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
http://www.breastfeedinginc.ca/content.php?pagename=doc-WFBW

Introducing a bottle to a breastfed baby - http://www.llli.org/faq/bottle.html
Paced Bottle Feeding -  http://youtu.be/UH4T70OSzGs

Checking the latch - poor latch http://youtu.be/KpRDSVH4s8Q
Checking the latch - same baby with a good latch on a different shape http://youtu.be/ZmlmRyuJBcc

Effect of breastfeeding and bottlefeeding on the oral cavity - http://www.brianpalmerdds.com/bfeed_oralcavity.htm

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
.








No comments:

Post a Comment