Wednesday, 29 April 2015

My baby is always hungry - maybe I don't have enough milk?

This is the last blog in our series about why mums in Northern Ireland give up breastfeeding within the first week of birth.  Feeling like she doesn't have enough milk is the reason that 17% of mums give up during that time, and this worry comes up again and again over the early weeks.  In most cases this is just due to our lack of understanding about normal baby behaviour.

Supply & Demand

As mums, our bodies are designed to produce milk.  We begin to produce colostrum as early as week 16 of pregnancy.  Colostrum is produced in small quantities - perfect for our small babies.  A newborn's stomach capacity is only around a teaspoon, so it makes perfect sense that we should produce small quantities during pregnancy (so that it is ready as soon as your baby is born), and for the first few days.

After we birth our baby and placenta, progesterone levels in the body drastically drop.  This drop triggers the onset of larger volume milk production within a few days.  This is hormonally controlled.  However you plan on feeding your baby, increased milk production will begin within a few days of birth and your breasts will fill with milk for your baby.  Along with this change comes a change from milk production being hormonally controlled to being controlled by milk removal.  The more milk your baby drinks, the more milk you will produce and as long as you feed your baby on cue you will make as much as your baby needs.

How Culture undermines us

The modern world is a difficult place for babies.  Our babies are born incredibly immature, with brains only 25% of adult size (this is proportionally much smaller than other primates).  Our babies have basic reflexes for survival, but are reliant on mum's body to provide a lot of their nervous system organisation and stability.  The neonatologist Nils Bergman believes that a baby should be in continuous contact with mum for the first 8 weeks.  When not in contact with mum his research shows that a baby becomes stressed, and his temperature and heart rate drops.  Babies are designed to be held on mum's body, in her arms or in a sling.  This is a lot easier and more natural than it may initially sound.

Then comes the specificity of human milk.  Depending on the care that their infant needs, mammals can be divided into 4 main groups and these groupings can be seen reflected in their milk.  These groups are:
  • Cache mammals e.g. Rabbit - mother goes out to eat and returns to the nest every 12 hrs.  Milk high in fat and protein to sustain the infants for this period
  • Nest mammals e.g. Dog/cat - infant is relatively immature and needs to be with the litter.  Mum returns to feed 4hrly approximately.  Milk lower in fat and protein
  • Follow mammals e.g. Cow - the infant is capable of following the mother shortly after birth and feeds approximately 2hrly.  Milk is lower in fat and protein
  • Carry mammals e.g. Primates /Humans - these are the most immature mammals.  Designed to be carried on mum's body and fed very frequently.  This milk is lowest in fat and protein as baby feeds frequently and  is high in lactose to help with rapid brain growth.  

Here lies the problem.  It is a problem of expectations.  If you are pregnant now have you considered that your baby will need to be held and fed so frequently?  For those of you who have their babies in their arms already - has the reality been anything like your expectations?  If we're honest I think most of us get a huge shock.  In this society our expectations of a baby are that they feed 3 hrly, and will sleep in between, or be alert and quiet so that mum can get on with other things.  This is not reality for most mums and young babies.  Young babies need to feed frequently.  They have tiny tummies, they are growing faster than they will ever grow again.  They are learning to feed and use jaw and tongue muscles that have never been used as intensively before.  Using new muscles is tiring so sometimes our babies need to feed a little and then rest, feed and rest.  That can make feeding a little and often process.  Think of it as a Couch to 5K for your baby.  In a few weeks his jaw and tongue muscles will become stronger and it is the practice and strengthening of the muscles used during breastfeeding that promotes normal facial development and means that he will be less likely to need orthodontics later.

Human milk is digested easily and quickly (a good thing for the digestive system and for growth of baby) and it is common for many breastfeed babies to feed every 90mins.  In fact Nils Bergman believes from his research that feeding every 90 minutes is normal and optimal for a newborn.  For a mum who expects 3 hrly feeding this can be a total shock, and baby seeming to be hungry again so quickly can leave her questioning whether she has enough milk.  This is truely a case of Stone Age babies in a Space Age society which has lost contact with basic needs of our babies.  Sometimes I wonder why we have such different ideas for our young than for ourselves.  It has been suggested that adults eat or drink every 90 mins - a glass of water, our ubiquitous wee cups of tea, a piece of toast here and there, maybe a biscuit or a bag or crisps between meals.  We are trying to maintain weight usually - or many of us trying to lose weight.  Of course a baby who is trying to double his weight in the first 6 months needs to eat more frequently!

