A dad at my breastfeeding support group this week had a bit of an epiphany. ‘It’s never felt like this before,’ his wife had said. We’d spent just 3 or 4 minutes together. I’d mentioned one or two things about the way she was holding her baby. It was enough to make all the difference.

Just like in golf, he noted, with a tiny change to swing and position the game had been transformed.

As a lactation consultant, you study for hours and hours and pages and pages and pages. You know lots of things you may not talk about from month to month. But there are twenty or so things you say nearly every day.

So many mums have their experience transformed by a tweak. They are sore, dreading each feed, wondering how things will ever change and one comment – that may not even be 20 words long – can make all that go away in an instant.

It’s one reason why even a rushed midwife or GP can turn breastfeeding around with the right training, even if they don’t always have the time to devote to a long support session.

Here are a few of my favourite tweak considerations:
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1. Get a glass of water. Take a drink. Notice how you tip your head back and your chin comes away from your chest? Now try to take a drink with your chin pointing down towards your chest. Not so easy. Try and do that every time you drink, and I think you’ll find you take less, give up sooner that you might otherwise and probably get a bit windy. So, tweak number one is hold your baby in a position where they can lift their chin away from their chest. If you are using a cradle hold or a cross-cradle hold, that means you might need to have them further away from the feeding breast’s armpit and slid more across towards the non-feeding breast. We talk about ‘nose to nipple’ because that’s encouraging the baby to reach towards the nipple with their head tilted back. If you are using a rugby hold, super important the baby isn’t too far forward so they end up curling around the breast with their chin hunched towards their chest. 

2. Don’t hold the baby’s head too high on the back of their head or push the baby’s head towards the breast. Babies are clever at protecting their breathing (why we don’t need to press our fingers into the breast near baby’s nose). And nature has given them a reflex which means when someone pushes on their head, they’ll be very unhappy about attaching in case they can’t rescue themselves when breathing becomes restricted. They may even push back and shallow the latch and sometimes even refuse to feed entirely. So, support baby’s head by holding around the base of the skull – supporting around their shoulders and chin and ears area – but no higher. Imagine Elvis towards the end of his career in Las Vegas with those diamond encrusted collars. You’re holding your baby’s Elvis collar and no higher. And even then, as gently as possible. Just enough to support baby’s head without being too bossy or firm. You might even be using a position where this isn’t a risk at all – you might be lying down or using a reclined position where your hand is nowhere near baby’s head. 

3. Beware the cushion myth. I am not kidding when I say that most people I meet using breastfeeding cushions are using them in a way that makes their life harder for themselves. The gap between your lap and the natural fall of your breast is probably very different from your mate’s. It’s going to depend on the length of your torso, the size of your breast, the way your breasts fall, the height of your lap which varies with your chair. It’s also going to depend on the shape of your baby. So how on God’s green Earth did we all get the message that the same size of breastfeeding pillow fits everyone?
 
Again and again and again, taller mums are slumping forward and hunching over their baby lying on their cushion. ‘This cushion must be right. I just have to contort myself to get to it!’
 
And shorter women also think that the cushion is surely the answer, so they put baby on the cushion and umm, there’s no space between their breast and the cushion for baby to fit. They often end up lifting their breast so baby can fit underneath. They might then have to hold their breast throughout the entire feed, compressing ducts and causing hand pain and usually not holding the breast in the same position the whole way through a feed so things wobble around.
 
Or folks might put the baby on the cushion and baby is a few centimetres too far away from them with sometimes not even the chin and chest making contact with mum at all.
 
Cushions can be handy to support mum’s arms, but it doesn’t normally work that the baby can’t be held by mum and is entirely on the cushion.
 
What often works even better is no pillow at all and mum leaning back a bit. Check out: http://www.mothering.com/articles/natural-breastfeeding/
 
4. Baby needs to be clooose. If you can see the buttons down the front of baby’s sleep suit, they are probably too far away. If baby’s arm is trapped between you, they are being pushed too far away. If there’s a big blob of your clothing and a breast pad between you, they are probably too far away. I once supported a mum who found night time feeds much more painful. She was sitting in the same chair to feed as she did in the day and was using exactly the same position but at night it was pinchy and uncomfortable. It turns out the difference was that the baby was wearing a sleeping bag at night. Just a few extra millimetres of padding meant that baby’s chest and chin was a little bit further away from mum’s body and the nipple wasn’t going back far enough into baby’s mouth. Baby’s chin needs to be close into the breast. It’s not going to work if the baby’s chin isn’t touching the breast at all. And the chin can’t touch if the chest is too far away. 

It’s common for a mum to say, “Wow it doesn’t hurt anymore!” followed by “I haven’t been having them close enough!”
 
