I talk a lot about humans and kangaroos when supporting new parents. You see one of the few mammals who birth their babies at a more underdeveloped stage than us humans are kangaroos. Kangaroo babies crawl up into mum’s pouch and then latch on to the nipple and pretty much feed 24/7. Human babies, if left to their own devices after birth, crawl up their mum’s chest and then latch on to the breast. They then need to be fed very frequently. But unfortunately we don’t have a pouch. But we have strong arms, I nice curvy body to lie on and we can make a pouch by wrapping fabric to help our arms.
Humans are “carry” mammals. These include all the apes and marsupials. The “carry” mammals birth the most immature infants out of all the mammals. They are completely dependent on their mothers for food, warmth and safety. Our babies are fed frequently and because of this our milk has very low levels of fat and protein.
Other types of mammal are “follow” mammals such as horses and giraffes. These babies can walk soon after birth and feed quite frequently as they can keep up with their mothers. Their milk is a little higher in fat and protein than carry mammalsnas they feed a little less. “Nest” mammals such as dogs and cats leave their babies and return several times a day to feed. This means the milk needs to be higher in fat and protein to help them wait for their parents return. And then there are “cache” animals such as rabbits and deer. They leave their babies in a safe place and return every 12 hours or so to feed them. Consequently their milk is much higher in fat and protein in order to sustain them for long periods.
Many baby books seem to think we are nest animals. We aren’t. Human babies expect to be held constantly and fed frequently. Our milk is the perfect consistency for this. This is normal newborn behaviour.
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.
“He’s just feeding for comfort” is a comment us breastfeeding supporters hear a lot.
And why not? Anyone who has breastfed will soon come to realise that breastfeeding is about far more than just food. Yes its handy that this act of liquid love is also optimally designed to grow and nourish our babies, but there is far more to it than that.
Of course babies ask to breastfeed when they’re hungry. And they’re hungry a lot! But they may also be thirsty and just want a quick drink, especially in hot weather. Or their bodies and brains may be in a fast period of growth which needs to be fuelled.
They may also ask to feed if they’re feeling cold, if they want a cuddle, if they’ve missed you, if they’re feeling lonely, or tired, or poorly, or scared. Or if they are in pain. All of these reasons are just as valid as hunger.
Breastfeeding your baby whenever they ask, ensures not only that they receive enough nutrition but that their physical and emotional needs are met as well.
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.
