Thursday, 10 December 2015

My breastfed baby has low weight gain. Is it a problem?

Sometimes in breastfeeding support you go through a period of weeks seeing dyads with similar issues.  The last few weeks it has been low weight gain in babies, so It gave me a prod to blog.

First things first - what is normal weight gain in a baby and are the charts relevant?  When someone posts on a forum about their low gaining breastfed baby, there is often a conversation about whether the charts are actually based on breastfed infants, and whether charts are relevant anyway.  Don't babies grow at their own individual rate? So let's deal with those 2 issues.

The charts are based on solely breastfed infants!  Not formula fed, nor mixed fed.  They are based on a 15 year growth study of approximately 8500 exclusively breastfed infants (they had to be exclusively breastfed for 4 months to qualify) from Brazil, Ghana, India, Norway, Oman and the USA.  These countries were chosen since they differed culturally, ethnically and economically.  The study found that babies who are breastfed optimally grow in a very similar way no matter what their background.  The charts therefore show normal growth of an exclusively breastfed baby regardless of where they are born in the world, including Northern Ireland.

When a baby is born, they are expected to lose some weight in the following 3-4 days due to loss of water, and then weight should begin to increase.  A breastfed baby has usually regained birthweight by 2 weeks, and should then continue to gain weight rapidly in the first 3 months.  So what about individual variation?  Don't some babies grow more slowly?

Let's go back to think about pregnancy.  Remember the approx 12 week dating scan?  It is done at that age because a foetus grows at a pretty defined rate in the first trimester and within a small margin of error we are able to tell the age of the foetus.  After this time growth becomes slightly more variable and individual, however we still expect the women's uterus to grow and for measurements of her fundal height to increase.  We expect the baby to continue to grow.  If growth became static, much slower than normal, or dropped through centiles we would think there was an issue.  The same stands for newborn growth.

Growth in the 4th trimester
Just as weight is predictable and similar for most babies during early pregnancy, the first 3 months of infant life (the 4th trimester) is also similar across breastfed babies (providing breastfeeding is going well).  Weight gain may be more variable after 3 months (and that is when the comments about watching the baby, not the scales are absolutely appropriate) but in the early weeks weight gain should be quite predictable.  On average a full term, healthy breastfed baby who is optimally fed gains 8oz a week, with boys gaining slightly more than girls.  On average girls gain just under 1.2oz a day and boys gain just over 1.4oz a day. (Elson et al 1989).  Obviously this is an average, and babies will gain more and less than this and that is normal.  No one expects your baby to be exactly average.  None of us are.  All babies are expected to gain at least 4-5 Oz a week at a minimum however, and lower than 5oz will probably trigger closer monitoring from your Health Visitor or midwife.  This may seem harsh or worrying, but there are very good reasons for monitoring.  Weight gain is one of the ways that some uncommon medical conditions are discovered!  
On web forums you may be told there is no cause for concern unless the weight gain falls through 2 centiles.  That is true for a baby over 3 months, but it is not the case for a baby under this age.  A newborn who has static growth or falls through 1 centile should have feeding evaluated.

Causes of Low Weight Gain.
Possible uncommon causes of low weight gain may be a congenital illness in the baby, infections, metabolic conditions etc, but in the vast majority of cases low weight gain is caused by low milk intake.    Low milk intake can be caused by a variety of things.  Perhaps it is a poor latch meaning that the baby isn't transferring milk well.  Perhaps the mum has been poorly advised about foremilk and hindmilk and  hasn't been switching sides frequently enough to stimulate good supply.  Perhaps the baby has a tongue restriction meaning that even when the latch looks good, the milk transfer is poor.  Perhaps the mum hasn't been taught how to identify good feeding at the breast, so that even though the baby seems to be feeding frequently, he isn't actually drinking.  Perhaps the baby also sucks on a dummy and therefore is spending less time at the breast.  Perhaps the baby has allergies which are impacting weight gain.  Maybe the mum's supply needs extra help due to hormonal issues, like diabetes, thyroid problems, PCOS, birth control or an issue with birth such as retained placenta or haemorrhage.  Maybe a birth issue has affected the baby's ability to suck effectively, perhaps an instrumental birth for example.   It could be any number of things, but what's important to remember is that baby's milk intake and mum's supply are linked.  If a baby isn't drinking well, or not frequently enough and therefore isn't removing enough milk from the breast, then mum's supply is not stimulated and it drops.  If mum's milk supply is low it is more difficult for a baby to transfer milk from the breast.

If your young breastfed baby is gaining less than 4-5 Oz a week then weight gain does need to be looked at.  It may be that at this time, top-ups are suggested to you by a midwife or HV.  I think it's important to make this point very clear - what they are really suggesting at this point is trying to get more calories into your baby.  Increasing calorie intake will make clear whether the issue is simply one of not enough milk, or whether there is one of those uncommon reasons for your baby's low weight gain, such as illness.  Increasing milk intake usually does not have to mean top-ups of formula.  In most cases early intervention means that steps should be taken to increase breastmilk intake.  Each mum and baby dyad are individual and the right steps for them may vary and should be worked out between them and their HCP or lactation consultant (IBCLC) but here are some general steps to approach increasing gain in babies who have a need of intervention in the early weeks.

