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Holistic Sleep

The case for the floor bed

Many parents worry how they can get their co-sleeping older babies into their own room and into their own cots. However, there’s another way which can be much easier, much more gentle and less stressful for everyone. The floor bed!

The difficulty of using a cot is having to settle them into it. Contrary to popular belief, many children under the age of 2 do not lie down and go to sleep happily on their own. Many still need a feed or a cuddle to do this. But getting them to go into the cot after feeding or cuddling to sleep can be difficult. As soon as you lower them down and let go, they’re awake again, either almost straight away or at the end of the first sleep cycle.

A floor bed can remedy a lot of the problems. Either just a mattress on the floor, or on a low slatted bed base, or on conjunction with a cot (or two) with the side taken off.

Here are some of the positives:

* Baby is settled to sleep in the bed they are expected to sleep in. Often a baby falls asleep in its parent’s arms or bed as this is the easiest way to get them to sleep. Then when the baby wakes up, they find themselves in their cot, sometimes in a different room. This can be very disorienting as any adult who has awoken somewhere different to where they fell asleep can testify!

* If the baby wakes in the night, the parent can settle them back to sleep in the baby’s own bed easily with a feed or a cuddle. No need to move them out of their environment.

* The fact it is on the floor means it is safe if they roll out or get up and wander in the night. And they will not try to climb out of the cot! Ensure furniture is screwed to the walls for safety and nothing can be pulled on top of them. Parents can also use a baby monitor.

* Parents can co-sleep part of the night in baby’s bed if necessary ensuring a good night sleep for all. This also means that the other parent can remain in the parental bed. The co-sleeping parent can sneak back to their own bed if they are still awake once baby has settled.

* It is a very gentle way to encourage a baby to move into their own room or in with their sibling whenever the parents think this is the correct time for their family.

* Later on the parent can gradually retreat by lying next to the child, lying a bit further away, popping out for a minute, until eventually they are happy with a story, a kiss and a cuddle and then sleep.

So for parents wanting a gentle way to transition a child to sleeping on their own space, this can be an ideal solution.

Photos courtesy of Gentle Parenting Twins and Triplets UK & Ireland facebook group.

Breastfeeding

New mums, be more kangaroo!

kangaroo

I talk a lot about humans and kangaroos when supporting new parents. You see one of the few mammals who birth their babies at a more underdeveloped stage than us humans are kangaroos. Kangaroo babies crawl up into mum’s pouch and then latch on to the nipple and pretty much feed 24/7. Human babies, if left to their own devices after birth, crawl up their mum’s chest and then latch on to the breast. They then need to be fed very frequently. But unfortunately we don’t have a pouch. But we have strong arms, I nice curvy body to lie on and we can make a pouch by wrapping fabric to help our arms.

Humans are “carry” mammals. These include all the apes and marsupials. The “carry” mammals birth the most immature infants out of all the mammals. They are completely dependent on their mothers for food, warmth and safety. Our babies are fed frequently and because of this our milk has very low levels of fat and protein.

Other types of mammal are “follow” mammals such as horses and giraffes. These babies can walk soon after birth and feed quite frequently as they can keep up with their mothers. Their milk is a little higher in fat and protein than carry mammalsnas they feed a little less. “Nest” mammals such as dogs and cats leave their babies and return several times a day to feed. This means the milk needs to be higher in fat and protein to help them wait for their parents return. And then there are “cache” animals such as rabbits and deer. They leave their babies in a safe place and return every 12 hours or so to feed them. Consequently their milk is much higher in fat and protein in order to sustain them for long periods.

Many baby books seem to think we are nest animals. We aren’t. Human babies expect to be held constantly and fed frequently. Our milk is the perfect consistency for this. This is normal newborn behaviour.

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Breastfeeding babies born at 36 or 37 weeks

A baby born between 34+0 weeks and 36+6 weeks gestation is defined as a late preterm baby. A baby born between 37+0 weeks and 38+6 weeks is defined as an early term baby.

For babies who are born at this time, establishing breastfeeding can be quite difficult. They are often well enough to remain on the postnatal ward with their mothers, which is great as they do not have to go to special care. But as such they often get treated the same as a full term baby and are left to “demand feed”.

The problem is that these babies often do not “demand” enough and prefer to sleep, although I prefer the term “cue-based feeding” or “baby-led feeding”. They are often too sleepy for the mother to be able to follow their lead completely. And if they do not feed enough, they get even sleepier and harder to rouse to feed. Also a lot of slightly early babies are not physically strong enough or coordinated enough to fully breastfeed, often until around due date or even a bit after. They have a few sucks, take on a little milk, and then fall asleep before they have had their fill.

