Category: Uncategorized

Uncategorized

Definition of an IBCLC

Kathryn Stagg IBCLC

Detective

An IBCLC will delve into their vast knowledge to try to work out what is going on. They will go away and research if necessary. They will share with their network of colleagues with permission if someone else has the knowledge that is needed. IBCLCs come from a huge variety of backgrounds with different specialisms.

Fuelled by rage against the system

Most IBCLCs are absolutely livid about the injustice of lack of breastfeeding support faced by women and birthing people every day in a capitalist society where baby milk companies are making money out of this situation. Every family deserves to have the feeding support they need. This can be peer support level or more specialist support for more complicated cases. They support everyone whether they breastfeed directly, pump, use formula or a combination of all of it.

They run on oxytocin

The next best source of oxytocin after breastfeeding directly is supporting someone else to breastfeed their baby. Lactation Consultants use this oxytocin and dopamine in order to keep on keeping on in a society that often works against them. It is addictive.

Baby observer

IBCLCs have a lot of training and knowledge around normal newborn behaviour and can usually explain why a baby is doing particular things. They pick up subtle cues and interactions which can tell a story. They have lots of tips to help new families cope and understand a baby’s cues and needs.

Milk maximiser

IBCLCs have all the tips to increase supply, give the parents the tools to understand if baby is getting enough milk and will celebrate every drop! Whether a baby is receiving all their milk or some of their milk IBCLCs will support you to increase or maintain.

Empowerer

IBCLCs support families to advocate for themselves and their babies around their care, to make evidenced based informed decisions around the health and well-being of their families. They encourage parents to question suggestions and decisions if they do not feel right.

Passionate and slightly obsessed

IBCLCs often become quite obsessed with finding out everything they can about breastfeeding and lactation and babies. They have to have 75 hours of continuing education every 5 years to stay certified , but most will have far more hours than this to quench their thirst for knowledge. More and more exciting information is being discovered all the time on milk composition and how the milk, breastfeeding, the baby and the mother all interact, so it is the gift that keeps on giving.

The long story

IBCLCs can support a family throughout their feeding journey, from establishing breastfeeding and milk production, to navigating the next phase, through introducing solids, returning to work and continuing to breastfeed into the toddler years and eventually stopping breastfeeding whenever the time is right. IBCLCs are there for the long haul.

What have I missed?

Uncategorized

Triple Feeding

Kathryn Stagg IBCLC

When babies are born a bit early, or a bit sleepy or a bit inefficient on the breast, they have higher risk of jaundice, low blood sugar and weight loss. They also may struggle to put on enough weight and regain their birthweight.

Often these issues can be overcome by concentrating on achieving a deeper latch, more frequent feeding, and by using breast compressions to increase the flow of milk. Compressions maintain active feeding for longer and increase the length of the sucking bursts. We should encourage baby to have a second go on the breast by waking with a nappy change and offering the other side.

However, it is sometimes clinically indicated that baby needs a little extra milk. Many of these parents start their breastfeeding journey topping up their babies with formula to make sure they are getting enough milk. But if their long term goal is to exclusively breastfeed, or even majority breastfeed, using formula will be detrimental to their future milk making potential. To protect their breastfeeding goals, it is important to encourage parents to pump whenever babies are getting milk from elsewhere. This expressed breastmilk can then be used for all or some of the top-up feeds, meaning less formula is necessary and milk supply is closer to the baby’s intake. The volume and frequency of top ups should be the minimum necessary to maintain an appropriate rate of growth.

The act of breastfeeding, top-ups and pumping is often called “Triple Feeding” because there are three parts. Doing all three parts, every feed can be very overwhelming and time consuming, so it is important to stress to parents that this is a temporary intervention. As soon as babies are breastfeeding more effectively they should be able to reduce and eventually remove the extra milk, or move to a more manageable combination feeding pattern. Triple feeding is not a long term solution.

Triple feeding is much less overwhelming if there is a helper to do the supplemental feeds. If no helper is available, do the best you can.

Triple Feeding Plan

*Wake baby, or pick up baby if they are showing early cues and waking

*Bring baby to the breast with a deep latch

*Watch for deep suck and swallows

*Use breast compressions to maintain active feeding and extend sucking bursts

*Once compressions are no longer stimulating deep sucks and swallows take them off and offer a cuddle. If baby wakes, offer the other side. If baby does not wake, wake them and offer the other side.

*Breastfeed baby on second breast with a deep latch and compressions if necessary.

*Once compressions are no longer stimulating deep sucks and swallows, pass baby to a helper if you have one, to top-up with expressed milk or formula, pacing the bottle feed.

*Pump for 15-20 mins with an efficient double pump, this milk can be used for future top-ups

NB If no helper is available then the baby will need to be breastfed and topped up and then pump as soon after the feed as possible.

Moving away from triple feeding and topping up

Before moving away from triple feeding regime, certain criteria must be met:

*Baby should be gaining weight appropriately with the top ups in place before thinking about reducing, and also be having appropriate wet and dirty nappies

*Baby should be able to latch well with deep sucks and swallows, developing longer bursts of sucking, especially towards the beginning of the feed. They should be maintaining active feeding for more than a few minutes

*Baby should be feeding at least 8 times in 24 hours and mainly waking themselves for feeds, more frequently is to be expected.

Once the baby is beginning to be more alert and breastfeeding is improving we can begin to gradually reduce the extra milk. Regular weight checks are necessary.

Frequency of feeding

Exclusively breastfed babies will often want to feed more frequently than every three hours. If babies are waking “early”, they can be brought to the breast. But we should not need to top up more frequently if weight gain is appropriate.

Reduce the volume of the top ups

Baby can be offered a third or fourth go on the breast before a top up is offered, called switch nursing. Each time a baby latches triggers another let down of milk and they will take more milk. This should mean a smaller top-up, or perhaps no top up.

Babies can be encouraged to settle on the breast. Both breasts are offered first, a smaller top up given in the middle, and then baby can be brought back to the breast to settle, taking some more milk directly.

Removing top ups

A baby will often be more settled in certain parts of the day. Mornings especially are a time when they tend to feed well and the parent may naturally have more milk.

Take a 4 or 5 hour period in the morning and just breastfeed, putting baby back on the breast as many times as it takes to settle. Top ups continue the rest of the day. Then extend or add another stretch of exclusive breastfeeding.

During night feeds, baby should begin to settle more easily without the need for extra milk.

Pumping

As the need for top-ups decreases, pumping can be reduced. Either pump whenever babies get extra milk, or pump the total 24hr top-up volume baby is taking over however many pumping sessions it takes to express that volume.

Kathryn Stagg IBCLC, June 2024

Uncategorized

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

Uncategorized

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. 

Uncategorized

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.