After sharing our breastfeeding story on the blog a few months ago, I was surprised and heartened to receive countless messages from other first time parents like us, both mums and dads, who were experiencing the exact same trials and tribulations as we were.
From concerns around nipple pain, tongue ties and babies’ weight gain to questions about milk supply, pumping, breast milk vs. formula and how dads can contribute to the whole nursing process, I realised that so many of us still struggle to find the help we’re looking for online.
And so, for today’s Ask the Expert feature, I decided to share your breastfeeding questions with Sioned Hilton, a paediatric nurse and the in-house Lactation Consultant at Medela UK, who kindly agreed to answer each one in turn, providing her expert insights and top nursing tips to help other new parents going through the same thing.
She really knows her stuff so I hope you find the following Q&A as useful and interesting as I did! Here goes…
DISCLAIMER: As we were told by numerous people during our pregnancy, first time parents are far more likely to succeed at breastfeeding if both mum and dad know the ropes. So, dads…this one is for you too!
Your breastfeeding questions answered…
How do I know my baby is getting enough milk while breastfeeding?
In the first week, both baby and mum are learning to breastfeed and initiate the milk supply. After day one, your supply will build and you should see lots of wet nappies (urine should be straw coloured and most nappies will be soiled). Lots of poo indicates lots of milk.
This will continue for around 4-6 weeks until mum starts making too much milk, at which point mother nature is very clever and starts tailoring supply to demand. Because of this, it is normal for an exclusively breastfed baby to not soil for up to 10 days during this period.
Another sign that your baby is getting enough milk is their contentment after feeds. Breastmilk is easy to digest, therefore it is normal for babies to indicate a need for a feed within a range of 1-3 hours in the early weeks, while grazing in the evening to boost mum’s hormones.
Weight and growth are other markers. By 14 days, your baby should be regaining his weight after an average 10% is lost after birth, as your baby adapts to the outside world. A steady weight gain of approximately 20-30 grams per day are guides and this will vary (which is normal!). You will also see growth in the length of your baby and their head circumference.
Why does my baby get frustrated on the boob?
There are several reasons why baby can get frustrated on the breast:
- The milk isn’t flowing or the breast is empty
- Your milk tastes different – after mastitis it can taste salty, while certain foods can also impact the taste
- Pregnancy and menses
- Teething – the baby’s gums and glands are tender
- Viruses and colds – babies are nose breathers so try clearing a nostril to help its breathing and be sure to take frequent rests
- The world beyond mum is exciting and interesting – i.e. visual distractions
- Nipple teat confusion – when a baby has several bottle feeds with a conventional teat
- Mum’s apprehension and anxiety may switch off the letdown hormone and therefore reduce milk flow
- Baby can have colic or reflux, which may influence feeding
Sometimes it is unexplained and mum feels that her baby is still hungry and that her milk supply is dwindling. It could be that baby is in a growth spurt, unwell, or post vaccinations.
However, if baby is refusing the breast and you feel it is more than just fussiness, seek advice from your GP or health professional.
My baby’s latch looks good but it’s still painful. What could be going wrong? What should I do?
While our understanding of a breastfeeding latch is good, a baby may have a high palate, a tongue tie or may be inadvertently creating a high vacuum in the intraoral space, which can result in a modified suck sequence.
Alternatively, it could be a breast challenge like vasospasm, circulation challenges, mastitis, blocked ducts, strong milk letdown or breast tissue fatigue.
Meanwhile a cracked nipple can create a path for infection into the breast, both bacterial and fungal. Even after antibiotics for a complicated infection like mastitis, some mums experience breast pain as the inflammation subsides and the cells heal.
If the pain is impacting on mum’s comfort, things to check are:
- The latch – check to see if there is a tongue tie, or if baby is nipple nursing (i.e. not a deep enough latch).
- Tongue Tie – if you suspect there is a tongue tie, seek advice from both your GP and a breastfeeding specialist. Not all tongue tie requires surgery but the majority do.