Make sure you understand what happens at the breast, and what you should be seeing.  
Your baby should begin a feed with fast fluttery type sucks.  Your baby is not transferring much milk at this stage but is stimulating the nerves in and around the nipple area which then sends a signal to "letdown" your milk.  During a letdown muscles around the milk producing areas literally squeeze your milk down the ducts to your baby.  You may feel this happen, but whether you feel it or not you can tell it's happening by watching your baby's sucking pattern.  The sucks will change to long slow sucks and swallows.  The rhythm becomes suck-swallow-suck-swallow.   This is when your baby starts to get good flow and volume of milk.  This should happen at every feed.  In the further info section at the bottom I have attached links to videos which will help you to identify good swallowing.  A letdown should happen at every feed.  If your baby is spending a long time at the breast and not drinking, he is not transferring milk well.  

A letdown lasts on average 1.5 mins (Ramsay 2004a).  Sucking will then change back to the fluttery sucking pattern for several minutes (maybe 5 mins) and then generally another letdown will be triggered.  It will be a longer time between subsequent letdowns (if any).  These are average amounts and figures from studies.  If your milk supply is already low however, you may find it takes longer to stimulate a letdown, the letdown may be shorter and there may be more time between letdowns.  If your baby is having slow weight gain, it generally doesn't help to have him on one breast for 45mins or longer in the hope of getting hind milk.  What may be happening is that your baby is getting minimal quantities of any milk whatsoever.  Swapping sides will increase milk intake.

Increase number of feeds
Young babies need to feed at least 8-12 times in 24 hours.  That means that a baby really needs to be feeding every 2 hrs during the day at a minimum.  If you are not feeding every 2 hrs, then offer 2 hrly, even every 90mins.  The neonatologist Nils Bergman says that the biologically normal frequency of feeds for a newborn is every 90 mins.  Many mothers still have a figure of 3-4 hrly feeds in mind, but it's important to remember that feeding every 2-3 hrs is normal until the baby is taking a significant amount of solids.  Consider how often you have eaten or drunk something today.  You may have had breakfast, perhaps mid morning cup of tea, maybe another class of water before lunch.  Perhaps you had another couple of cups of tea or water or a snack before dinner.  Adults actually "feed" at least as frequently as every 2-3 hrs as well in general, so it should be expected that a baby will do the same.

Increase milk intake in each feed
As above, make sure your baby is getting a good letdown at each feed.  Don't get caught up in the idea of foremilk and hindmilk to increase weight gain.  It is the volume of milk which is associated with weight gain, not the fat content.  Rather than sticking to one side for long periods, switching more often can help.  Where you need to increase weight gain quickly, particularly in a slightly older baby, what's often termed "switch nursing" can often help.  In switch nursing you begin on 1 breast to trigger the letdown.  Once the letdown is over, switch to the 2nd side to trigger a quick second letdown.  After it has slowed, return to the 1st side and let the baby remain on that side for as long as they are comfortable.  If your baby has been spending very long times at the breast with very little drinking this can substantially increase the amount of milk they take in at a feed.  It will also increase your supply.  A very small baby may not need to switch feed in this way, it may just be a matter of improving the latch and making sure that he feeds well from the breast at each feed.  Your lactation consultant will be able to work out the best strategy.

Work on your supply
If your baby has been slow to gain it is likely that you also have a low supply because the demand and supply arrangement isn't working optimally.  Switching sides frequently will help with your supply, but it may be that you will also need to express.  You can work out the best arrangement with your IBCLC or HCP but I often suggest power pumping.  The phrase power pumping as been used on the Internet for a few different strategies, but I prefer the strategy from IBCLC Cathy Watson Genna as I think it works well for mums who are feeding frequently and don't have a lot of time to sit and pump.  The details are in the further reading section.  The milk you express can be used as a "top up" while you are working at improving the milk intake at the breast.
Low weight gain in the early weeks has a knock on effect.  Sometimes the early weeks go by with weight gain which is low and just below normal range, but by the time he has reached 2-3 months and interventions are suggested mum's supply has been affected more definitely.  Milk supply is primarily set up in the first 5 weeks, and by the end of that time (assuming everything has gone to plan), a mother will be at full milk production.  A breastfed baby drinks roughly the same daily volume between 6 weeks and 6 months.  If you haven't reached full production by 5 weeks, it can be harder to reach full milk supply later.  It may require some extra support from galactagogues (foods, herbs or drugs which increase milk production) and support around expressing strategies.  For some, some short term supplementation of breastfeeding may even be needed until the baby moves on to solids.  This is why is it so important to identify and resolve any breastfeeding issues early.  It can be very difficult to confront the fact that your supply may be low, but with the right support and interventions at the right time, this can be turned around.

A word on silent reflux
In many cases babies with low weight gain also have a diagnosis of silent reflux.  The diagnosis is often made on symptoms such as arching at the breast and a crying unsettled baby much of the day.  It is important to note that arching at the breast and being unsettled are also signs of low milk intake.  Reflux may be a complex picture in many babies, but it does have a cause, and milk intake may be part of the solution.  Even with babies who have a picture of allergies (including blood in the stools), symptoms may be related to low milk intake.  Jack Newman, the Canadian paediatrician and IBCLC, has described cases in his practice where increasing milk supply and milk intake resolved the issue with blood in stool.

