessive fullness we experience in the early days of breastfeeding is about vascular engorgement (blood and lymph) and it’s about the body inefficiently storing unnecessary amounts of milk between feeds. As time goes by, the breasts get cleverer at storage (don’t forget milk is also made while a baby is actually feeding). There is also less blood and lymph needed in the breasts as breast tissue growth slows down. At the beginning, it’s often very obvious which breast is going to be fed from next. That feeling goes. And many mothers mistakenly connect it with a reduction in milk supply. We are not all supposed to continue feeling heavy and full throughout our breastfeeding experience. Don’t ever think ‘I’ll wait to let my breasts fill up!’ Noooooo. This shows a misunderstanding of how lactation works to a spectacular degree. When breasts are fuller, milk production slows down. When breasts are emptier, milk production increases. Emptier softer breasts may well be making a heap more milk in a 24 hour period than the engorged full versions.

· You do not have low milk supply because your baby feeds for a short time. Plenty of babies get everything they need in under ten minutes. Probably not five – but sometimes a feed might even be five minutes long. Lots of babies use their tongue and jaw muscles super efficiently and gulp and glug and slow down as the milk gets fattier and thicker and then come off happy. It might take them nine minutes or nineteen. A baby might start off life needing 30 minutes to drain a breast (when we say ‘drain’, breasts are never completely empty, it just means the baby has taken out all the milk they usefully want to). As a baby gets older, this can dramatically reduce. It doesn’t mean less milk is going in. If a small sleepy jaundiced baby falls asleep very quickly at the breast without some solid minutes of good swallowing, that’s a different story. Overall however, a longer feed does not always mean a better one.

· You do not have low milk supply because you have small breasts. Large breasts are a combination of fatty tissue and glandular tissue. You cannot tell much about someone’s milk production by the size of the breasts. If you are really worried your breasts don’t ‘look right’, we’ll come back to this later.

· You do not have low milk supply just because your baby wakes up a lot. Plenty of young babies feed with similar intervals day and night. Plenty continue waking every 2-3 hours for a while.

· You do not have low milk supply because your baby won’t ‘go down’ after a feed. So you feed your baby and they drop off to sleep on the breast. You move them to the Moses basket and they wake up as if you just placed them on a sheet of molten lead. And they seem to be rooting again. This happens because being next to you skin-to-skin was nice and cosy and relaxing and warm and it smelt good. The Moses basket is cold and NOT YOU. You probably triggered the Moro startle reflex when you moved them. You probably moved them about 15-30 minutes after a feed when the hormone cholecystokinin had dropped in their blood stream causing them to be more wakeful. Your teeny primate mammal baby finds the breast a lovely place to be. They like to suck to relax themselves.  Babies like second helpings. This does not mean you are not making enough milk.

· You do not have low milk supply because your baby will take milk out of a bottle after a feed. Put a teat against a young baby’s palate and you trigger that baby’s sucking reflex. Babies will usually continue to take milk beyond the point that they need it. This is one of the reasons we see links between bottlefeeding and obesity.


You do not have low milk supply you cannot feel your 'letdown' reflex (milk ejection reflex). Some women feel an electrical tingle at the point the milk lets down. Some don't. Crucially some feel it for the first few weeks and then it fades. This fading sometimes worries people. It does not mean anything has changed with your milk supply and it is perfectly normal for the sensation to go.

·You do not have low milk supply because you don’t pump very much milk. Pumping and breastfeeding are surprisingly unrelated. Your baby removes milk in a completely different way. Plenty of women with healthy milk supplies fail to pump much at all. Their bodies can’t be tricked into eliciting the milk ejection reflex (or ‘letdown’). Plus pumps don’t always work. Suction goes as valves get old.

These are the things that REALLY tell you a mother might have low milk supply:

·         Weight gain problems. A newborn is born and then loses weight. They regain birth weight at around two weeks. They then put on about 150-200g a week after that. That slows down after around four months. If your newborn loses more than 10% of their body weight, we might pay attention but we’ll also want to look at things like your birth. Did you have a drip in labour that filled you and your baby with fluid? Did your gorgeous newborn look a wee bit like the Stay Puft marshmallow man in their first photos? That fluid elevated the birth weight and as it comes out again in the first few days, we might see more of a weight drop. That doesn’t necessarily mean feeding or supply is a problem. However we wouldn’t want your baby to lose weight after about day five or lose weight a second time. It might take some babies three weeks to get back up to birth weight.

Have a look at the chart in your red book. Notice how we have birth weight line and then a space where the curvy lines don’t go and they start again at week two. Just because your baby was born on the 75th percentile, that doesn’t mean we would expect them to definitely re-start on the 75th after that two week gap. That’s why the lines don’t continue. That’s why we have that space. We start again at two weeks. Your baby might be on the 50th then. They then ideally will roughly stick in the same vicinity. But babies wobble around a bit. They might dip below. They might get close to the 25th. And then they might bob back up again. We don’t expect all babies to hug a line exactly. This chart is a guide. It’s about averages. It’s not about mathematical certainties.

·         Nappies. In the early days (first four weeks), we look at poo and pee. After your milk has come in (around day two to five), we’d expect to see six wet nappies in 24 hours and three poos the size of a £2 coin or bigger. After week four, some babies' poo rate can slow right down. This doesn’t mean anything is wrong. Some babies can skip several days between poos and this isn’t anything to do with milk transfer or supply. However if someone tells you it’s OK for a ten day old baby not to poo for a few days, don’t believe them. We’d need to investigate that situation. Only later on do we relax.

Weight gain and nappies. That’s it. Those are the only things that tell us about milk supply. You may hear people say that ‘babies should be settled after a feed’ but some babies get wind or need to poo or have reflux or wake up and want second helpings. Let’s be careful about even saying that. Let’s look at weight gain and nappies.

So let’s now assume you do have low milk supply. How many of you are still with me? I’m sorry if you are. I’m sorry if your baby only put on 60g last week and 90g or less or nothing the week before that and they are slipping down the percentiles. I’m sorry because I know how scary that can feel. Nothing feels like it matters more. There are things we can do.

