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Breastfeeding 36 or 37 week babies

Kathryn Stagg IBCLC

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 parents, 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”. Babies that were born premature are often discharged home at this gestation and so frequently have similar problems. 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 premature babies are fed responsively.

The problem is that these babies often do not “demand” enough and prefer to sleep. They are often too sleepy 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 take enough milk from the breast when they do wake to feed. 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 difficulties! Babies can lose too much weight, or jaundice can set in. The parent’s milk supply may not be stimulated enough, or they may lose their hard-earned milk supply if they were pumping in NICU. After a week or two of responsive feeding when the babies just are not ready, it is often decided they need supplementing, but because the baby has not been feeding effectively, supply is often low and they may need to use formula. And so the top up trap begins. These families need lots of support. They need good quality face-to-face breastfeeding support after discharge.

In the first 48 hours, parents of late preterm and early term babies should be encouraged to hand express after each feed. This will give them extra colostrum to give the baby, and also it will help prime the prolactin sites to stimulate a full milk supply. The colostrum can be given if baby is too sleepy and hard to rouse. A shot of colostrum boosts blood sugar and should give the baby energy to feed. Or it can be used after a feed if the baby last latched on but only fed for a short period. Colostrum can be given by syringe straight into the mouth or by finger feeding, or by spoon.

Once the parent’s milk begins to come in they could also add some pumping sessions if the baby is struggling to take enough milk. This supplement could be given by syringe, finger feeding, spoon, cup or a paced bottle.

This guide developed by Queen Charlotte’s Neonatal Unit, can be used to decide if the baby needs to be topped up. Most late preterm and early term babies fall into sections D, E or hopefully F! A full top up means a full feed, often using the calculation 150ml x baby’s weight in kg divided by the number of feeds in 24 hours. A half top up would be around half this number.

The “active feeding” part of this diagram from UNICEF is the main area of the feed we should be focussing on. This is where the majority of the milk is taken by the baby. This can be maximised by using breast compressions. They can be a useful tool to help the baby transfer more milk during the feed, and to remind them to keep feeding when they get a bit sleepy towards the end, so extending their active feeding time.

Parents should 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. (Marie Biancuzzo, Dec2018) They should be encouraged to feed their babies frequently. If a baby’s eyes are open they should be offered the breast! If their baby has not woken themselves by 3 hours from the start of the last feed, they should be encouraged to wake and feed. Once the baby begins to consistently beat the parent to this wake up, this is a sign they can move to responsive feeding. Most babies refer to feed more frequently than 3 hourly once they are full term, although they may have one or two longer stretched, especially after some cluster feeding.

Parents should also be shown how to ensure the babies are latching on well to feed. A baby of this gestation is often smaller, with a small mouth. An optimal latch is necessary for an efficient feed. Breast shaping can help to get a little more breast tissue into baby’s mouth. The C hold can be used when baby is upright or lying on their back and so their mouth is horizontal. The U hold can be used when baby is on their side and so baby’s mouth is more vertical.

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 weight gain and nappy output if shields are used as they can sometimes inhibit milk transfer. Once the babies are feeding well with a shield, support can be given to feed without them.

Parents may need support with continuing to pump for top ups if the babies are not ready to fully breastfeed. It is an incredibly intense routine and should only be a short term intervention. The baby should begin to become more alert and stronger and more coordinated quite quickly.

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. Parents often continue to supplement and schedule feeds far longer than they need to. Once the baby has adequate weight gain, generally waking themselves for feeds before the 3 hour schedule, and having a good proportion of “active feeding” during a breastfeed then they can be fed responsively and expressing gradually phased out. If parents are using formula to top up this can be gradually phased out. See my 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, updated June 2021

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

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. 

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BRAIN mnemonic and infant feeding

Kathryn Stagg IBCLC
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.

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Establishing milk supply with a pump

Kathryn Stagg IBCLC

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

 

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Gentle Night Weaning Your Toddler

Kathryn Stagg IBCLC

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!  

18blacktoddlerboyholdingteddywalkingongrasssmiling(2)_2_0

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