5. Mums are fiddling around and ‘checking the latch’.  It’s completely understandable that when someone tells you the baby’s mouth should be a certain way and the bottom lip should be flanged out like a fish lip, you think you are supposed to check! But the minute you push your baby’s cheek out of the way and have a bit of a rummage, you’ve made some adjustments. Better to go with a look at the baby as they approach the breast and the mouthful you saw them take and how it feels. And how the nipple looks when it comes out of baby’s mouth (might be elongated but shouldn’t be squashed and flattened at the end.) If the baby is close enough, you usually can’t see the lips at all. The rounded part of baby’s cheek is in contact with the breast and the lips are hidden. 

6. And while we are talking about lips, the top lip doesn’t need to flange out and do the fish lip thing. It can rest in a neutral position. An excessively flanged top lip can even be the sign of a shallow latch. I’ve met several mums who have been told that the top lip should stick out and even flip it out themselves to make that happen. Curled in isn’t ideal but it doesn’t need to flip out. 

7. Babies are sinking. Mums might start with baby on a squishy pillow and as the feed goes on, gravity does evil things and the baby starts to sink. The movement might be imperceptible but it’s enough to pull the baby away from the breast. That pregnancy pillow filled with beans that the manufacturers claimed was super for breastfeeding? Meh. If it’s bean-filled, it’s likely to sink. That favourite feather filled bed pillow? Going to sink. Holding all the weight of your baby on your arms and hands and sitting bolt upright? You are going to sink. You are not designed to hold the weight of your baby in that position for minutes and minutes throughout the day. It’s a big clue if you finish a feed rubbing your wrist and thinking, ‘phew, glad that’s over!’ Gravity is your enemy. You need to find a position which you can sustain. That might be the right cushion for you (or more than one) or again, it might be about leaning back. Babies also latch better when they are anchored. If they feel themselves slipping, they may even clamp down and things can get even more sore.
 
8. What’s the bottom cheek doing? Not many of us have nipples that come out from our body at precise right angles. So why do so many of us feed a baby as if that’s true? The baby is precisely ‘tummy to mummy’ and lying on a breastfeeding cushion as if our nipples are pointing directly in front of us. In fact, most women have nipples that point slightly down (or off to one side and down). But we put baby into the ‘right angle’ position anyway. What ends up happening is that the top cheek (which mum can see in a cross-cradle or cradle position) is nice and close to the breast and rounded. However the bottom cheek can be centimetres away from mum’s body with an unhelpful gap for air to get in and a shallowed latch. Get someone to check that the bottom cheek is touching the breast too. Look at your natural body shape. Your baby may need to look up towards your shoulder rather than at the back of the chair. You may be able to see both of their eyes.
 
9. Ear/ Shoulder/ hip in alignment. Get that glass of water again. Twist your neck and try to take a drink. It’s rrrreally hard. And if what you were drinking was gradually getting thicker and fattier, again, you’re likely to be taking in air and giving up sooner than you might. Baby can’t lie on their back and twist their neck towards you to come to the breast. We want the ear and shoulder and hip to all be pointing in the same direction. Even a baby with a twisted torso and the twist is around the hips can run into problems.
 
10. Look at your body. Look, that mum over there in Costa seems to be able to drink her coffee (yes, you can drink coffee) and is just supporting her baby on one arm! How the heck! Can I do that? You know how hairdressers’ clients turn up to their appointments with a celebrity photo and say, ‘make me look like that!’ That sometimes happens in breastfeeding too. ‘Can I hold my baby like that mum I saw?’
 
Sometimes the answer is yes and sometimes it’s no. Your humerus is the bone that goes between your shoulder and your elbow. Sometimes your humerus bone and the height of your breast isn’t ideal for particular positions. Long humerus and high firm breast? You may not be able to do the cradle hold. I mean seriously – you may NEVER be able to do the cradle hold. The baby will be too low. Short humerus and long low breast? You may not be able to do the position that that woman in Costa can do and drink coffee. You might always need a hand to support the breast if you want to do the cradle hold.
 
It’s not all about the pictures in that breastfeeding book or what your mates are able to do. It’s about the shape of your body and the shape of your baby. Do you need to factor in wheelchair arms? Do you need to think about how your breast texture changes in the day? It’s all very individual. Trying to make it work like everyone else does it can be unhelpful - which is why getting face-to-face help tailored to you can be so useful.
 
 
11. Give the baby more space for their tongue on the breast. You may have heard people talk about baby getting more of a mouthful of breast below the nipple than above. Or seeing some areola above the top lip and less (or none) below the bottom. If the baby has more space for their tongue on the breast, they have a chance of scooping more breast into their mouth and the latch being deeper. When the nipple is going in, picture it pointing towards the roof of baby’s mouth rather than pointing down the back of their throat. Even just a little bit of re-angling can make things easier.
 
