Friday, 29 December 2017

Having problems with getting a comfortable latch? - Don't forget your baby's feet!

Photo by Danielle MacInnes on Unsplash
Positioning and attachment is key to allowing a baby to open the mouth wide and attach deeply to the breast, and in turn that deep attachment is key to a comfortable, pain-free breastfeed.  We want some breast to be in baby's mouth rather than just the nipple, so that the nipple is positioned away from hard tissues like the gums and instead is framed by the wide palate and a soft tongue.

In earlier blogs I have talked about the importance of laid back feeding positions in order to trigger a baby's innate feeding reflexes to get a comfortable deep latch.  Often when I describe these positions, people they tell me that they've tried it but just can't seem to make it work and their baby doesn't seem to be able to latch on.  Often when I see them we work on tiny adjustments to help the baby find it's feet -  literally.  I often spend time talking about feet and feet placement - which might seem unrelated to breastfeeding on the face of it, but in fact is hugely important.

Babies use their feet when latching on.  They are part of the beautiful and intricate pattern of reflex behaviours that lead to an instinctive latch on.

In a 2008 study by Diane Colson, researchers noticed that mothers performed the same very specific movements in order to trigger feeding reflexes.  These are part of a mother's feeding reflexes.  They found that when mothers were in a laid back position with hands free they stroked their baby's feet which triggered toe fanning and toe grasping, which in turn triggered lip and tongue reflexes and helped the baby to attach to the breast and to feed.  You can think of this also in terms of how we are often told to tickle a baby's feet if they are falling asleep at the breast.  It's not just to wake the baby up, it's to specifically trigger feeding.

Hands on therapists, such as craniosacral therapists, osteopaths etc often work with long fascial lines in the body, and what's called the "deep front line" does run from the feet at one end right to the hyoid bone and muscles at the other.  As I explained in this blog, the tongue is attached to the hyoid bone and jaw and tongue movement is affected by hyoid muscles, so this may be part of the system link between that foot pressure and feeding reflexes.

On a more basic observational level however, babies just need to use their feet in order to feel positionally stable and to be able to adjust their bodies to latch on well.   If you have ever seen a video of the breast crawl after birth (where a newborn crawls to the breast and self attaches), you will see how important feet position is.  The baby plants it's feet on mum's body and then pushes forward, pulling the legs up, planting them in and then pushing again.  Moving like this, the baby feels stable, and it also allows the chin to deeply contact the breast which again aids in getting a deep attachment at the breast.  If a baby doesn't have this kind of contact, or doesn't feel positionally stable at the breast, it is much harder to get a good comfortable attachment.

So if you are struggling with getting a comfortable feed and you just can see that there is a shallow attachment and just can't figure out how to get it any deeper, look at your baby's feet.  Are they in contact with something - either you or perhaps a cushion?  If you are in a laid back position perhaps try having your baby lying along your body with feet against your thigh, or at at 45 degree angle with feet against your groin.  If you had a C-section and want to protect your wound you can have baby more across your body, but just check that your baby's feet are touching your side, or your arm, or a cushion.  If you prefer to use a cradle hold, make sure that you are also allowing your baby to feel positionally stable by ensuring that baby's whole body is firmly against yours with chin touching the breast and feet against something.  If you are still struggling in either position - take another look at the hips.  Both of your baby's hips should be touching you - your baby's pelvis should be flat against you - like froggy legs.  If one hip is against you and the other is angled away - your baby may not have good positional stability.

I often think there is too much focus on "the latch" in breastfeeding.  The latch is vitally important, but lots of things feed into "the latch" and how a baby attaches.  Good attachment isn't all about the lips flanging or  lining up nose to nipple etc.  Its about a bigger picture of how 2 people move, how comfortable and stable they both feel and how that leads to a comfortable feed.  Help your baby to find it's feet.

Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding.  Colson et al 2008  2008 Jul;84(7):441-9. doi: 10.1016/j.earlhumdev.2007.12.003. Epub 2008 Feb 19. -

Videos showing laid back breastfeeding -

Fascial trains - The Deep Front Line

Friday, 10 November 2017

Quick Thoughts from Northern Ireland Breastfeeding Research

This morning I attended the Advancing Breastfeeding Research & Practice conference organised by NIPHRN (Northern Ireland Public Health Research Network) and DMRS (Doctoral Midwifery Research Society) which was held at Ulster University.  This event looked at current research, and meta-analyses of breastfeeding interventions aimed at increasing breastfeeding rates, as well as discussing the importance of online peer support.

A common theme that came through the day is that what is currently being done to increase breastfeeding rates is not working.  Interventions which work in other areas of the world, don't seem to work here, due to the culture around feeding in UK.  New ideas are needed, some kind of a radical approach.  An update from PHA Health Intelligence found that women felt there was a lack of consistency between midwives / Health Visitors, and a lack of support from some.  Alison McFadden from Dundee University stated evidence that many HCPs don't have the required knowledge, attitudes or skills around breastfeeding but there was a lack of evidence of what works to equip staff effectively.  She stated that there was a lack of quality information on whether increasing breastfeeding education in HCPs actually increases breastfeeding rates.  This might seem surprising, but I'm sure we've all been to education or training sessions where we didn't actually apply what we learned!

