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2018 – a year in the life of a new IBCLC

Jan 2018 – The start of 2018 saw me setting up in private practice after finally qualifying as an International Board Certified Lactation Consultant. Such an exciting time. It’s been such a difficult journey but finally I had qualified. Next I built the first incarnation of this website, got all my forms together, found insurance, registered my business with Lactation Consultants of Great Britain “Find an IBCLC” so that local mums could find me. It started slowly with a couple of home visits in Harrow and Uxbridge.

I also began my role as Regional Coordinator for the East for The Association of Breastfeeding Mothers. My role is to support the volunteer Breastfeeding Counsellors with their National Breastfeeding Helpline duties, and the Trainee Breastfeeding Counsellors with their training. I also organise supervision and study days. I have been a Breastfeeding Counsellor with the ABM for several years now, taking calls on the National Breastfeeding Helpline and volunteering locally. Its a wonderful organisation and I am so proud to be part of the Central Committee.

Feb 2018 – Continued with a few home visits. Also I was very proud to host a “Supporting Breastfeeding Multiples” webinar for the National Breastfeeding Helpline. The technology worked and I had lots of lovely feedback about the session. I love talking to people about how to support twin and triplet mums to fulfil their breastfeeding goals. It’s the reason I trained as a peer supporter so many years ago when my now teenage twins were just 1 year old; to try to pass forward the amazing support I had received myself. So many people, including many health professionals, believe that it is not possible to exclusively breastfeed more than one baby. But it most definitely is, and with good, knowledgeable support mums can fully breastfeed if that’s what they wish to do.

Mar 2018 – This month saw a big surge in home visits mainly due to the weather I think! Its so lovely to be able to support a new baby and mother to breastfeed in their own home without the need to battle the elements. This is me dressed for the snow walking to my home visit as it was too dangerous to drive that day.

March also saw the launch of myself and colleague Miriam Feen’s specialist breastfeeding support group, The Lactation Corner.  Myself and Miriam have worked together in the past and volunteered together for years so I was very excited about this collaboration. We have a beautiful venue at Eastcote House Gardens with a lovely light room. We have a breastfeeding group there, and also run Introduction to Solids sessions and Preparing to Breastfeed sessions.

April 2018 – This month took me all over the local area, from Harrow to Iver to Denham to Edgware to North London. This IBCLC will travel (I do try to keep it to within half an hour of my house, although I will go a bit further for a twin or triplet mum!)

April also saw my first LCGB conference. What a wonderful experience! The highlight for me was Dr Jen 4 Kids, also known as Dr Jennifer Thomas. Such an inspirational speaker and she blew my mind with further information on breastfeeding and the microbiome. And of course then there was Nancy Mohrbacher! One of my all-time breastfeeding heroes. And amongst all these was my friend and fellow Harrow Peer Supporter Zainab Yate talking about her Breastfeeding Aversion and Agitation project. I was so proud of her and all she has achieved.

May 2018 – May was far more Harrow based which was a relief for my fuel bill! Supported a mum with Insufficient Glandular Tissue to try to breastfeed. Such a heart breaking situation. Unfortunately mums with this condition can struggle to make a full supply of milk for their baby. So we discussed maximising the efficiency of the feed, and we also used a Supplementary Nursing System to give baby some extra milk. Some was donor breast milk and some formula. This is where specialist breastfeeding support really comes into its own. The health professionals who were supporting her just did not have the specialist knowledge to maximise her chances of breastfeeding and couldn’t spend the 2 hours with her which was really needed to get to the bottom of her problems.

I also had my first booking for an antenatal/postnatal package. I love talking to mums about preparing to breastfeed. Gaining knowledge of normal baby behaviour and how to tell if your baby is getting enough is incredibly valuable before baby arrives and before the brain goes to mush!

June 2018 – June is always Conference time for the Association of Breastfeeding Mothers. This was my first conference where I was on the Central Committee. I realised just how much organisation this takes! This year the highlight was a visit from Kimberley Seals Allers who flew in from the USA to talk about her book The Big Let Down. It was a very thought provoking presentation. I highly recommend reading her book.

June also brought my first support session via Skype. Such a useful medium for follow up or general breastfeeding concerns, baby behaviour, returning to work, or other non latch related scenarios.

July 2018 – Home visits continue to be steady. The Lactation Corner have also begun to offer Introduction to Solid Foods sessions. This is a lovely interactive session with evidence based information and lots of myth busting! We either host it at Eastcote House or for a group of mums I one of their houses.

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Aug 2018 – I took a few weeks off and travelled round the country a bit seeing relatives. One highlight was trying out Ivan my self-build campervan for the first time. It worked, we fitted myself, my partner and 4 children all sleeping in a campervan!

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On my return from our adventures the volume of home visits sky-rocketed over the Bank Holiday weekend and the following week. Again I was travelling far and wide from North London to West London to Uxbridge to Watford supporting mums and babies with latching difficulties.