12. Don’t make your baby eat cotton. Breastfeeding clothes also assume we’re all the same. If you find them a faff – as you pull open a teeny slit to find your nipple hidden in there somewhere – I’m pretty sure your baby does too. If they ping back so the baby’s nose and cheek comes back into contact with fabric again, maybe rethink. I’ve even seen babies with fabric in their mouths with a look of resignation that says, “This is the best I’m going to get”. Cheap vest tops you can pull out of the way are very sensible. You can layer more than one so different bits are covered. And a bulldog clip is useful for securing fabric (not your chin holding your clothing and preventing it from flopping down onto baby’s face).
 
 
As I say, some of that really isn’t complicated. It’s what we talk through on the breastfeeding helplines and what we point out every day in breastfeeding support groups. While at the same time NOT saying that it’s ‘normal’ to be pain at 10 days or your nipples just need to get used to things. If you feel breastfeeding is just all too hard, remember you could be seconds away from fixing things. 

 
Let’s imagine you are breastfeeding your toddler and you discover you’re pregnant. It’s a much wanted pregnancy but perhaps you weren’t expecting that positive test quite so quickly. And now here you are, pregnancy test still drying, teeny tiny new person inside you and less teeny person on the outside, very much still in love with breastfeeding.

By still feeding your toddler, you’ve already been up against it in terms of what most modern cultures find comfortable and acceptable. Now you’re ticking the box for another misunderstood area of breastfeeding: one full of myths and nonsense and one lots of uneducated people claim to be experts about.

A useful starting point is finding a group online of mothers who have breastfed through pregnancy and beyond. That can be reassuring and immensely helpful but it’s worth remembering that every woman’s experience is different and it’s very hard to make predictions about how things will go for you.

I’m going to guess that when many people are looking at the drying pregnancy test, their thoughts shift to the consequences for their current nursling. Then soon, you wonder about the baby-to-be. Is breastfeeding during pregnancy ‘safe’?

What does the research say?

Let’s look at this study from 2012: A comparative study of breastfeeding during pregnancy: impact on maternal and newborn outcomes. Madarshahian F, Hassanabadi M. The study looked at 320 women in Iran, some breastfed during pregnancy and some did not. It showed that, “Results found no significant difference in full-term or non-full-term births rates and mean newborn birth weight between the two groups. We further found no significant difference between full-term or non-full-term births and mean newborn birth weight for those who continued and discontinued breastfeeding during pregnancy in the overlap group.”

So, breastfeeding during pregnancy didn’t ‘take nutrition away from the baby’ and it did not cause prematurity.

Another study of 57 Californian women from 1993: Breastfeeding during pregnancy. Moscone SR, Moore MJ. Just under half continued to breastfeed through pregnancy and after the new baby arrived. The new babies were healthy and appropriately sized.

However, it’s not all clearly positive. Another research study on 133 women in Peru found a link between breastfeeding through pregnancy and 125g on average less weight gain for the new baby in the first month. (Postpartum consequences of an overlap of breastfeeding and pregnancy: reduced breast milk intake and growth during early infancy. Marquis GS, Penny ME, Diaz JM, Marín RM. 2002)

Another study looked at 540 women in Egypt with sub-standard nutrition. Effect of pregnancy-lactation overlap on the current pregnancy outcome in women with substandard nutrition: a prospective cohort study. Shaaban OM, Abbas AM, Abdel Hafiz HA, Abdelrahman AS, Rashwan M, Othman ER (2015). This was not all positive news with increased risk of maternal anaemia and issues with infant growth. BUT there was NOT an increase in miscarriage risk when women breastfed through pregnancy.

How’s your nutrition and how are your iron levels? If you are a mother with access to good nutrition, it appears you have less reason to be concerned.

Does breastfeeding trigger early labour? Even for those women who were struggling with other issues, it doesn’t appear so.

Hilary Flower is the go-to person on the subject of breastfeeding during pregnancy. Her book, “Adventures in Tandem Nursing” is considered the bible on this subject. It was first written in 2003 and is now out-of-print but a second edition is currently being worked on. Her focus was on bringing the facts to pregnant mothers and she looked at this idea of triggering contractions or early labour in detail. She reminds us that we need oxytocin to trigger a milk ejection reflex (the letdown reflex) and this is also the hormone that can trigger uterine contractions. However, this doesn’t mean that breastfeeding in pregnancy triggers risky contractions and there are several safeguards in place. We need hormone receptor sites to exist before hormones get acted on by the uterus and they remain small in number until around 38 weeks of pregnancy. And even the hormone receptors that are in place can’t really do their job of causing contractions as there are oxytocin blockers in place like progesterone (made by the placenta) and proteins missing which would act as special agents to help the oxytocin do their job. Triple protection! So, oxytocin can carry on doing its breastfeeding jobs while baby remains protected in the uterus.