The importance on online peer support was discussed and the session on the local BFNI Facebook group brought some audible gasps when the volume of posts and support interactions was given.

Two sessions that I want to draw out a little here however were the sessions on Motivational Theory and Behavioural Change.  The Motivational Theory talk emphaised the importance of Self Efficacy and of Value. That to motivate any specific behaviour (like breastfeeding) you must have a balance of feeling capable and feeling like there is value to that behaviour.  It talked about how the breastfeeding support is currently unbalanced, with Value being emphasised to women prenatally during antenatal education, but at this time they are not given information to feel confident in how to do it.  Prenatally interventions emphasise Value but not Self Efficacy.  After birth, they are given support around Self Efficacy (practical support on how to breastfeed) but are not given information on the value of breastfeeding (there is no real distinction drawn between breastfeeding and artificial feeding).  We have a wider issue within society and health care provision that  breastfeeding is not always valued.  The session on behavioural change talked about the 3 components of change which are Capability, Motivation and Opportunity (Means, Motive and Opportunity by another name), and how each of these need to be addressed in interventions to change behaviour.

In all of these talks the interventions focused on breastfeeding women - trying to drive change in pregnant and postnatal women, but the Lancet Series on Breastfeeding (published earlier this year) was very clear when it said, 

"success in breastfeeding is not the sole responsibility of a woman 
— the promotion of breastfeeding is a collective societal responsibility.”

What was clearly presented to the audience today was a message that we need to do something quite different when thinking about interventions - so I'd like to propose something different.  We've tried interventions focusing on the pregnant and postnatal women, and we're not making any significant changes.  We know that there is an issue within healthcare.  Women report issues around perceived lack of Value in breastfeeding and lack of effective support from HCPs.  That hits the Lack of Value and Self Efficacy strands of motivation.  Women report that HCPs are very quick to suggest artificial milks both in hospital and in the community.   Value and Motivation - how about we address these within the care provision setting rather than focusing on pregnant and breastfeeding women?  How about we design interventions to drive behaviour change within healthcare as a driver of community change?  How about we motivate HCPs to better support and value breastfeeding?  We have some fabulous champions of breastfeeding within midwifery, nursing and medicine, but having some champions is not enough.  When a fundamental part of a job is providing breastfeeding information and support, everyone needs to be a champion.

A couple of days ago a pregnant woman told me that in an antenatal visit she expressed a wish to breastfeed, and her concerns about it since she difficulty breastfeeding previously.  She asked her midwives what help she could have.  She told me that her midwife said, "Sure, why not just give a bottle?".  In that one sentence we see both lack of value and lack of Self Efficacy.  How about instead of focusing responsibility on the woman (as the Lancet says), we motivate HCPs to change behaviour in how they respond to breastfeeding challenges.  How about we target interventions to promote the value of breastfeeding within health care professions?

How's that as a radical idea??

Sunday, 22 October 2017

Breast Shaping - It is ok to hold your breast!

Breast shaping (shaping / holding your breast with your hand in order to help your baby get a deeper latch can be very helpful for many babies in the early weeks of breastfeeding.  Recently, however, when I've suggested breast shaping to women, they are more and more frequently saying to me, "But is it ok to do that?  Won't I get blocked ducts?"  Generally they have been told by someone to stop doing it.  I am really uncomfortable with women being made to feel like they cannot put their own hands on their own body to help them with breastfeeding.  So let's talk about breast shaping, and lets talk about blocked ducts.

Breast shaping can help young babies latch for lots of reasons.  If a mum has flatter nipples, it can help to get the nipple deeper into baby's mouth.  If mum is engorged and the breast is very rounded it can help baby to get more of a grip on the breast.  If the breast is large and heavy it helps to lift the weight off baby's chin and chest.  Taking the weight off the lower jaw also helps babies to get their chin forward and move their tongue well.  For this reason it also helps tongue tied babies, or babies who's tongue is restricted due to head moulding from birth, to optimise their tongue and jaw movement.    It can also help a mum with larger breasts to be able to see her nipple and baby's mouth more clearly.

Like everything, we have itemised and named different ways to hold the breast.  Common terms are the C hold, the U hold and the Scissor hold.  

By naming them we kind of legitimise them as a technique with correct and incorrect usage, when in fact women throughout time have just used their hands on their body instinctively to help their baby, and they do it because it works and it does help.  In fact I think it is when women are instinctively using their hands that someone says to then, "Oh don't do that - it can cause blocked ducts".

Shapes and holds come in many forms.  The guide as to which hold might help best is the position of baby's mouth approaching the breast.  In the diagrams above I have added a little text explaining when they are often useful (If you click on the image it will enlarge).  The point of shaping is to make the breast a little narrower to aid with attachment.  The C hold for example is useful if a baby is laying up and down your body.  In this position the thumb is parallel with baby's top lip and the fingers parallel with the lower lip.  This hold wouldn't help with a cradle position as it would actually make the area that the baby was going to latch to even larger.  It would be essentially like turning a burger sideways and asking us to bite it.  In cradle hold therefore, the U hold (or alternatives) work better because it narrows the breast in the correct direction.  In U hold the thumb and fingers are parallel with the lips of a baby latching in cradle hold.