Sept 2018 – My youngest started school. He ran in without a second look. I put this down to him being a seriously high-needs baby and toddler who was, on the whole, responded to as best as I could. He is now so securely attached that nothing phases him at all! The youngest starting school is quite a monumental thing for our family. Now all 4 kids are at school. Not all in the same school, but all in school! This means I have a bit more time to really focus on supporting more mums alongside my other work commitments. Although there still does not seem to be enough hours in the day to do everything.

I also began working at an IBCLC led breastfeeding group in NW London. Its been fantastic to work alongside such passionate and experienced IBCLCs. I’m very lucky to have been given this opportunity.

Oct 2018 – My main focus this month was hosting a National Breastfeeding Helpline Study Day for the East of England. We went to Ely, Cambridgeshire, and lots of BFN and ABM breastfeeding counsellors, trainees and mother supporters came along. Subjects covered were Breastfeeding Premature Babies, Genuine Low Milk Supply, Breastfeeding in Slings, Gentle Night Weaning, and Referral Scenarios presented by me and some of my colleagues. The day seemed to be a great success and we got really good feedback.

I also tried my hand at doing a Facebook Live session on antenatal hand expressing of colostrum. It seemed to work well. I shall do more in the future on various topics!

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Nov 2018 – November turned out to be an incredibly busy month with home visits squeezed into every available slot in the week. I also managed to find the time to attend a Tongue Tie Study Day with Sarah Oakley, IBCLC and Tongue tie Practitioner. Quite a high proportion of the mums I support are having difficulties with breastfeeding due to their baby having a tongue tie. Sometimes we manage to work around it with improved positioning and attachment and ensuring baby is feeding as effectively as possible. But sometimes we decide we need to refer on to a tongue tie practitioner to have the tongue tie divided. This session consolidated the knowledge I had already gained in my IBCLC training on how to assess a tongue tie and its impact on breastfeeding.

And my Facebook support group, Breastfeeding Twins and Triplets UK tipped the 4000 members mark. I’m so proud of that group. Its such a wonderful, empowering and friendly Facebook group. We keep it evidence based and supportive, and me and my fantastic team of admins very rarely have to step in. Its my favourite place on the internet!

Dec 2018 – Breastfeeding support calmed down a little leaving me time to go and watch the film Tigers . This is such an important film from Danis Tanovic based on the true story of former Nestle Pakistan salesman taking on the baby milk industry with the help of IBFAN. I was disappointed to miss it when it was shown a couple of years ago so when the chance came again I jumped at it. There was an added bonus as co-writer and co-producer Andy Paterson was available for a Q&A session afterwards. I have just finished off the year with a couple of home visits.

December also sees me completing a Holistic Sleep Coaching course, just the assignment to go and I will be a qualified Holistic Sleep Coach. The Holistic Sleep Coaching Program focuses on supporting and empowering parents, providing gentle strategies (based on evidence), which never involve leaving babies to cry alone. I am very excited to be able to offer this service in the new year (once I’ve completed the assignment!). Watch this space!

And of course, continuing to offer Specialist Breastfeeding Support. It’s such a privilege to be able to help mums at this important time. Thank you so much to all the families that have invited me into their home.

 

BRAIN mnemonic and infant feeding

Thanks Shel Banks IBCLC Lactation Consultant for creating this meme on the mnemonic B.R.A.I.N. used for making decisions. She has made it relatable to medical care for you and your baby
So important to consider when health professionals or others are encouraging interventions that are not in your plan.

Topping up with formula because of poor weight gain is one scenario where this is really useful to use. Asking your midwife/health visitor/paediatrician these questions when formula top ups are being suggested may make them think a bit more about their recommendations. And will mean you can make an informed choice as to whether this is something that needs to be used. My experience of supporting many breastfeeding mums over the years is that often formula is offered as an easy and less time consuming solution than helping a mum to breastfeed more effectively or increase her milk supply. Generally very little thought is given to the consequences.

Benefits
– increased weight gain
– less risk of health problems related to poor weight gain

Risks
– drop in mother’s milk supply
– bottle preference
– baby developing cows milk protein allergy
– changes to the gut microbiome
– damaging maternal confidence in breastfeeding

Alternatives
– specialist breastfeeding support to assess feeding, improve latch and milk transfer
– increasing frequency of feeds
– breast compressions to increase milk transfer
– expressing mother’s milk to offer as a top up
– use of donor milk from milk bank or other trusted donor.

Intuition
– what is the mother’s gut feeling telling her? Mother’s intuition is often correct.

Nothing
– what happens if we wait? Sometimes mothers and babies just need time for their feeding to click into place
– sometimes weight gain will continue to be a problem and so an intervention is necessary.

Of course, formula can be life-saving given in the correct circumstances. But it should never be given without good breastfeeding support offered, risks discussed and alternatives considered.