Getting Help
The steps to identify the problem, resolve it, increase milk intake and supply are logical, but this is where you can really benefit from good breastfeeding support.  A latch check is usually not sufficient as it is generally just looking at the shape of the baby's mouth at the breast.  A thorough breastfeeding assessment from a skilled professional, such as an IBCLC (International Board Certified Lactation Consultant) will look at the entire feeding picture and can start to tease out if milk transfer has been an issue.  The lactation consultant can work on a feeding strategy with you to increase gain and increase supply to improve feeding while still under the care of your HV and HCP team.
It is normal for babies to want to spend a lot of time at the breast in the early days and weeks, and it is ok for them to comfort at the breast.  No where is more comforting to a baby that the breast.  It is also important that they drink well however and that they drink well at least 8-12 times a day.  If your baby is not drinking/ getting letdowns during feeding talk to someone about the feeding pattern.  If your baby hasn't regained birthweight in the first 2-3 weeks, breastfeeding should be assessed.  If you have a low gaining baby diagnosed with silent reflux consider meeting with an IBCLC to look more closely at how breastfeeding is going.  
The first weeks are important for weight gain, but it's not just about the baby.  Weight gain/milk transfer is important for the mother too, and both must be considered together.  It's not just about the growth of your baby, it's also about your supply.  It impacts both of you.  Resolving issues early in the early days means that problems are usually quite quick to turn around and can ensure an easier, worry free breastfeeding experience for as long as you choose to feed.  

Further Reading

Video of feeding showing how to recognise swallowing -
Video of baby at breast, but not feeding well -

Increasing milk intake at a feed -

Switch Nursing / Increasing Milk supply through Nursing -

Power Pumping -

When supplements are needed -

Nils Bergman interview on normal frequency of newborn feeding -

Jack Newman comment on blood in stools and milk supply -

Info on Growth Charts

Find a lactation consultant
Book a consult with Mammae -
Ireland -

Friday, 4 December 2015

Breastfeeding, Reflux, Stomach Acid & Gut Bugs

A few weeks ago I wrote an article on reflux and breastfeeding, and the need to look for a cause for reflux in your breastfed baby.  This is a companion article to that one, looking at the role of stomach acid in our bodies.  It seems that reflux is so frequently diagnosed (and often misdiagnosed) and acid suppressing drugs are now so prevalent that acid itself is being seen as an issue by some mums.    I wanted to write a little about what stomach acid is, what is does and the relationship between breastfeeding, acid and our gut health.  If you haven't already read the previous blog, please do so as it looks at the NICE guidance regarding acid suppression treatment and root causes of reflux.

Stomach acid & digestion

I wanted to start with a brief overview of what happens in the stomach and the role of acid.  Our stomach fluid is comprised primarily of hydrochloric acid, produced by cells in the stomach lining.   If you remember your chemistry from school, neutral pH is  7, acid is lower than 7 and alkaline is higher. Our gastric fluid is very acidic, with a pH of 1.5-3.5.  Smelling, tasting and chewing food stimulates our stomach to secrete this acid in preparation for digestion.  Obviously babies don't get a chance to chew food and wait for acid to be secreted, but perhaps this is another design reason why a baby sucks for a short time before milk lets down?  Perhaps it facilitates this process?  

Acid is vital for protein digestion.  Once food reaches the stomach, the acid environment causes the proteins in the food to unfold.  The acid then activates an enzyme called Pepsin which breaks down the protein bonds (literally breaks the protein apart).  If stomach acid is suppressed the proteins can't be broken down and digested.  Any vitamins or minerals which are attached to proteins (e.g. B12) can't be extracted and therefore can't be absorbed.
The gloopy mix of food and stomach acid is called chyme.  Once the gloopy chyme reaches the correct acid pH level it triggers the valve at the bottom of the stomach (the pyloric sphincter valve) to open and empty the stomach contents into the intestine.  If stomach acid is suppressed chyme has to stay in the stomach for a longer time in order to reach the correct pH to open the sphincter valve.

Humans are a complex ecological environment, containing around 10 times as many bacterial cells as we have human cells, and having a balance of healthy bacteria is key to our health.  Eating/drinking is a route for infection causing bacteria to enter the body, but a robust acidic stomach environment kills off a lot of pathogenic bacteria and prevents it from getting into our intestines.  It's a first line of defence.  If acid is suppressed however, the stomach has limited capacity to kill any problem bacteria.  This fact that chyme sits in the stomach for longer means that not only is the bacteria not destroyed, it has a chance to grow in the stomach and ferment the chyme.  This fermentation process creates gas and pressure in the stomach, which needs to be released.  The pyloric sphincter (bottom of the stomach) is a one way valve, and it isn't going to open until the chyme is at the right pH, so the 2 way upper sphincter valve (the lower eosophageal sphincter or LES) opens and reflux occurs!  
In addition to this gas effect, the suppression of stomach acid can actually allow pathogenic bacteria to grow around the upper sphincter muscle.  This growth partially paralyses the sphincter, and without correct function - reflux occurs.  Yes you read that correctly - acid suppression causes reflux.  The listed common side effects of Omeprazole, for example ( a commonly prescribed drug for infant reflux) are:
  • Vomiting
  • Flatulence
  • Stomach pain
  • Constipation 
  • Diarrhea

Gut bacteria & the immune system

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The surface of the digestive system is covered by a vast number of bacteria.  I recently heard the digestive system being described as an area outside of the body, which is an interesting way to think of it.  Essentially we have a tube from our mouth to our anus which carries food and other substances from one end to the other.  Our "body" is on the other side of this tube wall, and therefore the tube or gut could be thought of as an outside area where we absorb nutrition into the body.  It's an interesting approach which helps us to picture bacteria covering the gut wall on the "outside" surface in the same way that our skin is covered in bacteria on that outside surface.  
Our gut wall is crammed (hopefully) with beneficial bacteria, and these bacteria help to synthesise immune system cells called lymphocytes which protect the body from invaders.  They also play a role in other immune responses in fighting viral infections.  It is estimated that 80-85% of the immune system is located in the gut wall.  If the gut bacteria biome is damaged the whole immune system is affected.  