- Positioning – try different nursing positions.
- Circulation – applying a warm flannel and/or breast massage before feeds can minimize any vasospasm. If there is severe nipple blanching, discuss this with your GP as they can prescribe medication to help circulation.
- Thrush – if pain is affecting both breasts and intensifies throughout the feed, check and look at baby’s mouth for white spots. Alternatively, your baby may have a sore, spotty bottom. Both of these symptoms could indicate thrush, which needs to be treated for you both. Guidelines are now in place for mum to have this confirmed with a breast swab of milk and to start oral and topical treatment.
- Nipple Shields – if baby is applying a high vacuum, the use of a nipple shield can help to buffer and make feeding more comfortable.
How much pain is too much when breastfeeding?
Realistically, nipple tenderness and soreness is normal in the first week after birth as the nipple stretches when baby sucks. However, this should be short lived as the breast and nipple get conditioned to breastfeeding.
The properties of breast milk should also help keep to keep nipples healthy, while the glands in the areola will replenish and moisturize the skin. Although pain is one of the reasons mums stop breastfeeding, cracked nipples that do not improve and heal with nipple cream, such as Purelan, could indicate a complication. For example, it could signal that baby isn’t latching on well, may have tongue tie, or perhaps that mum has a mild skin infection that impairs the healing process.
With your second babies, many mums experience intense after pains when breastfeeding, caused by a surge of the hormone oxytocin, which tightens the uterus resulting in pain in the breast, thidue to the milk being squeezed out of the milk sacs (this is normal and counting to 10 often helps…it will pass).
If pain continues after you have had support and advice on your latch and you have excluded a tongue tie, it is recommended you go back and get a review with a breastfeeding specialist, no matter how long you have been a nursing mum.
Should I be worried about mastitis?
Mastitis is a consequence of poor milk drainage and or infection which can result in engorgement, potential blocked ducts and inflammatory in the ducts and milk cells. Being aware of how mastitis happens will help you to minimise the chances of you contracting it.
For more information on mastitis please visit: http://medelamums.co.uk/treating-mastitis/
What is the current UK/NHS policy around tongue ties? We had to go through 10 days of agony and get two lactation consultant referrals before they would properly diagnose it, which can’t be right, surely? Apart from going private, how can new mums speed up the process to get a suspected tongue tie fixed?
The NHS follows the NICE guidelines for postnatal care, to support effective and early support for breastfeeding mum and baby. There is a NICE guideline around tongue tie, although not all tongue ties require surgery. More often than not it is a combination of a feeding assessment, a review with some assistance to support more comfortable feeding, tweaking a position and providing advice to ensure that mum initiates her milk supply with information around expressing and advice to support breastfeeding and supplementation. There may be an immediate referral to a specialist lactation consultant or ENT surgeon that is certified to undertake the surgery.
Every midwife receives education and updates on breastfeeding and each hospital has a breastfeeding policy. Tongue tie should be assessed at birth by a paediatrician. Often though, these are missed and are only picked up when:
- a mum feeds back that nursing is painful
- a baby has difficulty sustaining a latch, or
- a baby is slow to regain its birth weight.
A feeding assessment is now part of the postnatal check around day five postpartum, following the baby friendly guidance, but the challenge then is convincing a GP to refer you to a specialist, in line with the NICE guidelines. It is worth noting that BFI evidence supports early surgery to protect and promote breastfeeding, so it’s worth familiarising yourself with that.
If nursing is uncomfortable and painful and it is seen that the tongue is restricted (i.e. baby cannot pull tongues, etc.) mums must seek advice early and get a referral. To find a specialist practitioner, there is a UK register for certified practitioners at http://www.tongue-tie.org.uk/tongue-tie-practitioners-nhs.html
Many new parents are unfortunately influenced by the postcode lottery. More practitioners are in the South and also private practice. Whilst it is understandable that the NHS should provide a service that is timely, there are limitations with specialists, how many mums they can see, as well as time for procedures and then lactation support. Most clinics are a combination of surgery and consultations.