1.       Find people. 

Find people who know about breastfeeding. Someone who tells you just to use formula in this situation is not who you need. If that’s all they can offer you, they don’t know about breastfeeding and you need someone else. You need someone who understands how lactation works. These people may actually still tell you to use some formula in some situations (or donor breastmilk) but they will do so alongside telling you how to protect and develop your milk supply. You also need people close to you to look after you. If you are going to do all the other stuff on this list, you need to have people who love you who will cook your dinner and run you a bath sometimes. And text you just before the weigh-in clinic next week to say they are thinking of you.

2.       Breastfeeding M.O.T.

Someone like a breastfeeding counsellor or IBCLC (lactation consultant) should check your latch. You might not be sore and your nipples might not be misshapen after a feed but something still might be going wrong. Your latch needs checking. Is baby’s chin deep into the breast? Is baby’s body close to yours? Is baby’s ear/ shoulder/ hip in a line?

They shouldn’t just check your latch but look at your breastfeeding management. Are you feeding enough? Maybe your baby doesn’t show cues very strongly and someone told you to wait for them and you’re sometimes going four hours between feeds? Maybe you need to feed more frequently?

They may also need to take a closer look at your baby. Is there a reason why baby may not be transferring milk effectively? Is this someone who can look at baby's tongue, jaw and palate? Are they familiar with the term 'tongue tie' and especially 'posterior tongue tie'? Would they know what to do if there was one? That might mean suggesting an exaggerated latch or different positions or it might mean referring you to a tongue tie specialist.

When are you changing sides? Too quickly? (and baby is missing the fatty milk). OR did someone tell you to stick on one side forever to get that ‘hind milk’ and the baby is on 45 minutes without doing a heck of a lot? Maybe you need to change sides at 20-30 minutes instead and get baby a greater volume of milk overall and fatty milk overall. Both of these habits can cause weight gain problems. Get someone to help you recognise what swallowing looks like so you’ll know when to change sides and when good feeding has finished.

3.       Google ‘breast compressions’. You’ll get to a video and handout from Dr Jack Newman. You can finish a feed with breast compressions and get an extra dose of fatty milk into baby.

4.       You have 3 sides and 4 sides. This is ‘switch nursing’. Try and go back to the first side. There will be milk there. The more breastfeeding you do, the more milk you will make. The second time you return to that breast, the milk will be fattier and richer and you’ll send great signals to your body to make more.

5.       Find time. 

If you are going to build up your supply, get help. You can’t devote time to switch nursing and skin-to-skin when you have to go to Tesco to buy milk and pick up another child from school. If this is ‘Operation Milk supply’, who can help you? You’ll read people talking about a ‘babymoon’. Go to bed, they say. Just you and the baby. Feed lots. If that sounds appealing, go for it. Personally my babymoon would involve the sofa and box sets and crisps. However there’s no point in babymoooning until next Christmas if your latch and breastfeeding management are the issues. Get that checked first.

6.       Using a pump.

 Baby feeding effectively is first choice but pumps can be useful. You can pump on an emptier breast to send even more signals to your milk supply. But we’re not going to take a baby off the breast do be able to pump.

You don’t need to wash and sterilize a pump every time you use it. Pop it in a plastic bag and put it back into the fridge between pumping sessions. 10 minutes is ample. If you are pumping for 30 minutes and ‘nothing is coming’ out, you are not getting a letdown and you are not doing yourself any favours. Use hand expression before and after (google ‘Marmet hand expression’) and prepare the breasts with warm compresses and massage if you can. You can take an hour and do some ‘cluster pumping’ or ‘power pumping’. Pretend to be a baby having a cluster feed. Pump for ten minutes. Break for five. Pump again and repeat.

Just check your pump is the best one available. If it’s second hand or you have had it a while, it might need servicing or replacement parts. You also might want to consider hiring a hospital grade double electric pump from someone like www.ardobreastpumps.co.uk to give yourself the opportunity to pump both sides together as effectively as possible.

Pumping shouldn’t hurt. Make sure your flanges are the right size – that means they are the right diameter for the size of your nipple. Don’t think that cranking up the suction will automatically do better things. And don’t think, “I don’t want to pump because I will empty my breasts and baby will have less milk.” Certainly they might be less appreciative if you pump just before a feed is due and you leave them with an emptier breast full of thicker fattier milk but pumping overall will increase milk supply and stimulate milk production. You are not ‘taking their milk away’.

You might also be someone who always gets better results with just using hand expression so stick with that.

Of course, you might not want to pump at all and just focus on feeding baby more effectively and frequently.

7.       Galactagogues. 

Taking herbs and medication that increase milk supply. Not right for everyone but some women really feel they helped. You need to read about side effects and dosage on sites like kellymom.com. Fenugreek, blessed thistle and goat’s rue are popular. Some doctors prescribe domperidone in certain situations. These are never a substitute for good breast emptying and a breastfeeding MOT.

8.       The science part. 

In a book, this bit would be under a little flap as we’re only talking to a small group of people.

Did you have breast surgery?

Are your breasts very widely-spaced or asymmetrical, or very tubular with a bulging areola? Did they not really change much in pregnancy (or puberty)?

Do you have PCOS? Some women with PCOS (not all) have a reduced milk supply.

These are times when it’s worth finding an IBCLC and getting technical.

Some doctors will do hormonal testing for you. There are medications that can help develop breast tissue especially in pregnancy.

What about your thyroid levels? This is something relevant for more people than you might realise. If you are trying everything and low milk supply continues to be a problem, ask your doctor to check your thyroid levels. There are sometimes medical reasons mothers have a low milk supply and doctors and lactation consultants may be able to help you.  These are not the most common reasons why people have low milk supply by a long shot. Hence the need for the flap.

Most people who genuinely have low milk supply got themselves into a pickle with using artificial nipples or not breastfeeding enough or breastfeeding ineffectively. And it can almost always be reversed.

Also remember that just because you had low milk supply in your first breastfeeding experience, it doesn’t mean a subsequent lactation will also be a struggle. The development of all that breast tissue first time round often helps.

Hold in your mind the fact that women can relactate after not breastfeeding at all for several weeks. We CAN send signals to increase supply again in the vast majority of cases. There are tons of us in real life and online who want to support you.

When you were preparing for this breastfeeding thing, you were worried it might hurt. Your sister-in-law worried you that your baby might feed ‘all the time’. You were concerned how you were going to breastfeed in public.