Acid suppression means that pathogenic bacteria, which would normally be killed in the acid stomach, survive and pass into the intestines where they upset the bacterial balance.  This affects the immune system.  Studies have shown significantly increased risks of gastro-intestinal infection and of respiratory infection, including pneumonia in infants treated with acid suppressing drugs.

Another link between digestion and immune function is in allergies.  There is a well established link between asthma and reflux.  1 in 13 people in the UK now have asthma, and as early as the 1930s a study found that 80% of children with asthma had low stomach acid (Bray, GW 1931).  A recent  study ( Untersmayr & Jensen-Jerolim, 2008) looking at protein digestion and allergies found the following:

"The data reviewed here suggest that the immunologic or clinical outcome after the consumption of a digestion-sensitive dietary protein depends to a certain degree on the gastric digestive capacity. If the food protein is exposed to gastric enzymes during transit, protein cleavage takes place, inducing either oral tolerance or immune ignorance toward the ingested food protein. However, if proteins persist during the gastric transit because of impaired digestion, such as during acid-suppression treatment, IgE-mediated food allergy can be induced. Gastric digestion might also influence the extent of reactivity in already sensitized patients. Physiologic gastric proteolysis substantially decreases the allergenic capacity of ingested food proteins, whereas severe allergic reactions at much lower amounts of ingested food proteins could occur if digestion is impaired"

In other words, an acidic stomach environment promotes protein digestion and substantially decreases the potential of an allergic reaction.  Or putting it another way (since an acid environment is the normal physiology ), acid suppression inhibits protein digestion and substantially increases the potential of allergic reaction.  Look at how many children are diagnosed with both reflux and cows milk protein allergy/intolerance.  Which came first?  Is the CMPI causing the reflux, or is the reflux medication causing the CMPI?

A 2012 article from the Journal of the Amercian Medical Association discussing PPI drugs and asthma in children stated,

 "Given their potential adverse effects, these medications should thus be used with great restraint for treatment of GER/ GERD during childhood. The substantial increase in use of PPIs in children during the last decade is worrisome and unwarranted." (Martinez, 2012)

Breastfeeding & Stomach acid

Part of the way that Breastmilk has an effect on the development of the immune system is through its effect on the type of bacteria which colonise a baby's gut.  If I can just quote a couple of studies which highlight this: 

In The impact of Breastmilk on infant and child health, Oddy (2002) states:

"The commensal (normal, healthy) microbial flora of the gastrointestinal tract as well as respiratory microbial agents, stimulate the functional maturation of the immune system (Holt, Sly &Björkson 1997).... 
The microbiology of Breastmilk has a large impact on bowel development and gut microflora"

Likewise Wold & Adlerberth (2002) say :

"Breast-feeding is associated with protection from the following infections or infection-related conditions: gastroenteritis, upper and lower respiratory tract infection, acute otitis media, urinary tract infection, neonatal septicaemia and necrotizing enterocolitis. Some of the protective effects may derive from an altered mucosal colonization pattern in the breast-fed infant. "

There is a direct link between the pH of a baby's GI tract and how they are fed.  Although the intestine is much closer to neutral than the stomach, breastfed babies have a more acidic digestive environment than a formula fed baby due to the gut bacteria that colonises the gut.  In the first 6 weeks of life breastfed babies have a lower gut pH of approx 5.1-5.4 compared to a formula fed baby's lower gut pH of 5.9-7.3.  The 3rd most abundant component in Breast milk is HMOs (human milk oligosaccarides).  Oligosaccarides are specific carbohydrates which canot be digested by the baby.  They are purely there to feed bacteria - specific helpful bacteria!  They encourage the growth or lactobacillus and bifida bacteria.  Lactobacillus species produce lactic acid, and what does lactic acid do?  It lowers the pH of the intestinal environment, making digestion easier and also creating a healthy environment for those  bacterial strains to continue growing.  Acid suppression makes it harder for these bacteria to colonise the gut by changing the balance of bacteria and allowing pathogenic bacteria strains to reach and establish in the gut.

Acid is not the enemy.  We are designed to have an acidic environment in our stomach, and human and our healthy, helpful commensal bacteria evolved around an acid digestive environment.  

That brings me full circle back to the previous blog on looking at the root causes of reflux.  Mothers and babies deserve someone to look in a holistic way at reflux rather than prescribing drugs with far reaching effects without full discussion.  If you are struggling with reflux in your breastfed baby and would prefer to look at how altering breastfeeding might help, have a look at my previous blog and contact a board certified lactation consultant or a qualified breastfeeding counsellor to look at root causes.  

We should  think carefully before undoing some of protective effects that breastfeeding promotes in our babies.

Further Reading

Articles on Low Stomach Acid and reflux:

Bray GW. The hypochlorhydria of asthma in childhood. Q J Med 1931;24:181-97.

