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A message for GPs: when a breastfeeding mother walks through your door...

2/3/2016

21 Comments

 
by Emma Pickett, International Board Certified Lactation Consultant
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Crocheted breasts used by lactation consultants and breastfeeding supporters in conversations with mums. These were made by https://www.etsy.com/uk/shop/AnatomicalknitsbyLGD
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
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​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
.

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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

​

21 Comments

Expect at least 50% to end up on the floor: starting your baby on solid food,

9/16/2015

1 Comment

 
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The Department of Health and the Department of Health of every other industrialised country in the world recommends the introduction of solid food at around six months. 


You may hear ‘rumours’ that this will change. 


You may hear people tell you that there’s something wrong with this recommendation and earlier is best. 


Not true. The recommendation to wait until six months was the result of some careful deliberation and an examination of a wide range of evidence that looked at issues like disease and allergy prevention. 


There are a few bits of infant physiology that are hard to argue with. Babies need the amylase enzyme to digest starch and it isn’t properly released until around six months. In the days when people would spoon rice cereal into their small babies like filling cracks in the wall with polyfilla, some of those nutrients weren’t going anywhere useful. Babies are born with what we call an ‘open gut’. This means the gut wall which separates the baby’s intestines from the blood stream is extremely permeable. Larger molecules that might cause disease and allergic reaction can pass through easily. Breastmilk does a clever thing as it forms a protective mesh over the gut wall that prevents various nasties passing into the baby’s bloodstream. However to get that mesh functional we need the baby’s gut flora to be the good stuff. Just as if we were going to end exclusive breastfeeding, adding in solids will change the gut Ph. and gut flora and some of that protection could be lost. However by around six months, gut closure has occurred in babies and introducing other food then appears to have less of an effect.

A baby who is six months can also participate much more in the feeding process. They can sit up and hold and bite and select and get that food is colourful and textured and wonderful. They can control the process, rather than simply be vehicles for beige mush. You’ll often hear people say, ‘But my four month old looks so longingly at us when we eat our bacon sandwiches. He looks so fascinated and he wants to reach out and grab my food. I don’t want to make him wait until six months’. Sure, but the same baby is probably going to look equally fascinated when you apply mascara and lipstick. Probably not the best argument for starting solids ahead of the recommendations.

“My baby is big. He’ll need solids sooner”. Nope. It’s really not the way it works. Our bodies are designed to make enough milk for twins. It can cope with your bigger-than-average baby.

“My baby is smaller. She’ll need solids sooner”. Nope. If you’re concerned about weight gain, there are more effective things we can do to increase calorie content.

“My baby doesn’t sleep well. He needs solids sooner”. This may well be the classic sleep phase we often see at around four months. Babies can wake more frequently for a variety of reasons including gross motor development ("I'm getting to a lighter phase of my sleep cycle and I CAN MOVE MY LEG. I HAVE LEGS. I'M MOVING THEM. And while I'm at it, where's that nice big mummy person gone? I'm fully awake now"). Or it could be teething. This waking phase is rarely connected to insufficient nutrition. We may even find that introducing solids causes more restless nights initially, not improved ones. Babies are experiencing new digestive sensations, pooing at different times and are more likely to be constipated.

This is one area where we may get a lot of pressure from friends and family. Many of them weaned at a time when the recommendations were different. If you’ve been breastfeeding, they are probably super keen to get the spoons out and literally get stuck in. You may hear this from your mother-in-law: “Well, Bob had baby cereal from six weeks and he’s just fine.” Bob now plays rugby, runs marathons, splits atoms – delete as appropriate. The anecdotal evidence argument is never a worthwhile one. Bob is probably a member of a generation with shocking levels of obesity, heart disease and diabetes. Perhaps if Bob hadn’t have been weaned at six weeks, he’d play better rugby and split more atoms.

The recommendations didn’t change because someone in government had a long lunch and was feeling cross with Heinz baby foods that day. Evidence looking at the health of babies breastfed for 3-4 months vs six months was reviewed. This evidence was relevant to babies living in all countries and in all conditions.

The recommendations may change again. More evidence is always needed. But right now ‘around six months’ seems right.

There are different ways to feed a baby solid food. Broccoli can be held by its convenient little handle and baby gums can mash down and take mouthfuls of stuff directly from the source. Or it can be steamed and pureed and spoon fed. Baby-led weaning is a method where spoon feeding doesn’t happen. Baby is in charge. Food is offered in pieces and chunks that can be held in a little baby fist and they just go for it. They sit and feed themselves while you sit and eat your own dinner.

Imagine two families with babies in a restaurant. On one table there is a baby sitting up and in front of him is a selection of finger foods:  a bit of pitta bread, some vegetables from mum’s plate, some chicken. While his parents eat and talk themselves, he picks up pieces of food and self-feeds. At the other table there is a baby being fed pureed foods. While his parents eat, he sits and watches and perhaps is shown books or toys. When his parents are finished, they ask the restaurant to heat up some puree and then a parent sits and feeds him with a spoon.

Both babies are being fed and getting the nutrition they need. One baby is part of the social experience of the meal and is moving towards feeding independence and one baby isn’t quite.

The advantages of baby-led weaning are that baby is experiencing food as a full sensory world. They touch it, smell it and see its natural colours. They are part of the family meal. Food starts out ‘real’ and never changes. Some babies may gag when self-feeding finger food but the chances of choking are no more than if a baby was being puree fed. Plus you don’t have to worry about eventually transitioning to more solid food. If you are really nervous about choking, this can be a good time to do a course in baby first aid. They are often available cheaply in places like local children’s centres or even take some time to look at some videos online: http://www.redcross.org.uk/What-we-do/First-aid/Baby-and-Child-First-Aid/Choking-baby.