This can lead to real problems! Babies can lose weight, or jaundice can set in. Mum’s milk supply may not be stimulated enough, or she may lose her hard-earned milk supply if she was pumping in NICU. After a week or two it is decided the babies need supplementing, but the lack of breast milk may mean they need to use formula.

These problems are also experienced by parents of more premature babies as they are often discharged around what would have been 36-37 weeks gestation with minimal breastfeeding support. They are often given the chance to “room in” for a couple of days to practise feeding and looking after their baby or babies full time, and this is often the first time the breastfeeding mother is allowed to follow her babies’ lead.

These families need lots of support. They need good quality face-to-face breastfeeding support after discharge. They need to be shown the subtle cues their baby makes to show that they need a feed; stirring, mouth opening, turning head from side to side, and the later cues including stretching, moving arms and legs, trying to bring hand to mouth. Crying and agitation are late cues. (Maria Biancuzzo, Dec2018) They should be encouraged to feed their babies frequently. Dr Tena Fry said in her interview with Maria Biancuzzo: “If a baby’s eyes are open they should be offered food”. Parents also ned to be supported to understand when their baby is not cueing frequently enough. We would suggest not to let a baby of this gestation go longer than 3 hours from the start of each feed to ensure they have a minimum of 8 feeds in 24 hours.

Parents should also be shown how to ensure the babies are latching on well to feed. And tandem feeding positions can be discussed to help with the intensity of breastfeeding new baby twins. Also breast compressions are a very useful tool to help transfer a bit more milk to the babies during the feed, and to remind them to keep feeding when they get a bit sleepy towards the end of the feed. Sometimes a baby of this gestation may have trouble latching directly on to the breast. Babies who are a little early sometimes latch better and feed more efficiently when using nipple shields. Close attention should be paid to milk weight gain and nappy output if shields are used as they can inhibit milk transfer.

Parents may need support with continuing to pump for top ups if the babies are not ready to fully breastfeed. And they need to be shown how to tell that their baby is developmentally ready and feeding efficiently enough to move away from 3 hourly feeds and on to baby-led, cue-based feeding. The problem is each baby is different. Some will be ready to fully breastfeed at 36 weeks, others at 42 weeks, and everything in between. But mums often continue to supplement and schedule far longer than they need to. We would normally look for each baby to be putting on weight as expected, generally waking themselves for feeds before the 3 hour schedule, and having a good proportion of “active feeding” during a breastfeed. Then if mum is pumping for top ups this can be gradually phased out. They will be safe to move on to baby-led feeding. If parents are using formula to top up this can be gradually phased out. See our guide here

Ideally each family would be guided by somebody highly qualified such as an IBCLC or experienced breastfeeding counsellor. This is a scenario that deserves specialist breastfeeding support in the home on discharge from hospital, to ensure they can maximise the breast milk intake of their babies.

 

Kathryn Stagg IBCLC 2019

Cue-Based Feeding for Late Preterm Infants: 5 Facts You May Not Know

The Baby Friendly Initiative

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Was consent sought before offering premature babies formula or fortifier in UK NICUs? Results of a facebook survey. March 2018 Kathryn Stagg IBCLC


This survey was designed to find out whether UK families with babies in special care who were born before 34 weeks gestation were asked for consent before their babies were offered cows’ milk based infant formula top ups or cows’ milk based fortifier and whether the risks were discussed. The motivation behind this study was a reply on a Facebook post from a mother who lost one of her premature twins to NEC (Necrotising enterocolitis) after he was given cows’ milk based fortifier without her consent. She is quite certain that the fortifier had something to do with the baby developing this deadly disease, although there is little formal research to this back this up. However, there is quite extensive research into the risks of developing NEC when babies are fed with cows’ milk based infant formula. More studies into the risks of cow’s milk based fortifier are desperately needed to ensure parents can make an informed choice. One study found no significant risk of NEC whereas another found there was an increased risk. Studies are summarised here: https://bestbets.org/bets/bet.php?id=2309

Fortifiers are made from processed cows’ milk protein with added nutritional supplements. It is often offered to premature babies as studies have shown that breast milk alone does not contain enough of the energy, protein, vitamins, minerals and salts needed by rapidly growing premature infants. There seems less risk of fortifier triggering CMPA (Cows’ Milk Protein Allergy) due to the proteins being hydrolysed.

Studies into the effects of infant formula on the development of NEC are summarised in this article from UNICEF: https://www.unicef.org.uk/babyfriendly/news-and-research/baby-friendly-research/infant-health-research/infant-health-research-necrotising-enterocolitis/

Infant formula, also processed cows’ milk, is often offered to babies where the mum is struggling to meet the required amounts of pumped breast milk, or if baby is struggling to gain weight on solely breast milk then high calorie formula can be used to help. A significant association between early neonatal exposure to cow’s milk formula feeding and subsequent development of CMPA/CMPI has been documented.  https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1399-3038.1994.tb00352.x

The survey was an anonymous exploratory study and shared on the “Breastfeeding Twins and Triplets UK” Facebook group and the “Parents of Preemies UK” Facebook groups. Those who took part were free to choose to participate and were aware anonymous quotes may be used. 191 parents responded, 131 had singletons, 54 had twins, 6 had triplets, so that equals 257 babies in total.