Does breast shaping cause blocked ducts?
The idea of blocked ducts can be frightening, particularly if you've had mastitis before or know someone who had mastitis.  The most common reason for blocked ducts is from milk not flowing freely.  The most common reason for that, in turn, is a baby not feeding well or not frequently enough. The situation where a baby is not latching on well and/or not removing milk well from the breast will increase the risk of milk stasis and a blocked duct.  A missed feed (e.g. baby sleeping longer than usual, or perhaps disruptions to feeds around holiday times) will disrupt the usual frequent flow of milk and increase the risk of a blocked duct.  Any kind of scheduling of feeds has the same risk.  Oversupply can also increase the risk just due to the volume of milk which might remain static in the breast after a feed.  The worry about oversupply is more common that actual oversupply however, in my experience - particularly around the 3 weeks mark.  Inflammation also raises the risk.  That inflammation may come from an infection, from allergy, from trauma.  Trauma to the nipple (usually from poor attachment at the breast) increases the risk of infection and of blockages.  Finally blockages can be caused by pressure on the breast.  This may be from sleeping position (particularly sleeping on your front), it may be from a tight fitting bra or clothes, and the theory goes - from fingers holding the breast.  Stress is also a significant risk factor.

To get an example of how often fingers/hands actually caused blocked ducts, I decided to have a look at the literature today.  There is plenty of literature on mastitis and showing blocked ducts as a precursor of mastitis, but not so much on the causes of the blocked ducts themselves.  Nevertheless this is what I found. 

A 1998 study by Fetherson [1] found that in first time mothers the risk factors for mastitis were, 

"blocked duct(s), restriction from a tight bra, attachment difficulties, and nipple pain during a feed were the significant predictors for mastitis "

It's worth remembering here that the tight bra and attachment difficulties (which cause nipple pain) are a cause of blocked ducts - which then may progress to mastitis, so the original issue was likely one of these.  In mothers who had breastfed previously the risk factors were stated as follows:

"blocked duct(s) and increased levels of stress were the significant precursors for mastitis"

A 2006 article by Suzanne Hertzel Campbell [2] in the Journal of Human Lactation on causes of recurrent blocked ducts states the following:

"Factors that can lead to plugged ducts include insufficiently emptied breasts related to following arbitrary cultural rules about restricting or timing feeds or sideswitching.... Older infants’ developmental changes, including increased mobility and greater interest in their environment, lead to sudden pulling at the nipple and less than optimal positioning. Infants with older siblings may be exposed to more distractions, causing them to quit feeding early and/or to nurse less often. In addition, at this age infants may start sleeping longer during the night, resulting in decreased breast emptying. Outside environmental factors that cause sustained pressure on the breast, such as infant carriers (especially front-holding), heavy purses or diaper bags, and restrictive clothing (eg, tight, underwire, or sport bras, bathing suit), may also interrupt the milk flow, resulting in plugged ducts.5,6 Other factors that may affect the woman’s physical and emotional health are fatigue and maternal stress."

I have bolded "sustained pressure" here, because I think this is extremely significant when we are considering the effect of holding the breast.  Lying on the breast for several hours, wearing a tight fitting bra for a day or overnight, wearing a top or dress which is tight for a day, is very different to holding the breast for latching on, or holding the breast for a short time during a feed.  Even if women need to hold the breast for most of the feed they generally shift during that feed.  It's uncomfortable for the shoulders, the back etc for a woman to hold one arm and hand position for the entire length of time that a newborn may be at the breast, so women move.  They shift their hands, they adjust their shoulders.  I don't think I have ever seen a woman rigidly hold a hand position for long periods while a baby feeds.  This idea of hands causing an issue, I believe also may come from an older idea of how the ducts operate within the breast.  It used to be thought that ducts move in lines directly to the nipple.  Like a tree, twigs lead to branches, which lead into larger branches, which lead into the trunk.  What we now know from scans however is that the ducts operate in an interconnecting network.  There are connections between lobes (branches) in the breast, unlike a tree (Geddes 2007 [3]).  Milk can flow freely through from one lobe to another to reach the nipple.

One other piece of information to consider here is what we as breastfeeding supporters often suggest if a baby's weight gain is low, and that is breast compression!  We actually suggest putting hands on the breast, and compressing in order to increase milk flow and to keep the baby sucking.  No one seems to see the contradiction here when telling women not to touch their breasts to help with attachment.  Breast compression works and is a helpful technique, and a technique which is hands on.