Establishing milk supply with a pump

There are several reasons milk supply may have to be established by expressing and not by directly breastfeeding. Mother and baby may have to be separated after birth due to prematurity or illness, or maybe baby just cannot latch on for some reason. Maybe baby is tongue tied, has a cleft palate or is too sleepy to feed effectively.

So how does a new mum start to establish a milk supply if she is not directly feeding her baby?

After birth you should be encouraged to hand express colostrum within an hour of birth if possible, or at least within the first 6 hours. Ask to be shown the technique by your midwife, or there are plenty of great video tutorials online. This one from Global Health Media is particularly good, click here. It is important to massage the whole breast and the nipple for a couple of minutes before starting. Hand expressing is recommended for the first two to three days until the milk begins to come in as colostrum is very thick and sticky and is in small quantities, so will get lost in a pump. However, if large quantities of colostrum are being expressed, you could move onto the pump earlier. Also there are settings on some hospital pumps designed for expressing colostrum and some mums respond better to this. The pump can also be used just for stimulation.

Babies only need a small quantity of colostrum, so every drop counts. These small drops can be sucked up with a syringe direct from the nipple or dripped into a small cup and then sucked into a syringe. This can then be given directly to the baby. You should be encouraged to hand express 8 to 10 times in 24 hours to mimic the baby’s feeding patterns. This will give enough colostrum to feed and to prime the lactation sites so that you will have the greatest chance to make a full supply or as near as possible. Some mums do struggle to express any colostrum in the first few days. It does not mean it’s not in the breast, we all start making colostrum in the second trimester of pregnancy, but it can be a bit challenging to get it out. If it is proving difficult then maybe ask about donor breast milk until your milk “comes in”. Most mums find they can express mature breast milk much more easily.

 

 

lilli put pumping

Moving on to the pump. Milk begins to “come in” around 3 to 5 days after birth, a process called “lactogenesis II”. It is triggered by the birth of the placenta and will happen whether a mum is breastfeeding, pumping or doing neither. Breast milk gradually changes from colostrum to mature milk over a number of days and volumes should begin to increase. Continuing to pump 8 to 10 times a day will help ensure you establish a full supply.

Top tips to establish a good supply!

Frequency – There really is no better way to get a full supply than to pump frequently; 8 to 10 times a day to begin with is essential. Some mums with large storage capacities may be able to drop a couple of sessions and continue to make enough milk, but for many frequency is the key. Expressing sessions do not need to be equally spaced. And if you miss one for some reason, try to shuffle up the others so you still get the same number over 24 hours.

Efficiency – Using a hospital grade pump is recommended. In hospital the staff should be able to provide one for you to use, normally in the pumping room, sometimes by baby’s cot or incubator. Once discharged, hospital grade pumps can be hired either direct from the manufacturer or from a local pump agent. If baby is in NICU there is often a discount code.

Breast shell size – It is really important to get the pump’s breast shell size correct. This will mean pumping should be comfortable and not cause any damage to the nipples, and it will also help maximise milk production. Just a note to say sometimes a pair of breasts need two different sized shells! And sometimes you need to change size as you go through your pumping journey as breast size changes. Nipple diameter is the key. Check your manufacturer’s information on this and experiment a bit.

Power pumping – This mimics a baby’s natural cluster feeding pattern and can help stimulate milk production. The pattern is as follows using a double pump: pump for 20 minutes, have a 10 minute rest, pump for 10 minutes, rest for 10 minutes and then pump for a further 10 minutes. This can be done once a day to help boost supply. If you are using a single pump then you can power pump by pumping 10 minutes on the left and then 10 minutes on the right, rest 5 minutes, pump 10 minutes on the left and 10 minutes on the right, rest for 5 minutes and then pump ten minutes on the left and 10 minutes on the right again.

 

power pumping

Hands on pumping technique – This is a technique which incorporates massage, hand expressing and pumping all at the same time. Many have found that this can greatly increase output. For a more detailed explanation watch this video

Hand expressing – after the flow has slowed you could try finishing off by doing some hand expressing. Often a little more can be squeezed out by hand

A hands free pumping bra – This can make the above massage much easier, as you use the bra to hold the pump onto the breasts and so hands are free. It also means you can pump and do other things at the same time. This can be essential, especially if you have older children. You can buy them or make your own by cutting vertical slots in an old bra or sports bra where your nipples are, and you can insert the cones through the slits.

Warmth – Applying a warm compress just before you express can help the let-down reflex.

Skin to skin with baby – Skin to skin, or kangaroo care as it is often referred to, helps boost oxytocin and encourages the milk to flow. Oxytocin is one of the key hormones involved in the production of breast milk and, amongst other things, stimulates the let-down reflex, meaning milk flows more easily when pumping.

Look at baby – Photos, videos, pictures, pumping next to the cot, listening to your baby. All these remind the breasts what they are supposed to be doing! They also stimulate oxytocin and help with supply.

