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Revised information on dealing with blocked ducts and mastitis

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Revised information on dealing with blocked ducts and mastitis

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If a blocked duct isn't dealt with quickly, milk can to seep out of the duct into the surrounding breast tissue, causing an inflammatory reaction, which is known as mastitis. Usually this presents as a red, hot, swollen and painful area on the breast, larger than when there is just a blocked duct. (On darker skin, there might not be redness).

Sometimes mastitis can be resolved in the same way as a blocked duct, but if a mother develops a temperature, starts to feel fluey, or if symptoms are not improving within 12-24 hours, a mother should contact her GP as antibiotics might be necessary. The antibiotic of choice for treating mastitis is usually flucloxacillin 500 mg four times a day for 10-14 days. Flucloxacillin is compatible with breastfeeding.

In addition:

NB. Ibuprofen 200-400mg should not be taken more than 3x/day. Higher doses may be prescribed under a doctor's guidance: https://www.nhs.uk/medicines/ibuprofen-for-adults/#:~:text=The%20usual%20dose%20for%20adults,least%206%20hours%20between%20doses

When a mother has mastitis, it's very important that she continues to remove milk from her both her breasts very regularly, either by breastfeeding or by pumping as otherwise she could develop a breast abscess. Her milk will be safe for her baby to drink.

Causes of blockages

A shallow latch - see a breastfeeding professional to check latch and check for tongue-tie. Taking a full history will allow them to fully assess the cause of blockages and nipple damage. Milk not being removed efficiently can cause block ducts and also affect supply so should be addressed as soon as possible

Always wear a correctly sized bra that is fitted and regularly check it's the right size. Wearing clothes which are too tight or with parts that dig in can also cause blockages

A mother holding her breast firmly during a feed.

Baby's arms or fingers can dig in when feeding/sling wearing so worth making sure nothing is uncomfortable or digging into your breast.

Toddlers can also cause blockages if they dig in elbows, knees or feet.

A tongue-tie.

Lecithin
Some women find they need to take lecithin regularly to keep blebs and blocks at bay:
https://kellymom.com/nutrition/vitamins/lecithin/
Breastfeeding when experiencing pain in the nipple or breast due to nipple damage, blocked duct or milk blister/bleb

Try to get as deep a latch as possible: a mother's nipple needs to be far back in the baby's mouth at the junction of the hard and soft palate, not at the front where the nipple will be pushed up against the baby's hard palate. The deeper the latch, the further back the nipple will go in the baby's mouth. Good attachment and positioning will often help to prevent further damage.

When dealing with nipple damage feed baby from the non-injured side first as babies latch and sucking will be stronger on the first breast and gentler on the second breast

Links:
https://breastfeeding.support/mastitis-symptoms-and-treatment/

https://www.carolsmyth.co.uk/blockage?fbclid=IwAR2BI89IHajg4ct5YC6wvUR_UBu8KWpjBpzNX7ml5nQLrFXL99K1eGFfziM

https://www.cordeliauys.co.uk/treating-a-nipple-bleb

https://www.cordeliauys.co.uk/moistwoundhealing

https://www.cordeliauys.co.uk/therapeutic-ultrasound

https://www.cordeliauys.co.uk/primary-engorgement

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If a blocked duct isn't dealt with quickly, milk can to seep out of the duct into the surrounding breast tissue, causing an inflammatory reaction, which is known as mastitis. Usually this presents as a red, hot, swollen and painful area on the breast, larger than when there is just a blocked duct.

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Breast compressions can help encourage babies to transfer more milk effectively

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Breast compressions can help encourage babies to transfer more milk effectively

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Kathryn Stagg explains how to do breast compressions.

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How much the baby is affected by a tongue-tie will depend on each individual baby's tongue muscle mobility and control. It is therefore very important to seek out a specialist breastfeeding assessment when a tongue-tie has been noted. Bottle-feeding and tongue-tie
Tongue-tie can make also make bottle-feeding more challenging. Babies can struggle to create a seal on the bottle teat, resulting in milk dribbling out of their mouth.
Types of tongue-tie
An anterior tongue-tie is when the baby's lingual frenulum extends partly or completely to their gum line. This tends to be easy to spot when the baby cries.

A posterior tongue-tie is when the lingual frenulum is thicker and further back in the baby's mouth. It is usually hard to detect without feeling inside the baby's mouth.
Frenulotomy
Releasing a tongue tie (known as a frenulotomy) is a quick, low-risk procedure, which is carried out by a tongue-tie practitioner, using sharp, sterile scissors which are blunt at the end. In young babies, this is done without anaesthetic as there are few nerve endings in that area of the mouth. If possible, mothers are encouraged to put their baby to the breast immediately afterwards, as breastmilk has pain-killing and antibacterial properties. There isn't usually much bleeding. As the wound heals, babies develop a white or yellow patch under their tongue that lasts a few days. Some dentists use a laser to treat tongue-tie, but this takes much longer and can leave babies traumatised.
To treat or not?
Not all tongue-ties need to be released in the first instance, especially if the mother isn't in any pain and the baby is gaining weight as expected. However, it is important to recognise that a baby who is feeding with a tongue-tie may feed less efficiently than other infants and is at risk for feeding-related problems.
Possible issues include: If you decide not to treat your baby's tongue-tie, it is advisable to:

Keep a close eye on your baby's weight gain. Weighing your baby on a 2-weekly basis until around 4 months is recommended.

Feed very responsively, including at night when prolactin levels are highest.

A few times a day, offer the breast even if your baby isn't showing hunger cues.

Avoid limiting your baby's time at the breast.

Avoid using dummies, which can mask a baby's hunger cues.

Ensure you always offer both breasts at each feed. Switching between breasts 3 or 4 times during a feed can encourage more active drinking.

Use breast compressions.

Post frenulotomy exercises
If parents decide to get their baby's tongue-tie divided, after the procedure, it is important to help the baby re-learn how to use their tongue well. There are rare occasions (about 1:100) when a particular type of tongue-tie (posterior) can grow back again, so to ensure the best results, please follow the tips below.

In the 24 hours after the tongue-tie release is done, it is important to keep the tongue moving as often as possible. Breastfeeding is the best way to get the tongue moving in the correct way again, as long as mum pays careful attention to good latching, so please encourage the baby to breastfeed as often as the baby is willing.

Another way to loosen the baby's tongue so that it can work well, is to play a 'mirroring game' with the baby. This involves getting the baby's attention and when it has focussed on your face, stick your tongue out. The baby will look for a while and then will try to copy you by sticking its own tongue out. Most babies love this game and the freedom they feel when their tongues move well!

In addition, after 48 hours:

You and baby can play 'tug of war' with your finger in the baby's mouth. Let your child suck on your finger, slowly trying to pull your finger out while they try to suck it back in

Slowly rub the lower gum line from side to side and your baby's tongue will follow your finger. This will help strengthen the lateral movements of the tongue.

Cogs Sutherland writes about her experience of having a tongue-tied baby We had our baby's tongue-tie divided very late at 16 weeks. I attended Cordelia's introducing solids workshop when my first baby was 4 months old and whilst she was holding him (when I went to the loo) she spotted what she and the tongue-tie practitioner later called a "corker" of a tongue tie. We had been told at birth at UCLH that he had a mild tongue-tie and it was recommended to just leave it and we saw various health professionals between then and Cordelia seeing him and I still don't know why no-one realised it was so significant. Although his weight gain had been a bit slow the lactation consultants at the breastfeeding drop-in were amazed he had managed to thrive so well and had found a way to feed and take on enough milk. He was an extremely chubby baby and I must have had a lot of milk. Then when I thought about it, it might have been because he fed ALL DAY LONG (and night!). He also got very tired feeding, but I had nothing to compare it too so I didn't know how a baby should be feeding. So now I always wonder what our early breastfeeding experience would have been like without the tongue-tie - easier I suspect.

I had concerns about having it done at this late stage because I wondered if would be more traumatic for him at this age than in the first few weeks. The benefits of having it done at 16 weeks that were explained to me outweighed those concerns and we decided to go ahead. The procedure was over very quickly and although he screamed, (and I had to swallow my tears) I stuck him straight on the boob and we had lots of cuddles that evening and skin to skin and no after effects at all. Half an hour later he was smiling and flirting with passengers on the train home! It improved his suck almost immediately and made feeding much more efficient and he was definitely less vommie and windy. He used to be very uncomfortable on his back too, in the first 3 / 4 months. I'll never know whether it was just his gut maturing or the procedure that helped!

I wish I'd got his tongue-tie released earlier because when we did get it fixed I realised what a hindrance it had been even though I had absolutely no pain - very luckily.

With my second baby I knew what to look out for and did experience pain immediately (with my first I had no pain beyond the first week or so) and got her tongue tie divided on day 5. Links:
https://www.tongue-tie.org.uk/

Find a tongue-tie practitioner: https://www.tongue-tie.org.uk/find-a-practitioner/

https://www.nhs.uk/conditions/tongue-tie/
http://www.cwgenna.com/ttidentify.html
https://journals.sagepub.com/doi/abs/10.1177/0890334404266976

What is Breast Compression? - Breastfeeding Support
https://www.laleche.org.uk/my-baby-needs-more-milk/
https://www.cordeliauys.co.uk/howtotellyourbreastfedbabyisgettingenoughmilk
Average Weight Gain for Breastfed Babies * KellyMom.com

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How much the baby is affected by a tongue-tie will depend on each individual baby's tongue muscle mobility and control. It is therefore very important to seek out a specialist breastfeeding assessment when a tongue-tie has been noted. Bottle-feeding and tongue-tie Tongue-tie can make also make bottle-feeding more challenging.

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In this article we examine the impact certain factors or certain health conditions might have on a mother's ability to produce all the milk her baby needs, either initially or long-term, and what she can do to ensure she is able to produce as much milk as possible.

1) Maternal conditions which can affect supply
Diabetes or gestational diabetes (GB)
Babies born to women with diabetes or gestational diabetes are more likely to be born with hypoglycaemia and jaundice. In order to bring up their sugar levels, these babies will need to breastfeed soon after birth and frequently, but they are likely to be sleepy and therefore may struggle to breastfeed straight away. Harvesting colostrum antenatally is therefore recommended. Often giving a baby just one or two 1ml syringes of colostrum will whet their appetite and give them the energy to breastfeed. (See my article Antenatal Harvesting of Colostrum). Supplementation with formula should be avoided if at all possible, as this could predispose the baby to developing diabetes.

If you have diabetes or GB, in order to establish your milk supply, please see the steps recommended below.