Now you wish you were so lucky to have a baby that ‘fed all the time’. If only you could experience breastfeeding at ALL, even if it hurt a bit. You envy the women who have a problem feeding in Starbucks. You should be so lucky.

Breast refusal is scary. It wasn’t what you were expecting. You thought this little person would come out wanting to do it.  No one told you anything else was possible. Your antenatal class teacher showed you some amazing video of a baby crawling up their post-birth mummy’s body and self-attaching. Trouble is - it seems your own baby hasn’t seen the same videos.

The 2010 infant feeding survey says that 27% of mothers stop breastfeeding in the first week because their baby was completely rejecting the breast or not latching properly. There are lots of people struggling with this problem and a lot of breastfeeding counsellors and lactation consultants trying to help them.

Just to say, it is completely normal for babies to sometimes appear to reject the breast in the course of successful breastfeeding. Just like we sometimes don’t fancy a meal, babies are the same. They don’t care what the clock says. Sometimes they are simply too tired or over-stimulated. Perhaps they are dealing with something to do with lower digestion and a poo is imminent. Sometimes they have some upper wind and although they are apparently hungry, it seems like some mysterious force field is preventing them from latching on. These are babies that may take a few hours before they feed successfully again but they will usually get there in the end. If we are seeing wet nappies, periods of alertness and there are no other medical concerns, we may just have to wait a while. We continue to skin-to-skin. We try different positions. It happens in the end.

Newborn breast refusal is a different thing. Sometimes these are babies who did manage to feed a handful of times over a few days but we are usually talking about babies who have yet to latch on successfully and transfer milk. They may refuse to latch at all and bob on the breast in a frustrated and desperate way. Perhaps they may appear at first to latch with the right gape and positioning. It actually does look like those photos from your antenatal class, but when the baby is ‘on’ nothing seems to actually happen.  It is like the photo – immobile and not the video version. They just sit there and fall asleep quite quickly.

What are we going to do?

Here are the first four rules when a newborn baby isn’t breastfeeding (credit to IBCLC Linda Smith for the last 3).

1.       Don’t panic.

I know that sounds trite but new mums are awash with hormones and especially if your birth wasn’t what you expected, a non-attaching baby can be a very frightening concept. You really weren’t prepared for this. Does this mean you are never going to breastfeed?

It is very very very important to hear this next part: 


With the right information and support, most mums of non-attaching babies will be able to breastfeed after a short while. 

There is a small minority for whom there are further complications but this is a minority.

I have known many many mums (and I was one of them) who had a baby who didn’t attach properly for the first few days and went on to breastfeed happily for as long as they wanted to, for months and even years.

I rarely share my own breastfeeding experience but Sam’s story is relevant here. When I was giving birth to Sam in 2004, my labour moved very quickly for a first baby. When I was in transition and felt ready to push, we called the midwife in and she shook her head with a smile and said, “Honey, no. You’ve got hours and hours to go yet. This is still early days.” This was without any examination or having been in the room with me any time recently. It was a back-to-back labour which can be quite uncomfortable and my birth plan suddenly went out the window. I panicked. She offered me pethidine – an opiate drug. I took it. She explained that it was never sensible to give it just before delivery as it can affect baby but this would be OK as I had ‘so long’ to go. Sam was born less than half an hour later. I was 10 cm dilated while she was administering the injection.

Sam was OK but he was very very sleepy and although we had a bit of skin-to-skin (which I don’t remember being called that then); he really wasn’t up to breastfeeding. Luckily another midwife saw the situation and told me to get pumping and syringe feeding.  He only breastfed properly for the first time on about day 3. He was initially syringe-fed colostrum and never needed any other milk.

Sometimes non-attachment is about the birth experience. Drugs that relieve our pain can annoyingly affect baby too. The first breastfeed and the first few days can be a far greater challenge when we’re waiting for things to get back to normal.

Research is very clear that even drugs seen as less hard core than pethidine, like those in an epidural, impact on early breastfeeding success over the first 24 hours: http://www.ncbi.nlm.nih.gov/pubmed/12583645

And we can get into a cascade where a mum doesn’t get those early feeds to happen, is encouraged to use a bottle or supplement in another way and she’s then not dealing with the consequences of the epidural but the decisions that led from that.

Some babies born with forceps or ventouse can experience cranial nerve bruising and discomfort which make the mechanics of early breastfeeding a struggle. Unfortunately the baby is unable to convey the fact they have experienced compression of the glossopharyngeal, hypoglossal or vagus nerve so please give them a while. If you have a headache, imagine the act of opening your mouth really really wide or someone holding the side of your head.

Are we saying that all babies who have assisted deliveries or whose mums take pain relief will struggle? No, of course not. Many will be fine and breastfeed well but this is about likelihood. I don’t know anyone who has turned down a forceps delivery when it’s recommended to them and that’s not what this is about. It’s about having information. Talk to your doctor when induction is suggested a week after the due date. What’s the evidence base for that decision because that may increase the chance of pain relief or an assisted delivery and that may make breastfeeding more of a challenge? If you are going down a certain road, know that breastfeeding support may be more of a priority. You may need to place an even higher emphasis on skin-to-skin after birth (though I hope it was high on your list anyway) and you may need a breast pump.

But we’re still not panicking because even if things go initially a bit pear-shaped, it’s likely you can still make breastfeeding happen. You follow these rules. You talk to people around you who know about breastfeeding. You look after yourself. You say hello to your gorgeous new baby who isn’t doing this on purpose and would really like to breastfeed too.

2.       Rule 2 is feed the baby. I know that might sound obvious but you’d be surprised. I’ve known situations where trying to breastfeed takes ages and ages and baby and mum and everyone are tired and baby drifts off to sleep and no actual milk was transferred.  Then baby wakes up and there’s another attempt to breastfeed. Sleepy young babies then start to conserve energy and sleep more (which makes breastfeeding even less likely). If we’re going to work on this, we need some fuel. Plus we obviously want baby to be hydrated and not lose too much weight – though it’s important to note that babies aren’t expected to take in a lot of milk in the first couple of days and are expected to lose some weight. We don’t need to glug huge quantities into them. Early feeds are teaspoons worth. However they get the gut moving, get the poo happening and have a PhD’s worth of useful purposes.

