Thursday, 25 June 2015

Protecting Breastfeeding While Offering Bottles

"If you gave him a bottle I could feed him for you"

Breastfeeding mums in Northern Ireland often feel pressure to let others feed her baby.   Whereas some mums feel happy to feed both at the breast or using a bottle, others some really want to feed at the breast exclusively.  If you do want to be able to have other people feed your baby as well as breastfeed hopefully this blog will give you some info on how you can do this.  I want to make very clear however, that it is also completely ok if you don't want other people to feed your baby.  Many mums find breastfeeding an incredibly special time. A time where they actually don't have to hand their baby around for someone to play with.  It's a time for both  to relax, recharge each other and fill up the oxytocin cup.  This is normal and natural and it's ok for you to feel like that.  Breastfeeding should be enjoyable.  It should make us feel relaxed and recharged.  Our babies grow so so quickly and every moment is precious.  Too many mothers worry that perhaps there is something wrong if they feel attached to breastfeeding.  If this is you it is important to know that this is normal.  It's ok to feel this way.  It's biological.  You are wired to protect and nourish your baby and what you are feeling is natural.  There will be lots of time later for others to feed your baby if you would rather wait.  In only a few weeks (and they will pass in a flash) your baby will be sitting at the table with you and can eat lots of things that other people have made for him.

Having said all that, the reality is that the vast, vast majority of breastfeeding mothers in northern Ieland will use bottles while still breastfeeding.  Some will use them simply for occassions of separation and others will choose to combine feeding at the breast and using a bottle more regularly.  For some combining the two is easy but unfortunately for others it can become a track to early unintended weaning, with the baby beginning to prefer the bottle.  There are a few small and simple steps that can help to minimise early weaning and to protect your breastfeeding relationship with your baby.  My aim is that by outlining them fewer mothers will wean earlier than they hoped.  I have labelled them as the 3 Protects:  Protect The Latch; Protect the breast Milk; Protect the Flow

Protect The Latch
Before we can protect the latch we need to perfect the latch.  The early weeks of breastfeeding are where both the mum and baby are learning the skill of latching and breastfeeding and it takes some time to really get the hang of it and to get comfortable easy breastfeeds each time. 
Often it is suggested that artificial nipples are avoided in the first 5-6 weeks and many mums do use a figure of 6 weeks of when it really started to get easy.  We also know from the breastfeeding statistics that getting to 6 weeks is a magic figure. Waiting until breastfeeding is well established before introducing a new way of feeding is less likely to interfere with breastfeeding.  
The other factor in protecting the latch is considering how the baby latches to a bottle.  Bottles come in all shapes and sizes and the teats also come in various forms:  narrow or wide bases, long or short teats, straight or angled teats, gradual or abrupt change from base to teat etc.  In order to protect the breastfeeding latch it can help to apply the same latching principles to the bottle teat.  When we breastfeed our nipple stretches to just around the transition between the hard and soft a palate in a baby's mouth.  The bottle nipple needs to reach the same place.  When we breastfeed the baby should have a nice wide mouth taking in lots of breast below the nipple.  In order to protect the latch we want the same  latch on the bottle.  If the teat is too long the baby will have to move back on the teat to get it in the right place in his mouth.  That leads to a shallow latch around the nipple of the bottle similar to how you suck on a straw. Equally if the base is too wide for the baby to latch on to well he may latch around the nipple of the bottle and straw suck.  This different sucking process can make combining feeds more difficult as the baby may learn to latch to a nipple that way - Ouch!  
To protect the latch it can help to think carefully about how your baby latches to your breast and try to mimic that as much as possible.  That doesn't mean you need to look for a bottle that looks like your breast - no matter what the marketing says no bottle looks or acts like a breast. What you do need to look at is how your baby is latched on your breast and try to ensure that the latch on the bottle looks as much as possible like that.