It may take a little longer for your mature breastmilk to come in; you can help it come in sooner by keeping good control of your blood glucose levels, by doing lots of skin to skin and by breastfeeding very frequently.

Once your mature milk comes in, you should be able to produce a full milk supply. Breastfeeding for more than 3 months is thought to help protect women with gestational diabetes from developing type 2 diabetes.
Hypothyroidism
If you have hypothyroidism, your thyroid hormone levels need to be checked after you give birth, to ensure you are taking the correct dosage of levothyroxine. Normally the dose is brought down after delivery but needs to be higher than pre-pregnancy. If supplementation is too low, prolactin levels will be affected, resulting in low milk supply. Unfortunately, doctors aren't always aware of this. For more detailed information, please see the Breastfeeding Network's (BfN) leaflet Thyroid medication and Breastfeeding.

As long as you are taking the correct dose of levothyroxine, you should have a good milk supply.
Polycystic Ovarian Syndrome
About 20% of women with PCOS are estimated to struggle with their milk supply, while 20% may have oversupply. The other 60% will have a completely normal milk supply. Please see the links below for more detailed information on galactagogues that can be helpful for PCOS. The risk of having low milk supply with PCOS can be minimised by taking the steps recommended below.
Breast surgery Breast implants
Most women with breast implants will be able to breastfeed without any issues. However, breast reduction surgery, or any surgery around the nipple that severs milk ducts, is likely to have an impact on a mother's chances of producing a full milk supply.
Breast reduction surgery
If you have had breast reduction surgery, it's very much worth giving breastfeeding your best shot because there is a lot of variability in the impact of breast surgery on lactation. Even if a mother isn't able to exclusively breastfeed her first baby, she may be able to fully breastfeed her second and subsequent babies, as the act of breastfeeding increases the growth of milk-producing tissue, and milk ducts can grow back.
Insufficient glandular tissue (IGT or hypoplastic breasts)
A very small percentage of women have hypoplastic breasts, meaning that they have very little glandular tissue. This is completely different from having small breasts.

The following characteristics might indicate IGT:

Widely spaced breasts (more than 4cm flat space between breasts).

Breast asymmetry (one breast much larger than the other).

No breast growth or changes, either during puberty or pregnancy or after the baby's birth.

Tubular breast shape.

Very large and bulbous areola.

Women with IGT are usually able to produce some breastmilk but will often struggle to produce all the milk their baby needs.
Recommended steps
If you fall into any of the categories mentioned above, and you would like to breastfeed your baby, it is still very much worth making every effort to do so. It's impossible to predict what a mother's milk supply will be like. Any breastmilk will be beneficial to your baby, and the act of breastfeeding is about much more than just milk. It's advisable to:

Arrange for support from an IBCLC Lactation Consultant or Breastfeeding Counsellor.

Harvest your colostrum antenatally.

Do lots of skin to skin from birth onwards.

Breastfeed within an hour of giving birth and then at least 10 to 12 times in 24 hours.

Hand express after all feeds for the first 3 or 4 days.

If your baby isn't breastfeeding, within an hour of giving birth, start hand expressing on each breast at least 10 to 12 times in 24 hours.

Once your milk comes in, if there are signs of lower milk production (see my article How To Tell Your Baby Is Getting Enough Milk), double pump with a hospital grade double pump after breastfeeding, especially if supplementation is necessary.

If giving supplemental feeds, always practise paced bottle feeding or use a Supplemental Nursing System.

The pituitary gland
An additional factor that can affect supply is dysfunction of the pituitary gland. Because prolactin, the hormone responsible for milk production, is produced in the pituitary gland, milk supply can be affected by:

2) External factors which can affect milk supply
Retained placenta
When a baby is born and the placenta is delivered, there is a drop in maternal oestrogen and progesterone levels, which triggers a rise in prolactin. If, following birth, even a small amount of placental tissue remains in the uterus, there will be an impact on milk production. As soon as this has been removed, milk production will usually normalise.
Under stimulation of breasts
Under stimulation is by far the most common cause of low milk production.

When discussing low milk supply it's essential to point out thatthe vast majority of mothers are physiologically capable of producing enough milk for a single baby, twins or triplets; it's effective, timely and regular removal of milk from both her breasts that tells a mother's body to make milk.
Under stimulation happens if:

1. Milk is not being removed from breasts regularly.

2. The baby is not able to breastfeed effectively, either due to incorrect positioning and attachment, or a physical issue, such as tongue-tie.

3. Both of the above.

1) Milk not being removed regularly enough Babies need to feed frequently
In order for a mother's milk production to be established and maintained in the early months, milk needs to be removed from both breasts at least 8 times in 24 hours. UNICEF talk about an average of 10 to 12 feeds a day, and many babies will need to feed more often than this.
Responsive breastfeeding is essential for establishing a good milk supply
When a baby is born, their mother's breasts are primed to make just the right amount of milk, depending on the stimulation they receive. If a mother has a naturally generous supply, her infant will need to spend less time on the breast, and feed less frequently, than the infant of a mother with a less generous supply.
The Feedback Inhibitor of Lactation (FIL)
Whenever breasts get hard and full, the Feedback Inhibitor of Lactation, a negative feedback mechanism, kicks in, telling them to stop making milk. This means milk production slows down when breasts are full and speeds up when breasts are emptier.
Breast storage capacity
Women vary in how much milk they can store in each breast before the FIL kicks in. If a mother has a smaller milk storage capacity, she will still be able to produce all the milk her baby needs, it just means her baby may need to breastfeed more frequently to get all the milk they need, and for her milk supply to be sustained. Long gaps between feeds will decrease her supply.
The impact of scheduled feeding
When babies are fed to a schedule, unless a mother has an extremely generous milk supply and large breast storage capacity, it's unlikely her breasts will get sufficient stimulation to maintain milk production.
The impact of only offering one breast per feed
It is essential to offer both breasts at each feed. If a mother only offers one breast per feed, her baby will be getting half as much milk as they could potentially get, and her breasts will be getting half as much stimulation.

Once a baby has come off the first breast, the recommendation is to wake them and offer the 2nd breast. At the next feed, they should go back to the 2nd breast.
Importance of night feeds
Prolactin levels are highest in a mother's body between 2am and 4am. Breastfeeding at night is therefore important for maintaining milk supply in the early months.
Dummies
Dummies can mask feeding cues, leading to reduced milk supply and slow weight gain.

Misunderstanding of cluster feeding:

In the first couple of months, it's typical for babies to cluster feed firstly at night and then in the evenings. Wanting to be on and off the breast almost incessantly for several hours is probably an evolutionary development to ensure breasts regularly get very frequent stimulation.

The vicious circle of supplementation

Unfortunately, it's common for mothers to misinterpret cluster feeding as a sign that they don't have enough milk, so they start supplementing with formula. This leads to less stimulation of breasts, creating a vicious circle in which mothers need to give more and more formula.
2) The baby is not be able to breastfeed effectively
In order for a mother's breasts to get the message to create a full milk supply, as well as breastfeeding very frequently, her baby needs to be able to remove milk from both breasts effectively. This means the baby needs to be able to take a deep mouthful of breast and draw milk out in a rhythmic suck-swallow pattern for somewhere between 5 and 45 minutes. The effective removal of milk (nutritive suckling) sends a message to the mother's body to make more milk. If a baby is sucking gently, without actually drawing milk from the breast (non-nutritive suckling), he or she could spend an hour or more on the breast without stimulating any milk production.
Reasons why a baby might not be able to breastfeed effectively:

Baby born premature or early
When babies are born prematurely, or even just a couple of weeks early, they might initially struggle to breastfeed efficaciously.

Sleepy baby
Babies born early are often very sleepy, and it can be hard to keep them awake and actively suckling at the breast.

Neonatal jaundice

Over 50% of newborns develop neonatal jaundice in the first 2 to 3 days of their life; in most cases, this is not a cause for concern. Babies are born with more red blood cells than needed outside of the womb, and as these are broken down, a yellow pigment called bilirubin is produced. Bilirubin circulates in the baby's blood and can cause their skin and the whites of their eyes to turn yellow. The main issue for most jaundiced babies is that it can make them very sleepy and therefore difficult to rouse and feed. The best way to flush the bilirubin out is for the baby to drink lots of breastmilk. Breastmilk is more effective in this regard than formula milk.

Tongue-Tie
A tongue-tie can make it harder for a baby to get a deep latch, to create a seal, and to transfer good volumes of milk. Sometimes a tongue-tie has an immediate impact on milk production, but if a mother has a naturally generous supply, the effect might not become apparent for a few weeks. Please see my article https://www.cordeliauys.co.uk/what-is-tonguetie

Attachment and positioning

If a mother isn't holding her baby close enough to her body, and in a position that enables the baby to take a deep mouthful of breast, there can be a similar impact on milk supply as with a tongue tie. Babies need to breastfeed, not nipple feed.

Tightness in the baby's head, jaw or neck muscles
A long second stage of labour, a difficult foetal presentation before birth, the cord round the baby's neck, or an instrumental (forceps or ventouse) delivery, can all create stiffness in the baby's body that might hinder their ability to latch deeply and achieve proper suck-swallow coordination. Cranial osteopathy can help to gently release any tensions in the baby's body. Please see the article on cranial osteopathy and breastfeeding on my website.

3) Milk is not being removed from breasts regularly and the baby is not able to breastfeed effectively

This combination is a double whammy for a mother's milk supply, and can quickly turn into a vicious circle in which the mother supplements with formula/ the baby is full of formula and not interested in breastfeeding/the mother's breasts don't get sufficient stimulation/her milk supply decreases/the baby gets less milk at the breast/ the baby can't draw much milk/the breasts get less and less stimulation.

Factors that are often misinterpreted as low milk supply
Please note that the vast majority of mothers are physiologically capable of producing as much milk as their baby needs.
Many mothers misinterpret normal baby behaviours, or other factors, as signs of low supply.

It is NOT a sign of low supply if:
The only reliable indicators of low supply are:
Please see my article How To Tell Your Breastfed Baby Is Getting Enough Milk.

Recommended steps to increase milk supply
If your baby isn't taking the breast:

Arrange support from an IBCLC Lactation Consultant or Breastfeeding Counsellor who can create a feeding and pumping plan for you.

Do lots and lots of skin to skin with your baby - this will stimulate your breastfeeding hormones and will promote feelings of wellbeing in you and your baby.

Hire or buy a hospital grade double pump - double pumping is like telling your breasts you have twins.