Untersmayr & Jensen-Jerolim.  The Role of protein digestibility and antacids on food allergy outcomes.  J Allergy Clin Immunol. 2008.Jun: 121(6): 1301-1310!po=38.7500

Martinez.  Children, Asthma, and Proton Pump Inhibitors Costs and Perils of Therapeutic Creep  JAMA January 25, 2012 - Vol 307, No. 4 p.406-407

Oddy, 2002 The impact of Breastmilk on infant and child health.

  • Wold & 
  • Adlerberth, 2002  
  • Breast Feeding and the Intestinal Microflora of the Infant — Implications for Protection Against Infectious Diseases 

    Acid Suppression and increased Risk of Pneumonia and GI infections -


    Sunday, 8 November 2015

    The importance of skilled breastfeeding support

    I've been thinking a lot about the importance of thorough breastfeeding support and how so many mums don't get the support they need.  Putting our baby to the breast to feed is a beautiful and simple act, but like so many things in nature, the deeper you look the more complexity you see.  Breastfeeding is actually a very complex interplay of a mother and baby, and if problems arise, having someone ask the right questions can make all the difference to helping you ease into an enjoyable breastfeeding experience.  A good breastfeeding assessment/consultation is not a "latch check".  It involves looking at the full picture of mum and baby to tease out exactly what is happening.  Without a wide view it is easy to misdiagnose an issue or to medicalise something which is actually normal or easy to resolve.

    To illustrate this I did some googling to see what internet sites list as symptoms for common issues which may arise in the early weeks.  This is what I found:

    Reflux Fast Letdown Tongue Tie Low Supply
    • Spitting Up
    • Slow Weight Gain OR
    • Fast Weight Gain
    • Fussy at the breast (back arching, bobbing on and off)
    • Frequent hiccups
    • Crying
    • Poor Sleep
    • Refusing the breast OR
    • Frequent feeding / comfort feeding
    • drawing legs up to tummy after feeds
    • coughing / wheezing
    • Frequent hiccups
    • Spitting Up
    • Slow Weight Gain OR
    • Fast Weight Gain
    • Fussy at the breast (back arching, bobbing on and off)
    • Noisy feeding (loud swallows / clicking)
    • Gagging 
    • Crying
    • Poor Sleep
    • Gassy
    • Green Stools
    • Refusing the breast OR
    • Frequent feeding / comfort feeding
    • Drawing legs up to tummy after feeds
    • Clamping down on the nipple
    • Spitting Up
    • Slow weight gain OR
    • Fast weight gain
    • Frequent feeding
    • Fussy at the breast (back arching, bobbing on and off)
    • Noisy feeding (loud swallows / clicking)
    • Gagging
    • Frequent hiccups
    • Crying
    • Poor Sleep
    • Gassy
    • Green stools
    • Opens mouth to attach but doesn’t, shakes head or bobs on and off before becoming frustrated
    • Clamping down on the breast to maintain latch
    • Slow weight gain
    • Frequent Feeding
    • Fussy at the breast (back arching, bobbing on and off)
    •  Crying

    These are by no means definitive lists, they are simply the most common symptoms I found listed for these conditions when I googled.  Pretty similar symptoms arent they?  A few differences, but in general they are the same symptoms.

    So what is a mum to think if her baby is arching at the breast?  She feels something is wrong and she searches the web and reflux pops up.  It fits her symptoms, she sees her Dr, and they diagnose reflux, with the medication that comes with that.  The problem is that the website didn't take a case history.  It didn't know that due to poor advice the mum had been feeding on one side for too long which had resulted in poor milk supply and baby was arching due to hunger and frustration.  Worse still, perhaps that mother found the fast letdown page and began block feeding to correct her "oversupply" and so reduced her supply further.

    Perhaps another mum searching for arching at the breast finds a tongue tie page, looks in her baby's mouth and sees a frenulum and goes to a provider to get it snipped.  That provider should be doing a functional assessment, but often that doesn't happen, so lets say the provider diagnoses on appearance and snips the frenulum.  Mum goes home but the problem doesnt resolve - becuase the problem never was tongue tie.  Maybe the problem actually was that the mum has been expressing every day on top of exclusive feeding and has a fast letdown due to the large supply, or maybe the problem was that her difficult forceps birth meant that her baby had some muscle restrictions which made it difficult for him to cope with a letdown.

    Each of the symptoms above has mutliple possible causes.  Fussy feeding / back arching can be fast flow / slow flow / uncomfortable positioning / wanting to swap sides more frequently / bottle preference / needing to burp / needing to pee (you'd be surprised how peeing can affect breastfeeding behaviour).  Breastfeeding mums who practice EC (Elimination Communication) often use bobbing on and off the breast as a sign that baby is asking to be pottied!   Colicky crying can be due to a growth spurt week as much as any of the other things above, and crying when laid down may simply be that the baby isn't in arms.  Babies need to be in your arms.  Spitting up also has multiple causes.

    The issue with these lists on websites is that they only focus on symptoms and only on one side of the equation.  As The saying goes:  "There is no baby.  there is a baby and someone".  A breastfeeding issue cannot address only the baby.  An assessment must also consider the mum.  A mother's supply is only as good as the stimulation she gets from her baby (or from expressing), and likewise a baby's latch can be dependent on the mother's positioning.  Whether mum is cue feeding, feeding on a schedule or using a dummy can change baby's intake.  Age of baby, feeding from one side or both, experience during pregnancy and birth all can play a role.  