You can tell from my obviously biased description that I’m a fan of baby-led weaning. It’s been recently promoted by the work of Gill Rapley, a health visitor who has written some useful books on the process. I heard her speak at a food festival once and she got us to do an exercise. We got into pairs. Someone spoon fed me a puree. I couldn’t communicate when I was ready for the next mouthful or easily communicate when I was done. I couldn’t smell the food or easily see the colour. The spoons of beige mush kept on coming. It tasted fine but I couldn’t even put a hand up to slow the process down or ask for a smell or ask to take a breath. It felt overwhelming and the spoons kept coming. After a few minutes, I started to feel like a torture victim. Clearly I am being melodramatic here but imagine you are breastfed baby who up until now has been fairly in control of their own feeding. Wouldn’t it be nice if solid food was an extension of that experience?

Of course, you may feel purees are right for you and be particularly attached to your steamer. Like with most things in parenting, you must do what is right for you. Lots of people combine pureed foods and finger foods in a baby-led weaning style. However I would recommend you at least find out about ‘baby-led weaning’ as it can be enormous fun.

Food before twelve months is ‘just for fun’ people sometimes say. Not quite true because in many cases, we will need to give baby additional sources of iron and other micronutrients before twelve months. When babies are born they get stores of iron from you and then as they breastfeed, they receive easily absorbable iron from the breastmilk. There was a time when scientists looked at the iron in breastmilk and thought it looked a bit low but we now know that was misleading as it is absorbed incredibly efficiently and is very bioavailable. Studies have shown that when babies are exclusively breastfed for as long as eight or nine months, they still have sufficient levels of iron in their system. However the recommendation to start solids at around six months gives them plenty of time to get up and running before we need to worry about there being a problem. It simply isn’t true that because we are now starting a little later, we’re in a huge rush to get huge bowlfuls of food into our baby or the world will end. We have time. It’s really important to remember that milk remains the primary source of nutrition up until twelve months. It’s only at twelve months that solids starts to take equal status and then gradually becomes to primary source of nutrition. Some eighteen month olds are still happily breastfeeding several times a day (and at night) alongside solids and it’s a valuable part of their nutrition. These statistics are helpful: In the second year (12-23 months), 448 mL of breastmilk provides: 29% of energy requirements, 43% of protein requirements, 36% of calcium requirements, 75% of vitamin A requirements, 76% of folate requirements, 94% of vitamin B12 requirements, 60% of vitamin C requirements (Dewey 2001). That’s not me saying everyone should breastfeed for 23 months. That’s me saying breastmilk continues to have good stuff in it, the best stuff. It’s not going to turn into some useless white fluid when your baby reaches six months and now it’s all about the mashed banana.



What should we feed them? Well, what do you like eating? There's very little a baby over six months can't have (something else that's easier after six months). We don't give a baby under 12 months honey because of the risk of botulism poisoning. We want to be careful about whole nuts which could be a choking risk but nut butters are fine. If you are worried about a history of family allergies, you should talk to your doctor but automatically avoiding certain foods may not be the most sensible approach - certainly not for everyone. You don't have to wait a few days before introducing another new food. You need to be sensible with sugar (and that includes dried fruit) and salt can be dangerous so if you are cooking meals for the family, season your own food separately after cooking. Babies can enjoy herbs and spices and strong flavours. They can eat eggs and seafood and meat and fish. Though you need to pay attention to the quantities of oily fish as they contain pollutants. Did you know that boys can eat more oily fish than girls? There's some more information here: 
http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/understanding-food-groups.aspx#close 

Babies can eat dairy products and they can also be vegan or vegetarians. They can drink water. They don't need juice. The suggestion is to minimise the amount of wholegrain foods a child eats under two years old.

Some people are concerned about how they are going to time their solid food meals. They are also worried about how to go about ‘dropping’ a breastfeed and reduce breastmilk appropriately. This is one of the great things about breastfeeding and introducing solids - you don’t have to stress about any of that. It happens naturally and organically and your baby is in charge with very little assistance from us. You just continue to breastfeed to your baby’s cues. That’s it. Bottle feeding mums do have to plan things out more carefully. Breastfeeding mums just continue to response to their baby’s cues and just ensure that the solids intake doesn’t increase too quickly.

When you introduce their first solids, think ‘milk first’. That means we don’t feed a solid meal when a breastfeed is due and then find they aren’t that hungry for breastmilk. Better to offer solid food in between breastfeeds or not long after a breastfeed. Food is like a new activity. You’ve introduced this wonderful new toy that tastes a lot better than the plastic giraffe they’ve been chewing on for a while. When two meals start to happen, milk is still ‘first’. It doesn’t have to be first in the sense that you breastfeed and then run from the sofa and plunge them into their high chair - just not long after or a few hours after. We don’t want the quantities of breastmilk they receive to really change much for a while. As they start to take more solids, gradually over a 24 hour period, they will take less breastmilk. You may not even notice it happening. Feeds may become a little shorter and intervals between breastfeeds a little longer. It will happen very naturally. 

Eat with your baby. Enjoy meals together.


1 Comment

Low Milk Supply 101

7/12/2015

 

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.

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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

When baldy doesn’t want your tit: newborn breast refusal

4/30/2015

7 Comments

 
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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?