Having the information to hand and the support of your breastfeeding specialist can aid your GP to do a timely referral to NHS clinics but the only other option is to go private. For a private specialist check their registration, and recommendations to ensure that they are who they say they are.
How do I increase my supply if it’s not growing by itself?
Your milk production starts getting ready during pregnancy, with the secretory differentiation of the milk cells. This means, under the influence of progesterone, oestrogen, insulin, thyroxine and other hormones, the milk alveoli increase in both size and density. Most this growth takes place in the last trimester for most women.
With the delivery of the placenta and the end of the pregnancy, the activation phase of milk production begins and over the first 2-5 days your milk comes to volume. It is in these first few weeks that these milk cells are sequenced to maximize their capabilities – the more you feed and empty, the more milk is made.
For a mum who is pump dependent, by day 7-10 we would be aiming for a volume of around 750mls per day, this may mean pumping every 2-3 hours for mum (8-12 sessions day and night). A newborn baby nurses from anything between 6-18 feeds a day to help this process. If there is an interruption to this, then the cells may not function effectively, the hormone Feedback Inhibitor of Lactation (FIL) will rise and this can down regulate supply and milk production.
Milk volume continues to build under the supply and demand until around 4-6 weeks postpartum, when it is then fine-tuned in demand to your baby’s needs. Many mums often have over supply initially if feeding is going well and then down regulate a little so they don’t feel as full before a need to feed.
If you are finding that your production is dipping, look at it overall. How is baby doing? Lots of wet nappies? Steady weight gain? With growth in length and head circumference? Many mums don’t have any difficulties but may feel that they have insufficient supply because baby is a frequent feeder. In this instance, check that your baby’s latch is optimal during every feed, monitor nappies, complement with expressing between feeds or after each feed to remove any milk that baby hasn’t taken off.
If you receive advice and are experiencing difficulties, to build your supply you need to empty more frequently. You may not increase the volume per feed/pump but with extra sessions you should increase the milk volume that is removed. Double pumping also supports a small increase in milk volume compared to single pumping and this also provides an additional milk ejection which enables a higher concentration of fat rich energy milk. Use of galactagogues can assist but these are advised in consultation with a lactation specialist and GP.
What do I do if my supply goes watery?
Human milk is very different to cow’s milk because there is less casein in it (this is what makes milk white). Mum’s expressed milk looks watery with a blue hue, and when stored in a bottle the fat rises to the top. Mature milk has all the nutrients your baby needs for healthy development, and your milk is never too watery or thin. Don’t worry that it looks watery. This is an amazing substance rich in immunoglobulins and antibacterial properties which are tailor made for human babies’ brain growth and development.
Is ‘nipple confusion’ a real thing? If so, what is it and how can bottle and breastfeeding mums avoid it?
Yes, it is a real thing! Nipple confusion can lead to a mum and baby ceasing to breastfeed. Not all bottle-fed babies get nipple teat confusion and some transition happily between breast and bottle. However, with extensive studies from Assistant Professor Donna Geddes and the team at the University of Western Australia, it is now proven that breastfed babies have a specific suck pattern to remove milk from the breast.
When breastfeeding the combination of tongue and jaw movement creates vacuum, and the position of the nipple in the baby’s mouth just short of the hard and soft palate is also important for babies to breastfeed successfully. This unique feeding behaviour of sucking swallowing and breathing ensures a successful transfer of milk.
With a conventional teat and bottle system the breast fed infant has to modify their instinctive suck pattern to regulate the free flow of milk that often occurs with bottle feeding. Using a conventional teat, infants are able to suck and receive milk immediately as the bottle is free flowing. The suck changes to manage this and you see babies using the lips and tongue to regulate and slow the flow using a very different suck pattern to breastfeeding. This is often where babies get a little ‘lost’. The more feeds they get from the bottle with a conventional system, the greater the challenges for latch when they try and nurse from the breast.