    A good breastfeeding assessment is not a latch check.  Checking a latch is like taking a photo.  It gives you a snapshot into what it looks like right at that moment.  Observing a feed, by contrast is a video.  Latches can change throughout a feed.  A baby may not be latching well to a full breast, but be comfortable on an emptier breast or vice versa.  A baby may change the latch at letdown.  They may latch well initially but change to a shallower latch within a few sucks.

    A breastfeeding assessment should involve listening to your story, your history of breastfeeding, how the birth went, how your baby has fed from birth till now, and how your experience has been (including any pain and trauma - the latch is not fine if you have trauma!).   It should look at the pattern of weight gain.  The IBCLC (board certified lactation consultant) or breastfeeding counsellor should observe a feed.  This doesn't just mean looking at the mouth, nose and chin at the breast.  It takes into account the entire positioning of mum and baby: is the mother comfortable and relaxed or are her shoulders tense and hunched (this affects shape of breast)?  Is she bringing baby to her breast or bring her breast to the baby?  Is the baby nicely aligned along head, back and hips?  Is the baby's head tilted back and his body in contact with mum?  If you see an IBCLC, a consultation may involve an oral assessment of baby to check any signs of tongue restriction.  It may involve a structure and function assessment to check for muscle tension in the body.
    A full assessment/consultation should address your concerns and help you to create a plan to meet what you want to achieve.  It should involve follow up as you work through your plan.

    Too many mothers who are in pain, or are concerned with some aspect of feeding simply have their latch checked and are told it is fine.  A snapshot photo in a world of 3D IMAX film.  A latch check cannot distinguish the reason for fussy feeding.  Skilled breastfeeding support is so much more.  If you are concerned about any aspect of feeding and are being told your latch is fine, please look elsewhere.  Look for an IBCLC or an accredited breastfeeding counsellor who will look at the whole picture of you and your baby.  Simply being told your latch is fine is not enough.  You should be listened to, feel cared for and be taken seriously.  Your breastfeeding supporter should inform and empower you with the information that you need.  Seek out skilled support that truely explores your concerns and meets you and your baby's needs.  

    Sunday, 11 October 2015

    A Tongue Restriction Isn't Always a Tongue Tie

    A few weeks ago I wrote a blog about the differences between a tongue frenulum and a tongue tie.  This is a follow on from that blog so If you haven't read it already I encourage you to read it first.  The previous blog discussed what a tongue restriction is, and how it affects tongue function.  
    This blog will look at the role of bodywork and explain why a tongue restriction isn't always down to a tight frenulum.  Other factors can be involved and many IBCLCs (International Board Certified Lactation Consultants) are now starting to question whether too many babies are having surgery, and if this is the correct intervention.

    Whereas an anterior frenulum is normally quite visible and frenotomy (the procedure to divide the frenulum) has been done for a very long time, the concept of the posterior tie is more recent.  Commonly posterior ties are diagnosed by pushing back on the floor of the mouth on the underside of the tongue.  

    Alison Hazelbaker IBCLC recently weighed in on the discussion on her blog.  If you aren't aware of who Hazelbaker is, she is a important name in the world of tongue restrictions.  She is the creator of the ATLFF tool which is used to functionally assess a baby's tongue and is the author of probably the most complete book on tongue-tie ("Tongue-Tie Morphogenesis, Impact, Assessment and Treatment").  As well as being a lactation consultant, Hazelbaker is a craniosacral therapist, so she understands both the tongue movement needed for breastfeeding and the effect of bodywork.  In her blog, she said, 

    "To my knowledge, no research has ever been done to verify that a restriction at the 
    tongue-base that presents as a thick, shiny string under the mucosa is an actual 
    tongue-tie. My experience as a structural therapist, and in the experience of 
    many a bodyworker throughout the world, has shown that this type of 
     tongue and/or mouth floor restriction resolves with simple bodywork; 
    that the actual cause of this type of restriction is an acquired soft tissue 
    strain pattern due to intrauterine or birth events."

    Hazelbaker clearly states that in her belief tongue restriction can be caused by damage or strain to soft tissue (tendons, ligaments, muscles, nerves etc) either in the uterus or during birth, and can be resolved through bodywork - not surgery.  This is what I wanted to explore a little in this blog, because it is something I don't see discussed regularly on local forums.

    Soft Tissue Tongue Restriction
    So what is Hazelbaker talking about when she mentions soft tissue strain, and how could it affect a baby's tongue?  This is where we need to dip into a bit of anatomy, which I will try to keep as brief as possible to prevent this blog becoming 30 pages long!  Stick with me - it will become clear.

    Image from under a creative commons license
    A baby's complex suck-swallow-breathe sequence requires the function of 6 cranial nerves, 6 cervical nerves and a few thoracic nerves coordinating 31 muscles in the lips, cheeks, tongue, jaw, chin, soft palate etc.  That's a lot of soft tissue! 

    This image shows some of the muscles of the tongue.  Muscles are usually labelled based on where they attach.  Glossus refers to the tongue, so tongue muscles will have glossus in their name. Look at where some of the tongue muscles attach. The muscle labelled Styloglossus attaches high up on the jaw bone close to the ear.  The large muscle below that labelled Hyoglossus attaches the tongue down to a thin bone in the neck called the Hyoid. The genioglossus attaches the tongue to the chin. Note how far forward the Hyoglossus and genioglossus muscles attach to the underside of the tongue.

