Michelle Baynham

18 Jan 2022

Whether you decide to breastfeed or bottle feed is a personal choice, and should be respected at all times. In the UK 81% of mums initiate breastfeeding, but less than 24% are exclusively breastfeeding at 6 weeks*. Common reasons for stopping breastfeeding earlier than planned are: baby not gaining weight well; concerns about low milk supply and painful feeds. Finding empathic, experienced and knowledgeable support will often resolve all of these issues and more, making a huge difference to your breastfeeding outcomes. The information provided in this blog is from Heidi Hembry, an International Board Certified Lactation Consultant and Mother Fit Expert. Heidi is an IBCLC with over 12 years experience supporting families to overcome breastfeeding difficulties.

In this blog she aims to answer some of your questions and concerns, to make your breastfeeding journey as easy as possible. No two journeys are the same and you may benefit from individual, tailored support in your home.

*UK Infant Feeding Survey 2010

Breastfeeding is a skill that you and your baby learn together, and this can take time. It is natural, but not like breathing, more like learning to walk, and some of us will experience more challenges, take more time and need more support than others. Historically we would have learned to breastfeed by watching our mothers, aunts, cousins, sisters and friends as we grew up, giving us 2 decades of visual learning surrounded by confident women who understood how it all worked. In our modern lives we have lost all of this learning period and are now learning on the job, alone, with our first babies. Be gentle on yourself. Learning a new skill while stressed and sleep deprived is not always easy, and you wouldn’t expect to be an expert immediately in anything else that you were trying for the first time – and we would almost certainly seek guidance and support from someone more experienced.

Skin to skin

Whether you have the birth you dreamed of, or all of the interventions that you had hoped to avoid, skin to skin as soon as possible is the most important thing you can do to help establish bonding and breastfeeding. In fact skin to skin is great for you and baby whether you are breast or bottle feeding. It performs an amazing array of functions for you both, and the more you have of it, the better.

The benefits of skin to skin contact:

Regulation of your baby’s:

Body temperature
Breathing
Heartbeat
Blood glucose
Inoculating baby with your natural microbiome**
Reduction of stress for you and baby
Increasing bonding
Increasing breastfeeding instincts in mum and baby
Stimulating oxytocin, one of the two main breastfeeding hormones

It can also:

Calm an upset baby and get them ready to feed
Soothe a baby to sleep
Rouse a sleepy baby for feeding

**your microbiome is the array or normal and beneficial bacteria, viruses and other microbiota that reside on and in your body, performing beneficial and essential roles as far reaching as aiding digestion, promoting healthy organ function as well as emotional and mental wellbeing

Baby and you may be exhausted after your labour; skin to skin will help you both rest and recover and get ready for breastfeeding. It’s much easier for mum and baby to instigate frequent feeding from skin to skin, than with baby in a bedside crib, wrapped and separated away from mum. Though most hospitals support skin to skin immediately after birth, it remains an important aspect of breastfeeding and bonding in the following days and weeks. You can’t overdo skin to skin!

Feeding your baby during this first golden hour of skin to skin after birth is ideal. They are born ready to learn and breastfeeding during this time can imprint excellent skills that are built on in subsequent feeds. Of course, there are exceptional circumstances when skin to skin can’t happen immediately, however, establishing this beautiful practice as soon as possible will be hugely beneficial to mum and baby, regardless of feeding choices.

How often should I breastfeed my baby?

All babies in their first few weeks of life should feed at LEAST every 3 hours (from the start of one feed to the start of the next) or a minimum of 8 times in 24hrs, though 10-14 is more normal initially. This can sound like a lot, but when you take into account how often we, as adults, feed and nourish ourselves across the day with meals, snacks, hot drinks & biscuits or sips of water, we can see that our babies really aren’t asking for anything different. Plus, they have been fed and hydrated 24/7 via the umbilical cord for around 9 months, so even an hour without food or drink can be a big change for them.

Responsive feeding according to baby’s needs (often called demand feeding) is also vital for building your milk supply in the first couple of weeks to meet your baby’s growing needs.