As a society we are all too frequently afraid to touch our breasts.  We have educational posters and videos to teach us how to check for breast cancer because we are unfamiliar with handling our breasts.  We are unfamiliar with our own bodies, how they feel and how they work, and this is part of what makes breastfeeding difficult.  Women since time immemorial have held their breasts while breastfeeding because for those women it helps.  It works.  
If your baby attaches better with breast shaping I would argue that it decreases your risk of blocked ducts, since poor attachment and drainage is likely the primary cause of blockages.

Get to know your body and your breasts, and if you instinctively feel that holding will help - try it.  If you feel your baby is bobbing about at the nipple and having trouble with attaching or getting the nipple deeply into their mouth, it's ok to try breast shaping.  If your baby latches on well with breast shaping but falls off when you let go, it's ok to hold the breast.    If it feels better and it is working, then it works for you.  Most of all, know that it's ok to touch your own body.  It's ok to hold your breast.  


[1] Risk Factors for Lactation Mastitis - Catherine FetherstonRM, MSc, IBCLC.  Journal of Human Lactation Vol 14, Issue 2, pp. 101 - 109 

[2]  Recurrent Plugged Ducts - 
Suzanne Hetzel Campbell.  Journal of Human Lactation 
[3]   2007 Nov-Dec;52(6):556-63.Inside the lactating breast: the latest anatomy research.  Geddes DT

Saturday, 5 August 2017

World Breastfeeding Week 2017 - A Call To Action

I've been pretty quiet over World Breastfeeding Week, as I am most years, to be honest.  I'm conflicted by it, and I think many people don't fully understand what WBW is.   Perhaps it's only through writing this blog that I've gained a much clearer sense myself.  There seems to be this idea that it is simply about celebrating breastfeeding, and so we should talk about it, and share pics and stories.  In fact, each year World Breastfeeding Week (WBW) has a defined purpose and intent.  So, yes of course we should celebrate breastfeeding but that's not the core of what WBW is.  What is the purpose for 2017?  

"WBW2017 will call on advocates and activists, decision-makes, and celebrants to forge new and purposeful partnerships. Together lets attract political support, media attention, participation of young people and widen our pool or celebrants and supporters"

Forge New and purposeful partnerships.  Attract political support?  Is that what this week is doing?  
What I see in my newsfeed, my emails and professional groups is lots of fabulous training made free this week.  That is brilliant, and it helps me as a professional to help support those who are having problems with breastfeeding, but does it forge new and purposeful partnerships?  Does it involve political decision makers?  I have to say No.

What about media attention?  Well let's face it, the media is, at best, "conflicted" on breastfeeding, and no less so in WBW.  I just checked what my email digest of breastfeeding news stories has brought to me the last few days.  This is the list of breastfeeding news story headlines in the order I received, from most recent to least recent:

1. Weird breastfeeding questions answered by lactation consultants.  (Mmhmm, you don't need media training to understand the subliminal effect that putting those first 2 words together creates)
BTW, a sub story linked from this was: 
Breastfeeding moms in developing nations have it even harder than in Canada (subtext here clearly is, "suck it up and stop complaining about lack of support.")

2.  Breastfeeding is currently failing to reach recommended standards across the globe (yep, tell everyone breastfeeding is failing but not how to fix it - that'll help)

3.  Mum who filmed herself breastfeeding her 4 year old daughter is called 'sick' by cruel online trolls.

4.  Breastfeeding:  Not a single country in the world today meets WHO, UNICEF standards (seems to me this is more of a celebration of formula marketing tbh)

5.  Teach pupils about breastfeeding say Royal College doctors. 

Now this last one is helpful.  This is something which would genuinely widen the participation of young people and widen the pool of celebrants and supporters.  That's 1 story out of the latest 5 that I received.  Let's move on to the next 5:

6.  Don't infantilise women.  Tell them how tough breastfeeding can be.  Ok this doesn't necessarily celebrate breastfeeding, but actually it's a message which I agree with - although I'd word it differently. Women do need to know that breastfeeding takes effort.  So does birth.  We infantilise women there too.  We need to tell women about their strengths and how they can meet the challenges of birth and breastfeeding and to learn about the power in their bodies.  This is my take on it.

7.  Presidents daughter speaks out after backlash over her breastfeeding photo

8.  Social media filling mums with anxiety over being perfect and breastfeeding (again anyone trained in media will understand how this associations breastfeeding with "perfection" and that this actually makes it seem to be something unattainable and unrealistic)

9.  Binky Felsted admits she felt uncomfortable breastfeeding in public for the first time

10.  Breastfeeding - the latest competition in the parenting game.

Sigh!  So are you starting to see why I feel conflicted about World Breastfeeding Week?  These stories and the negative media attention happens all year round, but more focus is placed on it during this week, and overwhelmingly the media is not working towards the goals of WBW2017.  At the minute the media, in the main, doesn't seem to be a purposeful participant.