Latch baby – If baby is beginning to latch on to the breast, pumping straight afterwards can make it much easier for the milk to flow as the baby will have stimulated the let-down reflex.

Distraction – “A watched pot never boils”. It’s the same with pumping. If you watch what you get, you will likely not get so much. Distracting with listening to music, relaxation recordings, mindfulness, watching comedy, chatting to other mums or friends and family all have been shown to increase milk production. Stress can inhibit the let down reflex so these techniques can help keep you relaxed.

Eat and drink – Good for health and energy of the mother, not necessarily for milk production.

Rest – It is really essential for mums to rest. Yes we also want them to wake once or twice a night to pump, but getting a good amount of sleep is so important to cope with the stresses and strains that you feel when a baby who is latching. Get help with all the usual household chores, looking after older children and cooking. Mother the mother so the mother is able to mother the baby.

Galactagogues – There are many foods or medications out there which either have some scientific evidence behind them or have anecdotal evidence that they can increases milk production. However, none of these work unless the milk is being removed frequently from the breast. They are not a magic wand. For more info on galactagogues have a look at this link
pump Sophie De Sousa expressed stash

It is important to look at 24 hour output, not necessarily what is expressed in each session. This is because there is often a wide variation in amounts from different times of day, and also each breast often gives a different amount. Over the first few weeks, we hope to see a gradual increase in volume in each 24 hour period.

Once babies are strong enough or well enough they should be able to move gradually on to breastfeeding directly. Make sure you seek some support from a trained breastfeeding specialist to help you achieve this.

Kathryn Stagg IBCLC 2018

 

Gentle Night Weaning Your Toddler

Babies and toddlers wake in the night. We know that. Babies  and toddlers often like to feed a lot in the night. That’s a given. But sometimes it all becomes too much. Sometimes its exhaustion, sometimes its nursing aversion, sometimes work commitments and sometimes it’s just that mum has had enough. Night weaning is generally not recommended until after 18 months by most Gentle Parenting experts. At this age they have some understanding of what is going on. Sleep is a developmental stage, like walking and talking, and babies and toddlers will do it when they are ready. Some will have large chunks of sleep from an early age and that’s fine, but others continue to wake frequently well into their second year.  There are definite genetic factors at play.

Breastfeeding is by far the easiest and fastest way to settle a baby back to sleep when they wake. But there may be a point where mum needs to stop it. This should be for the mum to decide and nobody else. She will know if she is ready to night wean. If she is not sure whether she should, then it probably is not the right time yet. It is nobody else’s decision; not the health visitor, grandmother or even the partner. And just to make sure you understand, night weaning will not necessarily make them sleep any better. They may still wake, and you will have lost the easiest way to get them back to sleep. However with lots of consistent alternative reassurance they will begin to be able to transition from one sleep state to another. Toddlers not being too over tired during the day will also help with this.

Breastfeeding at night is not so much about nutrition for toddlers. There is a big emotional context to it. Breastfeeding is helping them feel safe, to deal with all the big emotions of being a toddler, to deal with the pain of teething, to reconnect after being separated due to work and child care. There’s a whole load of stuff going on. So it’s important not to take away the other comforts that they are used to whilst you try to night wean. Co-sleeping, bed-sharing, cuddles, using a comforter like a toy. These can help the transition away from relying on the breast to settle back to sleep.

Find other ways to settle your toddler at night. There are many different things you can try as a replacement for breastfeeding; cuddling, stroking, patting, singing, use of a special toy or blanket, music, white noise, whatever works best for you. Some will work better than others and everyone is different. You will find the best option for your family.

One thing to try is to cuddle or stroke back to sleep whilst they’re stirring before properly awake. Toddlers go through sleep cycles from deep, slow wave, sleep to light REM (rapid eye movement) sleep regularly and it is during the REM sleep that they often fully rouse and need help to resettle back into a deeper sleep again. Unfortunately a toddler’s sleep cycle is much shorter than an adult’s. This only really works if you are bed sharing as you will need to be in close proximity to be aware when they are about to wake. But if you can cuddle or rest your hand on their body and settle before they are completely awake, you may find they go back into another deep sleep without fully waking and demanding to be fed. I found turning my toddler away from me and cuddling tightly from behind worked fairly well.

Try with just one of the night feeds. Try the first wake-up of the night and see if you can settle your toddler in a different way. This is the most likely night feed to be able to drop more easily. As the night progresses and morning approaches, sleep often becomes lighter and toddlers are more difficult to settle back to sleep. They often like to get up very early at this age. The most likely thing to help you stay in bed for a bit longer is to continue to breastfeed in the early mornings!  

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Find another comforter. Toddlers often like to have a comforter in bed and these can really help to transition away from breastfeeding being the major comfort. The comforter can be anything your toddler is attached to. It can be a toy or blanket, or sometimes physical touch can replace breastfeeding; my toddler would slide his hand up my sleeve for comfort. The replacement comforter should be introduced well before the night weaning process is begun as it should not be seen as a replacement for breastfeeding but a separate comfort. Then slowly you can encourage your toddlers to become more dependent on this and less dependent on breastfeeding.