**********************

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.

Picture
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

7 Comments

“You’ve got so much milk! You’re so lucky!” “No, I’m bloody not”: oversupply, ‘colic’ and ‘reflux’

4/22/2015

71 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Milk comes out because of your milk ejection reflex (the oxytocin arriving in the breast and contracting muscles to push the milk down through your ducts) and your baby’s ability to remove milk using their tongue and create negative pressure inside their mouth. It’s not much about gravity. But if liquid is flooding into your throat and you are UNDERNEATH the flow, that’s more likely to be overwhelming. You won’t feel safe taking a breath. You are more likely to feel out of control and feel the need to break off. When we feed babies in a cradle hold, cross-cradle hold or rugby hold and they are under the breast, it’s understandable they feel more overwhelmed. If we lean back so the baby is more above the breast, this is likely to prevent the milk pooling in the back of their throat and hopefully they will feel less out of control.
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You could get them on in their usual position but then scoot your bottom forward and lean back – just make sure you have back support for yourself. You could also use positions where the baby is seated, perhaps with one leg astride each side of yours and their mouth level with the breast. By changing position, we’re hopefully going to result in the baby staying latched on properly throughout the feed. This is going to mean less air getting in and less windiness, colic and possetting.

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

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

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

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

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

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

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

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

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

Picture
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

71 Comments

Shared parental leave: the boobs don't come off.

3/27/2015

9 Comments

 
The government has commissioned a nifty graphic to help us understand shared parental leave. Pink and blue to represent male and female? I suppose it’s an easy shorthand. Levitating blue milk defying gravity? We’ll let that one go. Anything else? What’s happened to breastfeeding? That’s a question we could ask about shared parental leave legislation as a whole.

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

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

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

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

The UK manages 1%.

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

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

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




Reading: 

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


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


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

9 Comments

Positions for breastfeeding 101

3/26/2015

0 Comments

 
You’ll hear two different messages about positioning and attachment that seem to contradict each other. On the one hand, baby is filled with natural reflexes and you are too and you are both created for this breastfeeding business by million of years of evolution. When baby comes out, they just instinctively know what to do and you do too – if you can just tap into those instincts. If you just lie back, a newborn baby will scoot themselves into position and away they go (cue videos of the breast crawl on YouTube).

Yet there’s another message coming through. Breastfeeding seems like an exact science. Mothers have to think about angles of mouth and hard palates and soft palates and size of gapes and catching gapes at the right moment and holding baby in a particular way.  It’s like learning to drive except the gear stick is wriggly and cries a lot. It’s left brain and right brain – not just a case of letting Mother Nature and her cosmic power flow over you.

These two messages seem completely at odds with each other. What’s true?

Well, like most things. It’s all a bit true. Some babies and mums do just seem to ‘get it’. It’s never sore. It’s easy. It works.

However some mums need to take a bit more control over positioning. Perhaps some of baby’s instincts haven’t quite come to the surface because birth was complicated. Perhaps first breastfeeding experiences didn’t go well and it took a few days to get up and running. Perhaps you don’t start out quite right (maybe that breastfeeding pillow wasn’t such a great idea?) and now you need to concentrate a bit more to make things comfortable. Perhaps you just need to take charge a bit more and it’s not quite clear why. You may not be able to predict beforehand exactly how your breastfeeding experience is going to go. You may have to just wait and see what happens.

Whether you are in the nature-led or mother-led group when it comes to positioning and attachment, there are certain positions that seem to be used by most people. It’s a good idea to get pictures in your head now and embarrass your partner by practising with a doll. Although be warned a doll doesn’t have that flexible neck and that heavy head and that gorgeous biscuit baby smell.

The most important thing to remember is that one position isn’t automatically better than all the others. You might work with a breastfeeding supporter who has a favourite and encourages you to try one position and then the next person to walk in the door could have another suggestion. As long as the key features are there, there are lots of options. You need that big wide mouth, the tongue extending over the lower gum ridge and chin touching the breast. Their bottom lip will be flanged down (though you don’t want to fiddle around too much to check or you’ll mess things up). Their cheeks will be touching the breast and you may not be able to see their lips at all. You need baby’s body nice and close to yours without their neck or body being twisted. Remember the ear/ shoulder/ hip all in a line. You try and swallow something with your neck turned to one side! You need to be comfortable: your hands, arms and back. It's worth mentioning now that the upper lip doesn't also need to be flanged out like a fish lip. It often rests in quite a neutral position. Ideally it's relaxed but a very out -turned top lip can be an indication of a shallow latch.


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The Reclined position


When you lie back, with the baby on their tummy on top of you, it does often seem to tap into some of their natural instinct and perhaps some of yours too. Sometimes when a baby has been really struggling to latch or even refusing entirely, lying right back and using the ‘biological nurturing’ position can make all the difference. We can give our arms a rest. We don’t have to worry about how to hold their head: whether we’re holding it too firmly, how that might feel for them after a difficult birth, are we squashing their ears? Have a look at www.biologicalnurturing.com. Babies will often self-attach and mum might just raise an arm to keep a baby in place and prevent them toppling off if they lean. If you’ve had a c-section it might be more uncomfortable if baby’s feet are placing against your scar and it’s going to depend a bit on your body shape and length as to whether this is a position for you. First you’ll need to lift baby onto your body (or get someone else to) and place their nose roughly around the nipple area and see what happens. Have their arms placed up either side of their head to help them stabilise themselves rather than down by their hips. It might look as if they are in a nearly crawling position. They may bob around and lift their head up and then plonk it back down again. You may not be able to see very much in terms of latching. It might a feel like you are a bit out of control. It can still be a great position and sometimes it’s worth lying back (literally) and seeing what your baby can do on their own. It may take a while before the baby settles down to feed so this isn't a position to rush. Have a go at the very earliest sign of hunger cues. It's best to try after a good stretch of skin-to-skin time. Results are unlikely to be positive if we scoop a baby out of a Moses basket, peel off their clothes and plonk them on when they are already pretty hungry.