    Image from under a creative commons license
    The Hyoid is more clear in this image of the neck. You can see how multiple muscles from the head and face attach to it above and then if you look at the underside of the bone you can see muscles attaching to the shoulder and the sternum.  

    The anatomy pages (where these images are from) describes the hyoid bone as:
    " a horseshoe-shaped bone that functions as a solid foundation on which the tongue can move"

    The hyoid is a little unusual in that it doesn't attach to any other bones, but instead floats, held in position by the muscles above and below.  So, we have a bone which is the foundation of the tongue which is held in position by muscles above and muscles below.  Are you starting to see how a strain on a muscle attached to the hyoid could affect the tongue?  

    The uterus is a pretty tight place at the end of a pregnancy and a baby who remains in one position for some time can be "moulded" into specific positions.  That might cause something like a baby's feet to be turned inwards or it could be that the baby's head is leaning to the side a little for example.  A baby who spends their final few weeks with their head tilted can have a slight tightness and shortening of muscles on one side of the neck compared to the other.  That makes sense doesn't it?  If we sleep at a funny angle for only a few hours we can feel the muscle tension when we wake.  So look at the neck image again and apply it to a baby who has their head tilted slightly to the side at birth.  Think of how that might affect the hyoid and the tongue.  Perhaps grab yourself a glass of water and drink with your head straight and then drink with your head tilted, to get an idea of how it affects the ability to "latch" to your cup and to drink.  If I tilt and drink I feel a lot of tension in my upper lip.  I have to tighten my lips around the cup rim in order to manage the flow of liquid.  Mmm... tightening and using lips to maintain latch - isnt that what a tongue restricted baby often does?  That tightening and using lips to grasp the breast causes pain and friction for mum and baby (nipple trauma and sucking blisters for baby) and often poor milk transfer.  When we pour from a glass we manage the flow of liquid by the tilt of the glass. I imagine if the water started gushing (like during a letdown) I would struggle to manage it.  All typical behaviours with tongue tied babies.

    A 2008 study (Rubie, Griffet, Caci, Bérard, El Hayek, Boutté) of 1001 babies found that 10.7% of babies that they studied had Moulded Baby Syndrome.  Moulded Baby Syndrome was classified as any of the following:  
    • plagiocephaly (where the skull may be flattened in one area or asymmetrical ) 
    • torticollis, (head tilted to the side and baby often looking in the other direction)
    • congenital scoliosis (a curving of the spine - this can be mild and not very noticeable)
    • pelvic obliquity (misalignment of pelvis)
    • adduction contracture of a hip  (misalignment of hips)
    • malpositions of the knees or feet
    An assymetrical skull can change the tension of one side of the tongue compared to the other by having assymetrical attachment points for the muscles.  A slight curving of the cervical spine could have an effect much like tilting your head to the side, where the muscle tension on the hyoid is assymetrical.  Assymetry of the pelvis and hips results in assymetrical tension on the spine, shoulders, neck and head.  All of which can affect the latch.

    The study found that moulding was 6 times more likely after an instrumental birth, 2.7 times more likely if baby was a breech presentation, 10 times more likely if there was low amniotic fluid, 1.98 times more likely in boys and 1.65 times more likely in a preterm birth.  The instrumental birth figure jumps straight out.  6 times more likely!  Think of the process of what happens during an instrumental birth compared to a normal birth.  A baby is designed to be pushed through the birth canal.  The bones of the head should mould to allow delivery and then over a short period after birth, they readjust position.  Vaccum, forceps and often also ceseareans pull a baby out by the head.  Is it surprising that the head and neck might feel strain?  Think of how those tongue muscles attach high on the jaw where forceps may press, or how the abnormal moulding caused by the suction of a vacuum may change the position of skull bones. A cesarean where a baby is lifted out by the head creates pressure to the base of the skull and the neck which can also compress nerves and muscles in the neck, including those associated with the hyoid.

    So, how much of an issue could that be here in Northern Ireland?  Well, the birth statistics for Northern Ireland in 2014 show that 12.9% of deliveries were assisted by instruments and 29.1% were cesarean deliveries.  Moulding isn't just an issue with assisted deliveries.  Even very fast or very slow unassisted vaginal births can cause abnormal moulding and the other figure to consider is the induction rate.  The induction rate was 33.4%.  Induced contractions are not the same as natural contractions.  They do not build in the same way and do not have the same pattern.  What effect do inductions have on normal/abnormal moulding during birth?  Perhaps it isn't surprising that the study found so many babies with Moulded Baby Syndrome.  Perhaps it also isnt surprising that there is a debate over how many babies are tongue tied, and whether the rate is rising.  We don't have figures for Northern Ireland, but the instrumental delivery rate in England in 1953 was 3.7%, and in 2013 it was 12.7% so the instrumental birth rate is certainly rising.