Shortening feeds. This can be especially effective if you are experiencing nursing aversion. Nursing aversion is a negative feeling some mums get when feeding. It is often hormonally driven, ovulation and menstruation can be a trigger, and pregnancy is a major culprit. So in order to continue being able to breastfeed, shortening the feeds can work well. You can talk to your toddler about having “a little bit”. To start with, tackle the bed time feed, pull off the breast by sticking in your little finger and breaking the seal just before your toddler is about to drift off to sleep and encourage them to do that last bit on their own. You can always re-latch them if it doesn’t work. Once the toddler is used to this you can gradually unlatch sooner and eventually they may settle to sleep from awake on their own. Some mums like to sing a song during this feed and when the song is finished, the feed is finished. If you are having a particularly bad day you can sing faster! Once they are good at settling to sleep without the breast they may be more able to move between their night time sleep cycles without feeding. They may settle for the song. Or they may settle with just a few of sucks.   

Talk to your toddler throughout the day about how boobies will be asleep tonight and how they can have some in the morning. Let your toddler choose which comforter they would like to use. Remind them again just before bed time. Try to keep it positive. When will they be able to feed again, you can feed once the sun shines, boobies have gone to bed and will be back in the morning. Try not to focus on rejection; on saying no, not now. Some parents find a Gro-clock can be a great visual aide for this method. The Gro-clock can be set to go from day to night at a certain time and you can explain to your toddler that they can breastfeed once the clock says it is morning. You can set an early time to begin with and extend it later on, once they get the concept. There is also a lovely book called “Nursies When The Sun Shines” by Katherine C Havener which focusses on night weaning and explains to the toddler that she will be able to nurse when the sun comes up.  

Dad sleeping with babies

If your toddler is happy to settle with your partner, and they must be truly happy, sometimes this can be a good technique to night wean. Your partner can go in first and try settling first. If it doesn’t work then you can go in and breastfeed back to sleep. Some babies are more receptive to this than others. But often only the breastfeeding parent will do and if this is causing further distress it may be a good idea to stop.  Remember for a toddler breastfeeding is a way to connect with you, their mum. So keeping the connection is important. We don’t really want to remove the mother completely from the comforting, just the breasts

Night weaning is often a very gradual process. Aim for small goals and baby steps. And don’t be afraid to stop if it does not feel right. Teething, illness, changes of circumstances, can all increase night waking and sometimes it may just be easier to go back to breastfeeding in the night again. Then once the unsettled period has passed you can try again. Also don’t be afraid to stop at a certain stage if you are all happy. Sometimes mums find that one or two night feeds are actually quite doable and continuing with these can actually make night times easier. Each journey is very personal between mum and her toddlers and what will work for one family will not necessarily work for another.d and j in bed

www.isisonline.org.uk/twins/

www.parentingscience.com/baby-sleep-patterns.html

www.feedsleepbond.com/how-to-stop-breastfeeding/

www.emmapickettbreastfeedingsupport.com/twitter-and-blog/weaning-toddler-bob-and-pre-schooler-billie-how-do-you-stop-breastfeeding-an-older-child

“The No-Cry Sleep Solution”; Elizabeth Pantley

“The Gentle Sleep Book”; Sarah Ockwell-Smith

 

Kathryn Stagg, IBCLC and ABM Breastfeeding Counsellor, Dec 2017

Dropping top ups gradually – a step by step guide

A lot of babies are discharged from hospital topping up with either formula or expressed milk. This can be for a number of reasons; babies were born early and were not efficient feeders, babies were premature and started life with tube feeds, babies have lost too much weight, babies had low blood sugar, baby may have had a tongue tie fixed, there was more than one baby! So how do we move on from this? Once a baby is efficient at feeding the breast, there are a number of stages we can go through to move towards exclusive breastfeeding. I cannot stress strongly enough to get some face to face breastfeeding support to make sure you have an optimal latch and that baby is feeding well.  Dropping top-ups should not be started until baby is gaining weight steadily, has plenty of wet and dirty nappies, and is generally settled between feeds. A breastfeeding specialist will help you determine this and talk about what to look for.  This journey can be started at any point depending on how much topping up is happening, or left at any point if happy with a  certain level of mixed feeding.

Nappy output, especially wet nappies, is a fundamental sign that baby is getting enough milk and staying hydrated, and is something mum can keep an eye on very easily. For a baby between 1 week and 4 or 5 weeks old we should see 3 to 4 dirty nappies a day and at least 6 wet nappies. For older babies they can go for days without a poo and be fine, as long as it’s soft and abundant when it does arrive, but there should still be lots of wet nappies. Baby should also be weighed between each stage to make sure they are still roughly following their curve on the growth chart.