First 24 hours

Some babies are born raring to go and want to feed often, straight away. Go with this – it can be tiring, but it will send all the right signals to your body to begin making lots of milk. Other babies are born exhausted and overwhelmed and need lots of skin to skin time, resting and sleeping before being ready to feed. This is great for you both, however, you should aim to rouse and wake your baby at least every 3 hours to offer them an opportunity to feed, hand expressing your colostrum each time if they are not yet feeding well. Without intake of colostrum, baby’s energy levels and blood glucose levels can dip, making it even harder to wake for an effective feed next time. If your colostrum isn’t being taken regularly by either your baby or hand expressing, your body doesn’t get all the signals it needs to make a great milk supply

Hand expression vs pumping

If baby is struggling to feed in the first few days, then hand expressing is an essential skill to learn. Your colostrum is thick and sticky, a bit like clear honey, and it is made in small volumes for the first 3-5 days until your mature milk begins to be made. Electric pumps are not very effective at removing this sticky substance, and even when they do, the small volumes are often impossible to get out of the comparatively huge bottle they are being pumped into. Hand expressing is a skill – it’s tricky at first, but the more you practice it the better you get. You should be able to get great support in your hospital to help you learn how to hand express, collect your colostrum in a small flat ended syringe, and safely feed it to your baby.

Breastfeeding patterns in the first few days

Frequent feeds continue and it is this frequency, along with effective feeding or expressing, that tells your body to make more and more milk. The more frequently your baby feeds, the more prolactin is stimulated. Prolactin is one of the essential hormones for milk supply and is produced at higher levels overnight. This is one of the reasons that frequent night feeds are especially important in the early weeks.

If baby is not feeding well, although waiting a long time between feeds to allow your breasts to get full may feel like a sensible step, it can be counterproductive. The longer your breasts are left with no milk removal, the less prolactin you stimulate. At the same time, a full breast left for a while will begin to send feedback to your body that baby doesn’t need the milk it has made, signalling a decline in production – the opposite of what you need in these first few weeks.

How do I know if feeding is going well?

What goes in has got to some out! So if you are seeing the right amount of wet and dirty nappies in the first few days and beyond, it’s a good indicator that baby is getting enough milk.

Day 1 – one wet nappy and 1 black meconium stool
Day 2 – two wet nappies and 2 dark stools
Day 3 – three wet nappies and 2 transitional light brown/green stools
Day 4 – four wet nappies and 2 yellow/orange/tan stools
Day 5 and beyond – five wet nappies and 2 yellow/orange/tan stools

If your baby is doing the above as a minimum (more is even better) then they are usually having an adequate intake of milk. After the first day, 12-24 hrs without a wet nappy, 24 hrs without a stool or black/dark stools beyond day 3, are a sign that baby is not getting quite enough milk and some changes are needed. You don’t immediately need to supplement with a bottle though. Here are some things you could look at improving/changing:

Feed baby more often – every 2 hrs is not uncommon at first.
Ensure baby takes both breasts at most feeds, not just one.
Watch for swallows and gently compress your breasts or tickle baby to encourage more active feeding.
Express after feeds if baby is too sleepy or not feeding well. This will improve your supply and give you some of your own milk for supplements if needed.
Get support to change the latch if you are in pain.

What if baby needs supplemental feeds?

If you and baby are struggling to establish effective breastfeeding, then supplementing your baby may be essential. The first choice of supplement is always your own expressed colostrum or milk if available. If you are unable to provide your milk, donor milk may be an option too, especially if your baby is in SCBU or NICU. First Infant Formula is a perfectly adequate choice if your own milk or donated milk are not available.