Hopefully if baby isn’t breastfeeding, you are being shown how to take the milk out of your breasts immediately. There’s a nice video on breast massage and hand expression here: http://bfmedneo.com/

This is a time when the mums who did some hand expression antenatally are at an advantage. You can read more about that option here: http://abm.me.uk/expressing-milk-baby-arrives-antenatal-expression-colostrum/

You can collect the colostrum in a syringe and ask someone to show you how to give it to baby using a cup or a syringe. I like syringe feeding as it means there is nothing wasted and you can pop your finger against the roof of baby’s mouth and get some sucking happening with the tongue extended over the gum ridge and a rhythm developing. Baby isn’t flat on their back but elevated enough to reduce the risk of aspiration. Baby starts to suck on your clean finger and you reward with a little bit of milk from the syringe in the corner of their mouth. Cup feeding also gets the tongue extended but it’s usually something you need to be taught.

Bottle-feeding isn’t considered first choice because it can teach incorrect tongue positioning, poor gaping and milk will flow without baby needing to use their muscles in the normal way.

However if it’s day three and baby hasn’t fed for eight hours and you are panicking and you can’t get hold of the midwife, giving a bottle may be a more sensible choice than not. You’re just going to try and do in a way that is as close to breastfeeding as possible. Have a look on YouTube for some videos on ‘paced bottle-feeding’. Some are quite extreme but take the principle that we want the baby to create negative space in their mouth and remove milk with effort. If the bottle is more horizontal and the baby is more upright, that is more likely to happen. The milk should not be so fast that the baby is overwhelmed and they are struggling to maintain breathing. Bottle feeding babies have lower oxygenation rates when they are feeding anyway so let’s be extra careful with flow.

We also want a baby feeding on the bottle to have a mouth that looks like a baby feeding on the breast.  It seems logical to still hope that the baby will gape with a wide mouth. When they breastfeed, they fill their oral cavity with stuff. It seems sensible to do the same thing when we bottle-feed rather than have a baby nipple-feeding with pursed lips. Let’s put the nipple above the top lip, ‘nose to nipple’. When the baby gapes we will bring the bottle into baby’s mouth when it is still wide. If the baby’s bottom lip is flanged down, that’s a good sign that the tongue is extending over the gum ridge rather than being pushed back as it can with artificial nipples. It may be more difficult to get a baby to do anything other than nipple-feed on bottles that have long nipples and very little silicon areola/ breast behind them. And a word of warning – it’s amazing how many bottles seem to be the “closest to the breast”.  It’s never going to be close and it’s going to depend which bit of the experience of breastfeeding you are prioritising. If we used paced bottle-feeding, we can slow the flow so I think it seems wise to try and get a space that allows gaping alongside that.

3.       Protect the Milk supply.

So baby is being fed and at number three, we are protecting the milk supply. That’s still ahead of trying to breastfeed and practising breastfeeding. If we maintain and protect milk supply, we’ll have options once underlying problems have resolved. If we don’t, when baby does start feeding it may not last long if they don’t find time at the breast rewarding.

In the first few weeks, our breast tissue is developing and we are laying down the ground work for our supply that will govern the rest of the time we breastfeed. Stimulating supply now will make difference months down the line. Plus if we don’t protect milk supply, we’re more likely to get blocked ducts, mastitis, engorgement and abscesses.

A lot of people will tell you that colostrum can only be hand expressed. Colostrum is sticky and there isn’t much of it and it can get lost in pumps and flanges. With hand expression, you can gather every drop. However once a day has passed, you may find it useful to start pumping too. It will save time and help your supply really kick in. You could perhaps hand express first and then pump for 5-10 minutes. As your milk transitions to mature milk, you may find it’s more time efficient to keep going with just the pumping. Some mums find hand expression super easy and continue with that but hand expressing 8-10 times in 24 hours can be hard work.

You can hire hospital grade double electric pumps. Your local NCT branch may have a pump agent. You can also hire direct from ardobreastpumps.co.uk. Pumping shouldn’t hurt and take a moment to check you have the right funnel/ flange size. Your pump rental agent can send out alternatives.

When a baby is non-attaching, a typical day may look like this:

Skin-to-skin, try breastfeeding for 15-20 minutes (if it works and milk is being transferred, go longer!); someone else gives a top-up while mums pumps. Everyone naps.

Repeat.

Baby will be feeding roughly every three hours (counting from beginning of feed to beginning) with perhaps one block of not feeding as long as 4-5 hours.

Ideally you are one ahead on the pumping. That means you don’t pump while a hungry baby is waiting for your milk. That’s likely to affect the way the milk flows and won’t help anyone. You should be pumping for the feed that comes after.

Mums often get better pumping results with a bit of breast preparation. Start with breast massage and warm compressions. In research, mums also got a good deal more out when they did some hand expression after the flow from pumping had stopped.

Newborn babies cluster feed so you could cluster pump too. Have an hour or so, perhaps in the evening, when you pump for 10 minutes, pause for 5, pump for 10 minutes, pause for 5, repeat.

4.       Work on the Breastfeeding

When baby is being fed and your supply is being protected, you can work on the breastfeeding.

Skin-to-skin is super important (have I mentioned that already?). We try to breastfeed when babies are quietly alert or a bit sleepy or hungry or not very hungry or not very hungry at all. Try it all. You can also try after a little bit from the bottle. Don’t think the breast always HAS to be first and if you’re giving up on the breast, that’s it. You could give 10ml from a syringe, try some breastfeeding, a bit more from a syringe, trickle the syringe over the nipple to encourage some licking and rooting. Move between breast and non-breast organically.

All feeds happen at a naked breast.

Try different positions. Have a look at www.biologicalnurturing.com and try some laid back breastfeeding. See if you can encourage some self-attachment.