    Clearly tongue ties due to a tight frenulum (an anatomical tongue tie) exist, and I discussed them more fully in the previous blog.  The gene associated with tongue-tie has been identified and for these babies, a frenotomy (the surgery to divide the frenulum) can save a breastfeeding relationship as well as have lifelong impacts on the oral and facial development of the child.  Locally I think there is plenty of awareness on forums about the option of frenotomy.  Not all tongue restrictions are due to anatomical reasons however.  Some tongue restrictions can be due to other structural tensions and can be resolved by releasing those tensions.  A baby may have a normal stretchy mucosal frenulum, but also have structural muscle tension making the frenulum seem more restrictive than it is.  A baby who is having breastfeeding difficulties may have the anterior frenulum blamed, only to later find that a frenotomy of that frenulum makes little difference.

    In most cases abnormal moulding or slight torticollis resolves itself over time, and so for most dyads, breastfeeding difficulties caused by this also resolve with good support.  The study discussed above found that 77% of plagiocephaly and torticollis were resolved within 8 weeks with parental interventions like careful positioning of babies.  Tummy Time, for example can be a very helpful breastfeeding intervention as it mobilises the throat and tongue and it's interesting that laid back breastfeeding (which many people find is a very easy position with a newborn) is a tummy time position.  Perhaps this natural resolution of tensions is where the idea of a tongue tie stretching over time came from - from babies whose tongues had structural restrictions (rather than anatomical) which naturally resolved.

    For some babies however, tensions are more persistent, as the remaining 23% in the study show.  Even with those that will resolve in the first 2 months, there is a breastfeeding mother and a baby who may struggle with painful feeding,  mastitis and poor weight gain during that time.  For some dyads, waiting for these structural issues to resolve is not a  option and they need help quickly.  For those babies, bodywork can be helpful.  By the term bodywork, I mean gentle manual therapies which release soft tissue restrictions, such as cranial osteopathy, craniosacral therapy or paediatric chiropractic.  Many IBCLCs who work extensively with tongue-tie recommend bodywork for babies with a tongue restriction and then later reassessment of tongue function before referring for a frenotomy, as the bodywork may resolve the restriction.  Even if it doesn't fully resolve the restriction some practitioners feel it makes visualisation of the frenulum easier if a frenotomy is needed.

    Earlier this year I had craniosacral therapy for the first time.  I had read repeatedly about bodywork and tongue restriction, and wanted to understand it personally.  I had a lot of feeding issues as a baby and had known for many years that I had an incorrect tongue posture and swallow.  When we swallow, the tongue should press against the roof of the mouth and there should be a backward wave.  Tongue tied babies frequently push their tongue forward to swallow (tongue thrusting), as I did.

    Please note the copyright on this blog applies to this photo
    This was my tongue before and after 1 session of craniosacral therapy.  Look at the difference in elevation of the mid and posterior tongue.  In one session my tongue function changed, my posture changed, I breathed more easily when I slept, amongst other things.  A tongue tied baby who had this difference in elevation of the mid tongue could have a vast improvement in breastfeeding without any division of the frenulum.

    Tongue tie care in Northern Ireland is very inconsistent and perhaps some of this blog and the previous tongue tie blog explains why locally mothers and babies have such different results from having a frenulum divided.  Some mothers talk about how a "quick snip" resolved all their problems, others found that it didn't help, or maybe made things worse.  Some dyads are referred for surgery (and frenotomy is a surgical intervention) without a proper breastfeeding assessment and with limited, if any follow up afterwards.  Most babies do not have a functional tongue assessment.  Some mothers are given information around bodywork whereas others don't get any information about this.  Some are given limited information about the surgery and others have a full care package where a lactation consultant works with a surgeon, consulting together, with risks and possible outcomes fully discussed.  Some families travel a considerable distance for this kind of care while others don't know it exists.  In each situation is a mother and a baby who are having some kind of feeding problems and usually a mother who is scared and worried about the thought of someone putting scissors in their tiny baby's mouth. 

    If you are having breastfeeding problems and are concerned about whether a tongue restrictions part of the issue, contact a lactation consultant (IBCLC) or accredited breastfeeding counsellor who can help you research all the options.  The first stage in any breastfeeding support should be looking at ways to optimise latch and milk transfer, but it should also involve a thorough history of factors in pregnancy and the birth.  It's important to remember that it's the minority of babies who have tongue restrictions and the vast majority of breastfeeding issues are related to other factors like latch / flow / positioning / frequency of feeds etc.  If a suck issue is suspected however, a functional tongue assessment should be done.  At present this needs to be done by an IBCLC (International Board Certified Lactation Consultant) or an appropriately trained HCP (healthcare professional).  If the tongue is restricted the family should be provided with all the options that can help.  Any subtle structural assymmetries of the head and body should be considered and the options provided to the family, including bodywork.  If the parents decide to have a frenotomy, risks and benefits and follow up care should be discussed.  Tongue tie division (frenotomy) is a surgical procedure.  It may be low risk but a baby experiences much of the world through their mouth and we should be cautious about interventions if they are not needed, and we should take as much care as possible and provide relevant information if they are needed.  

    Look for a breastfeeding professional who will look at the whole picture of you and your baby.  A quick snip isnt always the answer to a tongue restriction.

    Further Reading & References

    Tongue Tie
    Alison Hazelbaker. 2010.  Tongue-Tie Morphogenesis, Impact, Assessment and Treatment, Aidan and Eva Press
    ABM (Academy of Breastfeeding Medicine) Protocol -
    Video of Functional Assessment of the Tongue -

    Anatomy of the Tongue, Neck and Head
    Video of Tongue Muscles & Hyoid Bone -

    Studies referenced above

    BodyWork & Breastfeeding