Firstly we need to make sure baby is going to the breast every feed. If a feed is missed because of giving a bottle, mum’s milk production will go down. When milk is left in the breast it sends messages to the milk producing cells not to make any more. If the breast is emptied frequently the production goes up. The more you feed, the more you make. If baby will not go to the breast for some feeds then mum should express her milk instead. Also if baby is fussy at the breast an not feeding well, mum should be encouraged to express her milk to start boosting supply.

It is important to put baby to the breast during the night. It might be tempting to skip a feed and get some sleep but this can be detrimental to mum’s milk supply. Prolactin, the milk making hormone, is at its highest at night so we want to take advantage of this to put in an order of milk for the next day and help maintain a full milk supply. Learning to feed lying down can be life changing as long as safe bed sharing guidelines are adhered to. Your local breastfeeding specialist will be able to help you with different positions, making sure the latch is still good.

If baby is having a high volume top up after every feed (more than 30-40ml) but is now feeding efficiently and putting on weight steadily, the first step is to drop the volume of formula in each top up. Your baby will probably start doing this naturally themselves as feeding becomes more efficient, so follow their lead. Baby can be put back on to the breast to settle if necessary. This will increase the amount of stimulation for the breast and will help boost milk supply. It will also encourage baby to get used to settling on the breast. If the baby will not tolerate going back on the breast then mum can pump instead and replace some top ups with expressed. We want to start increasing mum’s milk supply towards the level that the baby is taking without risking weight gain issues. Mums should be encouraged to be baby led and allow the baby to feed frequently. If baby is still a little sleepy and not waking for feeds then mum should wake baby every 3 hours or more and feed at least 8 times in each 24 hours as a bare minimum. We measure the 3 hours from the start of each feed. It is good to clear the diary, get a feeding station set up with everything she needs; snacks, drinks, phone, remote control and some good box sets to watch, and do as much feeding and skin to skin as possible. I like to call this ‘Topless Telly Time’. Breast compressions, basically hand expressing whilst baby is latched on, can help increase the amount of milk the baby is getting whilst feeding and can also stimulate a sleepy baby to start sucking again.

Once the baby is on a small volume top up every feed (30ml or less) we can work to drop some of the top ups. It is important to get baby weighed before this next stage to ensure weight gain is steady and has not slowed due to the decreased top ups. If weight is suffering, adding some larger top ups will be necessary and get some further face to face breastfeeding support. It may be a case of waiting a bit longer to start decreasing. 

If the baby is growing well and has a good nappy output, a good halfway house is to aim to top up 3 times a day. Pick times of day when baby is more fussy and is less willing to go to the breast to keep your top ups. You will probably find that baby will start to do this themselves at certain times of day so again, follow their lead. But it is good to spread them fairly evenly over 24 hours. Take a section of the day and let the baby feed frequently or cluster feed during this time until they are settled enough. Feed when baby shows early feeding cues, do not wait for them to cry. Mum can put the baby back on the breast as many times as it takes. Skin to skin continues to be very beneficial at this stage. Over the next 3 or 4 days she should see some of the cluster feeding behaviour diminish or the frequency of feeds reduce a little as milk supply catches up to the needs of the baby. Remember the more often milk is removed from the breast, the more milk is produced. Breasts are factories, not store rooms. If demand is increased, production increases to match. Feeding frequently is completely normal for a breastfed baby, and they often have periods of fussy cluster feeding for the first few months, often in the evenings. Mum will learn what is normal for her baby if she follows his needs, and this will give her confidence that everything is going well. Continuing to get baby weighed during this time is important to ensure milk intake is sufficient. And keep in touch with local breastfeeding support. 

Another option is to pump after every feed and work to replace formula top ups with expressed milk. This technique will be necessary to increase milk supply if the baby is not so efficient at the breast, is not transferring the milk well, or is too sleepy to take a whole feed. Then as the baby becomes stronger and more able to feed baby will be able to take more milk directly and she will find that she does not need to top up as much and can reduce the pumping. Face to face breastfeeding support can help with this.

Once we have 3 top ups a day with baby led breastfeeding in between it is relatively straightforward to stop the last of the top ups. Mum can either stop them all at once or drop one at a time. It is often a relief to have the relative simplicity of just breastfeeding without all the faff of bottles, sterilizing, pumps and making up formula safely. Breast milk is always ready, day and night, it sends both baby and mum off to sleep easily, and it’s free!

For twins or triplets all of this still applies. It may be a good plan to get some support with tandem feeding. Tandem feeding obviously maximizes the time spent feeding as there’s less waiting time for babies. It syncronizes the babies’ feeding times and more importantly sleeping times! A strong feeder can help a weak feeder by stimulating the let down and getting the milk flowing. It increases milk supply and also the milk can have a higher fat content.

