Doula, hypnobirthing teacher and poet, Kati Edwards from Birth You In Love (http://www.birthyouinlove.com/) has made a fantastic new resource. She has travelled the length of the country to talk to people about all aspects of birthing and breastfeeding too. Her series of mini-videos are something I'm honoured to be part of.

You can see her introduction to the project here:

In the first breastfeeding video in the series, we talk about the 'benefits' of breastfeeding.

Video number 2: How do you prepare for breastfeeding? What do you need? 

Breastfeeding video number 3: should it hurt?

Video number 4: What's normal?

Video number 5: What can partners do?

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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.