Where did our unrealistic expectations come from?
Partly they have come through older childrearing recommendations.  In our parents and grandparents generations it was recommended to feed on schedules, to time breastfeeds. These recommendations came at a time when neurological development simply wasn't known or understood, and neither was milk production.  We know better now - and when we know better, we do better for ourselves and for our babies!
Even more recent recommendations can be confusing.  You may have been told in your antenatal class that babies feed 8-12 times a day.  I think this is probably where the idea of a breastfed baby feeding 2-3 hrly comes from.  There are 2 confusing issues that I see for mums being given this information:
  1. The baby friendly info suggests a baby should feed 8-12 times a day.  This often gets translated as telling you that you should feed your baby 3hrly, but that is not what the recommendation is saying. Think about the purpose of this recommendation.  The Baby Friendly Initiative is there for our healthcare professionals in order to make sure that our babies grow and thrive.  It is saying that they need to ensure that a baby feeds at least 8-12 times a day.  It says a baby should feed more than 8 times a day.  8 times is a minimum!  It is not saying you should not feed more than 12 times.  It is saying you should feed no less than 8-12 times.  In the early days helping baby to start gaining weight is key and so putting baby to the breast early and often is important.  A baby feeding 12 times a day is normal!  It is not an indication of low supply. 
  2. Babies do not feed in a defined way in regular intervals.  Do any of us?  Do you eat at exactly the same times as your friend/partner?  Do you eat the same amounts and take the same time over a meal?  What constitutes a feed anyway?  A baby may feed for a  little and then fall asleep for 20 minutes, then wake and begin rooting again.  Is that a 2nd feed or is that the same feed?  What about when baby seems to feed for a couple of hours - feeding and resting, feeding and resting?  Is that one feed of 2 hrs or was it more than one?  When does one feed end and another start?  For most newborns feeding, winding, nappy changing and feeding again can seem like it is a continual process.  Then there are the babies who feed really frequently during the day and take a longer stretch at night.  The idea of counting 8-12 feeds is not only almost impossible, it is stress provoking for mums.  If there is a figure in your head, it is extremely hard not to either try to fit that figure or to worry about not fitting that figure.  

The easiest way to transition into a stress free breastfeeding relationship is to follow your baby and put him to the breast as often as he cues.  It is also just as helpful to put your baby to the breast any time you feel your breasts full to relieve any discomfort.  By responding to your baby rather than the clock or a feed counter you ensure a healthy milk supply and a happy content baby.  That means you can enjoy your frequent nursings and really feel the joy of responding to your baby's needs and seeing him grow and be nourished at your breast.

Signs that everything is on track.  

Having a new baby can be an incredible shock, particularly a first baby.  A newborn needs us intensely.  He needs to feed very frequently, and that often brings the comment from others, "Is he feeding again? He must be hungry".  Even when we have all the research though, these comments can plant the little seed of doubt in a new mum. 

Some mums offer a bottle of expressed milk when doubt creeps in and then become disappointed when they find that their baby drinks a bottle after being at the breast.  Sometimes this is mistakenly seen as proof that their baby is still hungry and not getting enough at the breast.  The bottle feeding position that we commonly see is baby lying back and the bottle pointing down into his mouth.  In this position the bottle drips milk constantly, even a newborn teat.  The baby cannot stop the flow.  As milk hits the back of the baby's throat it triggers the swallow reflex.  The baby has to drink.  It doesn't mean he is still hungry.

Some mums express milk and then worry when they don't get the amount they expected.  Again this is not any indication of your supply.  Pumps do not work like a baby and they never remove as much milk as a baby.  The way we respond to plastic and electric is very different to our hormonal response to our baby.

Some mums offer formula and if their baby seems to go longer between feeds they take this as an indication of an issue with their milk.  Remember that formula is made from the milk of a follow mammal.  The protein level is higher.  This is appropriate for a calf who needs to double weight gain in 40 days but not for a human who needs to concentrate on brain development and slower physical growth.  This is not an indication of a milk supply issue, it is an indication that formula is harder to digest and that the baby's behaviour has become abnormal to deal with it.  In effect baby shuts down in order to divert energy to digestion.   It's like falling asleep after a massive Turkey and ham Christmas dinner - which isn't something you'd recommend eating every day, and baby is missing all that more alert learning time!