Protect the Milk Supply
If you have been following my blogs you may have noticed that I emphasise how we need to look at the dyad for all breastfeeding issues.  Breastfeeding is a relationship, a partnership and each issue has 2 sides.  The timeline of 5-6 weeks that is often suggested for avoiding artificial teats isn't just about "nipple confusion". It is important because that is how long it takes to fully set up a mum's milk supply.  It is known as the "calibration" phase.  During that time prolactin receptors are being established and the demand and supply cycle is being regulated to your baby's needs.  By 5-6 weeks your supply is a bit more fixed and will probably have reached the capacity that your baby will ever need.  From 5 weeks until 6 months your baby takes around the same volume daily (approx 25-30 Oz).  Whereas a formula fed baby needs greater and greater amounts of formula, a Breastfed baby does not and his body becomes more efficient at using breastmilk. From 6 months on the amount of milk he takes will gradually reduce as solids enter his diet.  
Once you have reached 5 weeks of exclusive breastfeeding your milk supply is more robust, and you can regulate it down and back up quite easily.  If the milk supply never reached the level needed by your baby during that time however, there is a risk that it will never meet all your baby's needs and supplementation will be needed on an ongoing basis.
What does that have to do with bottle feeding?  Well how bottle feeding is managed could potentially have an impact on that calibration phase.  The most obvious impact would be if the bottle contains formula.  Any formula that the baby gets is milk which isn't being drained from the breast and so impacts the demand and supply cycle.  Each ounce of formula is an ounce less that mum makes.  Whether that is an issue depends on whether you wants to exclusively feed at any stage and whether you express during the time that the baby is getting the bottle. The easiest way to make sure your supply is at the right level for your baby is to keep feeds at the breast during the calibration phase.  If you do want to offer a bottle during this timeframe keep the process of calibration in mind and consider expressing to mimic the feed.    
There also needs to be a little caution in the early weeks around night feeds.  Our babies are designed to feed at night, and our prolactin levels are highest at this time.  I have seen it suggested that perhaps babies evolved to feed more at this time when mum is resting and can dedicate time to feeding rather than working.  Babies take in a lot of calories overnight. Missing night feeds in the early weeks (even if you are giving milk expressed earlier in the day) has the potential to impact your still regulating supply.  This doesn't mean you can't give a bottle at night in the early weeks.  It just means that you should consider the possible impact to whatever your breastfeeding goals are.

Protect the Flow
It's not just the bottle and teat shape that differ during a bottle feed, it's also the way that a feed happens.  During a breastfeed your baby latches on and begins sucking.  He gets very little milk at first, only around 10ml before the first letdown.  This allows him to get his sucking organised in preparation for the faster flow of milk.  The letdown is then triggered and he does 20-30 long sucks and swallows.  The flow then slows and he gets a chance to take a breather, relax and reorganise while his sucking becomes the shorter flutter sucking again.  If he stays on that side for a while he may then trigger another letdown.
This is a very different process to bottle feeding.  In order to protect breastfeeding, caregivers are recommended to use paced bottle feeding to mimc breastfeeding.  Using paced feeding means that the baby controls the flow, and how much he drinks in a way more similar to breastfeeding.  Paced feeding involves reading the babies cues.  I have attached some links explaining it in more detail in the Further Reading section, but in essence it involves baby being more upright and the bottle more horizontal.  The bottle is offered and only after the baby is sucking in an organised way is the bottle tipped up so the flow begins.  After 20-30 sucks, or if the baby shows signs of wanting a rest the bottle is rested horizontally until the baby shows cues of being ready for more flow.  You can see how this mimics the breastfeeding process. The caregiver is also looking for signs of being content - fists near the face or signs of distress at the flow being too fast, such as splayed hands or a furrowed brow.
The second part of protecting the flow is the choice of teat.  Babies enjoy fast flowing milk and the risk of using a bottle with a fast flow teat is that your baby comes to prefer this flow to the breast.  Generally it is suggested that to protect breastfeeding you use a slow flow teat.  

Breastfeeding vs BreastMilk Feeding 
Although these steps make feeding from a bottle a bit more like breastfeeding it's important to point out that they are not the same, regardless of what is in the bottle.  The action of breastfeeding contributes to normal development of the facial structures, the jaw, the teeth and to the development of speech.  The tongue movement shapes the palate and breastfeeding is associated with less need for orthodontics later.  It makes sense to try to preserve as much breastfeeding as possible with these few simple steps if you do choose to also use bottles.

Obviously not everyone can or wants to wait for 5-6 weeks.  Some babies don't latch straight away and some dyads have breastfeeding difficulties or weight gain gain issues in the early weeks which mean bottles are used.  This doesn't mean that you will have an impaired supply or that the baby will not breastfeed well later.  It just means that care needs to be taken in order to protect the breastfeeding relationship.  Sometimes it is simply necessary to supplement or to feed using a bottle / cup / syringe or other method.  Some mums want to introduce a bottle earlier, and that is ok too.  The decision should always be an informed one and knowing a few simple steps to protect breastfeeding may help a mum to avoid unintended weaning.
As always, If you are finding that introducing a bottle has caused any breastfeeding issues, or you want to talk about how to introduce a bottle to your breastfed baby chat to a qualified breastfeeding counsellor or lactation consultant who can help you to meet your breastfeeding goals.