WBW2017 calls for advocates and activists to "attract political support".  What are we doing to achieve that this week?  We do know exactly what needs to be done.  The Lancet report last year spelled out exactly what is needed to increase breastfeeding rates.  I blogged about it in this piece about Jamie Oliver.  The report clearly stated that there needed to be political will to promote, support and protect breastfeeding.  Protection of breastfeeding already happening is the first step.  That includes legislation to protect breastfeeding.  Here in N.I. our legislation is the weakest around breastfeeding in all of the UK.  Breastfeeding in public is protected in N.I. under the Sex Discrimination Act 1976.  Under the act 
a woman is protected as part of her maternity status until 26 weeks post partum.  Breastfeeding is a continuation of pregnancy and is the normal feeding method for a baby and therefore the breastfeeding dyad is protected in public.  This, however is woefully inadequate.  What about the 27 week old baby?  THe WHO recommend breastfeeding continues alongside completmentary foods until 2 years and beyond.  What about families who don't fit into the mainstream maternity model, not to mention that feeding isn't specifically mentioned.
Legislation in the rest of the UK is much stronger and has clearer intention.  In England and Wales the law specifically mentions "breastfeeding" for the avoidance of any doubt.  In Scotland the law specifically protects feeding of babies up to 2 years.

So what's happening here in NI.  Well the previous Health Minister, Michelle O'Neill did commit last year to bringing stronger legislation into effect, but shortly after this Stormont collapsed.  So far, during WBW2017  I have seen one local political voice on social media talk about legislation this week.  That was Michelle Gildnernew.  I know that Claire Hanna MLA is also speaking about legislation at the Belfast Breastival today.  I'm disappointed not to be able to make the Breastival today.  I'm out of the country, but I massively applaud the organisers of this event.  This truely is an event which has worked to the goals of WBW2017.  How do we as breastfeeding advocates and supporters carry this work forward?  Well, I would suggest that we take action.  

Claire Hanna and Michelle Gildernew are vocal on this issue as they are/have been breastfeeding mothers.  They personally understand how women feel about breastfeeding in public and the support and protection needed.  But how do public representatives become champions of a cause if they do not have a personal interest.  Look at Owen Smith right now and his intervention over vaginal mesh in NI. This happened due to lobbying from affected women and is progressing even though Stormont is not functioning.  Look at the effect that the Irish language demonstrations or marriage equality parades are having.  They are changing the political conversations here.  This paragraph is not meant to be a political statement about any party or cause, but what I am saying is that in order to make political change, there has to be pressure.  Change only comes through pressure.  It's the same in all things.  In evolution, pressure from the environment causes mutation.  In labour pressure causes birth.  Pressure causes change.
So if we want WBW2017 to really make change, then where is the pressure?  WE are the pressure... But only if we apply the pressure.  If you want more support for breastfeeding here, if you are feeling disillusioned by WBW, then BE the pressure.  Contact your MLA this week and tell them why this legislation is important.  If Stormont doesn't look likely to return in the Autumn, don't let it drift.  Write to the Secretary of State.  Write to the Shadow Secretary of State.  Demand this change in legislation.  No one else is going to do this, if we don't.

One other thing I want to talk about in the context of "purposeful partnerships" is peer support.  Supporting each other while we breastfeed our babies.  Supporting our families, friends, neighbours and community members who breastfeed and teaching our young people about breastfeeding.  That can be in person or it can be online.  The kind of virtual communities developing now in breastfeeding support are incredible.  Women supporting other women is incredibly powerful.  When you support someone to breastfeed, whether that is physically helping, emotionally supporting or pointing them to where they can get the help they need - THAT is working to the purpose of WBW2017.  Those are purposeful partnerships, and that also needs celebrated.  I am so proud of the ripples that I see.  I am so proud when I see someone who I supported in some small way months or years ago, pass that information to someone else and lovingly support another person to feed their baby.  Well done to all of you out there doing your part.  Change happens both ways - from the top through political action, and from the bottom, person to person.

Support and compassion can be our watchword, as can clever reaction to media.  The media are well practised in encouraging women to critique other women.   Online media, telephone phone ins, shock jock radio and TV are all about click bait.  More clicks generates more revenue.  They don't care about supporting women or about what babies get human milk and what babies get artificial milk.  It's all about the money.  Don't buy into it.  If you see negative stories - don't share them.  Don't engage.  Create negative pressure.  If you see positive stories, share the hell out of them.  Create positive pressure.  Use the networks and purposeful partnerships to do that.

Let's be very clear.  How we feed our babies matter.  There is a difference to the growing human body between human milk and the modified milk of another mammal.  The research is clear and unequivocal, no matter how the media presents it.  Breastfeeding protects against child infections, malocclusions, cancers, diabetes, and is associated with higher performance on intelligence tests, even when maternal IQ is accounted for.  

Each year WBW leaves me conflicted, but perhaps that's because I haven't really responded to the fact that WBW is actually a Call To Action, and it is about new action each year.  Not just about celebratory words and photos but action which generates change.  It's about reinvigorating a lobby group which can get worn down during the year.  Each year I find myself disillusioned about the lack of progress since last year.  At the end of WBW this year I've decided to end the conflict by positively undertaking that Call To Action.  I am going to write to my MLAs and MPs this week asking them how protections can be progressed in our current political system.  I will create some pressure.  Will you join me?