Double pump at least 8 times in 24 hours, including once between 2am and 4am when your prolactin levels are highest. It's normally recommended to pump for 20 to 30 minutes, but please discuss this with your IBCLC or BFC. (Hand expressing, rather than pumping, is recommended in the first 3 or 4 days).

Check your breast shields fit properly.

Don't worry if at first you can barely produce any milk while pumping. It might take several days of regular pumping before you see an increase in output.

By cutting holes in an exercise bra, that fits comfortably, you can create a pumping bra to hold the pumpsets in place, allowing you to massage your breasts while double pumping, which stimulates production.

If your baby is breastfeeding:

Offer the breast as soon as your baby is showing early feeding cues.

Breastfeed your baby as frequently as they want, and at least 10 times in 24 hours. Wake them if necessary. UNICEF talk of an average of 10-12 breastfeeds in 24 hours and many babies need to feed more often.

If possible, increase the number of times you are offering the breast.

Always offer both breasts at each feed.

Compressing/massaging your breasts regularly during feeds will send more milk down to your baby.

Switching back and forth between breasts several times during each feed can help ensure a baby does lots of nutritive suckling. Once your baby is no longer actively swallowing on the first breast, switch them over to the other side.

Double pumping immediately after breastfeeds provides very effective stimulation. Don't worry if this means temporarily producing less milk. Think of it as an investment: you are sending in the order for the next feeding/pumping session.

If giving supplemental feeds, always practise paced bottle feeding or use a Nursing Supplementer. The traditional way of bottle feeding can lead to breast refusal because babies get used to a faster flow.

Discuss with your IBCLC or BFC the possibility of taking galactagogues, such as fenugreek, goat's rue or domperidone. (Fenugreek & blessed thistle: 3 tablets x 3 times a day). Please note galactagogues won't work unless you are also doing lots of breastfeeding and/or pumping.

Regular pumping can be stopped once supply has increased. These steps are hard work but often very successful.

Links:

Antenatal harvesting of colostrum: https://www.cordeliauys.co.uk/antenatal-harvesting-of-colostrum

Reasons for low milk supply: https://breastfeeding.support/reasons-low-milk-supply/

Hypoglycaemia of the newborn: https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2010/10/hypo_policy.pdf

Gestational diabetes: https://www.gestationaldiabetes.co.uk/breastfeeding/
https://www.laleche.org.uk/diabetes-and-breastfeeding/
Hypothyroidism: http://www.breastfeedingnetwork.org.uk/wp-content/dibm/2019-09/Thyroid%20medication%20and%20Breastfeeding.pdf
Polycystic Ovarian Syndrome: Breastfeeding and Polycystic Ovarian Syndrome (PCOS) : KellyMom Guest Post: Lisa Marasco Talks about PCOS and Breastfeeding Polycystic Ovary Syndrome and Breastfeeding - Breastfeeding Support http://www.bfar.org/index.shtml
Breast reduction surgery: https://breastfeeding.support/reasons-low-milk-supply/
https://www.breastfeeding.asn.au/bfinfo/insufficient-glandular-tissue-breast-hypoplasia
Insufficient glandular tissue: https://kellymom.com/bf/got-milk/supply-worries/insufficient-glandular-tissue/

Paced bottle feeding: https://www.youtube.com/watch?v=OGPm5SpLxXY

Supplemental nursing system: https://breastfeeding.support/supplementing-at-the-breast/

Cranial osteopathy: https://www.cordeliauys.co.uk/cranialosteopathyandbreastfeeding

Jaundice: https://breastfeeding.support/treatment-for-jaundice/

Positioning and attachment: https://www.laleche.org.uk/positioning-attachment/

The let-down reflex: https://www.ardobreastpumps.co.uk/the-let-down-reflex-by-cordelia-uys/

How to get the right size breastshields: https://www.ardobreastpumps.co.uk/size-matters/

The fourth trimester: https://sarahockwell-smith.com/2012/11/04/the-fourth-trimester-aka-why-your-newborn-baby-is-only-happy-in-your-arms/

If a baby needs more milk: https://www.laleche.org.uk/my-baby-needs-more-milk/

Breast compressions: https://breastfeeding.support/what-is-breast-compression/

Stanford Medical School video on double pumping: https://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html

Using a nursing supplementer: https://www.laleche.org.uk/nursing-supplementers/

https://breastfeeding.support/supplementing-at-the-breast/

Galactagogues: https://kellymom.com/bf/can-i-breastfeed/herbs/herbal_galactagogue/#:~:text=A%20substance%20that%20increases%20milk,that%20can%20increase%20milk%20supply

Domperidone: http://www.e-lactancia.org/breastfeeding/domperidone/product/

Dropping top-ups: https://breastfeedingtwinsandtriplets.co.uk/2017/06/07/dropping-top-ups-gradually/

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In this article we examine the impact certain factors or certain health conditions might have on a mother's ability to produce all the milk her baby needs, either initially or long-term, and what she can do to ensure she is able to produce as much milk as possible.

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When your baby is born, it takes about a month to achieve a balance between their needs and how much milk your breasts produce. It's vital you are breastfeeding at least 10 to 14 times in 24 hours to establish a good supply, and to avoid blocked ducts and mastitis.

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Breast inflammation is a relatively common condition affecting breastfeeding women encompassing a range of conditions such as engorgement, a blocked duct, mastitis or abscess. Mastitis is associated with a range of distinctive symptoms from a sore, painful breast to feeling unwell or having a fever (rise in body temperature). Breast inflammation is thought to be due to the body's reaction to a build up of breast milk in the breast. It is thought that when breasts are over full or engorged, high pressures on the delicate milk ducts in the breast can trigger inflammation.

This article

This article looks at the symptoms and causes of breastfeeding related mastitis, and ways to prevent and treat it. Related articles include Engorged Breasts, Blocked Milk Duct, Breast Lumps and Do I Have a Breast Abscess?

Symptoms of mastitis

The symptoms of mastitis can include:

Soreness, pain, heat and swelling (inflammation) in the breast

A sore lump or tender spot inside the breast

Colour changes to the skin. In lighter skin tones there may be areas of red or pink skin on the surface of the breast which may include red streaks or lines. In darker skin tones areas of skin with mastitis may look brown or purple as well as red or changes in skin tone may not be visible.

Flu-like symptoms such as feeling achey, shivery or run down, headache.

Bacterial infection

Mastitis is not always associated with a bacterial infection. Mastitis symptoms often clear on their own after a day or two of careful preventative treatment-see below. If a bacterial infection is present, this is usually due to Staphylococcus aureus (Staph) or Streptococcus (Strep) but breastfeeding can continue. The US based Academy of Breastfeeding Medicine (ABM) explains:

Bacterial mastitis is not a contagious entity and does not pose a risk to the infant nor require an interruption in breastfeeding.

What causes mastitis?

Different authors have different opinions on the causes of inflammation of the breast. One explanation is that high pressures in the milk making tissue and ducts cause mechanical strain which can rupture cell membranes and lead to inflammation. Causes of such a high pressure under this model include:

Poor position and attachment

Poor positioning (the way baby is held to breastfeed) or a suboptimal latch (the way a baby attaches to the breast) can make it more difficult to drain or "milk" the breast. During breastfeeding a baby needs a big mouthful of breast tissue as well as the nipple in their mouth, see our Latching Tips. Incorrect positioning and attachment, including a poorly fitted nipple shield, could lead to sore or cracked nipples, engorgement, blocked milk ducts or mastitis.

Infrequent feeds

A baby who is not breastfeeding often enough, perhaps due to scheduled feeds, separation from mother, frequent use of a pacifier to delay feeds, busy holiday/stressful periods or a mother or baby who is feeding less due to illness.

Massage and vibration

Vigorous massage, vibration, or something pressing firmly into the breast throughout a feed could interfere with milk flow such as a finger, a tight bra or other clothing, the straps of a heavy bag, mother's sleeping position or a poorly fitted breast pump.

Additional risk factors that have been highlighted by other authors include:

Smoking increases the risk of breast abscess and inflammation in the ducts behind the nipple (breast periductal inflammation).

Breast trauma for example a toddler knocking the breast, or any scarring within the breast or nipple including previous breast or nipple surgery; breast implants, reduction surgery, nipple piercing or skin infection.

Diet and inflammation. Eating a high proportion of inflammatory omega-6 polyunsaturated fatty acids (PUFAs) while having very few anti-inflammatory omega-3 PUFAs may promote inflammation in the body including breast tissue. In addition, a diet high in refined sugar discourages a healthy microbiome (friendly bacteria within our bodies) favouring bacteria that may contribute to inflammation and disease instead. One study found that eating traditional fermented foods such as kefir or homemade yoghurt may be protective against mastitis.

A mother who does a lot of vigorous exercise especially using the upper arms and chest (Wambach and Spencer, 2021 p 285).

Preventing and managing mastitis

New insights into traditional ways of preventing and managing inflammatory conditions of the breast continue to evolve. Recent publications to guide us include The Academy of Breastfeeding Medicine's Protocol #36 The Mastitis Spectrum (2022) and a series of papers by Australian doctor and breastfeeding specialist Pamela Douglas. The following is a summary of recommendations for preventing and managing breast inflammation taking new and previous information into account.

#1 Breastfeed often on demand

Breastfeeding frequently on demand with your baby in a deep, comfortable latch (see #2) will help prevent and manage mastitis. If your baby is not breastfeeding, or not able to breastfeed well yet, frequent hand expressing or pumping can be used to regularly remove breast milk instead (see #3). It is important that your baby, hands or your pump remove enough milk from your breasts to stay comfortable at the first sign of engorgement or a blocked duct. Strategies to support frequent feeds include maximising skin-to-skin contact between mother and baby after birth, offering each breast about 12 times in a 24 hour period (no need to watch the clock) and letting baby suckle for comfort as well as nutrition (Douglas, Vol 18: 1-29 2022).

#2 Good position and attachment

A good position and latch helps prevent or resolve breast inflammation. See Breastfeeding Positions for Newborns, Breastfeeding Videos and Latching Tips or seek help from your IBCLC lactation consultant or breastfeeding specialist to check your baby's latch. Douglas writes that prolonged or unequal pressures on the breast could exacerbate breast inflammation and cautions against deep massage, firmly shaping or compressing the breast during feeds, tight or overly supportive bras or using a pump that is poorly fitted (Douglas, Vol 18: 1-20 2022).

Although nipple shields may have a helpful role for some mothers (Douglas, Vol 18: 1-29 2022) the Academy of Breastfeeding Medicine protocol #36 recommends avoiding shields although this is based on consensus or opinion rather than high quality research (Mitchell et al, 2022) .