I think we can say science is on our side. Which makes sense when you think that throughout history women have been breastfeeding older babies and having sex and getting pregnant.

Do you know anything about the history of pregnancy testing? Today, we might know we are pregnant days after conception. For generations, it was based on guess work, someone examining your urine’s appearance and something about rabbits (early 20th century pregnancy tests involved injecting urine into a rabbit and observing a change in their ovaries). A lot of breastfeeding women couldn’t rely on whether they had missed a period as periods may only just be settling in or may not have even appeared yet. Some breastfeeding mums get pregnant without yet having a period. They ‘catch the first egg’. Then they go and see their doctor and the doctor brings out the chart that predicts due date based on last menstrual period, “errr…2015?”

Nature isn’t daft. If breastfeeding during pregnancy was hazardous, I doubt you nor I would be here. Hilary Flower mentions that if you have a high-risk pregnancy, you should talk to your health care providers about your specific situation but if you are safe to continue sexual intercourse, breastfeeding is very very likely to be fine too.

Science might say that breastfeeding during pregnancy is safe but that doesn’t mean you have to do it, or that it’s super easy for everyone. There is a wide range of experience and you need to reflect on what feels right for you.

The age of your current nursling might be a factor in your decision. If they are 7 months, you might feel differently than if they were 4 years old and you were getting a bit tired of breastfeeding a plastic truck several times a day.

If your baby is 7 months, or at any age where milk is still a significant proportion of their nutrition, you’ll need to do some thinking. It’s likely they will need an alternative source of milk (still doesn’t mean breastfeeding needs to end). Most women who are breastfeeding when they are pregnant do notice a decrease in milk supply – often a very significant one. This can start as early as the first few weeks after that positive pregnancy test. Whatever you do, your body will be resetting in its lactation story and you will go back to making colostrum during your pregnancy. It happens at different times and some mums might go through a period of feeling like they have virtually nothing and their child is ‘dry nursing’ before colostrum then appears and quantities seem to increase again.
Nurslings behave differently during the changes of pregnancy. Some self-wean as the quantities drop. Some self-wean when things seem to taste a bit different. Some care not a jot that changes are happening and would carry on breastfeeding whatever was coming out or if nothing was.  Word of warning: colostrum has a laxative effect. That’s one of the reasons it’s so great for newborns as it helps them to pass meconium. Potty training a toddler? Brace yourself.

What else can you expect? For some women, not much else. Pregnant and breastfeeding felt a lot like not pregnant and breastfeeding. You’ve just got to worry about the bump being in the way towards the end. (This was my experience).

Other women struggle with sore nipples from increased sensitivity that probably has something to do with hormonal changes and sometimes aversion to breastfeeding can be a problem.

The reduction in milk supply can also be upsetting for some. It can come at a time when we might already have mixed feelings about giving birth to another child. We know what positives a new sibling can bring for your toddler but there’s sometimes a feeling of loss or even guilt as we’re concerned how their life is going to change – especially in the first few months. And when milk seems to be going too – that can feel doubly hard. Unfortunately, there isn’t much you can do to increase milk supply in pregnancy when changes are starting. All the usual stuff doesn’t work: pumping, herbs, just feeding more frequently. Many herbs that we might consider when we want to increase production are not thought to be safe in pregnancy. It appears that milk storage is affected for almost all women (only a small minority don’t feel their supply has diminished). You might want to consider using a supplementary feeding system at the breast, so baby can remain attached and get other milk through a lightweight tube.

It’s important to remember though (and this is engraved on the heart of many of us in breastfeeding support) that BREASTFEEDING IS NOT JUST ABOUT MILK. Your little bloke with the plastic truck might not care a jot if supply diminished and milk tastes different because this is only partially about milk. It’s also about connecting to you, relaxation, safety and contentment. That big world out there is only getting bigger and breastfeeding is home.

If you are happy to continue with that, breastfeeding is still working.