When in doubt, look at the signs of milk intake.  Does your baby come off the breast happy and content?  Are you seeing enough wet and dirty nappies?  Finally the absolute sure sign - is your baby growing and gaining weight?  If weight gain is an issue look for good breastfeeding support to turn it around.  If you are seeing these signs then you can reassure yourself that everything is going ok, and these frequent feeds will space out as your baby matures.

Trust your baby and trust your body.  It is ok for your baby to feed this frequently in the early days.  It won't always be this way.  As your baby grows and matures he will start taking more defined feeds with space between them - more like the cultural expectations set us up for.  In the very early weeks most babies spend much of their time at home, feeding, winding, pooping and growing.  Right now just relax and melt into those feeds.  Enjoy your baby at your Breast and trust your body.  Your body grew your baby from a single cell into a beautiful bundle of joy.  It can continue to provide everything your baby needs.  

Further Reading

Wednesday, 22 April 2015

It Hurts! Moving towards Comfortable Breastfeeding

The next blog in our series looking at the first week is on Sore Nipples /Painful Breastfeeding.  The 2010 UK Infant Feeding Survey lists "having painful breasts or nipples" as the reason that 22% of women in Northern Ireland who start breastfeeding have stopped within the first week.  There's a lot of conflicting information that reaches pregnant mums around this issue and I have heard many pregnant mums here in NI say they have heard that breastfeeding is painful.  Is this surprising when 22% of their friends /family who started breastfeeding stop for that reason?  Despite this, antenatal literature and breastfeeding support sites commonly state that breastfeeding should never be painful, and if it is something is wrong.  So how does this set our expectations?

What is the reality?
Antenatal educators walk a very fine line in trying to prepare mums with accurate expectations, and yet trying to give very positive information.  They are trying to cater to all women, and different women want different information.  Some want to know everything so they can be prepared for all possibilities, and some would rather just deal with any obstacles as they arise.  Often breastfeeding educators often don't want to say anything negative at all, in case they discourage women who are 'on the fence' about how to feed their babies.  The fact is that those women are hearing information from society at large though.  I think on the whole, I hear more mums say they wish they had known more about what to expect so I am going to try to be as honest as possible on the early days.

When a baby is latched on well, mum's nipple is in a part of the mouth known as "the comfort zone".  The areola and breast underneath mum's nipple is within baby's mouth and her nipple is drawn far back towards his soft palate.   When against the soft palate mum's nipple is surrounded by soft tissues and feeding is comfortable and painless.  In order to reach the comfort zone, mum's nipple is stretched quite far into her baby's mouth.  In fact her nipple stretches to over twice its normal length.  

Most new breastfeeding mums do experience some pain in the first few days.  Even with what looks like a perfect latch many new mums do experience pain.  I have never found anything completely definitive on the cause, but I favour a suggestion that it may be due to this stretching of the nipple.  Most of us have never had our nipples stretched to that degree prior to breastfeeding, and it requires the ligaments behind the nipple to stretch.  If we stretched the ligaments of any other part of our body to twice their normal length we would expect to feel it!  Why should a nipple be different?  The absolute key point to this is that it happens in the early days only.  Most new breastfeeding mums experience some pain in the first DAYS.  This pain is only when baby latches and draws the nipple in.  It lasts a few seconds.  I will say that again - it lasts a few seconds within the first few days!  It should not last for the duration of the feed, and within a few days (for most it is less than a week) the latch pain is gone and breastfeeding should be entirely painless from start to finish.  Perhaps the ligaments have loosened a little by this point.
Some sources suggest the pain is due to the milk ducts being used for the first time, and the reason that the pain disappears after a few seconds is because the milk begins to flow more quickly.  