#3 Hand express or pump to comfort

During bouts of breast inflammation, frequent breastfeeds and/or expressing enough milk to stay comfortable is recommended to reduce inflammation and so that the milk volume will naturally adjust to your baby's needs (Mitchell et al, 2022; Douglas, Vol 18: 1-20 2022). If your baby can't breastfeed, isn't feeding well yet or can't keep up with the volume of milk, you may need to hand express or use a breast pump for a while. Bear in mind pumping with a poorly fitted flange can cause breast inflammation see Do I Need a Breast Pump? and How to Increase Milk Supply When Pumping for tips on finding the right fit.

Don't over pump

Excess milk removal (regularly pumping more milk than your baby can drink) could be counter productive by stimulating milk supply further and perpetuating a cycle of too much milk and inflammation. It is therefore not necessary to over pump to try to empty the breasts, or to reach the hind milk as a general breastfeeding strategy.

#4 Reduce a milk supply gradually

To avoid or manage engorgement it is important to remove milk frequently. It is not a good time to feed less often, try to reduce a milk supply or stop breastfeeding while a breast is painfully engorged and inflamed. Where needed, down regulating a milk supply slowly will protect against engorgement and similarly if you want to stop breastfeeding this is best done gradually (Douglas, Vol 18: 1-20 2022), see How to Stop Breastfeeding.

#5 Breast movement but no deep massage

Breast massage may worsen inflammation. There is some disagreement between practitioners on whether massaging a lactating breast can help or hinder inflammation. One study found careful use of very gentle light touch massage combined with hand expression may help to drain an engorged breast thoroughly to prevent mastitis developing. Newer thinking cautions that a deep or vigorous massage could traumatise a breast and worsen engorgement and inflammation (Douglas, Vol 18: 1-20 2022, Mitchell et al, 2022). If considered, any massage technique should use no more pressure than applying cream to the skin or stroking a pet, see Engorged Breasts, and Blocked Milk Duct.

Breast gymnastics. Natural breast movement may prevent breast inflammation yet bras and sedentary lifestyles can restrict breast movement (Douglas, Vol 18: 1-20 2022). Douglas says the type of breast massage sometimes called breast gymnastics may have a role in preventing breast inflammation (Douglas, Vol 18: 1-20 2022). Douglas explains that breast gymnastics involve lifting and gently moving the breasts in various directions, often with circular movements using the whole of the hand or palm laid gently over the breast. For more information on bras see Nursing Bras FAQ on this website.

#6 Pain relief

Warm compress? Some mothers may find a warm compress on the breast is soothing and helps with pain relief. Warmth across the nipple can help release hormones to trigger the let-down before you breastfeed or express. However warm compresses or showers could cause blood vessels to widen (dilate) and bring even more fluid to the area adding to any engorgement. Warmth has not been shown to help mastitis in studies (Mitchell et al, 2022; Douglas, Vol 18: 1-20 2022).

Traditional remedies. Around the world there may betraditional local remedies for breast inflammation. In France some mothers use a green clay poultice as a topical remedy to soothe breast inflammation. One traditional remedy of using a poultice of grated raw potato or carrot to reduce pain and discomfort is mentioned in The Nursing Mother's Herbal 2003, p.149 by Sheila Humphrey.

#7 Self care

Rest, remember to eat and drink plenty of fluids. Lawrence and Lawrence state bed rest is recommended during mastitis. What we eat can influence the levels of inflammation in the body (see above) (Hurd, 2015; Hurd-Reeves, 2019; Basim, 2020).

Medication or supplements for mastitis

If you are not starting to feel better after 12-24 hours of treatment, contact your health care professional for advice in case medication is required (NICE, 2021; ABM 2022).

Antibiotics

Most women with inflammatory mastitis recover without antibiotics or interventions other than control of symptoms, knowledge of the physiological anti-inflammatory response, and regular communication with their health professional (Mitchell et al, 2022). The Academy of Breastfeeding Medicine says it is important to reserve antibiotics for bacterial mastitis and explains:

Use of antibiotics for inflammatory mastitis disrupts the breast microbiome and increases the risk of progression to bacterial mastitis. Furthermore, nonselective use of antibiotics promotes development of resistant pathogens. Prophylactic antibiotics have not been shown to be effective in the prevention of mastitis. It should be noted that many antibiotics and antifungal medications have anti-inflammatory properties, and this may explain why women experience relief when taking these.

A health care professional will prescribe compatible antibiotics if a bacterial infection is suspected after 24 hours of a mastitis action plan, or if the mother is very poorly(Mitchell et al, 2022) . The organisations below discuss specific antibiotic choices and doses and currently recommend a 10-14 day course of antibiotics:

Nisin is an antibacterial peptide produced by the bacterium Lactococcus lactis that kills other bacteria and is used as a food preservative. One study found swabbing nipples with a nisin solution was an effective alternative to antibiotics in treating mastitis due to stahylococcus.

Probiotics?

The results of studies on the use of probiotics to prevent or treat mastitis are not clear. Arroyo et al compared giving mothers strains of Lactobacillus species isolated from breast milk with conventional antibiotic treatment. They found that women who took the probiotics improved more and had lower recurrence of mastitis than those who took antibiotics. Another industry funded study found improvement in the risk of mastitis after giving the mothers a probiotic. However, Amir et al describe a number of concerns about the validity of Arroyo's study, and similar trials, and call for high quality randomised control trials to establish whether probiotics are an effective treatment for mastitis. Douglas states that there is little evidence to justify use of probiotics for prevention of mastitis (Douglas, Vol 18: 1-20 2022).

Lecithin?

The food supplement lecithin is sometimes suggested to help reduce the constituency (thickness) of breast milk so reducing the risk of blocked ducts and associated mastitis. However not everyone agrees with the idea of thickened milk causing obstructions and Douglas says that current studies don't support the ingestion of lecithin to thin breast milk (Douglas, Vol 18: 1-20 2022). Dr Tom Hale of Hale's Medications and Mothers' Milk [paywall] says lecithin would be broken down in the stomach and intestines long before being absorbed and there isn't any evidence for its use. See Blocked Milk Duct for more information.

Vitamin C

Some practitioners recommend a mother ensures she is taking plenty of vitamin C during mastitis see Vitamin C and Breastfeeding for more information.

Recurrent Mastitis

If you keep getting episodes of mastitis or blocked ducts an IBCLC lactation consultant or breastfeeding specialist can be very helpful to identify the most likely reasons why. They will review your history fully, and check whether your or breastfeeding management could be the underlying cause for mastitis to keep returning. Other risk factors for recurring mastitis include:

Breastfeeding on a schedule instead of whenever baby wants (on demand)

Stopping breastfeeding abruptly on the affected side during an episode of mastitis.

Deep or vigorous massage could traumatise delicate breast tissue and may cause more inflammation (Morgensen et al, 2020; Mitchell et al, 2022; Douglas, 2022).

Diet and inflammation. Recurrent blocked ducts and associated mastitis may be linked with a diet that is high in refined carbohydrates (sugar) and/or a high proportion of inflammatory omega-6 PUFAs coupled with few anti-inflammatory omega-3 PUFAs (Hurd, 2015).

Preventing recurrent mastitis

In most cases, addressing the above causes will resolve repeated mastitis. Additional clinical guidance includes:

Culture specimens from breast milk and send nasal swabs from both the mother and baby for culture (NICE, 2021).

Consider chronic bacterial infection, pseudomonas infection, secondary fungal infection, underlying breast disease such as a cyst, tumour or other medical cause.

Pay attention to hygiene eg discard any potentially contaminated nipple creams or ointments, wash pump equipment thoroughly (NICE, 2021). Note: The Academy of Breastfeeding Medicine says there is no evidence to support poor hygiene as a cause of bacterial mastitis (Mitchell et al, 2022).

Other causes of breast inflammation

If mastitis does not seem to respond to treatment or keeps recurring there may be something else happening. For a review of other causes of deep breast pain associated with breastfeeding see Why Does Breastfeeding Hurt? and see below:

Thrush. Fungal infection has historically been described as a cause of deep breast pain however more recent research highlights multiple other conditions to explain these symptoms casting doubt on breast thrush.

Not mastitis? Check with your health professional if mastitis does not improve with treatment. Although rare, other conditions such as cellulitis or inflammatory breast cancer can be mistaken for mastitis.

Frequently asked questions

#1 Can I continue breastfeeding my baby if I have mastitis?

Yes, even if antibiotics are needed, breastfeeding can continue during mastitis (Mitchell et al, 2022). Antibodies in breast milk will help protect the baby from any infection and stopping breastfeeding abruptly could cause more problems. Breast milk is sometimes said to taste slightly salty from a breast with mastitis but this doesn't usually pose a problem to the baby.

Most cases of infection based mastitis are caused by Staphylococcus aureus bacteria (staph). For more information about breastfeeding and staph infections including infection by methicillin-resistant Staphylococcus aureus (MRSA) see Staph, MRSA and Breastfeeding.

#2 What can I do if my baby can't latch or my milk won't flow?

Sometimes engorgement behind the nipple can change the nipple shape making it difficult for your baby to latch and having the effect of someone stepping on a hose, stopping the flow of liquid (i.e. breast milk!). If you're struggling to express any milk at all or your baby can't seem to latch due to engorgement, have a look at Engorgement Relief When Milk Won't Flow for ideas to help you.

#3 What is the treatment for blocked milk ducts?

An untreated blocked duct (local build up of breast milk) can lead to mastitis. Treatment for a blocked duct is the same protocol for relieving engorgement or mastitis, see Blocked Milk Duct for more information.

#4 What does a white spot on my nipple mean?

If you have a small white spot on your nipple alongside symptoms of mastitis, this could be a "bleb"; a small blockage to one of the nipple pores. See the section about milk blisters or blebs in Blisters on Nipples for more information.

#5 Bra or no bra?

It's important to ensure a tight fitting bra is not the cause of the mastitis. NICE (National Institute of Health and Care Excellence) guidance recommends avoiding wearing a bra, especially at night ( NICE, 2021) whereas Lawrence and Lawrence say to wear a supportive bra during mastitis that doesn't cause painful pressure (Lawrence, 2016). For more in depth discussion on the pros and cons see Nursing Bras FAQ.

#6 Why is my breast milk thick or lumpy?