How do you know milk is being transferred? You may hear some swallowing but not always. You should notice baby’s chin moving and occasionally pausing to show a swallow. Dr Jack Newman has a video called ‘really good drinking’ that may help: http://www.breastfeedinginc.ca/content.php?pagename=vid-reallygood

If you have very flat or inverted nipples, it may appear that baby is searching for something but not quite able to get purchase and stay on. You may need some help learning how to shape your breast and nipple. You may even end up using nipple shields to help a non-attaching baby attach. Nipple shields get a bad rep but this is a situation where they can be useful and a baby may end up breastfeeding as a result. It’s always better though to use a shield with some qualified support. They can cause further problems if the wrong sized shield is used, if they are applied poorly and the latch is still a problem.

Getting qualified support is a good idea whatever your nipple look like. You can ask your midwife for local recommendations. Perhaps that person is your midwife or her colleague. You may have a local volunteer breastfeeding counsellor who can meet you at home or who runs a local group. You may choose to pay for a private lactation consultant and you can find one at www.lcgb.org.

It’s also sensible to get someone to look inside baby’s mouth, someone who knows that tongue tie can affect breastfeeding. I know that might sound daft but some healthcare professionals are poorly trained in tongue tie and it’s a leading cause of non-attachment in young babies.

You can read more about tongue tie here: http://www.cwgenna.com/ttidentify.html

Babies can also struggle if they have high palates and this often goes alongside having a tongue tie.

If your baby does have a tongue tie that still doesn’t mean you won’t be successfully breastfeeding soon. You can learn different positions and breast shaping techniques that can help. Your baby may also benefit from a simple procedure where the membrane that holds their tongue tie is cut with a pair of round-ended scissors. This is called a frenectomy. Your midwife or GP should be able to refer you to your local NHS tongue tie service. You can also find private practitioners here: www.tongue-tie.org.uk.

I know this is scary but please believe that if you find the people that can help you this is still likely to work out.

I know mums who have had a baby finally attached at 48 hours, one week, two weeks, three weeks and six weeks. The 27% who gave up in the first week according to the infant feeding survey weren’t speaking to the right people. We were visited at the ABM conference by a mum who attached for the first time at 18 months (that got your attention, didn’t it.) No one can tell you how long to keep going with this but it’s true that you might give up when there’s still a chance your baby will happily attach. You have to decide when it’s right for you.

You could certainly continue exclusively breast milk feeding your baby if that’s what you want to do. I could write another 3000 words on why that’s a good idea. You can read more about exclusive pumping in a useful book written by Stephanie Casemore: http://www.exclusivelypumping.com/

Good luck. Be strong. Find helpers… and did I mention skin-to-skin?

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Is your baby older and was previously successfully breastfeeding?

Some babies may start to refuse the breast after a period of successful breastfeeding. That can also be confusing and upsetting. It can happen as a result of flow confusion if they have had regular experience of bottles. In that situation, you could perhaps speed up the flow at the breast (perhaps by increasing supply or using breast compressions). If you’ve been using bottles a fair bit, your supply may have taken a dip and may need a bit of attention. Breast compressions are useful when the milk starts to get fattier and slower and baby may be finding it a bit harder work. A bit more on breast compressions here: https://www.youtube.com/watch?v=Oh-nnTps1Ls

You can also slow things on the bottle in comparison. The section above on paced bottle-feeding talks you through some of that. If you are confused and unsure, visit your local breastfeeding support group. Don’t think they are just for people with new babies and people who don’t use bottles.

Breastfeeding babies who’ve never had a bottle in their lives can also go on nursing strikes. A self-weaning baby doesn’t give up breastfeeding overnight; it’s normally a gradual and gentle process that takes no one by surprise. It also rarely happens under 18 months old. Nursing strikes can be sudden and with no obvious cause.

Some good thoughts on nursing strikes here: http://www.lalecheleague.org/faq/strike.html

Get your GP to check baby doesn’t have an ear infection and check in baby’s mouth. Could your baby have a blocked nose? Most nursing strikes will resolve within a few days. Feed the baby and protect your supply.

When we’re so used to new mums worrying about low milk supply, it’s easy to forget what life is like for women at the other end of the spectrum.

Imagine a baby with the natural urge to come to the breast but when they get there they find it overwhelming, distressing and unsafe.

Imagine a young baby who chooses NOT to breastfeed when they need comfort and reassurance.

Oversupply can be miserable for everybody concerned and it doesn’t help when you’re surrounded by people telling you how lucky you are.

It’s important that we know what oversupply can look like, what to do about it and what it’s not. There is an epidemic of confusing oversupply and its accompanying symptoms for ‘colic’ and ‘reflux’. There are many babies right now being dosed with infacol, lactase drops, Gaviscon and reflux treatments, when the issue is simply that mum has too much milk or that improvements can be made with an adjustment to positioning.

It’s not clear why some mums seem to produce more milk than their babies need. In some cases it might be as a result of expressing with powerful modern electric breast pumps (and mums getting the message that regular pumping is part of normal breastfeeding). Perhaps they have more prolactin than average or large amounts of glandular tissue. Often there’s no obvious cause.

The problems will normally start to show themselves after the first week or so. It may be that some feeds are less of a problem (perhaps nights are easier) or that every feed is a struggle. A baby will look like someone dealing with a large volume of liquid being pushed down their throat which is not surprising as that’s often what’s happening. You may hear spluttering and choking. A baby may break off to take a breath (and mum may notice a spray of milk). A baby may cry or be obviously distressed and grumpy.

This baby will probably not feed for long. They may not need to because they are getting what they need in such a short time. As a result, these are the babies of mums who really don’t need the ‘advice’ to ‘feed for at least 20 minutes or baby won’t reach the fattier milk’ and a great demonstration of the fact that you can’t make rules about how long a feed should last.

Sometimes a baby may break off prematurely when actually they could have done with a bit more. If this is going on it will be reflected in the baby’s weight gain and these are the babies who are more likely to have mucousy green frothy nappies or have some digestive discomfort. These are the babies who are going to develop the symptoms that look a lot like ‘colic’.