You might also be wondering what life is going to be like when the new baby arrives. How does breastfeeding work when there is a newborn and a toddler? Pretty much like it did the last time there was a newborn – nature gets on with it. While breastfeeding during pregnancy doesn’t ‘use up’ colostrum, during in the first few days after the birth, it’s sensible to let the newborn do their thing first before the older nursling gets a turn. And once your mature milk transitions, you can make decisions based on how your newborn’s nappies and weight gain are getting on. Sometimes there is talk of restricting a baby to one breast and a toddler to another. Most lactation consultants agree that’s not sensible. Ideally you want the newborn to have the option of both and continue to have the option of both fully lactating as their breastfeeding experience continues. Toddlers feeding after newborns are very effective at helping a milk supply to develop and tipping into oversupply is more of a worry than running out of milk. A toddler is also fabulous at relieving engorgement in the early days post-partum. Flashback to my 3-year-old son announcing proudly to his grandmother (not entirely on board with natural term breastfeeding) that he ‘helped mummy because her milkies were really full’!

Does the toddler feel jealous of the baby having ‘their milk’? I have yet to meet a mother who feels that’s been a problem. In fact, many feel that it can help in the arrival of a new member of the family. Toddlers are likely to need some extra support, but breastfeeding is still there for them. The thing that has always provided comfort and reassurance. And good news! It’s changing back to regular milk and there’s lots more of it! What might not be sensible is weaning a toddler in the last few weeks of pregnancy so if you are thinking tandem breastfeeding really isn’t for you, it might be wiser to wean sooner rather than just prior to baby arriving. If that’s you, I wrote an article on weaning an older child which you might find helpful:
http://www.emmapickettbreastfeedingsupport.com/twitter-and-blog/weaning-toddler-bob-and-pre-schooler-billie-how-do-you-stop-breastfeeding-an-older-child

It sometimes happens that an older child who hasn’t breastfed for a while asks to do so again when a new baby is on the scene. That might be because they weren’t a fan of the colostrum. Or there might be some other things going on in their head. Are they ‘testing’ whether they still get to be your baby? Are they just curious? Some resume breastfeeding at this point. Some are happy to have a taste of expressed milk in a cup. Some ask and run away giggling and don’t mention it again. There’s no right or wrong answer on how to deal with this but ideally, we’re looking for ways to minimise rejection and any refusal is done so as gently as possible.

Still think it’s a bit hippy and ‘risky’? This is the American Academy of Family Physicians (folks on the opposite end of the spectrum from hippy and risky):
“Breastfeeding during a subsequent pregnancy is not unusual. If the pregnancy is normal and the mother is healthy, breastfeeding during pregnancy is the woman’s personal decision. If the child is younger than two years, the child is at increased risk of illness if weaned.
Breastfeeding the nursing child during pregnancy and after delivery of the next child (tandem nursing) may help provide a smooth transition psychologically for the older child.”
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We can’t guarantee it’s all smooth but breastfeeding through pregnancy and beyond is something mothers have been doing for millennia and there’s very little to fear and lots to embrace. Those of us who do it are often those who have taken the path of child-led weaning and it instinctively feels right to let the nursling make the call. But you’ll make the decision that’s right for you.

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

You may have seen the Lancet series on breastfeeding that was published last week [1] and you may have seen the headlines that announced the UK was the “world’s worst at breastfeeding” [2].

It’s a time when those of us in breastfeeding support feel both energised by the Lancet’s affirmation that breastfeeding matters in all countries: “Our systematic reviews emphasise how important breastfeeding is for all women and children irrespective of where they live and of whether they are rich or poor”. [3] And also disappointed that the media’s emphasis was on UK ‘failure’ and it quickly turned to the ‘failure’ of individual women. [4]

As Dr Rollins stated at the launch of the Lancet papers, we need a different focus: “This is not about individual mothers either succeeding or failing. This is not about one lobby group winning over another; it´s not about our individual comfort zone or fashion; it´s about the survival and health of women and children today and in future generations” [5].

These are big issues and they require big thinking and money. At a time when money is hard to find. Health visiting and community breastfeeding support have moved to local authority funding from NHS England and these are the same people looking to save significant chunks from their budgets. There is a local authority in London threatening to decommission health visiting services in 2017. Peer support services are being slashed – even the ones run by volunteers [6]. Children centres are closing and the few groups run by volunteers are struggling to find places to meet [7] Infant feeding coordinator positions are being lost. There is no breastfeeding lead or national committee on breastfeeding in England and the post of Welsh lead has just been cut.

Things are about to get very real for GPs in the world of breasts. Imagine a mum giving birth and being discharged by the community midwife (already stretched and unable to give sufficient time to breastfeeding support) and then when breastfeeding goes pear-shaped after 10 days, the GP is her only port of call. If I had a pot of money to spend on breastfeeding support in the UK right now, I would spend it on talking to GPs about breastfeeding. In a country where the infant feeding survey is cancelled, helplines running on a shoestring, health care professionals being trained by formula companies [8], I’d still spend it on talking to GPs. If I had unlimited time too, I would buy every GP a coffee and say, ‘Can I just have five minutes of your time to tell you a handful of things that will change lives?’