Mum may get to a stage where she is at maximum capacity for breastfeeding, whether there be physiological reasons for not being able to produce enough milk and baby just cannot maintain weight on solely breastfeeding, or maybe she decides she needs to keep some formula for other reasons. If this is the case she can mix feed and do one or two whole feeds of formula each day, and continue with baby led breastfeeding for the rest of the day and night. Or she could continue to top up some of the feeds. Any amount of breast milk is so important for baby and for mum. We must value every single drop. Once baby moves on to solid foods and begins to reduce their milk intake naturally, the formula can be dropped then and breastfeeding can continue for as long mum and baby enjoy it. 

Kathryn Stagg IBCLC Aug 2017

References:

http://kellymom.com/bf/got-milk/supply-worries/enough-milk/

http://kellymom.com/hot-topics/milkproduction/

 

Transitioning your premature baby onto the breast- a parent’s guide

When a baby or babies have arrived early, Mum often feel stressed and helpless and feel one of the few things they can do is to provide breast milk. Preterm breast milk is different to that of a mum who delivers at term. It has higher levels of energy, fats, protein, vitamins and minerals, and most importantly it has higher levels of immune factors. It is highly valued in the neonatal unit and mums are usually supported to hand express colostrum within the first 6 hours after birth, and then move onto the pump to provide breast milk for tube feeds. The hospital should be able to advise on renting a hospital grade double pump for when mum is discharged. It is important to pump frequently; we recommend 8-12 times in 24 hours making sure at least one is between 2-5am when hormone levels are at their highest. There will be a more detailed blog on establishing milk supply through pumping soon.

 But what next? How do we go about actually breastfeeding? Is it possible to move to exclusively breastfeeding when you have had such a traumatic entrance to the world? The answer is yes, but it will take time.

Once premature babies hit around 32-33 weeks gestation they often begin to start developing a suck, swallow, breathe pattern in short bursts and may start rooting for the breast. Hopefully mum will have already been given the chance to have lots of kangaroo care with her baby before now, but at this point it can really help transition the baby from tube feeds onto breastfeeding.

Learning to breastfeed when you are a premature baby is a long, slow, tiring process and it requires everybody to have lots of patience. To start with babies can have skin to skin time, or kangaroo care, be encouraged to lick the nipple and if they are ready to possibly have a few sucks. A baby can begin with non-nutritive sucking at the mum’s recently pumped breast to provide a gentle experience without an overwhelming flow of milk. Then a fuller breast can be introduced. But at this early stage the majority of any feed will still be  expressed milk through the feeding tube. The staff will encourage mum to maybe try baby once or twice a day at the breast so as not to tire them out too much. Once they become stronger and start to suck and swallow more efficiently its time to move to more frequent feeds. It can be a good plan to try baby at the breast during their tube feed as they will begin to associate the act of breastfeeding with the feeling of having a nice full tummy. A nipple shield can help the smaller baby to latch onto the breast, especially if they have been given bottles. There is evidence that suggests shields can incease milk intake in preterm infants in the early days. Remember ask for lots of support from the hospital staff during this time. This is actually one of the benefits of having babies in special care.

When the babies appear to be feeding better and getting much more milk we can move on to the next stage. This can be at different ages for different babies. For some it can be around the 36-37 week gestation mark, others need to get to near full term. The hospital staff will help give confidence that it is time to move to the next stage. Whilst some babies will be able to move straight on to exclusive breastfeeding from tube feeding, this new enthusiasm for feeding can be a bit misleading as the suck can still be uncoordinated and inefficient and the babies can still tire easily. If we move on to exclusive breastfeeding too quickly, it can cause problems with babies not taking enough milk, becoming too tired and then starting to reduce their weight gain. So for many babies its advisable to continue to top up with expressed for a while. A lot of mums choose to top up by a different method than tube so the babies can get home. Hospital staff may use a tool like the Breastfeeding Assessment Score below to calculate how much top up to give baby. They will calculate to work out exactly how much milk  depending on baby’s weight, gestation, growth about how much a full feed is.

For twins and triplets it is important to remember that they are individuals. One baby may be much better at feeding than the other. It can be hard not to compare and be worried and frustrated  if one baby is not managing to feed as well. But, with time, it is very likely that they will catch up and both will feed well from the breast when ready. 

Generally hospitals prefer to use bottles to feed babies their top ups, or during the night when mum is not there. They are easier, there’s less waste and staff are pushed for time so go for the easier option. So to minimise the impact of using a bottle on breastfeeding, it is important to use a paced bottle feeding technique. Paced bottle feeding means letting the baby take control of the speed of the feed and when to take breaks and when to finish. Sit baby in an upright position and keep the bottle as horizontal as possible whilst still filling the teat with milk to avoid intake of air. Baby should be encouraged to latch on to the bottle like the breast, so touching the top lip to encourage baby to route and bring baby onto the bottle chin first, teat into the roof of the mouth. Stop frequently and make sure you do not force baby to have a certain amount. With this slower feeding technique, the baby will be able to tell it is full and finish the feed when satisfied. And baby will be more able to transfer  between bottle and the slower flow of the breast.