Further Reading

Firstly a couple of pieces challenging if bottles are needed, from Dr Jack Newman

Introducing a bottle to a breastfed baby -
Paced Bottle Feeding -

Checking the latch - poor latch
Checking the latch - same baby with a good latch on a different shape

Effect of breastfeeding and bottlefeeding on the oral cavity -

Finally I am linking a book created by an IBCLC and a speech therapist on combining breatfeeding and bottle feeding.  I do not agree with everything in the book, for example I do not think a bottle needs to be introduced early or that a baby needs to practice regularly (if a baby only took a bottle because they were used to it they would never take it the first time).  That being said, the book has good information on shapes and sizes of teats and how they affect latching, information on pacing, and an analysis of flow rates of different commercial bottles.  For mums who either need to or choose to regularly use bottles the book could be helpful

Tuesday, 9 June 2015

A tongue frenulum vs a tongue-tie

Tongue ties are a hot topic in breastfeeding right now and there is a lot of confusion and misunderstanding about tongue restrictions both among mums, and among a lot of health professionals. Part of the confusion is caused by the fact that research in this area is new and ongoing and like all research which is pioneering it causes divided opinion.  In years gone past the opinions would have been discussed and argued over within journals and professional communities, but now everything is out there on the web, and it creates a lot of murky waters for worried parents to wade through.

A worried breastfeeding mum who is in pain, or hears clicking during feeds, or is concerned about weight gain or windiness (or any other multitude of symptoms) does a quick google or asks on Facebook and up pop dozens of articles on "tongue -tie".  Mum takes a quick look at her baby's tongue, sees a frenulum and then worries that their problems are caused by this "tie". I have a personal interest in tongue restrictions and I will write a future blog about them in more detail (including my own experience as a tongue tied adult) but in this blog I just want to clear up one common misunderstanding around "ties" and frenula: 

A frenulum is not a tongue tie!

Please do not think that I am minimising the impact of tongue restrictions in this blog.  They can have an enormous impact on breastfeeding and beyond and too often mums and babies do not get the help that they need.  It is exactly this confusion and misunderstanding around frenula and ties which leads to those babies who need help not getting it, and those who don't have an anatomical restriction getting misdiagnosed.  This blog is aimed at simply giving a bit of clarity to what a frenulum is and what is normal and how we know if there is an issue.

Almost all of us have a frenulum.  The tongue is one of the earliest structures to form in an embryo and when it begins to develop the tongue is fused to the mouth floor.  As the pregnancy continues a process of freeing the tongue from the floor of the mouth begins and there is degeneration of the tissue which anchors it to the mouth floor.  How much frenulum is left at birth, where it attaches and how thick it is varies from individual to individual.  With such variation there has always been difficulty in deciding what is normal so frenula were instead categorised by where they attach and how they look.

Classification of frenula
Often tongue frenula are described by a grading or typing system, where Type 1 means the frenulum attaches to the tip of the tongue and so is visible down the entire length of the tongue; Type 2 attaches a few mm behind the tip of the tongue, Type 3 attaches mid tongue and Type 4 is usually under the mucosa on the floor of the mouth.   Type 1 and 2 are known as anterior and Type 3 and 4 are known as posterior.

This classification system describes the appearance of a frenulum only.  It is not a severity scale and does not mean that a baby has a degree of "tongue-tie".  It is simply a way of describing what can be seen.  What matters though is not necessarily how a tongue looks but how it functions.  Let's go back to breasts and breastfeeding for a moment.  We have a "typing" system for breasts too.  We describe them in cup sizes.  Just like the frenulum typing system, cup sizes is about appearance.  Does cup size actually mean anything when it comes to their function, which is breastfeeding?  No!  Having a D cup is not better or worse than having a B cup.  It is simply a description of appearance.  In general all women produce about the same volume of milk over 24 hours.  It is function that is important not size and appearance.  Frenula are the same - what really matters is how they function.  

A recent study from Sweden examined and categorised the frenula of 200 babies and categorised them by type.   They found that 199 of the 200 babies had a visible tongue frenulum: 5  were of Type 1, 147 of Type 2 or 3, 47  were Type 4.  The fact that all but 1 baby had a visible frenulum should reassure us that the presence of a frenulum is normal in our babies.  It does not indicate a problem. They also found no correlation between the typing system and breastfeeding, so nothing which indicated that any particular type was a "tie" or interfered with breastfeeding.