Colic isn’t a very useful word. It’s a term used as a threat to new parents. It’s the thing we fear but we don’t really know what it is we are fearing. Unhappiness and lots of crying seems to be the basic summary but normal healthy otherwise happy newborns will have periods in an ordinary day where they are fussy and unsettled. It’s normal for a baby to cry on and off for most of an evening. It’s normal for a baby to only be calmed on the breast and want to feed almost constantly for several hours. It’s normal for parents for feel desperate and confused and perhaps worry that either there’s a problem with milk supply or their baby is behaving unusually because something is wrong. If they are calmed on the breast (even if only for a short time and they don’t actually appear to be swallowing much) then that sounds like normal evening fussiness.  One definition of colic (Wessel’s definition) is three hours of crying,  three days in a row,  three weeks in a row. By that definition, no one can say that a week old baby has colic or even a two week old baby. Normal evening fussiness may not develop in the first couple of weeks. A common call to the helpline goes like this: “Help! When we first got home from the hospital, our baby slept in the Moses basket in the evening and we ate dinner and watched TV and then we all went to bed together at 11ish. Now my baby cries most of the evening. He wants to feed constantly from about 6pm to 10pm. I haven’t even got time to eat dinner or go to the toilet. Is this colic?” That doesn’t sound like colic but normal cluster feeding or growth spurt behaviour and normal behaviour for a baby in the first few weeks of life. The parents who get the evening shift are luckier than the ones who get the 1am-4am slot. 

It’s also normal for babies to be windy. The reality is that a large group of mums perceive their babies to be windier and fussier than average but we can see that statistically that doesn’t make sense. If lots of babies have periods of being fussy and windy and unsettled, that IS normal. We need to check latch and positioning because when there’s a problem that means an opportunity for air to get in. It’s surprising how many babies struggling with wind and digestive pain are more comfortable once changes are made: the gape has improved;  the tongue is placed correctly on the breast; the head is tilted with the chin burying into the breast and once that cheek is touching the breast (on both sides). It's also normal for babies to be grumpy just before they poo. You'd think this natural process would be nice and easy but no.

However beyond what’s normal, babies dealing with oversupply and overactive letdown are more likely to be windy and more likely to be dealing with digestive discomfort.

How would we know it was due to oversupply? We’ll see that classic behaviour on the breast of the bobbing on and off and struggling with faster flow. We may also find a baby who is more likely to get hiccups, get trapped wind, produce explosive poos and bring up milk after a feed.

Bringing up milk after a feed isn’t the reflux we worry about. The word reflux just means ‘a flowing back’. It’s normal for some milk to come back out when little babies have immature sphincter muscles at the top of their stomach. If they take in too much milk, a bit comes back up again. That’s not a negative, that’s a safety mechanism that prevents stomach stretching and overfeeding. Plus the baby gets breastmilk with all its lovely growth factors and immunological factors sliding past on the way down and on the way back up again! When an air bubble comes out, sometimes milk comes out. The milk surrounding the trapped air bubble will come out too. All perfectly normal. Messy but normal.

When it’s not just milk coming out but acid too and a baby is in pain, that’s the reflux that we might worry about. A baby bringing up with a look of surprise on their face rather than a look of pain doesn’t need medication. These are the babies with a “laundry problem” rather than a “medical problem”. Unfortunately it’s the laundry problem babies that are sometimes still finding themselves in the GP surgery. Parents are worried that too much milk is coming up and they want to stop it happening. Sometimes these are parents focused on intervals between feeds and believing that that the small amount of milk coming out is preventing them from reaching the 3 or 4 hours their baby book says should be the aim. GPs may provide Gaviscon – a thickener that stops the stomach contents from lifting up through the oesophagus – but as we already know this may not be the ideal if this process is actually a safety mechanism. Gaviscon has other side effects: the thickening continues through the system and these babies may start to develop constipation and certainly have firmer stools. We end up seeing babies in genuine pain with constipation due to medication that was trying to solve a problem that wasn’t actually a problem in the first place. When you give a baby infant Gaviscon, you are giving them sodium alginate and magnesium alginate which form a gel in the stomach when they come into contact with stomach acid and thickens the stomach contents. Let’s not do that unless we really need to, not to avoid normal posseting. 

When babies spit up, it can look a lot. Mums talk about ‘the whole feed’ coming back up. This is unlikely to be the case. If you get 1 fluid oz (30ml) of cow’s milk out of the fridge and spill it down the front of a baby gro, I think you’ll be surprised how far it will go. They will be drenched. If a baby is taking in 60-80ml and even 20 mls comes out, that’s still going to look like a lot but the majority is left happily behind. It can be normal for a baby to posset after EVERY single feed. This still isn’t a baby in need of medication.  Another problem with giving Gaviscon is delivering it to a breastfeeding baby. The manufacturers suggest mixing the powder with cooled boiled water to make a paste and then giving it AFTER a feed using a syringe or spoon. I worry that many mums will be tempted to give a bottle (with potential impact on latching or milk supply) just to deliver this medication. Plus giving a young baby something in a spoon when they will usually still have a tongue thrust reflex is an impossible mission. Syringe feeding a sleepy baby (breastfeeding contains hormones like oxytocin and cholecystokinin which encourage drowsiness) is likely to be an aspiration risk. This may well mean feeds end early and babies are broken off before the right amount of high fat content milk has been reached.

So please let’s not give Gaviscon to babies that bring milk back up but aren’t in pain doing so.

If ‘colic’ or ‘reflux’ is to do with oversupply, it can be fixed. Colic is usually used to describe babies with digestive discomfort. They may raise their legs while crying or we may hear their tummies rumbling. They may be red in the face or rigid with discomfort. It has been suggested that these babies have issues with their gut flora and probiotics may help. They may have hypersensitivity of nerves in the gut and the underlying cause is not known, though babies will usually grow out of it between 3 and 4 months. Some of these babies may have food intolerances. A reaction to dairy protein is a possibility though that will usually be accompanied by other symptoms such as a skin condition, unusual stools (which may even be blood flecked) and weight gain issues.  Mums who smoke are more likely to have babies with colic.

Increasingly, companies are marketing products at these understandably desperate mums. Gripe water is an old-fashioned remedy which historically contained nearly 4% alcohol (and various herbs, bicarbonate of soda or ginger).  We now realise giving babies a raft of mysterious untested ingredients seems like a bad idea when we know so much more about gut flora and the relationship of our vital friendly bacterias to the Ph of our gut. Most of us know now that it’s not wise to give young babies herbal teas or plant extracts but if the product is being made by pharmaceutical companies then we inherently trust it.  Mums are being told to use ‘colic drops’ that often contain lactase. The theory is that babies are reacting to lactose and need help digesting it. Lactose is the sugar naturally found in all breastmilk (it’s not about dairy intake) and true lactose intolerance is very very rare. To give lactase drops, we’re spoon feeding those young babies with the tongue thrust again. This time when they are hungry and hoping for breast.