If the pain is lasting more than 30 seconds into a feed then it is likely that your nipple is not in the comfort zone and the latch should be adjusted.  Some breastfeeding support professionals will suggest that you unlatch and relatch at this point.  Other professionals suggest you should try to adjust baby's latch mid-feed in order to avoid the latch pain another time. (see the links at the end of the blog).  Whichever way you decide to approach it, do not continue through a feed with a painful latch.  Don't be tempted to think, "well, it's a bit uncomfortable but it will probably be ok".  It should be painless after the initial latch - entirely painless.  If it is uncomfortable it is likely that the latch is not deep enough.  That means your nipple may be compressed against the hard palate of your baby's mouth rather than the soft palate, and that actually causes trauma - grazes and cracks.  Grazes and cracks are common in the early days but can be avoided entirely with a good latch. Everything comes back to the latch.  In the comfort zone your nipple is safe, and without any compression or friction any grazes or cracks heal incredibly quickly.

Can you do something to prepare your nipples before giving birth?
Years ago women were advised to "toughen up" their nipples before birth, with weird suggestions like using methylated spirits, or brushing the nipples.  Ouch!  I can kinda see where these ideas came from, but nipples don't get tougher during breastfeeding!  They perhaps get more stretchy, but not tougher.  No preparation is needed.  Just as no preparation is needed for your cervix to dilate or your perineum to stretch for you to birth your baby, no preparation is needed for your nipples.  

Perhaps we should consider birth as a process rather than a event that ends when a baby is born and the cord cut.  Birth is not just about a baby.  It's also about the birth of a mother and it can help to think of her birth like a contraction - with a building stage, a peak and an easing off.  The build up may have a period of Braxton hicks or pre labour etc, reaching a peak where she labours and birthes her baby.  The easing off period involves after pains of her uterus contracting and the beginning of breastfeeding.   Mums who choose not to breastfeed still produce milk in the early days, and without breastfeeding to remove the milk they feel the pain and discomfort of engorgment which lasts throughout the day, rather than for a few seconds at certain times of day.  For those who do breastfeed, the afterpains of both the uterus and nipples ease and resolve within days and the breastfeeding mother has been born! 

When pain is not normal
I do want to emphasis is what is normal and to be expected, and what requires help.  Initial latching pain/discomfort is normal.  It should last less than 30 seconds in any feed and be gone completely in a few days just as the uterus afterpains are.  Just as those uterus afterpains can be managed, so can the latch.  Some mums will use painkillers, and some will use their labour breathing techniques.  

If pain is lasting longer than 30 seconds, or is not improving after the first week this is not normal and suggests the latch could be adjusted.  Cracks and grazes are not normal and need treated; care also needs to be taken to adjust the latch.  Any pain between feeds, pain within the breast, redness or feeling of heat in the breast is not normal and needs assessed.  Your midwives (hospital or community) can help you with the latch and with information around any adjustments or treatment.  You can also contact your local breastfeeding support groups who will have a trained breastfeeding counsellor /lactation consultant who can support you with latch and treatment information.  

How will I know if the latch is ok?.
Getting a good latch is the key to easy breastfeeding.  There are lots of articles online and in print about how you can assess a good latch, like your Off To A Good Start booklet (for NI readers).  They summarise points like these - there should be more areola visible above the nipple than below, baby's mouth should be wide and lips flanged, baby's chin should be against the breast and his nose should be off the breast.  Those are good guidelines to check your latch against.  Ultimately though, you will know that you have a good latch if feeding is comfortable after the first few seconds.  The previous blog talks about how to use your instinctive reflexes to help get a good latch right from the start.  

Using the biolgical feeding position will help enormously.  If you choose not to use this position and are holding your baby across your chest remember to support your baby's neck and shoulders rather than holding his head.  If you hold his head he is unable to tilt his head back and get a wide gape.  Pregnant mums in NI have seen a lot of bottle feeding, but not so much breastfeeding.  Latching to a breast is different than latching to a bottle.  Don't be tempted to treat your breast as a bottle and to place your nipple in your baby's mouth.  Line up your baby's nose to your nipple keeping his chin into your breast.  It will look like he can't reach your nipple with his mouth, but he will!  In this position he can tilt his head back and reach forward to get a nice deep latch.  He needs to be in this position to get plenty of breast below the nipple into his mouth.  This is the key to a deep latch and to breastfeeding, rather than nipple feeding.  There are diagrams and videos showing a good latch in the further information section below which will help, as will getting to a local breastfeeding support group and a good antenatal breastfeeding class.  