Mum and baby will hopefully be given the chance to ‘room in’ for a night or two before they are discharged. During this time they’re often encouraged to move on to more baby-led feeding as opposed to hospital routine based feeding. But babies can still be sleepy and not wake for feeds at this stage so its important to make sure that they feed at least every 3 hours as a minimum. 3 hours is measured from the start of each feed.

For a lot of preemie mums, their first experience of being at home with their early baby is to be in an intense breastfeed, top up, express routine, every 3 hours or more, day and night. This is utterly exhausting and overwhelming and mums can often not see past this stage. However with good feeding support from health visitors and breastfeeding specialists and the discharge team from NICU, mums can move on to exclusive breastfeeding.

Whilst the baby still needs top ups it is imperative that there should be somebody to look after mum. This routine is so full on that there is not much time for anything else, especially sleep! Somebody to do the top up whilst mum expresses can be a life saver as this can save time and could give mum half an hour extra break before she has to start the process again. Breastfeeding makes you hungry and for mum’s energy levels it is important that she eats properly, so having someone to feed her whilst she feeds the babies is a great idea. Every single breastfeed given and every single drop of expressed milk should be valued and encouraged. Emotional support reassuring her that she is doing a brilliant job and that soon it will become much easier can keep everyone going through this incredibly tough time.

Support can be invaluable at this time but a lot of mums feel unsure about taking their preterm baby out to groups due to risk of infections. This is where home visits from well informed health care professionals and good online support can step in. Online support especially can be great, as long as it is properly moderated, as mums can make contact with others who have been in the same position or are going through it at the same time. Peer to peer support is incredibly important. There is also often somebody around at 3am during the night feeds to sympathise!

So how do we know when a baby is feeding well enough to move on from this routine? Often around due date or just after, babies suddenly ‘get’ feeding. Their suck becomes more coordinated and they can remove more milk from the breast. You can watch for the full term feeding pattern of sucking fast for a minute to stimulate the let down, and then move on to deep slower jaw movements with pauses in between. You may be able to hear swallowing. Breast compressions can help to get a bit more milk into the baby if they are still seeming a little inefficent or sleepy at the breast. They often have a big feeding frenzy at around due date and sometimes want to cluster feed. This can be very unnerving for a preterm mum who is used to having a sleepy baby who needs to be woken for feeds. Cluster feeding should be encouraged and explaining to mum that it is completely normal behaviour and will help baby get lots of milk. However it does not necessarily translate in to weight gain immediately. It can be very discouraging when baby has been feeding all night and only put on a small amount the next day. However you often find a day or two later and it pays off.

For twins or triplets it may be a good plan to get some support with tandem feeding. Tandem feeding maximizes the time spent feeding as there’s less waiting time for babies and it is a more efficient use of time. It helps synchronize the babies’ feeding times and more importantly sleeping times! A strong feeder can help a weak feeder by stimulating the let down and getting the milk flowing. It also increases milk supply and the milk has a higher fat content.

Dropping or reducing the top ups gradually can make it a bit less stressful. For more detailed info in reducing top ups see our other blog here

But here’s an overview: Mums can reduce the volume of top ups and put babies back on to the breast if not settled. Mums often find that babies are more settled during certain times of day or night and these can be the first feeds to just breastfeed. Encourage mums to allow the baby to have a second or third go on the breast if they do not settle after the first feed. Offer the other breast so baby gets a nice fast flow of milk. For twins or triplets you can just put them back on the same one and mum will get another let down of milk.

Aiming for maybe 3 top ups of expressed a day and being baby led in between is a good starting point. Mum can keep an eye on nappy output during this time to give her peace of mind and she may prefer to weigh the baby before moving on from this stage to give her confidence that everything is going well. Sometimes when babies move on to more direct breastfeeding, their weight gain can flatten off a little bit. This can be really discouraging but it can take a bit more energy to fully breastfeed and they can tire themselves out and burn more calories. As long as they are still gaining this is usually ok and they will set off following their curve again given a bit of time. This may be a good time to get some reassurance from a breastfeeding specialist.

Once mum is feeling confident and babies are feeding well it is relatively easy to drop the last few top ups. Mum can either stop them all at once or drop one at a time. It is often a relief to have the relative simplicity of just breastfeeding without all the faff of expressing and washing bottles. Some prefer to still keep an expressed feed in their routine so that they can have a break.

 Breastfeeding is so important for babies, but even more so for premature babies. But establishing breastfeeding in the neonatal unit is like a marathon, not a sprint. It is a slow process taking every ounce of patience and determination. But it is worth every bit of stress.

Kathryn Stagg IBCLC, Aug 2017

References

Breastfeeding and Human Lactation, enhanced 5th edition, Wambach & Riordan, 2016

The Breastfeeding Atlas, 6th edition, Wilson-Clay and Hoover, 2017