At least if a mum gives Simeticone drops (which help air bubbles to clump together to leave the body more easily) it can come directly from the dropper. Although I’m not sure we have research on giving babies ‘natural orange flavour’ several times a day.

I know there are mums who find some of these products useful. Of course, babies with genuine acid reflux find thickeners helpful.  I know there are mums who like giving droppers and other products. They feel it helps. I’m not down on everything on the shelves in Boots the Chemist.

I’m just saying that if you suspect oversupply or positioning and attachment might be your issue, get some breastfeeding support before going down to the pharmacy or to the GP. Let’s try and solve the underlying problem rather than fiddling around with spoons and exposing our babies to unnecessary chemicals.

Chemicals can be wonderful but let’s save them for the babies who can’t have their issues resolved after a fifteen minute chat with a lactation consultant or breastfeeding counsellor.

If your baby is gulping and choking and it appears to be about the volume of liquid going down their throat; if your letdown pain is quite strong; if you pump a large amount in a very short time; if you get extremely engorged and uncomfortable inbetween feeds – these could be clues that oversupply is an issue. You may hear baby clicking which indicates a loss of seal and can be associated with a large volume of milk. Baby may slip off or attempt to shallow the latch to cope with the flow.

What can be done about it? First of all, let’s check that some of these issues aren’t about positioning and attachment problems rather than oversupply. Babies may protest, shallow their latch, be fussy, slip off and wiggle around when mums just need to position them in a different way. We’ll assume you’ve had positioning checked and it’s clear there’s too much milk. Let’s also check you haven’t been removing your baby from the breast prematurely which can also result in some of the lactose overload problems and fussiness associated with oversupply. Ideally baby will come off the breast when they choose to do so or when they have stopped actively feeding and swallowing. If you are not sure what swallowing looks like, this video can help: https://www.youtube.com/watch?v=7giyNvlCW18 It's also true that babies with tongue ties (especially posterior tongue ties that are often missed by healthcare professionals) are sometimes the babies struggling at the breast - bobbing on and off and choking and spluttering. Babies with tongue restrictions will have problems grooving the tongue and swallowing the bolus of liquid effectively. If your baby is fussy, it's a good idea to get their tongue assessed alongside a general check of latch before you start any kind of supply adjustment.

How old is baby? If baby is under six weeks, you might be in a group of mums who start off with overproduction but things settle down as the body gets used to your baby’s natural levels of intake. Your body regulates from the higher prolactin baseline to the one that will become the norm for the rest of your time breastfeeding. So it may well be that your supply eases without you having to do anything at all. If we fiddle around with your supply in the early weeks and then you experience this shift, things might go too far the other way so it may be wise to hold on and see. That doesn’t mean that you can’t do anything though if your baby is really struggling with fast flow.

Milk comes out because of your milk ejection reflex (the oxytocin arriving in the breast and contracting muscles to push the milk down through your ducts) and your baby’s ability to remove milk using their tongue and create negative pressure inside their mouth. It’s not much about gravity. But if liquid is flooding into your throat and you are UNDERNEATH the flow, that’s more likely to be overwhelming. You won’t feel safe taking a breath. You are more likely to feel out of control and feel the need to break off. When we feed babies in a cradle hold, cross-cradle hold or rugby hold and they are under the breast, it’s understandable they feel more overwhelmed. If we lean back so the baby is more above the breast, this is likely to prevent the milk pooling in the back of their throat and hopefully they will feel less out of control.

You could get them on in their usual position but then scoot your bottom forward and lean back – just make sure you have back support for yourself. You could also use positions where the baby is seated, perhaps with one leg astride each side of yours and their mouth level with the breast. By changing position, we’re hopefully going to result in the baby staying latched on properly throughout the feed. This is going to mean less air getting in and less windiness, colic and possetting.

I’ve heard of mum pumping before every feed to take off the faster milk. This really isn’t sensible as you’re stimulating your supply and telling your body to keep production at this level. One option might be to get the letdown started and then you could let the faster milk flood off into a muslin cloth before reattaching baby but this wouldn’t be fun in the long term. Some mums also get results by pressing on their breast with the side or heel of their hand at the begnning of a feed and blocking off a section of their breast but again this isn’t wise in the longer term and it could increase your risk of blocked ducts.

If changing positioning doesn’t help things and your baby is a couple of months old, it could be time to consider reducing your supply on purpose. We know that when the breast is full, this slows milk production. A fuller breast stretches the prolactin receptors in the alveoli so more prolactin can’t be received. A fuller breast accumulates a whey protein known as FIL (feedback inhibitor of lactation) and this seems to slow milk synthesis.

Before we play around with supply, we want to make sure that this isn’t a baby struggling with other issues such as weight gain. It is true that some mums with significant oversupply could still have a baby with weight gain problems. If a baby is taking in a large volume of milk, they may be filling up before they get to the higher fat content milk. They may have frothy green mucousy stools and be particularly gassy from getting the larger doses of lactose which we find in the lower fat content milk. When lactose is in large quantities, baby may not be able to digest it all effectively. It may travel through the gut undigested and this faster transit can result in greener poos. Undigested lactose can move into the large intestine and start to ferment and produce extra abdominal gas.  Good bacteria are important part of digestion so it makes sense that we are concerned that babies with digestive problems are potentially struggling with gut flora issues. If we take the edge off your supply, they should hopefully start to receive proportionally more of the higher fat content milk.

However it’s not sensible to intentionally reduce your milk supply without proper supervision if your baby has green stools and weight gain problems. This can also be a sign of insufficient milk supply. A baby may also bob on and off the breast and protest when the flow is too slow. This is a time to talk to a lactation consultant or an experienced breastfeeding supporter. It’s important to note that green poo can be a normal coloured poo for a happy healthy baby. We’re only going to worry if it’s frothy, mucousy and accompanied by other symptoms.