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Rugby-Hold

The rugby hold or football hold (when North Americans are writing about it) can be a good choice particularly when babies are little. Depending on your body shape and the shape of your breast, baby may be lying on their back or on their side or on a diagonal at your side. Importantly, baby shouldn’t have to twist their neck to reach the breast. Remember the ear/ shoulder/ hip in a line thing? If your breasts are larger, it’s more likely baby will be on their back. Remember to start with nose-to-nipple. If you start with mouth to nipple, the baby won’t do that lovely head tilt that brings the chin to the breast. The important thing with this position is that you want the head tilt so that the chin isn’t tucking into baby’s chest. The baby’s head should be stretched away from their chest. You try and drink a glass of water and swallow with your head tilted down! You’ll be supporting baby’s head by holding them around the base of their neck. Often your fingers will end up round their ears. The palm of your hand will be around the top of their back. You’re supporting their neck and the base of their head but you’re not putting pressure on their head. It’s a supportive but gentle hold. If they want to tip back, they can. If you put pressure anywhere, it’ll be on the top of their back to keep their chin tucked in close to the breast. Your arm should be supported probably by a cushion. It’s not easy to do this position with baby dangling in mid-air. This position is often good if baby has a tongue restriction or if baby hasn’t been doing really wide gapes in a cradle or cross-cradle hold.

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Cross-Cradle

With this position, you start with baby’s weight on your arm. You want to be able to move their body across you and if you’re just holding their head, it may feel like you’re yanking them uncomfortably. The whole baby moves when we do ‘baby to breast’. You support their head by holding them round the ears, neck and top of their back. Imagine Elvis at the end of his career is Las Vegas. Your hand is the big Elvis collar. You want to check there isn’t clothing bunched up between you. A bra rolled down with a breast pad squashed inside it could push baby’s chest far away enough from your body that it affects the way baby will attach. Baby’s hands also can’t be between you. The bottom arm can be hugging your body and round towards your armpit or right down their side by their hip. Lots of new mums says that the baby’s hands are ‘getting in the way’ and it can seem to be very frustrating. Remember that baby uses its hands to help it find the breast and centre itself. If you can get baby’s chin and face to the breast quickly, you’ll find that very often the arms will instantly calm. Dab the baby’s nose against the nipple and wait for the gape. 

Take a moment. It’s OK for this bit to take a couple of minutes at least. They will hopefully gape and tilt their head as they reach up for the nipple. When you feel you’ve got that gape, you’re going to move baby’s body quickly and plonk them on. Their bottom lip will be as far away from the nipple as possible. Just check your arm is well-supported. You’re not going to be able to hold the weight of a baby’s head throughout a feed on just a few fingers. It’s often a good idea to bring your other arm round and support baby’s head on that forearm. So perhaps start in a cross-cradle hold and then move into a cradle hold. You might even be then able to move your cross-cradle arm out slowly and leave baby in a cradle position. That gives you a spare hand for essentials like drinking, eating and reading. Or you might have cushions supporting your cross-cradle arm and taking baby’s weight. Another option is that you lean back so that baby’s weight is going through your torso. What’s going to be hard is an increasingly heavy baby balancing on your arms and hands as you sit bolt upright. By the way, you don’t need to sit upright for the milk to flow. The milk will flow even if you are leaning right back. It’s your milk ejection reflex, the baby creating negative space in their mouth and the baby’s tongue that moves the milk around. Gravity doesn’t have a lot to do with it.
One thing worth remembering, some women have naturally shorter forearms. You may not be able to have baby resting on your arm and be able to support the base of their head. Your arm may literally not be long enough. So if this position seems to be a struggle, you’re not going mad. You just needed a few more centimetres of arm. You may do better with a bit of cradle hold and using both arms for support, or the rugby hold.  

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Cradle hold


This is often the picture we imagine when we visualise breastfeeding for the first time. There aren’t many images of the Mother Mary and baby Jesus doing the rugby hold or laid-back breastfeeding. Baby’s head is resting somewhere around the crook of your elbow. Their body is close to yours and their hands aren’t squished between you. No clothing bunched between you. You dab baby’s nose around the nipple and when they gape, you bring them even closer to your body. You want their chin massaging the breast. Their head is ideally slightly tilted which gives them even more chance that the chin and tongue have good breast contact. When you bring them nice and close with that gape, focus on two things. First, you want their bottom lip to come as far away from the nipple as possible. It’s OK if the top lip is much closer. If you see any areola (and there’s going to be a lot of variation with this as areolas come in lots of different sizes), you can see some areola above the top lip but none below the chin. And secondly, try and picture the nipple heading up towards the roof of their mouth. You’re aiming for a point on the roof of their mouth rather than heading down towards the back of their throat. Once baby is on, check that you are well-supported. If you had to lean forward and move the breast around, something is probably going to adjust during the feed in a way we don’t want it to. Baby will have moved to you. Baby to breast is the phrase we say. We want you to finish a feed as comfortably as when you started. You shouldn’t have back ache or feel relief that your arm no longer has to do any work. If you finish a feed rubbing your sore arm or hand and thinking, ‘glad that’s over it’, something needs to change. You may have been slightly slipping during a feed without even realising it if something was uncomfortable. We only have to move a few millimetres for problems to start. The baby’s nose may sometimes be touching your breast. This is particularly likely if you have larger softer breasts. It’s not panic stations if a baby’s nose does make contact as babies will prioritise breathing and come off and adjust if they need to. You can tuck their bottom in a bit more and see if that tilts them so that their nose is a little more free. Ideally you’ll have got them on anyway with that head tilt that drives their chin in without burying the nose into the breast. What we want to avoid is pressing a finger into the breast to keep breast tissue away from the nose. That’s not a great plan for various reasons. Firstly, it means you are potentially affecting the flow of milk by pressing on a milk duct –some are quite close to the surface of the skin. It can also increase your chance of getting milk ducts and possibly mastitis. It’s also taking the emphasis away from that good quality head tilt
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Lying down