Healing Sore Nipples
There are lots of really good resources on healing sore nipples on the web, so I have put them in the further information section rather than trying to reinvent the wheel.  The most important part of healing any trauma is getting the latch right.  Once you correct the latch and have your nipple in the comfort zone your normal healing processes resolve any cracks and grazes very quickly.  If you don't correct the latch you nipple continues to have friction which means any grazes take much longer to heal.  

A quick note on lanolin!  Nipples heal more quickly if kept slightly moist - to prevent any cracking.  Some mums will use lanolin for this, some will use proprietary compresses available from pharmacies, some will use something like coconut oil.  I often hear mums talk about how helpful lanolin is and suggesting that new mums "slather it on" liberally before or after feeds.  I think there is a lot of confusion in the community about the role of lanolin.  Lanolin is a wax secreted by sheep on to their wool.  In breastfeeding it is used to stop a damaged nipple from drying out.  It does not heal cracks (your body heals the crack), and it isn't a cure for a latch problem.  Using a lot of lanolin (or any other slippy substance) before feeds actually makes your breast slippy and that makes it harder for your baby to breastfeed well.  If you choose to use lanolin to help with cracks, it is only used after feeds until the nipple has healed.  Then it is no longer needed.  It is not an essential piece of breastfeeding equipment and many breastfeeding mums never use lanolin.

If you need some help correcting a painful latch contact someone who can help ASAP.  The sooner it is done the quicker you will heal, your baby will be able to transfer milk more easily and the easier breastfeeding will become.  An upcoming blog will look at who provides breastfeeding support in NI, but for now your local options in the first week are your community midwife, your local peer support mums, voluntary breastfeeding support organisations like La Leche League, or a lactation consultant (IBCLC).

Remember that your birthing latch pains should ease and be entirely gone within a few days of the birth of your baby and then feeding should be entirely painless from start to finish.  Not only painless, it should be enjoyable, pleasant and relaxing.  Within a short time latch pain is completely forgotten, and just like labour pain we move into a kind of amnesia that it ever existed... And that's as it should be.  With so many reasons why we should breastfeed, it just makes sense that nature dissolves the memory away into a forgotten haze and leaves us instead with the beautiful bonding experience that is comfortable breastfeeding.

Further Information

Latching Information

Videos of a good latch and Adjusting a latch mid-feed
These videos are all from Dr Jack Newman ( -This video is actually demonstrating a supplemental nursing system, but 1 min in you see Dr Newman adjust baby's chin.

Healing Sore Nipples

Wednesday, 15 April 2015

First week (Part 2) - Hands in the Way / My Baby is fighting me

In the last blog post we began looking at the most common reasons for mums in NI to stop breastfeeding in the first week.  Just to remind us, these reasons were listed in the 2010 Infant Feeding Survey as:
  •   baby not sucking / rejecting the breast (33%)
  •   having painful breasts or nipples (22%)
  •   mother feeling she had insufficient milk (17%).

Although the survey lists baby not sucking and rejecting the breast as 1 reason, I think this actually covers 2 separate scenarios so I have separated them into 2 blog posts.  Last week's blog covered baby not sucking.  This blog will cover what mums describe as baby rejecting the breast or fighting the breast.

My baby pushes me away and shakes his head
A baby needs to feed when he is born.  It is a biological necessity for life that we need to eat.  A baby is also primed to find his mother's breast and to breastfeed when born, so why would a mum say that her baby  is "fighting" her.

Much of this may be due to the way that breastfeeding is "taught" in recent years.  In a previous blog I briefly mentioned how our support networks would have been very different a hundred years ago.  If you had been giving birth in Northern Ireland in 1915 you would likely have already been very familiar with breastfeeding. You probably had several siblings and would have seen them being breastfed.  You probably asked your mum about what she was doing at different stages and would know how a baby latches, what it looks like, and how to deal with problems.  If you were the youngest you probably saw your elder siblings or your aunts or cousins breastfeed before you gave birth.  You would have seen women in shops, friends in their home breastfeed - it would have been common place.  Today we mostly get our information from a short antenatal class, and usually some NHS literature - maybe the Bump To Breastfeeding DVD or the Off To A Good Start booklet.  It's very different from the experiential learning from observing and interacting with a breastfeeding mum.