Gestation in weeks                            

<25+9 9% 17
26+0 – 27+6 19% 36
28+0 – 29+6 24% 44
30+0 – 31+6 19% 37
32+0 – 33+6 30% 57

During their time in NICU these babies were given the following:

Donor milk 23% 43
Fortifier 64% 123
Formula 52% 99
Just breast milk 19%           36

This is how the rate of supplementation varied for different gestation babies.

(gestation in wks) <25+9 26+0 – 27+6 28+0 – 29+6 30+0 – 31+6 32+0 – 33+6
Donor milk 29% 22% 25% 35% 11%
Fortifier 94% 86% 82% 57% 32%
Formula 35% 50% 36% 49% 72%

Before your baby/ies were given formula or fortifier was consent sought and were risks explained?

No consent sought 31% 58
Consent sought/no risks discussed 44% 81
Consent sought/few risks discussed 15% 27
Consent sought/full risks discussed 10% 19

Was donor milk discussed and consent sought?

Not offered 68% 126
discussed/no consent 3% 6
discussed/consent 29% 54

As this survey covered from very early babies up to 34 week gestation one would imagine that the majority of time donor milk was not offered was for the later babies. However on further analysis, 50% of the babies less than 26 weeks, nearly 65% of babies between 26 and 28 weeks and over 60% of babies around 60% of 28-32 week babies were not offered access to donor milk.

I was also interested by the difference in numbers where consent was sought between formula/fortifier and donor milk. Perhaps donor milk is deemed far more risky than formula and fortifier? In reality, I am not sure this is the case.

Here are some quotes from the survey:

I was very clear that I wanted to breastfeed only but they asked me to consent to formula in case it was needed before I managed to harvest colostrum. No discussion about the risks of formula or the importance of breast milk. If I hadn’t been aware already I might not have understood the benefits of breast milk for premature babies.

Both my babies were prem. I had to fight to give my son my milk. They gave him formula without my consent. With my daughter I actually had a NICU nurse tell me that I would fail at breastfeeding and shouldn’t even bother trying! It broke my heart.

I felt pressured into giving fortifier by the dietitian even though the nurses informed me that they didn’t like to give it to babies, none of them would give me enough info as to why as they didn’t want to be seen as disagreeing with another member of staff (the dietitian) All my boys now have CMPA and I’m wondering if there’s a link.

I wish more units allowed donor milk – it’s so important.

When I had my 26 weeker I expressed for a while and one day I came in and my milk was getting something put in and all I was told it was fortifier he needed it and that was it.

Twin one was given formula on day one as nurses said he needed feeding, went on to solely breastmilk about day three then on to fortified breast milk shortly after. Twin two was given breast milk until he was on full feeds then given fortifier on day 9. Day 10 twin 2 became very ill with NEC and died within hours.

Was NEC (Necrotising enterocolitis) discussed with you?

Yes 30% 57
No 70% 132

NEC was only discussed with 30% of the families. Again maybe this low figure was due to the older age range, but on further analysis NEC was discussed only with between 30-40% of parents with babies born in the higher risk zones of 26-32 weeks gestation, rising to 50% of families with babies of less than 26 weeks gestation. 

Conclusion:

Although the risks of fortifier are still unclear, consent should always be sought and use discussed before babies are given it. The risks of giving formula are much more apparent; increased risk of NEC and development of CMPA and yet still it seems that consent is not always sought before it is given to babies. For 31% of the babies on this survey, consent was not sought. This needs to change. 

Breastfeeding

Babies feed for all sorts of reasons

responsive feeding meme

“He’s just feeding for comfort” is a comment us breastfeeding supporters hear a lot.

And why not? Anyone who has breastfed will soon come to realise that breastfeeding is about far more than just food. Yes its handy that this act of liquid love is also optimally designed to grow and nourish our babies, but there is far more to it than that.

Of course babies ask to breastfeed when they’re hungry. And they’re hungry a lot! But they may also be thirsty and just want a quick drink, especially in hot weather. Or their bodies and brains may be in a fast period of growth which needs to be fuelled.

They may also ask to feed if they’re feeling cold, if they want a cuddle, if they’ve missed you, if they’re feeling lonely, or tired, or poorly, or scared. Or if they are in pain. All of these reasons are just as valid as hunger.

Breastfeeding your baby whenever they ask, ensures not only that they receive enough nutrition but that their physical and emotional needs are met as well.