Health care professional bashing is a national pastime. Right after the breath where we say how proud of the NHS we are. But please don’t imagine that those in breastfeeding support don’t get how hard this is. You have ten minutes to talk a mother who is presenting with complex issues wrapped up in emotions and sleeplessness with a chaser of internet research. You have to be a generalist and the lactation bit really wasn’t a focus in your training. We understand that and we’d like to correct that but now you are in your surgery and working a day that doesn’t give you time to go to the toilet, we get that ship might have sailed.

Before you move onto your next webpage, please skim this one. I am an IBCLC, International Board Certified Lactation Consultant. That means I took two 3 hour exams after a thousand hours of supporting breastfeeding mothers. And I recertify every 5 years after a further 75 hours of education in lactation. I am chair of a national charity (www.abm.me.uk) that helps to run the National Breastfeeding Helpline and have spoken to more than 3000 mothers myself on that helpline. I run three drop-in groups in North London and have done for seven years. I visit mums in their home and spend all day texting, emailing and phoning to discuss breastfeeding issues. I don’t know everything but I do know what is likely to walk through your surgery door and what will be helpful for you to say to them.

Mothers need help with medication. They want to continue breastfeeding and treat their other conditions. They don’t want to stop breastfeeding for even a day. That’s like asking them not to be a mother when breastfeeding really matters to them. It is hard to get reliable information on the compatibility of breastfeeding and medication as manufacturers will have rarely paid for the necessary licensing for breastfeeding mums and the responsibility is pushed back on to you. Luckily in the UK, we have other people who will take that responsibility. The Breastfeeding Network runs the Drugs in Breastmilk helpline: https://www.breastfeedingnetwork.org.uk/detailed-information/drugs-in-breastmilk/. The factsheets on this site give a summary of the main medications for a range of conditions. The compatibility of anti-depressants and breastfeeding may be especially relevant to some of the new mums you see: https://www.breastfeedingnetwork.org.uk/antidepressants/ Research has shown that ending breastfeeding can increase risk of postnatal depression so supporting mums to use medication that is compatible is an important role of the GP [9]. As well as using the factsheets, you or the mother can contact the helpline directly to speak to a specialist pharmacist. The ‘Breastfeeding and Medication’ page can also be found on Facebook: https://www.facebook.com/breastfeedingandmedication/info?tab=page_info. Messages are answered by trained volunteers

Mums walk in the door with mastitis. Let’s just check first it’s not a blocked duct that can be resolved with good self-help measures. A blocked duct means firmness and even tenderness in the breast but the mother feels generally well and there is no pyrexia. This can be resolved with increased drainage of the breast, warm compresses on the firm area and massage. An electric toothbrush is handy for massaging the affected area. The mother may benefit from using different positions to help with draining the breast effectively or pumping after a feed if there is concern the baby is not feeding well. If infective mastitis is suspected, antibiotics should be accompanied by increased drainage and the massage and warm compresses. If a mother does not continue to breastfeed frequently, it is more likely she will go onto to develop an abscess. Antibiotics are required if a mother's symptoms are severe and a bacterial infection is evident but not simply because a breast is firm and uncomfortable, not least because the dyad may go onto develop nipple and breast thrush as a consequence. https://www.breastfeedingnetwork.org.uk/wp-content/dibm/BFN%20Mastitis%20feb%2016.pdf

​Mums will walk in with sore and damaged nipples. This may sometimes be the entry point for the staph aureus which is the common cause of mastitis. ​The most common cause of nipple damage will be positioning and attachment issues. Of course, in the ideal world, you’ll be referring a mother to a breastfeeding support group, a lactation consultant or a trained health visitor. However there are things that take less than three minutes to point out that could make all the difference. Is the mum leaning forward to ‘put’ the breast in the baby’s mouth or moving the breast unnaturally (so then inside the baby’s mouth it springs back into its natural position and gets trapped against the baby’s hard palate)? Damage is likely to be caused by nipple abrasion against the hard palate usually because the baby does not have enough breast tissue in its mouth. The baby’s gape is important. And when the baby gapes, we want to maximise the space of their tongue on the breast. Their chin should be making close contact, the baby’s body close, the baby not likely to drift if mum’s arms get tired. We want the baby to take a large mouthful of areola below the nipple. This lactation consultant explains how simply leaning back can make all the difference and the fact we falsely believe a mother should sit bolt upright is often the problem:
 