Thursday, 22 June 2017

Breastfeeding, Fertility and SubFertility: Breastfeeding in Pregnancy - are there risks?

This is part 3 of a blog series on Breastfeeding, Fertility & Subfertilty.  Part 1 looked at breastfeeding and the menstrual cycle.  Part 2 looked at fertility and avoiding or getting pregnant while breastfeeding.  This third part looks at breastfeeding while pregnant, whether it can pose any risk to the pregnancy, things to consider about breastfeeding and common experiences.

Breastfeeding while pregnant may be an odd concept to some that don't know that it's possible, but many women do feed while pregnant.  Some will wean while pregnant, either through choice or their baby self-weaning, and others will continue to feed through pregnancy and then tandem feed afterwards (feeding both their baby and toddler).  Some women who never intended to breastfeed in pregnancy will find themselves doing it as they don't want to wean their toddler.  Other women who really wanted to breastfeed in pregnancy can find they have awful nursing aversion in pregnancy and wean as they just don't want to continue.  Just like the fertility experiences we discussed in Part 1 and Part 2, experiences of feeding in pregnancy can vary widely.  

What happens to milk supply?

Although I want to concentrate on fertility, and safety/risks of breastfeeding during pregnancy in this blog, I think it's useful to have a couple of paragraphs on milk supply.  I find that many women who are trying to get pregnant while breastfeeding don't realise the impact it will likely have on their milk supply, and the potential need to supplement their baby, and it's something which is important to consider before hand.

This figure shows the anatomy of the breast. The left panel shows the front view and the right panel shows the side view. The main parts are labeled.
Image under creative commons from
Once a pregnancy begins, progesterone levels begin to rise.  This is due to the feedback loop which causes the corpus luteum to stay functional and producing progesterone rather than degrading (See Part 1).  High progesterone has an impact on milk supply.  

When we are breastfeeding, we store milk within alveoli, which are balloon type structures in the lobes of the breasts.  Our breastmilk is made and then stored in these alveoli.  Normally the walls of the alveoli are impermeable, and create a sealed container to hold the milk until the baby feeds.  They are made impermeable due to tight junctions between the cells along the borders of the alveoli.  When progesterone is high however (like in pregnancy) the junctions between the cell walls become leaky and so large quantities of milk can't be stored.  The milk leaks out.  This means that most women find that their milk volume changes in pregnancy, and becomes less.  When it happens varies from woman to woman.  Some notice a change in how often their baby/toddler is swapping sides and looking for more milk even as early as 6- 8 weeks.  Most will certainly see a difference by the 2nd trimester.  Along with this decrease in milk volume can be a change in taste.  Milk may taste saltier. Some babies/toddlers don't mind this, and some object.  Some toddlers even nurse, and then ask for a drink of water and then go back to nursing.  Younger, not verbal, babies obviously are unable to tell you about the taste and if they feel a need for more hydration, but may be more fussy.

Although a very small number of women see no real change in milk volume, usually by mid pregnancy milk volume is very low as it changes to colostrum.  In Adventures in Tandem Feeding, Hillary Flowers suggests that around 50% of nurslings wean during this time, and about 50% continue.  How this drop in milk volume might affect your baby/toddler can be different depending on age.  If your baby is much under 12 months and still dependent on milk as the main source of calories, you will likely need to add in a supplemental milk.  If your baby is around 12 months increasing solids may be enough.

After birth the opposite process happens with the tight junctions.  The delivery of the placenta causes a sudden drop in progesterone, and the junctions become tight and make the alveoli walls impermeable again.  This allow large amounts of milk to be stored and the sensation of "milk coming in".    

Having said that, let's move on to the safety / risks of breastfeeding during pregnancy.  Many women are advised by healthcare providers to wean during pregnancy - but is this evidence based?  What do we know so far....

Does Breastfeeding Cause an Increased Risk of Miscarriage?

Most of the resources I have read online on breastfeeding and miscarriage refer to the book Adventures in Tandem Feeding by Hillary Flowers.  In her book Hillary deals with the potential risk of uterine contractions caused by breastfeeding and whether those may cause miscarriage.   Hillary dismisses this as an issue because the receptors on the uterus to begin labour are not in place until shortly before birth.  In my experience, women who are sensitive to the contractions can often feel them happening while feeding even early in pregnancy. This is often compared to the contractions of an orgasm, which in most women is not thought to be a risk to the pregnancy.  In cases of high risk pregnancy however, some women are advised to avoid sex due to this risk.  Hillary Flowers has summarised the information about contractions and the uterus in an article on the Kellymom site, which I have linked in the further reading section, and so I won't repeat the same information here.  What I want to look at instead are the hormonal implications of breastfeeding in pregnancy, which I have never seen addressed well before.

If you haven't read Part 1 of this blog on fertility and subfertilty, then it might be a good idea to look at it first, or to refresh yourself with it if it's been a while.  In Part 1 I talked about the gradual process of returning fertility while breastfeeding, and how for a significant period of time women may be subfertile.  In a subfertile state the woman may be having regular cycles, and be ovulating in each cycle, but hormone levels may not be where they would be if she were not breastfeeding.  