Keep in mind that volumes are best kept small and frequent in the first few days (just like a newborn’s natural feeding patterns), especially if you are planning a return to breastfeeding. Baby tummies are very small at birth, and though they are designed to grow rapidly (see graphic below) larger supplements early on can grow their tummy at a more rapid pace than your natural milk production would do. This can lead to baby becoming frustrated with your supply and you to lose confidence… so more regular supplementation is introduced and the cycle continues. E.g a 30ml supplement on day one will grow baby’s 5ml tummy to 30ml, however you are still making 5-10ml of colostrum, which will now not fill baby’s larger capacity. In addition, the large volume will take a long time for baby to digest and so regular stimulation of the breast is less likely.

10 mins every 2 hours will give you and baby better opportunities to work on breastfeeding than 30ml every 3-4hrs.

Supplements (expressed or formula) will help baby to be well nourished and gain weight, though they may do little to improve breastfeeding. If you are supplementing your baby and you plan to drop these top ups, it is essential that you express often and reach out for experienced support to help overcome the difficulties that you and/or baby are having.

How to get a deep and comfy latch

Remembering the acronym CHIN can be very helpful to achieve a deep and comfy latch

Head free

In line

Nipple to nose

Close

Holding your baby in close to you helps them to feel safe and secure, putting more focus on feeding. A baby feeling unsupported may be too worried and uncomfortable to feed well. Holding your baby close also means they can access the breast more easily – ideally your baby should be close enough to you that it feels as if they could be in skin to skin if clothes were removed.

Head Free

A free range of movement from the head allows baby to get a nice wide mouth for latching. Something as little as one finger on the back of the head is not advised. This stops baby from tilting their head backwards and leads to them arching their back. Make sure to add support by the back of the neck and shoulders. Newborns have very unstable heads and we want to completely avoid any flopping movement. As soon as we support the neck and shoulders, the head is stabilized. Gentle support around the neck and shoulders is all you need.

Inline

In line refers to baby’s ear, shoulder and hips all being aligned. A different way to think about this is that baby needs to be facing forwards in relation to their own body – just like you face forwards to take a drink, rather than turning your head over shoulder, or rotating at your waist. It’s just not comfy. If you notice baby is lying on their back, tuning over their shoulder to reach your breast, try rolling baby in so they are ‘tummy to mummy’ and nicely aligned for comfort and better latching.

Nose to nipple

Lining your nipple up to baby’s nose gives you both the best opportunity to get a deep latch. In this position, baby will now raise their head to reach towards your nipple with their mouth, lifting their chin from their chest in the process. This starting position also lines the bottom lip up with the areola, keeping the tongue far away from the nipple, nipple going in high in the mouth by the upper gum. This off-centred latch means that baby’s tongue works on your areola breast tissue to massage and extract milk, instead of compressing and pinching your nipple – which hurts

Remembering the acronym CHIN will be helpful. The chin itself is also important in breastfeeding. Touching baby’s chin to your breast often triggers a wide gaping reflex that will allow you to get a deep latch. And when baby is on and feeding with a deep latch, you will see their chin deeply embedded into your breast, with their nose slightly free. If instead, you are seeing baby’s nose touching your breast and a small space between baby’s chin and your breast, this can be an indicator that the latch needs a bit of adjustment.

What if breastfeeding hurts?

Pain is usually your body’s indication that something isn’t quite right, and the same is true with breastfeeding. Nipples don’t “toughen up”. Mum’s and babies learn together to get a better, comfier latch in the first few days. Even if a latch “looks good”, if you are in pain it’s usually not effective or sustainable for you or your baby. Pain is most often caused when baby’s tongue is too close to your nipple, compressing it against the hard palate and gums. For your baby, this is like trying to drink through a squashed straw – they have to work very hard, but they can’t get a lot of milk volume. Feeding this way can become exhausting for baby, or last for hours without them being able to get a full feed and settle well.

For you, painful nipples means feeding is unpleasant and stressful, exacerbated if baby struggles to gain weight. If feeding is painful it is vitally important that you get support to change the way you and baby are latching. Midwives and Health Visitors can sometimes give excellent support, however, if they have not been able to help you make effective change, consider seeking out more experienced support from an IBCLC, qualified Breastfeeding Counsellor or Peer Supporter.

Michelle Baynham

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