Being able to breastfeed while lying down is one of the essential breastfeeding mummy skills. It’s right up there with being able to eat one-handed and opening a clasp on a nursing bra without losing your marbles.You might think you can get up all through the night and breastfeed in a chair but after a few weeks of that, it starts to become less fun. When you breastfeed lying down you can rest and you may even be able to sleep. 70-80% of breastfeeding families have the baby sleeping in their bed with them at some point. It’s a good idea to read more about bed-sharing and some of the risk factors so you can understand how to do it as safely as possible. I recommend visiting isis online: https://www.isisonline.org.uk/where_babies_sleep/parents_bed/.  This is the Infant Sleep Information Service and if being called ‘ISIS’ helps sleep-deprived new parents to remember its name, that’s no bad thing. This is an excellent resource filled with useful accessible evidence-based information. It’s the place to visit if you want information about safe sleep for your baby.

When you breastfeed lying down, the principles of good attachment are the same. We still want that nice wide gape. We still want baby’s body close to mum’s body. What often works well is to have both mum and baby on their side. Take a moment to look at the bedding around you. Ideally your duvet is tucked under you or well away so it can’t flop on to baby. You may be determined that you won’t fall asleep while you are feeding but it’s sensible to think through what might happen if you did. Make sure baby is far away from your pillow. Perhaps put your pillow on a diagonal away from him. What is on other other side of baby? Babies can move surprisingly far even when they are very small. They can get trapped between walls and beds. Partners that aren’t breastfeeding don’t benefit from hormones that keep you more tuned into baby so ideally baby isn’t in the middle between you. One option is to have a side-car cot next to your bed and that’s behind baby when she feeds. After the feed, you may be able to slide her back into her space but if not, at least if she did move, she’s only got her cot space behind her. Some mums are so worried about falling asleep with baby in the bed that they get up and move to a sofa. It is far more dangerous to fall asleep on a chair or sofa than it is in a bed.When it’s time for latching, have your baby’s nose level with your nipple. Nose to nipple is particularly important in this position. We really want baby to be reaching up and tilting their head back to get to the breast. This will give their tongue optimum space on the breast, really get the chin pressing in nicely  and help their nose to be as clear as possible (though some mums with larger softer breasts may still find baby’s nose touches). When the baby tilts and you get that gape, you press in on the top of their back and bring them as close as possible. You’ll probably need to keep that hand there so their chin and body stays close.  The other hand may be propping up your head so you can see what's going on and once the feed has started, you can lit back down on the pillow. If you do fall asleep, your hand may start to relax and the baby may end up rolling onto their back to sleep once the feed has finished. When it’s time for the other breast, switch yourself round so your head is at the other end of the bed – go ‘top to tail’. Your breasts will be again on the outside and baby will be in the safer outside position in the bed (assuming there’s a partner on the other side).




Pick the position that seems to work best for your baby, your breasts, your chair, your life. If you can have a couple up your sleeve that's useful because it means the breast will get drained in different ways and it gives you options depending on where you are. Most mums do appreciate the opportunity to lie down so being able to breastfeed in bed is certainly worth practising. Don't let anyone tell you that one position is necessarily 'best'. Quite often people are loyal to the position that works best for them but there any many different options - including several not described here. If you are comfortable and baby can get the milk out effectively and you can reach the remote control - those are the things that really matter.



Thanks to Estelle Morris for the illustrations. http://www.estellemorris.co.uk/
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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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Having dinner out in a restaurant is the WORST thing you can do: new parenthood and relationships

3/2/2015

1 Comment

 
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People ask, “Why don’t more people in the UK breastfeed until six months or beyond?” Obviously the reasons are complex. It’s often about people not being able to access the breastfeeding support they need in the first month. It’s also about new parents not realising what’s normal when it comes to breastfeeding and being surrounded by a bottlefeeding culture that undermines their confidence. However I think a little bit of it is connected to the way British women think about their breasts and their bodies. I think a little bit of it might also be because we don’t know how to be a breastfeeding mum and be a sexual partner at the same time.

From when we are very small, we are surrounded by the message that boobs are about sex. We see it on billboards, in daily newspapers, on magazine covers. Think of all the images an average 20 year old woman will have received about her breasts and how many of those images are about a woman feeding her baby. And that’s just the girls – never mind the new fathers.