Some mothers notice their pumped breast milk can be lumpy or clumpy If milk has a thick or clotted consistency within the breast this has often been assumed to be a risk factor for breast inflammation, however Douglas says there is no evidence that sticky or clumped milk could block ducts (Douglas, Vol 18: 1-20 2022). Unless a mother expresses her milk, the presence of thicker or lumpy breast milk and whether it could sometimes be a variation of normal would not be apparent. Theories for causes of thickened milk include mastitis and diet.

Mastitis. Some mothers may notice their expressed breast milk has lumps or clots forming in the collection container just after pumping, or seem to come directly from the nipple. In The Breastfeeding Atlas, 6e, p97 authors Wilson-Clay and Hoover share that clumpy, lumpy milk is an indication of early mastitis in the dairy industry and could also be linked to breast inflammation in humans as some women have reported clumpy milk during mastitis episodes. The cause of the lumpy milk may be a result of coagulase, a protein made by Staphylococcus microorganisms that produce fibrin; a substance that causes clotting. A culture of the lumpy milk may locate a particular organism for treatment.

Summary

Mastitis is the name for an inflammation in the breast thought to be due to a high pressure volume of milk in the breast. Mastitis can be very painful and a mother may have general symptoms similar to flu (shivers, temperature, feeling unwell) as well as a very painful sore breast (or two). At the first sign of engorgement or early mastitis-frequent breastfeeding, or hand expressing/pumping just enough so that the breast is comfortable again can help relieve symptoms. Sometimes mastitis is associated with a bacterial breast infection and may require antibiotics. There are several antibiotics for treating mastitis that are compatible with breastfeeding-there is no need to stop breastfeeding or stop frequent milk removal during an episode of mastitis. Stopping breastfeeding/removing milk when the breast is inflamed could lead to a breast abscess. If mastitis keeps coming back, check your baby's latch and positioning with your breastfeeding specialist or IBCLC lactation consultant and stay in touch with your medical professional.

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Breast inflammation is a relatively common condition affecting breastfeeding women encompassing a range of conditions such as engorgement, a blocked duct, mastitis or abscess. Mastitis is associated with a range of distinctive symptoms from a sore, painful breast to feeling unwell or having a fever (rise in body temperature).

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In this article we look at what happens when a new mother's mature milk comes in, and how to manage the engorgement.
Colostrum
Pregnant women produce colostrum, mothers' first milk, from half-way through their pregnancy:

https://www.cordeliauys.co.uk/what-is-colostrum

Colostrum is produced in small volumes, and is all babies need in the first few days. It's the birth of your baby and the delivery of the placenta that tells your body to start making mature milk.
What do we mean by milk 'coming in'?
Although mature milk production starts around 30 to 40 hours after a baby's birth, mothers don't usually feel their breasts becoming fuller until sometime between Day 3 and Day 4. With second and subsequent babies, mature milk tends to come in sooner.

Some women will notice their breasts suddenly become much larger and firmer; for others it's a more gradual process. All new mothers will find that their breasts increase in size considerably, as extra lymph fluid, and blood, flow to their breasts and they fill with mature milk.

Just before your milk comes in, you may notice the veins on your breasts becoming more visible.
How to minimise your chances of getting extreme engorgement

Breastfeed within 2 hours of your baby's birth.

Breastfeed very often, especially in the first two or three days. It's recommended to aim for 10 to 14 feeds (or more) in 24 hours. This will also be great for establishing your milk supply.

Avoid going longer than 3 hours between feeds.

Offer both breasts at each feed.

Make sure your baby is well latched and positioned and is transferring milk effectively. Ask for help if not.

Engorgement can be alarming
Having breasts that are painful, rock-hard, warm and tender, and which rival Dolly Parton's, can come as a shock. Some women also experience painful swelling in the breast tissue under their armpits, and some develop a fever.
A perfect storm
The discomfort and increase in size tend to coincide with a cocktail of new-mum hormones coursing through your body, causing a rollercoaster of emotions. You will probably also be suffering from several nights of disrupted sleep, as well as starting to come down from the high you experienced when meeting your baby for the first time. Many women find themselves feeling tearful and overwhelmed.
Don't panic
The good news is that for the vast majority of women, this period of emotional volatility and significant engorgement rarely lasts longer than 24 hours.
Your baby might suddenly not be able to latch
When engorgement sets in, it's common for babies who were breastfeeding quite nicely suddenly not be able to latch. This is because the nipple and areola swell up so much that the nipple disappears, so for the baby it's like trying to latch on to a pumped-up football.
How to relieve the engorgement

If normally tolerated, you can take ibuprofen.

Breastfeed as frequently as possible, aiming for every ½ to 2 hours during the day, and every 2 to 3 hours at night.

Apply cold compresses: 20 minutes on, 20 minutes off; this helps with the swelling.

To make compresses: take two clean nappies, pour cold water in them, place them in the freezer for an hour, and then apply one to each breast.

# data[].attributes.attachment_link.description
In this article we look at what happens when a new mother's mature milk comes in, and how to manage the engorgement. Colostrum Pregnant women produce colostrum, mothers' first milk, from half-way through their pregnancy: https://www.cordeliauys.co.uk/what-is-colostrum Colostrum is produced in small volumes, and is all babies need in the first few days.

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Article on wind, colic and reflux by Sherridan Stymest IBCLC

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Article on wind, colic and reflux by Sherridan Stymest IBCLC

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Into Parenthood | Sherridan Stymest | Lactation Specialist

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I'm often asked how, and when, to 'wind' a baby? I'm also frequently asked about colic and reflux and what to do with an unsettled baby.

All babies will experience some periods of fussiness in the early months. It's a very normal occurrence and shows that their digestive system is beginning to work. Wind may be released out of one end or the other. It's a whole body workout as they learn to coordinate the opening and closing of different sphincters. All of this is new to them, they've never had to do it before, and it may feel strange! They may bring their knees up, flex their hips, push down with their feet, clench their fists, frown, contort and change colour. In some cases, it may be dyschezia, a functional condition that can cause up to 30 minutes of crying, as a baby passes a normal soft stool. This is extrmely difficult for parents to watch, but it can be painless and doesn't need any medication. Unlike adults, babies have a limited range of movements and can't easily adjust their positions or tell you what's wrong. It takes a lot of coordination to poo! plus imagine trying to do so, lying on your back!

Infants have a range of behaviours and symptoms that make them appear unsettled, some normal and some that require more medical attention. The term 'colic' is now a frequently used phrase that is used to describe many things, including trapped wind, food intolerance, constipation, tummy ache, or something else.

As a parent, It's distressing watching little ones in pain, so it's helpful to have a term that names this. 'But it is worth asking: 'Does naming it also pathologise it?'

Traditionally, babies were carried and spent most of the day, uptight on a parent, meaning that they could feed frequently and food could easily be digested. Babies have immature oesophageal sphincters, that are designed to relax and open frequently, allowing the release of pressure from excessive feeds or any gas or wind to escape. Breastmilk is an amazing source of nutrition that also carries many microbes and anti viral and bacterial substances that bathe and coat mucosal surfaces - so a baby that regurgitates breastmilk gets a double protective coating. Sometimes, after positting milk, they lick their lips and, reminded by its deliciousness, ask for more.

Reflux

Reflux, is a normal occurance in a young baby. Its technically known as gastro-oesophageal reflux or GOR, and is the term used to describe the contents of the stomach going up into the oesophagus. Basically, something going the wrong way through a valve. It may come all the way up, and out, or it may come partially up, or be re-swallowed - silent reflux. A baby can easily bring up food if it has taken too much, or if there is any harm from keeping it down. If left lying on their back, and unable to change position, or if the stomach is full, food coming back up is physiologically normal and a protective process. Half the babies in the UK will reflux or spit up some milk at some point in the day. Some will bring up a little, and others much more, the frequency and consistency will vary widely. Its also worth remembering that a little bit of a spilt milk, looks much more dramatic than it probably is. Have a look at Lucy Ruddle explaing this here
Reflux disease (GORD)
Gastro oesophageal reflux disease, or GORD, is different from reflux, and is a medical condition that needs a proper diagnosis. According to NICE guidelines GORD should only be considered if a baby has two or more of the following symptoms:

If your baby has any of the above please see a Health professional ASAP.

GORD is a serious medical condition, described as a reflux of stomach acid that irritates the lining of the oesophagus and is sometimes aspirated into the lungs causing inflamation, scarring and narrowing. Studies that have looked at this acid hypothesis, cast doubt that it is actually the cause of damage and pain. Nevertheless, its common to see babies prescribed strong medication, many of which can have long term consequences, and its questionable if it is actually needed. The tests needed to check if it is GORD are difficult and invasive. If a baby is failing to thrive then medication along with proper support is absolutely needed, but in my opinion it is often given without good reason. The medications prescribed however, still often use acid suppressing drugs like PPI's (proton pump inhibitors) so we do really need some good studies to inform our practice.
Wind/burping
This randomised controlled trial looked at burping or winding as a preventative measure for colic and reflux, in healthy babies. It showed that actively patting a baby on the back did not significantly lower these events, but there was an increase in reflux episodes in those routinely winded. So, perhaps we are creating a so-called 'laundry problem' and wasting precious time patting babies, when we could be cuddling them and letting them gently fall asleep in our arms. Could we trust that they will burp if they need to?

Fussy symptoms tend to be more apparent in the evening, when it gets dark, say, from 6-10pm, sometimes known as the 'witching hours'. At this time it is very normal for a breastfed baby to cluster feed. Often spending several hours going from breast to breast.

These times are more challenging, but are thankfully, generally followed by a relatively longer sleep. The baby will continue to feed several times throughout the night, but tends to manage to go back to sleep quite well, especially if feeding in the side lying position while bed sharing. In the morning, they often have a big feed, from a full breast, and then are relatively happy for the rest of the day, feeding often, and gradually becoming more fussy as the evening draws in. This behaviour can be very normal, and I see this pattern frequently in the first few weeks of life, sometimes lasting up to the third month when the baby's gastrointestinal system matures.

However, some babies can be much more uncomfortable and the normal soothing from their parents doesn't seem to help. They may cry for long periods, have unpleasant smelling gas and frothy smelly stools. These babies are labelled with colic, the Greek word for colon, described in 1954 by Morris Wessel as 'persistent crying for more than three hours a day, for at least three days a week, for at least three weeks in a row'. Devastating and very painful for babies and their parents.

Some colicky symptoms may be relieved by the way the baby is feeding.

