Some older babies and toddlers try lots of different behaviours when they are feeding. Things like pinching, twiddling the other nipple, kneading, grabbing hair, putting hands in your mouth, biting, coming on and off, feeding standing up and all sorts of acrobatics. Some of these are cute. Some hurt!
Its important to remember that although all of these behaviours are normal, if you are finding something intolerable, it is a 2 way relationship! You really don’t have to put up with it!
Start early! If your child starts to do something you don’t like, work on it immediately. It’s true a lot of behaviours are temporary as they are just exploring, but you don’t want them to keep doing it if you can’t stand it!
Distraction – if it is something their hand is doing, give them something else to play with; a toy, necklace or scarf perhaps. Or move their hand to a part of the body which is less sensitive (I’m thinking not the nipple!!)
Offer alternatives. Try offering to do something else. Maybe take them off and offer a toy, play, go out, give them a teether to chew, a snack or drink instead. If they want to nurse again, offer the other breast as sometimes the faster flow reduces the behaviour
Use some gentle discipline. If unwanted behaviours continue, take them off and explain simply that they can’t feed if they do that as it hurts or you don’t like it. Offer them an alternative or if they want to continue feeding then they must not do it. Even quite young toddlers can understand this concept, although they might not like it! But boundaries a important. This is actually a great way to introduction the concept of body autonomy. It is your body after all!
Use a code word – some people have concerns about the way their child asks to breastfeed. Maybe they yell BOOB! or start to help themselves by undoing your bra or pulling your top down. Maybe they just scream. Developing a baby sign or code word can make this easier to deal with. They can still make their wished to feed clear but in a respectful and gentle way.
If your child is asking to nurse very frequently in the daytime and you are struggling, there are some things you can do. Distract! Give other options of things to do. Go out. Change of scenery. Nurslings generally aske to feed a lot less if they are busy. Offer a snack or drink. They can be hungry or thirsty, although toddlers like to feed for all sorts of other reasons of course. Nap on the move. If your child tends to feed to sleep then doing a car/buggy/sling nap can break this cycle. Use language like “after …” not just No. No is rejection. After lunch or after we get home means they will still get to breastfeed, just not right now. Validate and acknowledge their feelings. Understand that not breastfeeding is challenging, they may be cross with you, they may need some extra support with this. That does not mean you have to do it. “I understand that your really want some milk right now, but we are in the supermarket buying some yummy food to eat. You can have it as soon as we get home. Here have a biscuit to keep you going” You may end up with screaming but remember they are only letting you know they are not happy about this. And that is ok.
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.
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.
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
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.
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!
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.
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.
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 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.
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
Breastfeeding and Human Lactation, enhanced 5th edition, Wambach & Riordan, 2016
The Breastfeeding Atlas, 6th edition, Wilson-Clay and Hoover, 2017