We are bombarded with all these messages about what breasts are ‘for’ and then we’re told when we’re pregnant, “Oh, by the way, forget all that, THIS is REALLY what breasts are for. It’s really important. It’s best for baby. OK?” It’s quite a brain shift.

We also live in a society where we no longer live in extended families and the couple is the centre of our household. Successful couples in our culture are perceived to be couples with active sex lives and sometimes when we are a new parent, we’re finding our way when it comes to sex. We’re trying to work out how to be a mother and how to be a sexual partner at the same time. Meanwhile dad (or partner) is trying to figure out how to support you in your new role as a mother and understands this teeny new person is your new priority. But they would quite like to feel loved as well. I never subscribe to the view that breastfeeding makes new dads feel excluded. But realistically, when there’s a new baby at the centre of your world and dad is shunted back to work after only 2 weeks of paternity leave while you carry on getting to know this new person, it’s tough.

Sex isn’t just about sex. It’s a way for people to feel connected and loved and special. When your partner is asking for sex, it’s not just about wanting to get their ‘rocks off’. Most adult males (and females) are pretty proficient at organising the offing of rocks all by themselves. It’s also about wanting to connect with you and feel that they still matter and your relationship as a couple still matters.

It’s very easy when you are a new mum to get into a downward spiral of feeling negatively about sex and sex starting to feel like another chore. New motherhood is a time when you may actually find yourself using the cheesy expression ‘touched out’. A little person is touching and needing us all day long. New motherhood is exhausting. If we feel ‘needed’ by anyone else who might place physical demands on us, it can feel like a step too far.

Not to mention the fact that after the birth we may have physical reasons for not feeling quite ready for sex. There is some suggestion that breastfeeding can result in lower oestrogen levels and this might result in increased levels of vaginal dryness. This may be true for some women in the early months and lubrication can be useful. Although some may claim that breastfeeding ‘affects your hormones’ in a way that impacts on libido, it’s difficult to make any hard and fast rules when it comes to libido. In pregnancy, we all have fairly similar hormones flying around and some women feel very sexual and motivated and others switch off sex entirely. Whatever might be causing sex to feel difficult for some new mothers, we need to be conscious of what’s going on and recognise that we need to spare a bit of mental energy for our relationship.

When it comes to protecting and cherishing your relationship there are some things that are worth spelling out:

·         Everyone is more tired and we aren’t always brilliant communicators when we are tired. We may be snappier and less patient and need to be more conscious of the words we are choosing and the way we are saying things. Stuart Heritage, writing in The Guardian, talked about his relationship with his wife in the early days of parenting: "The fact that we haven’t murdered each other yet is little short of a miracle, especially given that my method of dealing with tiredness (snippy sarcasm) is directly at odds with hers (irrational sensitivity to snippy sarcasm)."

·         It’s worth pausing and taking a moment to think through what’s really important. If your partner doesn’t put on a baby’s nappy in exactly the same way you might, that might be a comment worth letting go. In the beginning, you were both muddling through this parenting thing together but as the hours went by you probably spent more and more time with the baby and they possibly felt more excluded and disempowered. You simply had more practise. It is your job to mother your child but also to help your partner to be a new parent in the best way that they can. OK, if they are rrrreally bad at putting the nappy on, you can say something.

·         There may be new ways to be intimate. In the olden days (a few weeks ago before baby), it might have seemed logical for couple time to consist of evenings out, dinner in a restaurant and sex before falling asleep in bed. These are spectacularly bad ways for a couple to try and reconnect when they have a new teeny baby. Evenings and bedtimes are often the times when we feel the most exhausted. There are also the times when baby wants to cluster feed and is at their most demanding. Whereas 9pm once felt like the beginning of an exciting evening, it now feels like a time when your body is pretty convinced it really shouldn’t have to be operating fully conscious. We may have to rethink what ‘couple time’ means. Time as a couple doesn’t have to mean time separated from baby. It is possible for the three of you to curl up on the sofa and watch a great movie. Or go for a walk in a beautiful place. Or have a nice meal in a restaurant. Young babies sleep and when they don’t sleep, they breastfeed and that tends to be peaceful and straightforward. You might prefer to be in that restaurant at 6pm or 2pm instead of 9pm. If you are ready for time away from baby (and don’t force yourself until it feels right – this isn’t a test of anything), take care with who you choose to look after your baby. It may be that your first meal out isn’t with your partner at all because that’s who you first trust to be at home with baby while you eat out with a friend. When it comes time for the babysitter to give you couple time, it might make sense for the babysitter to be there from 2pm to 7pm giving you a chance for a meal and an experience and still get home for bed. Or how about a babysitter who takes the baby to park or a family member who takes baby to their own home while you and your partner share a bath and have some intimate time? Or how about you share a bath and have some intimate time with a baby in a Moses basket nearby? You can be both things at once – a mother and a partner. We feel we have to compartmentalise ourselves and that just isn’t true. No one has to ‘switch off’ being a mother in order to be intimate and connect with their partner. And intimate time doesn’t have to mean putting a penis into a vagina (even less likely if you're not a heterosexual couple). There are lots of options that you can talk about honestly. If communication is open, you don’t have to avoid other physical affection because you fear that you are sending signals you are ready for sex when you aren’t.

·         Talk. Sometimes we feel that new parenthood is supposed to be lovely and we’re supposed to be thrilled and grateful and jolly. The reality is that it’s very difficult. Any relationship with weak points is likely to find those weak points even more exposed. It’s a time to communicate honestly and kindly.