I also wrote about the research on how suckling interferes with the GnRH pathway and increases the suppressing effect of oestradiol.  McNeilly's 1993 article "Lactation Amenorrhea" stated:

"Suckling appears to suppress the normal pattern of pulsatile release of GnRH 
and hence LH and prevents the normal growth of follicles. 
The normal positive feedback effect of estrogen on LH release is abolished, 
and estradiol exerts an enhanced negative feedback effect on both LH and FSH. 
Thus, while suckling continues, any follicle that starts to develop and secrete estradiol will inhibit further LH release and therefore stop growing. 
When suckling declines, the pulsatile pattern of LH returns to normal, 
sensitivity to estrogen negative feedback declines, and follicle growth can continue and ovulation will occur.

So suckling prevents the normal growth and maturation of follicles.  We also know that from Part 2, McNeilly stated that

"After the return of menstruation during lactation, 
the frequency of ovular cycles progressively increases 
but does not return to normal until complete weaning has taken place."

Many women find that when breastfeeding, their luteal phase is short.  We know that the luteal phase lasts as long as the corpus luteum lasts.  After ovulation, the corpus luteum produces high levels of progesterone.  The corpus luteum should continue to function for around 12 days and then begin to degrade.  As the levels of progesterone drop, the uterine lining is shed, around 14 days after ovulation.   If the luteal phase is shorter than this, it is due to the corpus luteum degrading earlier than it should.  It ran out juice, or had produced as much as it could essentially.  This may be due to lower hormones at the start of the cycle.  Lower oestradiol due to breastfeeding may result in a slightly less mature egg, and therefore a slightly less mature corpus luteum that just doesn't last as long.

This is significant in pregnancy because the corpus luteum function is vital in early pregnancy.  When pregnancy begins, a feedback mechanism stops the corpus luteum from degrading and causes it to continue functioning and producing high levels of progesterone.  The corpus luteum continues this function until the placenta fully takes over, which begins around 8 weeks, but doesn't complete until 14 weeks.  So the corpus luteum needs to be functioning right until the end of the first trimester.  Is it possible that a woman with a short luteal phase who gets pregnant could have a corpus luteum which runs out of energy and function before 14 weeks?

A 2008 study by Arck et al in Reproductive BioMedicine Online found that the risk of miscarriage was significantly increased in women who had lower progesterone prior to the onset of the miscarriage, and recommended progesterone supplementation to support the pregnancy and decrease the risk.    A Cochrane Database Systematic Review done in 2011 by Wahabi et al found that inadequate progesterone in early pregnancy is linked to miscarriage and that supplementing with progesterone is an effective in preventing early miscarriage.  Many fertility clinics do supplement women for  the first trimester (sometimes up to 20 weeks) with progesterone in order to maintain the pregnancy.  Progesterone supplementation in pregnancy has also been found in a Cochrane review to reduce the risk of pre-term birth in women with previous preterm birth and in women with a short cervix.
Tracking your cycle (See Part 2) will allow you to get a sense of what your hormonal profile is like before you conceive, and whether you are having a normal luteal phase, or whether your progesterone levels may be a little low.  A progesterone test with your GP is another way of checking your progesterone levels.  This is often referred to as a Day-21 progesterone test.  This "Day-21" figure comes from the idea that ovulation happens on day 14.  If you do not ovulate on day 14 (and many don't), then the test should be done 7 days after ovulation, not on day 21.  The NHS considers a progesterone level of over 30 nmol/L to be normal and to demonstrate that ovulation has happened.  Some fertilty clinics however see 30 nmol/L as a subertile figure and an indication that a slightly immature egg has ovulated, and would consider a level of 60 nmol/L to be optimal.

Obviously many women breastfeed through pregnancy and have entirely normal and healthy pregnancies and births, including women who have a short luteal period.  There are also very many women who have miscarriages when they are not breastfeeding.  Miscarriage occurs in around 1 in 4 pregnancies, so is already a pretty high risk, regardless of breastfeeding.  Although there is usually no way to know why a miscarriage has occurred we do know that there are risk factors.
Age is a risk factor (20% of pregnancies in women aged 30-39 end in miscarriage compared to 10% in women under 30).  Smoking, alcohol, excess caffeine, thyroid conditions, low body mass index are all risks.  Low progesterone is also a risk factor, and a short luteal phase (which may be due to breastfeeding) can be a symptom of low progesterone.  Could this mean that in some women breastfeeding was a risk to the pregnancy before conception began?  Does continued suckling during the early pregnancy for these women have a further effect to hormones?  There is very little data on any of this, and every woman needs to make the decision on whether you feel breastfeeding poses any extra risk for you or not.  If you are an older mother, have a luteal phase of 10 days when breastfeeding, and have been finding it difficult to conceive while breastfeeding, you may come to a very different conclusion about the risk than a younger mother who is breastfeeding, has a 14 day luteal period and got pregnant very quickly and easily while breastfeeding.  There is no right or wrong decision as to whether you should breastfeed in pregnancy or whether you should wean.  Neither route is better than the other, and each woman has to weigh up what will be the best overall route for her within her family circumstances.