We do know that some babies do seem to have a frenulum that affects breastfeeding however, so why would some babies have issues and others not?  A 2010 study from Brazil suggests that a normal frenulum is made of mucous membrane and therefore is stretchy.  They found that problem frenula contained type 1 collagen cells instead of mucosa.  Collagen has very minimal stretch and therefore prevents the tongue from lifting.  This makes appearance a poor way of assessing whether a frenulum may be an issue because a tongue may have a frenulum which looks like it would be restrictive but in fact it is stretchy mucosa and not a problem.  Likewise another baby may have a tongue that looks like there is a minimal frenulum but in fact it does restrict the tongue from functioning well.  

Assessing function is now considered to be more important than assessing appearance, and that probably makes sense to most of us.  We would find it very odd if we visited a physiotherapist with knee pain for example and the physio looked at our knee and simply described how it looked.  He/she may be able to see there is inflammation and swelling for example, but without checking the range of motion of the joint there is no way to know how the knee is affected.  The tongue is no different.  From ultrasound studies we now know much more about the function needed to breastfeed effectively, and a baby's tongue can be assessed by a trained lactation consultant (IBCLC) or healthcare professional using a gloved finger.  The assessment should be gentle and playful and the baby should enjoy it, just as they enjoy sucking on your finger.

This discovery that function and appearance are not necessarily linked is why the Swedish study concluded that:

"the term "lingual frenulum" should be used for anatomical description and that the term "tongue-tie" be reserved for a lingual frenulum associated with breastfeeding difficulties in newborns."

Many IBCLCs now prefer to refer to 'tongue restrictions' or to 'TOT' (tethered oral tissues) rather than 'tongue tie', because the phrase tongue tie has become synonymous for so many people with the presence of a frenulum.  The picture becomes increasingly complicated as more recent work in the field suggests that even when a tongue is restricted, it does not necessarily need to have a surgical intervention.  A tongue can seem to have impaired function due to other structural issues like muscle tightness from birth.  Releasing the tension can solve the functional problem.  This is a complex area and I will delve into it in the future blog but for now what I want to get across is the importance of realising that having a frenulum is normal and does not always mean your baby is tongue tied.

There is so much talk about tongue tie in breatfeeding circles at the minute, and it is easy to think that perhaps your breastfeeding difficulties are caused by a tongue issue.  Knowing that having a frenulum is normal and that most of us have one can maybe help to alleviate those worries.  If you are not having a breastfeeding problem then it is likely that your baby's frenulum is just that - a normal frenulum.  If you are having difficulties then just because your baby has a frenulum doesn't mean that he has a tongue restriction or that a frenulum is the cause of those problems.  There aren't any good definitive statistics on how many people are tongue-tied, but several studies have placed the incidence at 3-4%.  One study placed it at 10%.

If you are concerned about your baby's frenulum contact a breatfeeding counsellor or lactation consultant to talk things through.  Breastfeeding is a skill that both we and our babies need to learn together and it can take a few weeks to get the hang of things and to start working well together.  The first few days can be hard, there can be some temporary pain even when things are going ok  (my previous blog on this), and pain can linger on when the latch isn't quite right regardless of a frenulum.  In fact one study found that 92% of mums encountered problems or pain in the early days.  If tongue-tie incidence is below 10% then most mums must have issues due to other factors.  Growth spurts, changes in milk supply and the normal fussy periods can make things more complicated.  The symptoms associated with a tongue tie (e.g. clicking, pain, slow weight gain, reflux etc) can also be caused by other issues and in most cases changing positioning, getting a deep latch or working on your breastfeeding management can resolve problems.  Snipping a normal frenulum won't resolve any breastfeeding issues and causes an unnecessary procedure to a baby, so checking other steps first makes sense.  

With so much on the Internet about ties and division, navigating the whole area can be tricky and scarey.  Babies who do have tongue restrictions need support and their mums need good information so they can decide how to move forward.   Mums with babies who have normal frenula need good support to overcome their breastfeeding difficulties.  Breastfeeding professionals also aren't immune from the confusion around tongue-tie.  We all need reassurance about what is normal and we need to ensure we take a wide view of both mum and baby when we encounter breastfeeding problems. Most of us have a frenulum and most of us are not tongue-tied.

Part 2

Further Reading
Swedish study on frenula -
Study on issues after birth - 
Functional assessment of tongue function -