“In the commonly used cradle, cross-cradle, and football/rugby holds, mothers and babies must fight the effects of gravity to get babies to breast level and keep their fronts touching. If gaps form between them (which can happen easily with gravity pulling baby’s body down and away), this disorients baby, which can lead to latching struggles. The pull of gravity makes it impossible for a newborn to use his inborn responses to get to his food source and feed…In these positions, gravity can transform the same inborn feeding responses that should be helping babies into barriers to breastfeeding. Head bobbing becomes head butting. Arm and leg movements meant to move babies to the breast become pushing and kicking. Mothers struggling to manage their babies’ arms and legs in these upright breastfeeding holds have often told me: “I don’t think I have enough hands to breastfeed.”
http://www.mothering.com/articles/natural-breastfeeding/
 
Videos from Nancy Mohrbacher show a powerful alternative:
https://youtu.be/rHXolgD4r44
 
And this image from Nancy Mohrbacher may help

​Latching issues can also cause vasospasm and blanching of the nipple. It can also be responsible for neuralgia deeper in the breast. A mother with Raynaud’s syndrome may experience nipple pain when breastfeeding is otherwise going well. She may find applying warm dry compresses after a feed helpful and in severe cases nifedipine can be prescribed: http://www.raynauds.org/2011/02/08/help-for-pregnant-breastfeeding-moms/
 
If it’s not an issue of latching, you may be prescribing topical antibiotic cream or considering treatment for thrush: https://breastfeeding.support/thrush-on-nipples/
 
Thrush will usually develop after a period of pain-free breastfeeding. If a mother is getting misshapen nipples after a feed and the nipples appear to show mechanical damage, latching will remain the primary focus. Even in the absence of symptoms, both members of the dyad will need thrush treatment if one is suffering. Miconazole oral gel is not licensed under four months due to a risk of choking but mums can be taught to apply the gel safely and it is shown to be more effective than nystatin suspension. Deeper breast pain is often connected to neuralgia but ductal thrush is a possibility. The pain will develop as the breast empties and peak shortly after a feed (or pumping session) has finished. Fluconazole is not licensed for breastfeeding mothers. However it’s worth noting that the amount that gets through in milk is 0.6mg/kg/day. The amount that can be given to a baby within the license is 6mg/kg/day (Dr Thomas Hale).
 
A mum experiencing constant nipple pain and damage despite support with positioning and attachment and may also have a baby who struggles to stay attached, feeds for excessively long and may feed frequently, isn’t putting on weight adequately, could have a baby with ankyloglossia (tongue tie).  An overview here: http://www.cwgenna.com/ttidentify.html. Posterior sub-mucosal tongue ties can be particularly difficult to identify on first look. You should have a referral pathway that gives you access to a tongue tie clinic locally: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/support-for-parents/tongue-tie/

 A Mother may come for help when they suspect they have low milk supply. Is there anything you can do? It is worth noting that many mother lack confidence and perceive themselves to have low milk supply when they are experiencing normal breastfeeding:  http://www.emmapickettbreastfeedingsupport.com/twitter-and-blog/low-milk-supply-101
 
If a mother’s breasts are feeling softer, if they no longer leak, if their baby is not sleeping for extended periods, if their baby is cluster feeding – all that can be normal. As can a mum whose body does not respond to a breast pump and they find it hard to trick their bodies in achieving the surge of oxytocin needed for the milk ejection reflex when a plastic pump is all that’s there to stimulate it.
 
However if a mother is showing further signs and her baby is experiencing faltering growth, she may be asking you to help. Has she already received good quality breastfeeding support? Has her baby’s positioning and attachment been checked? Is she feeding regularly and not switching sides too quickly (but also not staying on one side beyond the point the baby is transferring milk because someone has mistakenly told her a baby MUST feed for 30 minutes). Could she benefit from hiring a double hospital grade pump to help boost supply? Is she in the process of reducing her use of formula and giving her milk production a chance to develop?
 
What else could be happening?
 
The impact of thyroid dysfunction on low supply can be devastating and a significant minority of mothers experience thyroid issues post-partum: https://www.llli.org/breastfeeding-info/breastfeeding-and-thyroidism/
 
Some mothers, perhaps those with insufficient glandular tissue, may be asking you for a prescription of domperidone. This is an off-label use of the drug and there have been some concerns with using it for lactation in the last few years. Some research indicated a link between domperidone and cardiac issues. However the issues were among patients over 60 who had cardiac problems, who were taking other medication which caused arrhythmia or were taking a dose of domperidone greater than 10mg three times a day. https://www.breastfeedingnetwork.org.uk/wp-content/dibm/BfN%20statement%20on%20domperidone%20as%20a%20galactogogue.pdf
Research has shown that domperidone causes a steady increase in milk supply over a placebo. As the Breastfeeding Network specialist pharmacist notes, “We do not have research suggesting that domperidone causes risks to otherwise healthy, young women who are breastfeeding.”
 