It may be their latch, to the breast or bottle, the way they are being held, the flow of milk, or supply. It can also be a misinterpretation of a baby's cues, due to unrealistic expectations of normal baby behaviour. I have seen many babies getting upset because they want to feed or have a cuddle, but in a society that informs us that babies should be on a three hourly schedule and shouldn't be spoilt, this signalling can be easily read as pain or colic. This can then cause more upset in the baby and parent and cycle more stress and nervous system activation. An IBCLC and a CST therapist can help with these things and I would always recommend checking in to see if they can support you. Here is a study that looks at how CST - craniosacral therapy helps reduce the number of crying hours, colic severity and increases sleep.

Dr Howard Chiltern,a neonatologist, believes that colic is a symptom of overwhelm. He suggests that some babies struggle with being born evolutionary premature and often feel like they need to be back in the womb. 'Colic has never been about pain in the abdomen or anywhere else for that matter. There is no question that the baby looks like he or she is in excruciating tummy pain. The baby doubles up, knees in chest, and screams like there's a knife twisting in his gut. But it's not about pain, it's about stress and overstimulation of the poor baby's sensory nervous system'. He discusses how holding them close and helping them to feel womb like can be 'the most important lesson to learn : how to keep themselves calm and feel secure'

This is a great article that looks at this fussiness in the early months, often called the fourth trimester, and suggests ways to help comfort your baby and make the world feel more womb-like.

The type of milk a baby receives, breastmilk or formula can contribute to gas.

It depends on the different enzymes in the milk and bacteria present in the gut to digest it and break it down. This process can create pressure and both hydrogen and methane are among the gases that can contribute to this. Some gas will be easily released, while some may be trapped and move around in the gut, creating discomfort or pain. There have now been a number of studies that have identified a difference in the gut biome (dysbiosis) and gasses present in babies with colic symptoms, like this one and this one.

Gas or wind, can be caused by fermentation and digestive processes in the intestines. This is a normal action of healthy bacteria breaking down food particles, like milk sugars and human milk oligosaccharides (HMO's). Lactose, the main sugar in breastmilk, is important not only to brain development, but also the prevention of infection. If you have an abundant milk supply, there may be too much lactose for the baby's gut to absorb. It can leak into the colon and ferment, producing lots of hydrogen gas and liquid poos.

These microbial colonies are a vital component to our health and well being and are known as the gut 'microbiome'. As adults we have about as many bacterial cells as human ones and the more we learn about them the more we understand about our health and immunity. For example, HMO's are not digested by the infant and pass whole into the large intestine where the majority of bacteria are found. They act as a prebiotic and encourage the growth of good bacteria as well as blocking pathogens and viruses. We each have a unique microbiome that is established in the early months after birth, through inherited bacteria, as well as those digested and from our environment.

The first barrier to microbial infection is stomach acid.

The breastfed baby's normal stomach pH is sufficient to kill most pathogens. The child who is not breastfed has a less acidic stomach pH, allowing more bacteria to survive its journey into the intestines. Some of these rogue survivors, can multiply in the stomach and ferment food, producing gasses and alcohol as a result! Therefore, medication that neutralise stomach acid can actually increase the danger of infection. Medication that suppress stomach acid are sometimes required, but should be prescribed with caution. Many manufacturers advise against giving them to children as they have not been thoroughly researched.

Parents caring for an unhappy baby may be pleased to hear that for most it will get better at around 3 months of age. Helping to make the babies environment more womb like in their transition into the world can help a lot. Holding them upright on your body, or in a sling, white noise, gentle jiggling and rocking can make a difference. Warmth and gentle abdominal massage can be useful, as can a warm bath together. Feeding support from an experienced practitioner will also help you to understand if there is anything about the way they are fed that will help. As a parent, I would urge you to get help, to support you during this difficult time, so that you can be more available to help your little one. If you don't have friends or family close by, consider looking for a postnatal doulas.

If you are concerned, please see your GP or paediatrician for a proper diagnosis and testing, if your baby has severe symptoms they may benefit from medication.

Here are some of the more common ones prescribed:

Block histamine and therefore the creation of stomach acid.

Both the above do reduce acid, but studies have found that they don't prevent crying or reflux symptoms, perhaps, suggesting that it's not caused by acid.

These medications have side effects: headache, stomach pain, wind, constipation, diarrhoea, nausea and vomiting.

They are also not recommended for use with infants. Several studies have also found that these drugs can cause respiratory infections, fractures, pneumonia and gastro-intestinal infections in adults and older children. There is also discussion about the long-term consequences of omeprazole on osteoporosis.

Stomach acid is essential to break down proteins, which are common antagonists to allergies like CMPA - cows milk protein allergy.
Acid suppressants need to be reduced slowly to not cause a rebound effect and stimulate excess secretion of acid making symptoms worse.
Remember that stomach acid is our first barrier to microbial infection. A breastfed baby's normal stomach pH is less than 4, making it sufficient to kill most pathogens swallowed.

Some products have been specifically made and targeted towards breastfeeding babies. However this has received criticism because actually the mother's milk can provide all necessary bacteria as well as the prebiotics for the friendly bacteria to eat, if the mother's milk contains them. So with the breastfed baby, the wisest course of action would be to supplement the mother, not the infant. And with a far broader spectrum product than that.

If you have a baby that is unhappy, 'sicky' or uncomfortable, please seek support to see if it is feeding or allergy related, or physiologically normal before you consider any medication.

Further sources are thanks to Carol Smyth for her book ' Why Infant Reflux Matters' and the Babyem course on infant allergies, reflux and colic.

If you need support to help you with an unhappy baby, please contact https://www.cry-sis.org.uk/

I specialize in creating websites for solo-entrepreneur women who own service based businesses. I make sure that all your other tools are hooked in to your website to make your client experience is smooth and automated!

http://www.calibratedconcepts.com

I'm often asked how, and when, to 'wind' a baby? I'm also frequently asked about colic and reflux and what to do with an unsettled baby.

All babies will experience some periods of fussiness in the early months. It's a very normal occurrence and shows that their digestive system is beginning to work. Wind may be released out of one end or the other. It's a whole body workout as they learn to coordinate the opening and closing of different sphincters. All of this is new to them, they've never had to do it before, and it may feel strange! They may bring their knees up, flex their hips, push down with their feet, clench their fists, frown, contort and change colour. In some cases, it may be dyschezia, a functional condition that can cause up to 30 minutes of crying, as a baby passes a normal soft stool. This is extrmely difficult for parents to watch, but it can be painless and doesn't need any medication. Unlike adults, babies have a limited range of movements and can't easily adjust their positions or tell you what's wrong. It takes a lot of coordination to poo! plus imagine trying to do so, lying on your back!

Infants have a range of behaviours and symptoms that make them appear unsettled, some normal and some that require more medical attention. The term 'colic' is now a frequently used phrase that is used to describe many things, including trapped wind, food intolerance, constipation, tummy ache, or something else.

As a parent, It's distressing watching little ones in pain, so it's helpful to have a term that names this. 'But it is worth asking: 'Does naming it also pathologise it?'

Traditionally, babies were carried and spent most of the day, uptight on a parent, meaning that they could feed frequently and food could easily be digested. Babies have immature oesophageal sphincters, that are designed to relax and open frequently, allowing the release of pressure from excessive feeds or any gas or wind to escape. Breastmilk is an amazing source of nutrition that also carries many microbes and anti viral and bacterial substances that bathe and coat mucosal surfaces - so a baby that regurgitates breastmilk gets a double protective coating. Sometimes, after positting milk, they lick their lips and, reminded by its deliciousness, ask for more.

Reflux

Reflux, is a normal occurance in a young baby. Its technically known as gastro-oesophageal reflux or GOR, and is the term used to describe the contents of the stomach going up into the oesophagus. Basically, something going the wrong way through a valve. It may come all the way up, and out, or it may come partially up, or be re-swallowed - silent reflux. A baby can easily bring up food if it has taken too much, or if there is any harm from keeping it down. If left lying on their back, and unable to change position, or if the stomach is full, food coming back up is physiologically normal and a protective process. Half the babies in the UK will reflux or spit up some milk at some point in the day. Some will bring up a little, and others much more, the frequency and consistency will vary widely. Its also worth remembering that a little bit of a spilt milk, looks much more dramatic than it probably is. Have a look at Lucy Ruddle explaing this here
Reflux disease (GORD)
Gastro oesophageal reflux disease, or GORD, is different from reflux, and is a medical condition that needs a proper diagnosis. According to NICE guidelines GORD should only be considered if a baby has two or more of the following symptoms:

If your baby has any of the above please see a Health professional ASAP.

GORD is a serious medical condition, described as a reflux of stomach acid that irritates the lining of the oesophagus and is sometimes aspirated into the lungs causing inflamation, scarring and narrowing. Studies that have looked at this acid hypothesis, cast doubt that it is actually the cause of damage and pain. Nevertheless, its common to see babies prescribed strong medication, many of which can have long term consequences, and its questionable if it is actually needed. The tests needed to check if it is GORD are difficult and invasive. If a baby is failing to thrive then medication along with proper support is absolutely needed, but in my opinion it is often given without good reason. The medications prescribed however, still often use acid suppressing drugs like PPI's (proton pump inhibitors) so we do really need some good studies to inform our practice.
Wind/burping
This randomised controlled trial looked at burping or winding as a preventative measure for colic and reflux, in healthy babies. It showed that actively patting a baby on the back did not significantly lower these events, but there was an increase in reflux episodes in those routinely winded. So, perhaps we are creating a so-called 'laundry problem' and wasting precious time patting babies, when we could be cuddling them and letting them gently fall asleep in our arms. Could we trust that they will burp if they need to?

Fussy symptoms tend to be more apparent in the evening, when it gets dark, say, from 6-10pm, sometimes known as the 'witching hours'. At this time it is very normal for a breastfed baby to cluster feed. Often spending several hours going from breast to breast.

These times are more challenging, but are thankfully, generally followed by a relatively longer sleep. The baby will continue to feed several times throughout the night, but tends to manage to go back to sleep quite well, especially if feeding in the side lying position while bed sharing. In the morning, they often have a big feed, from a full breast, and then are relatively happy for the rest of the day, feeding often, and gradually becoming more fussy as the evening draws in. This behaviour can be very normal, and I see this pattern frequently in the first few weeks of life, sometimes lasting up to the third month when the baby's gastrointestinal system matures.

However, some babies can be much more uncomfortable and the normal soothing from their parents doesn't seem to help. They may cry for long periods, have unpleasant smelling gas and frothy smelly stools. These babies are labelled with colic, the Greek word for colon, described in 1954 by Morris Wessel as 'persistent crying for more than three hours a day, for at least three days a week, for at least three weeks in a row'. Devastating and very painful for babies and their parents.