Breastfeeding Aversion

Although some people breastfeed in pregnancy with no discomfort at all, most probably do have stages where they aren't enjoying it so much.  Nipple pain is common in pregnancy due to the hormonal changes, and many have periods of breastfeeding aversion, where they find breastfeeding unpleasant, or in some cases feel strongly that they just want the nursling to stop right now.  Adventures in Tandem Nursing (linked below) is a great resource for this which talks through different mother's experiences, how long it lasted and how they managed those feelings.  It can be very helpful to know that those feelings are common.  What is interesting to me about breastfeeding aversion is that it tends to occur at times of pregnancy, ovulation or menstruation.  They are important times for the reproductive cycle.  Women often respond by feeding less, or for shorter periods as a coping mechanism.  Is it possible that the body is giving us signals at that time to reduce sucking stimulus, in order to optimise our hormone secretion and create the maximum chance for a further healthy pregnancy?  

Any other considerations in pregnancy
Other than miscarriage, is there anything else to consider when breastfeeding in pregnancy? This is what we know from the research.  A number of studies have looked at whether breastfeeding affects the weight of the baby at birth, and found that there was no significant difference between expected weight and birthweight.  One study of Guatemalan women however found that although the difference was not significant, newborns tended to be lower in birthweight the longer the older child fed into the pregnancy (Merchant et al 1990).  They also found that the mothers who breastfed had reduced maternal fat stores despite consuming more of the nutritional supplements than other mothers.  The authors concluded that the fetus was protected at the expense of the mother, so being aware of your own diet being adequate may be important.  This isn't really surprising given the demands on the mother's body when both gestating and lactating.
A Peruvian study (Marquis et al 2002) looking at 133 women who breastfed in the 3rd trimester found that the babies had lower weight gain during the first month of life.  The babies spent more time breastfeeding, but took in less milk.  In one third of the cases the older sibling was being breastfed after birth, so it might be fair to think that perhaps the baby was gaining less weight due to the older sibling feeding, but the authors discounted this as a cause of the low weight gain.  In fact babies where the older child was weaned in the 3rd trimester took in least milk, those who were tandem feeding took in more, but the babies where there was no breastfeeding in pregnancy took in most milk in that first month, and gained weight best.  In this study BFP refers to Breastfed in Pregnancy.  NBFP refers to Never Breastfed in Pregnancy.
"When milk intake of the other child was considered as part of total milk production, the difference between BFP and NBFP mothers was reduced. The mean 1-month intakes of infants increased progressively from BFP/no tandem breastfeeding (762.5 ± 232.4 g/24 hour), BFP/tandem breastfeeding (768.6 ± 192.3 g/24 hour), to NBFP (813.0 ± 161.8 g/24 hour), demonstrating that tandem feeding did not account for the low milk intakes of BFP infants."

Whether this is applicable to Western societies with different diets is not clear.

So - is breastfeeding a risk to pregnancy?  Short answer - maybe, maybe not.   It really depends on the individual circumstances - the family trying to conceive, their fertility/subfertility status, their obstetric history, and how much breastfeeding is impacting that individual woman.  It also depends on what you define as risk - is miscarriage, pre-term birth etc the definition for you, or is an effect to weight gain, or larger draw on your own nutritional stores a risk for you?  Some women have had several pregnancies while breastfeeding subsequent children, and others very clearly feel that breastfeeding may have impacted their miscarriages, pre-term births or their ability to conceive.  Tracking your cycle when it returns can give you an insight into how breastfeeding is affecting you, as well as helping you to understand your own bodily processes in a much clearer way.

Fertility while breastfeeding is something I feel really passionate about - helping women to understand how it affects them and their cycle and hormones.  That passion comes from a personal journey and some difficult personal experiences.  For those of you who find that trying to conceive while breastfeeding is much more difficult than conceiving when you are not breastfeeding - I understand the difficult emotions involved with that.  It's important to remember just how much you are asking your body to do, and how much your body is already doing.  The lactating breast uses more energy than your brain!  You are creating a superfood, building an immune system, creating a personalised medicine.  The Lancet Breastfeeding Series states:

"If breastfeeding did not already exist, 
someone who invented it today would deserve a dual Nobel Prize in medicine and economics. For while “breast is best” for lifelong health, it is also excellent economics. Breastfeeding is a child's first inoculation against death, disease, and poverty, but also their most enduring investment in physical, cognitive, and social capacity."

Looking at it from an industrial perspective, Jon Eliot Rhode writes on economics:

"The lactating mother is an exceptional national resource, 
for not only does she process coarse cheap foods to
produce a unique and valuable infant food, but also the production
process (lactation) provides immeasurable benefits to health."

Pregnancy and breastfeeding are both everyday miracles and we forget just how amazing they are and what an amazing job your body is already doing.  Look at your nursling, and remember!                                      

Further Reading

Hillary Flowers on uterine contractions and breastfeeding in pregnancy -