A way to reduce supply, when we are confident that is the problem, is to use a technique called block nursing. This means the baby stays on one breast for a block of time. This isn’t because we aim for them to have slower milk for a few feeds in a row but because it means the neglected breast will accumulate milk and the body will receive signals to reduce production. If you aren’t already doing single-sided feeding (offering only one breast for each feed), you can start with that. If that doesn’t improve things, you could then spend 24 hours experimenting with two feeds on each breast. That’s going to mean something like 4-6 hours with all the feeds being on the same side. The neglected breast may become engorged and even a little bit uncomfortable and this will send messages to reduce production. Then you swap and the other breast gets its turn to be fed from for a block of time. After 24 hours of blocking, you could then return to single sided feeding and see if things are any easier. In some extreme cases, mums may need to block on one side for three feeds or even more.

This technique can mean that mums are more at risk of blocked ducts or even mastitis. Once you come back to the neglected breast after a gap of time, flow may be particularly overwhelming so this is a good time to use that technique where the first milk floods off into a cloth before the baby attaches properly. After the first feed back on that side, it’s a good idea to check that no firm areas remain and the breast has been drained effectively. You may have firm areas before a feed and even lumps which may just be the glandular tissue full and distended under the skin. All the way along, let’s use our instincts. If a baby is indicating that they aren’t happy staying on one breast and they need more, this may be a time to abandon this method and try something else and check our thinking.

If mums have a history of mastitis (and that may not be unusual if mums have a history of overproduction), the idea of block nursing can be a scary one. An alternative option is to use natural remedies that reduce milk production. Applying cabbage leaves to the breast can reduce supply (which is one reason we want to be cautious in recommended this to brand new engorged new mums). Sage is also a useful herb. I once spoke to a breastfeeding supporter who claimed she spoke to more mums with supply problems after Thanksgiving and Christmas and all the sage and onion stuffing. That sounds a bit unlikely unless they are serious stuffing fans but sage does appear to have an effect. If you are not ending breastfeeding, you’ll need to be cautious. Kellymom.com (http://kellymom.com/bf/can-i-breastfeed/herbs/herbs-oversupply/) recommends taking ¼ teaspoon of dried sage three times a day for up to three days. It can be combined with food or drank with vegetable juice.

Some mums also reduce their milk supply using pseudoephedrine, an ingredient in decongestant and cold and flu medicine. Birth control pills containing oestrogen can also reduce supply. However I hope no one is starting off with decongestants and hormonal contraception without proper guidance and having tried other remedies first.

Sadly there aren’t fixes for every baby with colic symptoms or reflux symptoms. Some of these families are going to need medication and all the support they can get. However let’s just check that babies we know aren’t part of the trend of misdiagnosing colic and reflux when actually the problem is latching and positioning or oversupply and it can be sorted with some skilled help. I have known many mums and babies who have had ‘colic’ and ‘reflux’ disappear overnight with after a short conversation on latching or a couple of days of supply adjustment. But that doesn’t make the pharmaceutical companies any money, does it? And our GPs may not have the 15 minutes to spare nor the training in breastfeeding to resolve an issue that could be pretty straightforward.

Perhaps just as well it uses bottles as the image because what are the chances that a woman returning to work at just two weeks is going to be able to continue to breastfeed?  Is the government assuming that 'these' mums just won’t care about breastfeeding so what does it matter? There are certainly many women around the world who make breastfeeding and employment outside the home work. The UK isn’t likely to be her home.

In the UK , it’s down to pure luck whether a woman’s employer will be supportive of her aim to express milk at work and retain her milk supply and breastfeeding relationship. There are employers finding little offices, sourcing mini-fridges, letting teachers off doing playground duty – quietly and without fanfare. And there are employers who don’t understand the point, can’t envisage how facilitating a mother to pump milk might work and see no need to bother. Women are feeling vulnerable and unable to fight fights they don’t feel entitled to fight. A woman could try and make her case citing health and safety legislation and by mentioning the equality act but her employer can politely ignore her. As ACAS says in its document ‘accommodating breastfeeding in the workplace’, “The law doesn’t require an employer to grant paid breaks from a job in order to breastfeed or to express milk for storage and later use. Neither does it require an employer to provide facilities to breastfeed or express milk.” This toothless document then goes on to explain what nice employers might choose to do. This isn’t helping the women phoning the national breastfeeding helplines in tears and in pain at their desks. It was produced at the request of the government when charities like Maternity Action and the breastfeeding groups pressured government into acknowledging that breastfeeding protection was missing in this legislation. It doesn't help. National laws provide for breastfeeding breaks in more than 90 countries worldwide. We are not one of them.

In the UK, a breastfeeding mother has the legal right to ‘rest’ but not to express and store her milk. Health and safety guidance might suggest that an employer could provide a room and a time for a mother to pump but they are only required to allow her to rest. We don’t want to rest. Give us ten minutes to use our double electric breast pump perhaps three times in a working day and most of us will be able to continue to give our baby’s breastmilk for as long as we want to.

The USA, the land of the free and the spectacularly rubbish maternity leave has 16% of babies exclusively breastfeeding at 6 months (Source: CDC Breastfeeding Report Card 2012). Terrible. Awful. Embarrassing.

The UK manages 1%.

The USA has 47% of babies getting any breastmilk at 6 months. We have 34%.

America has women regularly returning to work at 6 weeks. Yet they return to a workplace where their president has a declared them to have the legal right to ‘reasonable break time’ for expression up to 1 year after birth.

Allowing a ‘reasonable break’ means both mothers and employers are encouraged to have a sensible and fair dialogue. It’s a good place to start. In a letter on this subject, minister Jo Swinson claimed legislation was not possible as expression was so individual (yet for some reason the right to ‘rest’ is not?!). The law doesn’t need to be prescriptive. It just needs to empower women to start conversations. It will make continuing to breastfeed while working normal and manageable. Remember this isn’t just about the rights of mums and dads, this is about the rights of babies. We need never assume that a woman returning early to work would OF COURSE be ending breastfeeding.




Reading: 

http://www.acas.org.uk/media/pdf/2/i/Acas-guide-on-accommodating-breastfeeding-in-the-workplace.pdf


http://www.maternityaction.org.uk/wp/advice-2/advice/accommodating-breastfeeding/


http://mprp.itcilo.org/allegati/en/m10.pdf