We live in a society where teaching methods are dominated by analysing, categorising, breaking things into steps.  That may work for maths problems, but it doesn't work so well with breastfeeding.  Over the years breastfeeding has been treated as a step by step process and instructions for latching created.  The instruction book might say things like this:  Make sure your baby is in a straight line, head free, chin to breast, wide mouth, bring him in close.  
Those things are indeed an accurate observation of what a baby needs to latch, but they don't really tell you how to hold your baby or to get both of you working together.  They are logical steps.  They are what is known as left brain thinking.  They might look like a sensible approach when we are pregnant, but when you are in the early days of breastfeeding, awash with hormonal changes and trying to adjust to motherhood working out how to get each step to turn into a latched baby sometimes isn't so easy.  What mums actually describe is that their baby is hitting her, or pushing her away, or shaking his head.  Mums say things like, "he shakes his head to say No".  This can lead to a feeling of rejection in a new mum and many stop breastfeeding without ever really having a chance to experience it.

Left brain vs Right brain

Breastfeeding doesn't really work as a set of instructions.  Learning to breastfeed is more like learning to ride a bike.  You could set out instructions which might mention something like this:  Stand with each leg on either side of the frame, hold the handlebars straight, move one peddle to an almost vertical position, push this peddle down, maintain balance by turning the handlebars, push off this peddle to reach a sitting position, place the other foot on the free peddle, maintain balance by moving your body.
Again, it describes what happens, but it certainly doesn't teach you how to do it.  You can't learn how to maintain your balance on a bike unless you try it.  We feel it in our body.  It is experiential learning.  It is right brained learning.

In normal circumstances, when a baby is born, both mum and baby are in a biological state where they are primed to breastfeed.    Left to their own devices a set of behaviours happen.  As we discussed in the last blog, if placed on mums body, a baby will crawl to the breast and latch on.  These instinctive behaviours don't just happen in baby.  Studies have shown that mums also participate and through stroking their baby, they seem to trigger exactly the right reflexes to latch at just the right time. It is a intricate and beautiful dance.

The reason that breastfeeding more easily when the baby is tummy down on mum's semi reclined body is because babies are designed to be "tummy feeders".  We are mammals, and just like kittens or puppies, babies are designed to lie on their tummy to latch and breastfeed.  In that position your baby is stable.  He can crawl to your breast. He can use his hands on either side of your breast and push against you in order to lift his head and see where your nipple is.  Lifting his head also means that his head are nicely tilted back so he can get a wide gape and a deep latch.  That means he can get milk more easily and it is more comfortable for you.  You and your baby are in sync, reacting to each other's subconscious, instinctive cues and breastfeeding naturally follows.  It is right brain instinctive behaviour, but it is easily over-ridden by our logic and analysis.

If we over think breastfeeding and follow the instruction manual of latching, the reflexes work differently.  A very common position we see in breastfeeding booklets is cradle hold - mum is sitting upright, holding her baby on his side.  Her baby may still try to follow his instinctive reflexes, but now he is in an unstable position.  His hands that are trying to push against the breast to tilt his head back now seem to be in the way.  Mums try to move them, to tuck them away, and baby moves them back.  The head movement that is ideal to move into the right position to self latch now seems to be bobbing around and unable to latch.  Without support to let mum know that this is actually perfect breastfeeding initiation if she just leans back a little into more of a relaxed slouch on the sofa position, she is left feeling that her baby doesn't want to feed.

 Laid-back breastfeeding - image from

In a slightly reclined position breastfeeding becomes easier.  It doesn't mean that you always need to feed in this position, but it can help to use those reflexes in the early days.  Once we understand how it feels we can experiment, we can try riding with one hand, no hands, doing a wheelie.  It becomes easier to feed in any position.

Experiential learning also comes through observation.  In the same way that your great grandmother learned breastfeeding from her family circle, you can learn it from watching other mums.  Going to your nearest breastfeeding support group when you are pregnant can be invaluable.  It's amazing how much you can learn from watching other mums and their babies.  See how babies move.  See how they use their hands, understand how they bob and move their heads to latch.  If you can't get to a group, watch the videos at the bottom of the page.  They can't replicate what you learn in person, but they give a good overview.  Sometimes the difference between a struggle to breastfeed and an easy comfortable latch is just in understanding our baby's behaviour.  Babies know how to breastfeed.  So do we - sometimes we just need to get our left brain thinking out of the way.  Relax.  Lean back. Hold your baby on your body and allow both of you to feel your way.