Metoclopramide is sometimes prescribed as an alternative prolactin-booster but we need to be aware this is known to increase risk of depression and should only be given for short periods.

Breastfeeding doesn’t feel like a ‘choice’ for many of the women seeking your help.  For lots of mums, it is a choice and it might be a choice that they decide not to go for.  That is of course up to them and their families. But for many of the desperate women in pain and struggling, this is one of the most important things they will ever do in their lives. To discuss moving to formula instead of looking at the root of their problems or to discuss your personal views about formula feeding is a waste of precious minutes. You may have struggled with breastfeeding yourself, or watched your partner struggle. It can be difficult to empathise with the woman sitting in front of you who appears to prioritise breastfeeding beyond what you consider logical. It may make you feel uncomfortable about your own choices. Other healthcare professionals may get a chance to debrief their own breastfeeding experience but you rarely do.
 
Do not doubt that there are women who seek your help who would literally have a toe amputated if it meant that they could solve their breastfeeding problems. And they’d be happy for you to do it right there and then. And that’s about the level of pain they are experiencing right now, but still they persevere. ‘Why don’t you give up?’ is what they are already being told by mothers-in-law and friends and sometimes partners when they cry at 3am. They are asking for your help because that isn’t the way they want to go. When their nine month old is on a nursing strike and is suddenly refusing the breast, they want you to check for an ear infection before you talk about formula. They get it’s an option. Ending breastfeeding and using formula really isn’t a secret. If you don’t know the answers, then it’s valuable to have a sense of what is available to you locally in terms of signposting. Your local health visiting team should have information available on local support groups and drop-ins. What leaflets does the local post-natal ward give out? There are four charities in the UK that offer breastfeeding support: the NCT, the Breastfeeding Network, the Association of Breastfeeding Mothers and La Leche League. Is there a local La Leche League meeting near you?
 
If you aren’t familiar with local drop-ins, mums can also speak to breastfeeding counsellors through the National Breastfeeding Helpline: 9.30-9.30 365 days a year on 0300 100 0212. All the charities have their own separate helpline too.
 
If a mum needs more specialist care, a lactation consultant may be useful. An IBCLC may be attached to the local hospital or they can find one at www.lcgb.org .

 They may also be women breastfeeding past 12 months and even 2 years and 3 years. They are doing that because they are meeting their child’s needs and their knowledge of the constituents of breastmilk and its continuing immunological benefits may possibly supersede yours. If you are personally uncomfortable with it, it’s not a conversation you need to have. Do you believe that breastmilk ‘loses its benefits’ as time goes on? What is your evidence-base for that belief? Can you find its source? 

It looks as though the role of GPs in lactation support is likely to become even more significant in the coming years. There are places where you can access more training. UNICEF have an e-learning package that you may find useful: http://www.unicef.org.uk/BabyFriendly/Resources/Training-resources/E-learning-for-GPs/ Or here from BMJ learning: http://learning.bmj.com/learning/module-intro/breast-feeding.html?moduleId=5003232 
You can also find free videos here: http://www.health-e-learning.com/resources/free-lectures?lang=en
Shadowing a lactation consultant or a breastfeeding counsellor at a support group will also be a valuable way to spend some time.
 
As the Lancet series says, ‘breastfeeding is generally thought to be an individual’s decision and the sole responsibility of a woman to succeed, ignoring the role of society in its support and protection.’ [10]. Those of us who talk to breastfeeding women every day know we cannot underestimate the impact of just 10 minutes of contact with a well-informed GP. The effect is felt in her immediate relief as she walk away from the surgery and in the lifelong impact on her and her baby’s health.
 
Notes:
[1] http://www.thelancet.com/series/breastfeeding
[2] http://www.bbc.co.uk/news/health-35438049
[3] Victora, C.G. et al (2016) Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet 2016; 387: 475–90.
[4] https://heartmummy1980.wordpress.com/2016/02/03/are-you-strong-enough-to-change-the-world/
[5] https://www.facebook.com/DrJackNewman/
[6] http://www.essexchronicle.co.uk/Essex-County-Council-cut-support-breastfeeding/story-28078350-detail/story.html
[7] http://www.bbc.co.uk/news/uk-england-wiltshire-34983055
[8] http://www.babymilkaction.org/archives/7167
[9] http://www.cam.ac.uk/research/news/breastfeeding-linked-to-lower-risk-of-postnatal-depression, http://www.ncbi.nlm.nih.gov/pubmed/25138629
[10] Rollins, N.C. et al (2016).  Why invest, and what it will take to improve breastfeeding practices? Lancet 2016; 387: 491-504.

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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