·         You do have to make time for your partner. Don’t roll your eyes at me for spelling that out. You may think you hardly have time to brush your teeth so get stuffed. Truthfully, your baby benefits from parents who are connected and loving. Do you find yourself feeling angry towards your partner more than you feel loving and appreciative? You may need to talk more. Taking time to listen to your partner and show kindness is for all of you as a family.  A bestselling baby writer suggests women drink a large glass of red wine and force themselves to have sex even when they don’t feel like it. If this is what sex has come to mean to you, you need to talk more with your partner and use a bit more imagination. One of the symptoms of postnatal depression is a feeling of resentment towards your partner, a disinterest in sex and a lack of motivation in reconnecting. It might be that your partner is simply a complete prat and all these feelings are justified. Some relationships may breakdown in the first few months after a baby is born and that might not be a bad thing. However if you feel that life isn’t quite going the way you’d like in other ways too, take a moment to talk to someone about how you feel and just check you don’t need further help.

·         Be kind to yourself too. Our bodies change when we are new mums. They are supposed to. That can feel weird when we are surrounded by magazines and images telling us that flat tummies are the meaning of life and breasts aren’t about babies. Breastfeeding itself doesn’t make your breasts sag by the way. That is the effect of pregnancy hormones and may happen to people who don’t breastfeed even for a minute. Breastfeeding may make inverted nipples evert for ever more but it’s not going to permanently change your breasts. And even if it did make a little alteration, most women would feel it was more than worth it for the all the positives – including reducing a mother’s risk of breast cancer. If you feel you want to lose weight, that can still happen while you are breastfeeding.  Breastfeeding mums can still run and play netball and swim in the sea. Just don’t push yourself to do too much too fast because you feel you need to rush to change your body back into the way it was. Your baby will only be a baby for a short time. Before you know it, it will be all about finding shoes and reading stories and playing football and banging drums and wearing sparkly dresses. Your priority right now is meeting this new person and getting to know them and caring for them and taking on probably the most important role of your life. 

Our relationships should be robust enough to deal with these difficult phases and changes. When baby has changed into a bloke who worries about rent and his next holiday, your relationship with your partner will continue to be a core aspect of your life. We need to integrate 'being a mother' into who we are rather than expect 'being a partner' and 'being a mother' to live in different boxes. These women are more likely to make breastfeeding work in the longer term and they are more likely to make relationships work too.

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Low supply 101 http://www.emmapickettbreastfeedingsupport.com/twitter-and-blog/low-milk-supply-101

2/12/2015

2 Comments

 
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2 Comments

How to train as a Breastfeeding Counsellor

11/25/2014

32 Comments

 
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Do you think you might want to train as a breastfeeding counsellor?

Here’s a quick quiz…

1.       Do you find a woman breastfeeding in public puts you off your coffee because…

(a)    It’s a bit awkward

or

(b)   You sit there wondering whether she’d mind if you went up to her and congratulated her for feeding in a café

(and after much deliberation you eventually decide on the ‘warm smile/ thumbs up’ combo)

If you answered ‘a’, this is probably not the article for you.

2.       Can your facebook wall easily display photos of the breasts of five different women from two different continents in one week?

3.       Does your partner mention to pregnant strangers that they might want to talk to you about breastfeeding?

4.       Does your mum save newspaper clippings of articles on breastfeeding? (when you actually heard about the article two weeks ago and have already have three online discussions about it)

5.       Do you wish everyone could breastfeed for as long as they want to and you get frustrated when you hear that doesn’t always happen?

This may be the article for you then.

Becoming a breastfeeding counsellor in the UK is fundamentally about volunteering your time to help mothers to reach their own breastfeeding goals. You will need to be able to empathise, offer emotional support and information. You will need to appreciate that not all breastfeeding mothers look the same or make the same choices. You will not be offering ‘advice’ but empowering mums (and their partners) to make their own decisions.

It is immensely important and rewarding work and breastfeeding counsellors are desperately needed.

It's worth noting that this is not going to be a new career path for most people who train as a breastfeeding counsellor. If you train as an NCT practitioner, you may be able to make a career out of it. There are also some paid breastfeeding support roles available in some parts of the country depending on projects in your area, but these are few and far between.

What is for sure is that the skills you learn, the experiences you have, the people you meet will make this worthwhile – both in a ‘future employment’ sense and a wider life-changing sense.

There are four main organisations you can train with in the UK. There are some things different about the training (cost, location, philosophy of the organisations).

There are some things that are the same about all of them:

You’ll be focusing on the needs of the mother and baby and putting your personal experiences to one side whenever possible.

You will use good listening skills to support mums and their families.

You will be expected to provide evidence-based information – that means information based on science, research and best practice. You won’t be giving personal opinions.

You’ll be working as a team with other people supporting the mum. You may refer to GPs or health visitors or midwives. Breastfeeding counsellors don’t work in isolation and are great at sign-posting to other services.

You’ll get on-going training and supervision to help you in your role.

Here’s how you can go about getting trained:

If you want to train with the NCT, you have a couple of options. You can take the paid option to become a self-employed NCT practitioner. http://www.nct.org.uk/nct-college/work-opportunities#level5   NCT BFCs may take sessions of antenatal classes, run support groups and work on the NCT helpline. The course costs approximately £6,500 and takes two years to complete. It can be done in less time if you study full-time. There are some bursaries available. You study for a foundation degree with the University of Worcester and take the ‘breastfeeding pathway’. You start with the essentials course to become a ‘birth and beyond practitioner’ and then go onto do the breastfeeding specialism.  You will need to have breastfed one child for at least six months. The breastfeeding pathway consists of 3 modules (counselling skills, applying counselling skills, understanding women’s experiences of breastfeeding): each requiring 2 study days and 5 tutorials. Some of the study days will be at the University of Worcester and some arranged in a more local area depending on numbers of students. The course will include writing a 3000 word essay, short answer questions, tutor group discussions and a range of learning experiences.