Many babies will present with fussiness or frustration, as milk is not immediate and the let-down is not triggered. With more bottles being given, mum’s milk production may also down regulate and less may be available too. As a result, mum may suddenly experience nipple soreness as the latch has changed when babies nipple feed again.
This is why there is guidance to advise no bottles and teats in the early weeks when breastfeeding is getting established, and many mums are advised to supplement using a cup or syringe instead. These too have limitations and can lead to a different suck pattern, as they don’t create a vacuum and the tongue laps milk. Meanwhile, with a syringe, it is placed in the cheek and all your baby needs to do is swallow. So, in reality, you can get nipple confusion from a conventional teat, cup, spoon or syringe.
Medela, with the lactation research team at the University of Western Australia and Japan designed an innovative, award winning, research-based feeding device that mimics the natural instinctive suck pattern of breastfeeding, called Calma. This supports the introduction of expressed breastmilk to babies to compliment breastfeeding when mum is not available to nurse. It is recommended that mum and baby are established at breastfeeding before introducing a bottle so lots of early practice.
For more information on the Calma Feeding Device, check out this video.
How long should I pump for? Should I be emptying my boobs every time?
For an average mum, pumping time would be around 15 minutes per breast, based on research from the University of Western Australia. There are factors that can support effective milk removal such as double pumping, ensuring that mum has the optimum vacuum for her comfort, the correct breast shield size, that she holds the shield to get a seal but does not compress the breast tissue etc. If all is ok, it then depends on mum’s storage capacity – if the milk is still flowing continue to pump until the milk flow stops.
You should always empty your breasts when expressing unless you are choosing to stop breastfeeding, in which case you would leave milk in the breasts to activate the FIL responses to down-regulate supply. If expressing is taking longer than expected, look at the vacuum setting and shield size as this can make a huge difference to the time spent in expressing.
What’s the best way to stop breastfeeding and move onto formula?
Ideally this should happen gradually when a mum is planning the end of nursing. However, sometimes it needs to be sudden or as a result of baby deciding that they no longer want to nurse.
When it is planned, it is advised that a mum starts by dropping a feed every 2-3 days, extending the gaps between sessions to trigger the hormone FIL to help with down-regulating supply. Over 2-3 weeks the baby will nurse less frequently until mum feels that she can stop with no discomfort or breast fullness. For some mums who have been nursing for several months it can take some time to not experience any leakage.
If mum needs to stop suddenly or baby refuses to nurse she will again need to down regulate gradually but with using a breast pump or hand expressing. Initially mimic baby’s feeding pattern but express only for around five minutes, so that there is milk left in the breast, thus triggering a rise in FIL. Then, if mum experiences no discomfort after a few days, she can extend the gap between pumping sessions and drop feeds so that she is only pumping day and night, then just once a day before ultimately stopping.
The reason to take it gradually is to minimize engorgement and mastitis. Some mums may also get blocked ducts and the last thing you need is to then have to treat this with increased feeding frequency and full breast drainage, thereby delaying the shift to stopping milk production. Start introducing supplementary feeds to your baby as you down regulate. If your baby is over 12 months’ old, a store of expressed breast milk or cow’s milk can be used. If under 12 months, your baby needs to receive formula milk though.
I hope you’ve found today’s Ask the Expert feature interesting! As always, please do feel free to share it with any new or expectant parents who might find it useful too.
For more from Sioned, she runs a weekly drop-in-clinic and monthly Breastfeeding Café live on the Medela Facebook page to answer mums’ breastfeeding questions, as well as a monthly Pregnancy Hour to help mums-to-be prepare for their first breastfeeding journey. Sioned can also be contacted via the Medela website here.