Some colicky symptoms may be relieved by the way the baby is feeding.

It may be their latch, to the breast or bottle, the way they are being held, the flow of milk, or supply. It can also be a misinterpretation of a baby's cues, due to unrealistic expectations of normal baby behaviour. I have seen many babies getting upset because they want to feed or have a cuddle, but in a society that informs us that babies should be on a three hourly schedule and shouldn't be spoilt, this signalling can be easily read as pain or colic. This can then cause more upset in the baby and parent and cycle more stress and nervous system activation. An IBCLC and a CST therapist can help with these things and I would always recommend checking in to see if they can support you. Here is a study that looks at how CST - craniosacral therapy helps reduce the number of crying hours, colic severity and increases sleep.

Dr Howard Chiltern,a neonatologist, believes that colic is a symptom of overwhelm. He suggests that some babies struggle with being born evolutionary premature and often feel like they need to be back in the womb. 'Colic has never been about pain in the abdomen or anywhere else for that matter. There is no question that the baby looks like he or she is in excruciating tummy pain. The baby doubles up, knees in chest, and screams like there's a knife twisting in his gut. But it's not about pain, it's about stress and overstimulation of the poor baby's sensory nervous system'. He discusses how holding them close and helping them to feel womb like can be 'the most important lesson to learn : how to keep themselves calm and feel secure'

This is a great article that looks at this fussiness in the early months, often called the fourth trimester, and suggests ways to help comfort your baby and make the world feel more womb-like.

The type of milk a baby receives, breastmilk or formula can contribute to gas.

It depends on the different enzymes in the milk and bacteria present in the gut to digest it and break it down. This process can create pressure and both hydrogen and methane are among the gases that can contribute to this. Some gas will be easily released, while some may be trapped and move around in the gut, creating discomfort or pain. There have now been a number of studies that have identified a difference in the gut biome (dysbiosis) and gasses present in babies with colic symptoms, like this one and this one.

Gas or wind, can be caused by fermentation and digestive processes in the intestines. This is a normal action of healthy bacteria breaking down food particles, like milk sugars and human milk oligosaccharides (HMO's). Lactose, the main sugar in breastmilk, is important not only to brain development, but also the prevention of infection. If you have an abundant milk supply, there may be too much lactose for the baby's gut to absorb. It can leak into the colon and ferment, producing lots of hydrogen gas and liquid poos.

These microbial colonies are a vital component to our health and well being and are known as the gut 'microbiome'. As adults we have about as many bacterial cells as human ones and the more we learn about them the more we understand about our health and immunity. For example, HMO's are not digested by the infant and pass whole into the large intestine where the majority of bacteria are found. They act as a prebiotic and encourage the growth of good bacteria as well as blocking pathogens and viruses. We each have a unique microbiome that is established in the early months after birth, through inherited bacteria, as well as those digested and from our environment.

The first barrier to microbial infection is stomach acid.

The breastfed baby's normal stomach pH is sufficient to kill most pathogens. The child who is not breastfed has a less acidic stomach pH, allowing more bacteria to survive its journey into the intestines. Some of these rogue survivors, can multiply in the stomach and ferment food, producing gasses and alcohol as a result! Therefore, medication that neutralise stomach acid can actually increase the danger of infection. Medication that suppress stomach acid are sometimes required, but should be prescribed with caution. Many manufacturers advise against giving them to children as they have not been thoroughly researched.

Parents caring for an unhappy baby may be pleased to hear that for most it will get better at around 3 months of age. Helping to make the babies environment more womb like in their transition into the world can help a lot. Holding them upright on your body, or in a sling, white noise, gentle jiggling and rocking can make a difference. Warmth and gentle abdominal massage can be useful, as can a warm bath together. Feeding support from an experienced practitioner will also help you to understand if there is anything about the way they are fed that will help. As a parent, I would urge you to get help, to support you during this difficult time, so that you can be more available to help your little one. If you don't have friends or family close by, consider looking for a postnatal doulas.

If you are concerned, please see your GP or paediatrician for a proper diagnosis and testing, if your baby has severe symptoms they may benefit from medication.

Here are some of the more common ones prescribed:

Block histamine and therefore the creation of stomach acid.

Both the above do reduce acid, but studies have found that they don't prevent crying or reflux symptoms, perhaps, suggesting that it's not caused by acid.

These medications have side effects: headache, stomach pain, wind, constipation, diarrhoea, nausea and vomiting.

They are also not recommended for use with infants. Several studies have also found that these drugs can cause respiratory infections, fractures, pneumonia and gastro-intestinal infections in adults and older children. There is also discussion about the long-term consequences of omeprazole on osteoporosis.

Stomach acid is essential to break down proteins, which are common antagonists to allergies like CMPA - cows milk protein allergy.
Acid suppressants need to be reduced slowly to not cause a rebound effect and stimulate excess secretion of acid making symptoms worse.
Remember that stomach acid is our first barrier to microbial infection. A breastfed baby's normal stomach pH is less than 4, making it sufficient to kill most pathogens swallowed.

Some products have been specifically made and targeted towards breastfeeding babies. However this has received criticism because actually the mother's milk can provide all necessary bacteria as well as the prebiotics for the friendly bacteria to eat, if the mother's milk contains them. So with the breastfed baby, the wisest course of action would be to supplement the mother, not the infant. And with a far broader spectrum product than that.

If you have a baby that is unhappy, 'sicky' or uncomfortable, please seek support to see if it is feeding or allergy related, or physiologically normal before you consider any medication.

Further sources are thanks to Carol Smyth for her book ' Why Infant Reflux Matters' and the Babyem course on infant allergies, reflux and colic.

If you need support to help you with an unhappy baby, please contact https://www.cry-sis.org.uk/

I specialize in creating websites for solo-entrepreneur women who own service based businesses. I make sure that all your other tools are hooked in to your website to make your client experience is smooth and automated!

http://www.calibratedconcepts.com

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Wind, colic, reflux? an unsettled baby, what's normal and how to help? - Into Parenthood | Sherridan Stymest | Lactation Specialist

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I'm often asked how, and when, to 'wind' a baby? I'm also frequently asked about colic and reflux and what to do with an unsettled baby. All babies will experience some periods of fussiness in the early months. It's a very normal occurrence and shows that their digestive system is beginning to work.

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New information on treating blocked ducts:

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New information on treating blocked ducts:

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Breast milk is made and stored in small milk producing sacs (alveoli) in the breast and delivered to the nipple via little tubes (milk ducts). When a baby begins to breastfeed, release of the hormone oxytocin triggers the let down reflex which causes the cells around the alveoli to contract forcing breast milk into the milk ducts towards the nipple. Milk is released through the holes in the nipple (nipple pores). This article looks at the phenomenon of a "blocked milk duct" that is associated with breast inflammation and how to prevent and relieve it.

What is a blocked milk duct?

In the past a blocked (or plugged) milk duct has been described as one through which milk can't flow due to a blockage of some kind such as a plug or clog of milk leading to local engorgement of milk. Newer thinking moves away from the idea of thickened milk blocking a milk duct. Instead it is thought that excess milk in the breast causes inflamed and swollen breast tissue that can surround and close a duct. Some authors also hypothesise that ducts can narrow from an overgrowth of pathogenic bacteria in the breast coined "mammary dysbiosis" (ABM, 2022) but others say there is no evidence at all for this theory (Douglas, Vol 18: 1-20 2022).

Whatever the exact cause, if an area of the breast becomes engorged this can press on and narrow other ducts close by-creating a local blockage and slower milk flow from that area of the breast. A useful comparison can be to liken this to a traffic jam; once heavy traffic blocks the main road into the town centre, all roads leading to the town will quickly be affected. Once milk is not flowing in one area of the breast it can quickly become uncomfortably engorged and affect a wider area, and, if this is not relieved, it could develop into mastitis.

Causes of a blocked milk duct

Blocked milk duct is a type of breast inflammation along with engorgement and mastitis and is caused in the same way. Anything that hinders milk flowing easily from all areas of the breast (ie good breast drainage) could cause breast inflammation e.g. poor positioning (the way baby is held to breastfeed) and latch (the way baby attaches to the breast), a tight bra or shoulder bag/back pack strap pressing on breast tissue, or even breastfeeding to a schedule instead of on demand. Previous breast surgery, scar tissue, a finger pressing into the breast, nipple piercing or a blocked nipple pore could also cause blocked ducts (breast inflammation).

Preventing a blocked milk duct

Ideas to prevent blocked milk ducts include:

Check that breast milk can flow freely from all areas of the breast-a baby's position and latch are important as they can help or hinder this. Contact a breastfeeding specialist if breastfeeding is not comfortable and pain free or you have any concerns about positioning and attachment.

Breastfeed at frequent intervals on demand and avoid long periods without feeding or expressing-see How Often Should a Newborn Feed?

Let your baby finish the first breast first before offering the second side but do not try to stay on one breast to "reach the hindmilk"

Check nothing is cutting into the breast such as tight clothing, a finger, poorly fitted bras-including nighttime bras, or whether baby carriers, slings or heavy bags are causing any pressure on the breast.

Signs of a blocked milk duct

Symptoms of a blocked milk duct often include local pain and tenderness in the breast in the engorged area. If close to the surface of the breast, there may be an obvious breast lump due to a build up of milk. The mother will usually feel well in herself and won't have a temperature unless the breast inflammation has progressed to mastitis. Some mothers notice that milk expressed from "blocked areas" may look like strings of spaghetti and mucus may also be present and some may observe milk with lumps in it. Theories for thickened milk are described further in Mastitis Symptoms and Treatment.

How to clear a blocked milk duct

Since engorgement, blocked duct and mastitis are all stages of breast inflammation, management strategies are the same for them all. However not all authors agree on best practice and more research is needed to arrive at a consensus. Most practitioners agree with the following strategies:

Feed your baby often to keep milk flowing, at least every two hours (Douglas, Vol 18: 1-20 2022; Mitchell et al, 2022). If baby isn't breastfeeding, hand express or pump frequently instead. If milk won't seem to flow and the breast is very hard and engorged see Engorgement Relief When Milk Won't Flow.

Check your baby is latching deeply (has a big mouthful of breast tissue as well as the nipple in their mouth) and is emptying the breast thoroughly (Douglas, Vol 18: 1-20 2022; Mitchell et al, 2022). A lactating breast is never truly empty so in practice this means removing or draining most of the available milk until you are comfortable again. If you're not sure about this contact an IBCLC lactation consultant for help.