You can also qualify as a VOLUNTEER NCT breastfeeding counsellor: http://www.nct.org.uk/nct-college/course-options/nct-voluntary-role-breastfeeding-counsellor-training.  You need to have breastfed for a minimum of six months before you apply. The training costs £625 rather than £6500. It still takes a couple of years and is spread over 15 tutorials and study days. Again locations vary but some sessions will be at the University of Worcester. Babes-in-arms can come to study days and you can bring an older breastfeeding child too provided you also bring an extra carer for them. Volunteer counsellors support mothers without receiving payment and may support at drop-in groups and throughout their local community.

If you train with La Leche League, you’ll be called a La Leche League leader rather than a breastfeeding counsellor: https://www.laleche.org.uk/content/thinking-about-lll-leadership.

It’s a good idea to read the La Leche League book, 'The Womanly Art of Breastfeeding' (which is a good read for anyone interested in breastfeeding) and familiarise yourself with the ten concepts that are important to La Leche League. That’s not to say a La Leche League leader wouldn’t support any breastfeeding mother whatever her parenting views but just that the La Leche League is underpinned by a philosophy that will shape your appreciation of the mother/ child relationship and all leaders will share:  https://www.laleche.org.uk/sites/default/files/LAD%20Brochure%20final%20Jan%202011.pdf
You should also find out if there are La Leche League meetings local to you and attend some. 
https://www.laleche.org.uk/find-lll-group

You’ll be expected to have breastfed for at least nine months. Many leaders train with an established leader at an established meeting but if you don’t have one close enough to you, there are other ways of doing it. The training is a combination of face-to-face and written work and can take two years depending on your pace. The pace will be very individual to you and might depend on things like the age of your children. You can find out the current fees by contacting LLLGB.

La Leche League leaders will usually support at a local meeting (they may share running a meeting with other leaders) and can also support on the LLL helpline.

You can also become a breastfeeding supporter with the Breastfeeding Network. That’s their word for a breastfeeding counsellor equivalent – not to be confused with ‘peer supporters’ from other organisations who will have done a shorter course. Training happens locally and is face-to-face: http://www.breastfeedingnetwork.org.uk/get-involved/train-to-be-a-registered-volunteer/

Opportunities depend on funding and what is available in your local area. This is what is currently available: http://www.breastfeedingnetwork.org.uk/get-involved/train-to-be-a-registered-volunteer/areas-where-we-are-able-to-provide-some-training/

You will not have to pay any training fees. You start by training as a breastfeeding HELPER and then you can go on to do the supporter training if it’s available. Helper training consists of 12 two-hour sessions and babes-in-arms are welcome. Supporter training usually takes approximately two years to complete. The expectation is you will volunteer for the BfN after your training by offering face-to-face support at groups or on the BfN helpline or National Breastfeeding Helpline (phone or webchat). The training will often take place in tutors’ homes and consists of written and oral work.

The last charity you can train with is the Association of Breastfeeding Mothers. Like the Breastfeeding Network, you start with the first level course (which the ABM calls ‘Mother Supporter’ course) and then you can go on to train to become a breastfeeding counsellor which takes approximately 18 months to two years. http://abm.me.uk/about-the-abm/training-with-the-association-of-breastfeeding-mothers/

You need to have breastfed for a minimum of six months before you apply. The course costs £100 and you also have to be a member of the ABM. It is then expected that counsellors volunteer on the helpline for a minimum of two years after training. The ABM helps run the National Breastfeeding Helpline with the BfN and have their own helpline. Many ABM counsellors also support in their local community. The ABM training is a distance learning programme. This means that you submit written modules and communicate with tutors via email and phone and through online discussion. There are some practical activities such as observations and practise phone calls and you are required to attend one study day a year. The advantage to a home study course is that you don’t have to leave young children and the training can happen anywhere. However it is not a learning style that works for everyone and requires independent organisation and reading at home. There are eight additional modules after the initial Mother Supporter course has been completed.

So those are your options. If you read those descriptions and felt excitement and anticipation, this may be a path for you. If you read them and thought, ‘that sounds like a tremendous hassle’ – perhaps not.

There are other ways you can support mothers depending on your passion and your experience:

You may be interested in becoming a doula (breastfeeding support is often part of a doula's role too): http://doula.org.uk/content/becoming-doula
Or perhaps training to become a home start volunteer: 
http://www.home-start.org.uk/volunteer/
Or volunteering for a charity like Bliss: http://www.bliss.org.uk/get-involved/ or PANDAS, who help mums with depression: 
http://www.pandasfoundation.org.uk/get-involved/volunteering.html#.VHSVZYusXg8

On Twitter and Facebook, you’ll find counsellors and trainers from all of these organisations who I’m sure will be happy to answer any of your questions.

If you have the time and the inclination, you can make an incredible difference to the lives of new mums and babies. Your commitment is desperately needed.

Information accurate as of November 2014. Check website links for current updates.


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    Author:
    Emma Pickett IBCLC

    Find me on twitter: @makesmilk

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    A Lactation Consultant supporting families in North London.

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