More Reading

Tuesday, 7 April 2015

First week (Part 1) - My new baby won't latch /won't suck

The UK Infant Feeding Survey provides valuable data about breastfeeding and bottle feeding across GB and NI. The latest survey was published in 2010 and covered babies born from 2005-2009.  The survey tells us that 64% of mums and babies in Northern Ireland started breastfeeding after birth.  By the time those babies had reached 1 week old 26% of those mums had stopped breastfeeding and moved to a substitute formula.  That's over a quarter of the mums who wanted to breastfeed having stopped in the 1st week.  The most common reasons for stopping in the 1st week are listed as:
  •   baby not sucking / rejecting the breast (33%)
  •   having painful breasts or nipples (22%)
  •   mother feeling she had insufficient milk (17%).
The next few blogs will form a series looking at these reasons and the causes. The more pregnant mums know about normal breastfeeding and what interferes with getting started, the more likely they are to reach their personal goals.

The Breastfeeding Puzzle

Breastfeeding doesn't just happen on it's own.  It's a process which starts with birth, and what happens during and after birth can have a big impact on how easy it is to get breastfeeding started.  We are actually really lucky in NI to have so many hospitals who are BFI (Baby Friendly Initiative) accredited.  This means that after birth you should get skin to skin time with your baby.  This is designed to allow time for your baby to breastfeed.  BFI also means that babies "room-in" with their mum, which means they stay by mum's bed, rather than being taken to a nursery area.

Let's consider a common birth scenario in our hospitals.   A baby (let's call him Jack) has just been born.  It was a long labour, and his mum (let's call her Emily) is tired, but excited and wants to breastfeed.  Jack is placed straight on to Emily's tummy and she gets to see her beautiful baby for the first time.  She can't believe he is finally here.  During labour she had some pethidine, and it passed to Jack through the placenta and he is a bit sleepy.

The midwives help move Jack up to Emily's Breast and they gaze at each other.  The room is busy.  Emily's partner is taking pictures and texting family, the midwives are writing up notes and checking the placenta.  After some time in her arms Jack is taken to the side of the room to be weighed and measured and then placed into dad's arms while the midwives provide some aftercare and checks to Emily.  Afterwards Jack is placed back in Emily's arms and in a few minutes he falls asleep.  Jack and Emily are taken back to the maternity ward where she places Jack carefully in the maternity crib by her bed.  

Time passes.  Emily feels like she would like to pick Jack up and cuddle him, but he is sleeping and she doesn't want to wake him.  Doesn't everyone say that you shouldn't wake a sleeping baby?  Anyway the midwives have suggested that she rest.  More time passes.  Jack is still sleeping.  She starts to get a little concerned that he hasn't breastfed yet, but he seems content in the cot.  She doesn't lift him, even though she really wants to hold this little guy that she has waited so long to meet. 
Later a midwife comes to check if he has fed yet.  She lifts Jack and helps to latch him on, and he feeds.   Emily feels so happy.  She watches Jack feed and then fall asleep at her Breast.  She holds him a little longer and the and then places him back into the cot to sleep.  She goes to sleep too.  She is discharged a few hours later.  At home she tries to latch Jack and he latches but doesn't seem to suck.  Maybe her baby doesn't want to breastfeed?  Emily is discouraged and her confidence in her ability to breastfeed drops. 

What has happened?

Babies are hard wired to perform certain steps after birth; steps which lead to breastfeeding.  Studies looking at unmedicated normal birth found that when placed on mum's body, babies do the following in this order:
Open their eyes, massage the Breast, put hand to mouth, root, put moistened hand to the breast (which causes mum's nipple to become erect), extend their tongue, lick the nipple and finally breastfeed.  These actions also have an effect in mum.  It increases mum's oxytocin levels which helps with milk let-down, uterine contractions and bonding.  All these steps can take a little while, and a baby can only stay awake for around an hour or 2 after birth. 

Our babies are primed to take advantage of this alert time with the inbuilt reflexes mentioned above to lead them to the breast and to latch, without any help from mum.  A great example of a newborn crawling to the breast and self attaching can be seen here.  So why doesn't this always happen?  Lots of reasons.  In NI, birth often doesn't go as we planned.  In the vast majority of births, some kind of intervention has happened, maybe mum has had pain medication which passes over the placenta, maybe there has been an instrumental delivery or a c-section.  Interventions adjust the normal pattern after birth.  Babies are very immature and the pain medications can make them a little sleepy so that the normal reflexes don't show in the same way.  It may make them too sleepy to latch, as in the example of Jack and Emily, or alternatively it may leave their movements and their sucking uncoordinated so that although they latch, they don't remove milk well.  If it was an instrumental delivery they may be bruised and a little sore and that may interfere with the normal steps to latching.  Separation can also play a role.  Studies have shown that separating mums and babies for only 20 mins can mean that when they are returned to mum, babies don't show the normal feeding reflexes.  Since babies can only stay awake for a relatively short time after birth sometimes a baby falls asleep before having the first breastfeed, or may have latched but not actually fed.  Many things can interfere with getting that first drink of colostrum, but getting breastfeeding started is about a lot more than the first breastfeed.  The reality is that most of us in NI will have some kind of intervention during the birth, so how can we maximise the chances of getting breastfeeding started well?

The importance of Skin to Skin

Babies are designed to be held on their mum's body after birth.  The neonatologist Nils Bergman, describes how a mother's body is the baby's natural habitat and how a baby can tell if they are with mum even when asleep.  When on mum's body a baby's nervous system is more organised and the baby is much more capable of showing clear cues and of coordinating movements to latch and feed.  In the example above Jack slept in his cot rather than in Emily's arms.  It is really common in our hospitals that a new mother watches her baby in his cot and wants to pick him up, but doesn't as she feels unsure of whether it is the right thing to do.  It's ok to pick up your baby.  Hold your baby.  Enjoy your baby.  It's ok that he is sleeping, he can sleep in your arms.  Did you know that a baby can breastfeed while asleep?  You may find that when your baby is in a light sleep, if you have him near your nipple, he may rouse and wriggle and latch on and that's how he gets his first breastfeed.

Remember those steps that a baby goes through to breastfeed after birth?  They don't just happen straight after birth.   If you do miss that first awake period, and you put your baby on your tummy the next time he wakes, the reflexes will kick in to start the process again -  but all the steps need to happen again.  It can take some time.  Don't be discouraged if you pick up your baby and he doesn't latch straight away.  Keep him at your breast.  Give him the discovery time.  You will probably find that he will gradually make his way to the breast and latch if you give him enough skin to skin time with you.

What if your baby still doesn't latch?

Breastfeeding is about more than the first few hours or the first few days.  If things don't all fall into place easily after birth, that's ok.  There are lots of routes to getting breastfeeding started, and this is where it is important to know who to ask for help.  If your baby doesn't latch immediately the important things to remember are to feed the baby your colostrum so that he does get milk.  Keep your baby close.  If you are in the hospital ask the midwives to help.  You can easily express a few drops of colostrum onto a spoon and give it to your baby.  Would giving a bottle box formula be easier?   Look around the maternity ward!  The chances are that most of the babies have had some kind of intervention during their birth and are sleepy too.  The mums who are using formula are struggling just as much and are spending a long time trying to feed small amounts of formula to their baby.  It's just the same, but your baby is getting the massive benefits of colostrum - which have a lifetime effect on protecting his gut.  If you express every hour or 2 and give it to your baby he will begin to wake up in time.  Keeping him skin to skin means that when he does become more alert he's right where he needs to latch and start breastfeeding. 

If you are at home and finding your baby won't latch, look for skilled help.  Keep feeding your baby your colostrum frequently.  Rest with your baby and allow yourself lots of skin to skin time.  Your community midwives can help with getting your baby to latch, or you can ask a voluntary breastfeeding counsellor or a lactation consultant.  Many health trusts in NI also have peer support mums who will help.  There is support available if you just ask for it.  It's ok to ask.  A couple of hundred years ago you would have probably birthed your baby at home, surrounded by your mum and other female relatives (all of whom would have been experienced in breastfeeding).  Your skilled support would have been built in to your family unit.  Today our skilled support is in a wider support circle of other women who have breastfed their babies and will help you to breastfeed yours.  It gives you strength to tap into this network of support.

Breastfeeding in the first few days can just fall into place or it can be tricky - but parenting is a messy and tricky business.  Your baby wants to breastfeed, he just needs a little time.  Give him time, and hold your baby.