Don't over pump (regularly pump more milk than your baby needs) as this could worsen the engorgement (Mitchell et al, 2022)

Check whether you have a blocked nipple pore-a bleb or milk blister-on your nipple which is contributing to or causing the blocked milk duct. A bleb may be an inflammatory response to nipple trauma, see Blisters on Nipples for more information.

Cold therapy. If there is a lot of accompanying engorgement, heat can bring more swelling to the area whereas cold therapy between breastfeeds, can reduce pain, swelling and inflammation. See Engorged Breasts for more information about using cold compresses to relieve pain and engorgement.

Pain relief. There are medications compatible with breastfeeding that can be taken for pain or to help reduce inflammation where needed. The Breastfeeding Network has a fact sheet discussing pain killers and breastfeeding. However, one author notes that over dependence on medications to bring down a fever can interfere with the body's own mechanisms to down regulate the inflammatory response (Douglas, Vol 18: 1-20 2022).

Rest. It's important to look after yourself, rest where possible, and remember to eat and drink.

Check with a health professional and breastfeeding specialistifthere is no improvement in symptoms after 24-48 hours (Newman, 2017), and be vigilant for signs of mastitis.

Strategies over which some practitioners disagree include:

Trying unusual breastfeeding positions to help clear the blockage. Unusual positions such as kneeling on all fours to feed a baby lying flat on the floor (dangling the breast over the baby), or having the baby's chin pointing towards the blockage are often suggested to help mothers. Trying different positions may help mothers whose regular feeding position is suboptimal however Mitchell et al say the unusual positions highlighted are not evidence-based and may be unsafe (Mitchell et al, 2022) while Douglas states they could worsen inflammation (Douglas, Vol 18: 1-20 2022).

Warmth. Some mothers find it helpful to use warm compresses or a heated pad over the blocked milk duct either just before a breastfeed/before pumping or during a breastfeed/pumping session. Lactation consultant and author Marsha Walker mentions combining a warm compress with direct massage over the blocked area during a breastfeed. Note that although warmth can provide pain relief it can also widen blood vessels and worsen symptoms (Mitchell et al, 2022; Douglas, Vol 18: 1-20 2022).

Lecithin. Lecithin is an oily substance which is said to help prevent blocked ducts when taken as a dietary supplement by the mother. It is said to reduce the constituency (thickness) of breast milk and therefore the tendency for milk to thicken in the ducts. However the idea of thickened milk as a cause of blocked ducts has fallen out of favour, and Dr Tom Hale of Hale's Medications and Mothers' Milk [paywall] says lecithin would be broken down in the stomach and intestines long before being absorbed. Lawrence and Lawrence mention rubbing lecithin into the nipple after feeds if there are blocked nipple pores (sometimes called blebs or milk blisters) If considered, Dr Jack Newman, a Canadian paediatrician and breastfeeding author, discusses a dose of 1200mg four times a day (Newman. 2017) while authors Wambach and Spencer mention 1600mg lecithin daily (Wambach and Spencer, 2021, p 283). See below and Best Breastfeeding Diet and Foods to Avoid for more on diet and inflammation.

Gentle breast massage before or during breastfeeding/pumping is sometimes advocated to help release milk. While natural breast movement or "breast gymnastics" are generally accepted as helpful, too much pressure or rough handling could cause further damage or inflammation to the breast tissue. Some practitioners advise against massage altogether (Douglas, Vol 18: 1-20 2022). If used, a massage should only involve the same kind of finger tip pressure used when applying a lotion or moisturising cream. Different authors advocate slightly different approaches to massage, see below for a discussion of these and for more information see Engorged Breasts and Nursing Bras FAQ.

Applying steady pressure or breast compression to the area with the blocked duct (hard lumpy area) during a breastfeed or pumping session may help to release milk (Newman, 2017) but care must be taken not to increase inflammation by vigorous handling of the delicate breast tissue and some practitioners are not in favour of this strategy (Douglas, Vol 18: 1-20 2022).

Massage techniques

Not everyone agrees with using breast massage techniques to provide relief for a blocked duct or engorgement (Douglas, Vol 18: 1-20 2022). If used, it is very important to be gentle and not bruise or further inflame breast tissue by rough handling or vigorous deep massage. Techniques sometimes suggested include:

Lymphatic breast drainage therapy

The lymphatic system is a waste drainage system for the body. Gentle massage of the lymphatic drainage system in the breast is said to help redistribute excess fluids that are unrelated to milk, moving them towards the lymphatic drainage system via the arm pits (Walker, 2017). This is thought to help relieve severe engorgement or blocked ducts and assist milk to flow. Lactation consultant (and breast surgeon) Katrina Mitchell has developed a handout Lymphatic Massage in Breastfeeding showing how to do this type of massage using very light touch circular movements similar to that used to stroke a cat.

Therapeutic breast massage

This is a type of massage useful for engorged breasts involving a combination of techniques. Lymphatic breast drainage is used to help move fluid towards the armpits alongside alternating massage and hand expression. Maya Bolman and Ann Witt of Breastfeeding Medicine of Northeast Ohio discuss therapeutic breast massage in lactation (TBML) in the clip below. A mother can sit up as in the video, or she may find lying on her back to do the massage is more effective.

Wide toothed comb

Using a wide toothed comb to gently stroke/massage the affected breast is sometimes suggested and has helped some mothers. This is thought to improve circulation and reduce congestion similar to the traditional art of gua-sha therapy.

Cicular movements

The following clip from Global Health Media discusses using circular hand movements on the breast from the armpit to the nipple to help clear a blocked duct (watch from 3:00 to 5:00)

Six step recanalization manual therapy (SSRMT)

Zhao et al. describe a six step manual therapy for resolving blocked ducts. This involves preparing the breast to widen the ducts and unblock any nipple pores (steps one to four) and then relieving the congestion by manual therapy to expel blocked milk from the ducts (steps five and six). The six steps together are said to take five minutes per breast with the authors reporting good results... out of 3497 women with plugged ducts 98.5% responded positively to the treatment.

1. Preparation. Wash hands and have clean towels and a clean collection container available

2. Nipple pores. Check the nipples for any blocked nipple pores. Wipe with a dry towel to remove any dried milk or flakes of skin. Stretch the nipple as needed to facilitate the process.

3. Nipple manipulation. Hold and lift the nipple to stimulate the let down of milk (milk ejection reflex)

4. Push and press the areola from different directions

5. Push and knead the breast from the base towards the nipple (milk will spurt from the nipple if this is successful!)

6. Check the breast thoroughly section by section for engorged areas (milk stasis).

Further ideas for persistent blocked milk ducts

Ultrasound and other therapies

Mogensen et al discuss the possibility of using ultrasound to treat blocked milk ducts and engorgement and share a suggested ultrasound frequency, intensity and duration of treatment. Therapeutic ultrasound is thought to act as a deep-heating agent that can increase cell activity, reduce pain and increase circulation (Mogensen et al, 2020). However Douglas says there is no evidence to support the use of therapeutic ultrasound for breast inflammation (Douglas, Vol 18: 1-20 2022).

Some mothers have tried to mimic the effects of ultrasound with the vibrations from the flat end of an electric toothbrush held against the blocked duct (Newman, 2017) but mechanical gadgets could damage delicate breast tissue and increase bruising or inflammation. Mogensen et al also discuss other physical therapy techniques such as kinesiology taping, and the traditional Chinese medicine technique of cupping therapy (Mogensen et al, 2020).

Probiotics and vitamin C

Vitamin C and probiotic supplements are sometimes mentioned as possibly helping the mother who suffers from blocked ducts or mastitis. See Mastitis Symptoms and Treatment and Vitamin C and Breastfeeding for more information.

Recurring blocked milk ducts

Sometimes a mother may find she keeps getting the symptoms of blocked milk ducts or mastitis, no sooner has one episode cleared than another takes its place. As with recurring mastitis, there are a number of risk factors to be aware of that can increase your chances of recurring breast inflammation:

Poor positioning and/or a shallow latch (with or without sore nipples) leading to poor breast drainage

Oversupply of breast milk

Restricting breastfeeds to a schedule instead of on demand

Using a nipple shield if it affects how well milk is removed from the breast

Using a breastfeeding pillow if it is interfering with good positioning

Previous breast surgery includingbreast reduction surgery, breast implants, a biopsy, nipple piercing or any scarring in the breast

A previous episode of mastitis that hasn't cleared properly

Diet. Breast inflammation may be associated with a diet that is high in refined sugars and/or a diet that is very high in omega 6 fatty acids compared with anti-inflammatory omega 3 fatty acids.

Stress , exhaustion or fatigue (Lawrence, 2016)

A mother who has allergies may be more susceptible to blocked milk ducts. And, if a baby has allergies/tummy ache this may increase the chance of blocked ducts or mastitis due to a suboptimal feeding technique.

Immunoglobulin A deficiency was linked with blocked ducts in one study.

A breastfeeding specialist is the ideal person to help identify causes of recurring mastitis and see the section "Recurrent mastitis" in Mastitis Symptoms and Treatment for further discussion of treatment ideas.

If your blocked milk duct is still there...

A blocked milk duct that isn't getting better after several days of trying the ideas above should be checked with your doctor for a firm diagnosis. If any engorgement is not relieved this could lead to mastitis or even to an abscess if left unchecked. Some breast lumps might not be blocked milk ducts after all e.g. a galactoceole is a milk cyst-your doctor can help with a diagnosis. Most medical tests for diagnosis are compatible with breastfeeding. Work with your doctor and IBCLC lactation consultant to help solve your breast inflammation and prevent it from returning.

Summary

Breast milk is carried to the nipple by tiny tubes or milk ducts. Inflamed breast tissue around the ducts could narrow or close them making it difficult for milk to flow freely and create engorgement. Treatment for a blocked milk duct is the same as for mastitis or engorgement; to prioritise milk removal from the breast and keep milk flowing. If a blocked milk duct isn't cleared promptly within a few days, check with your health care professional for a firm diagnosis. A blocked duct could lead to painful engorgement and mastitis.

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Breast milk is made and stored in small milk producing sacs (alveoli) in the breast and delivered to the nipple via little tubes (milk ducts). When a baby begins to breastfeed, release of the hormone oxytocin triggers the let down reflex which causes the cells around the alveoli to contract forcing breast milk into the milk ducts towards the nipple.

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Therapeutic ultrasound for blocked ducts and mastitis

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Therapeutic ultrasound for blocked ducts and mastitis

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In recent years, a new form of treatment has become available to breastfeeding mothers who are experiencing blocked ducts and mastitis. In addition to the usual self-help steps, such as applying heat, and doing lots of breast massage, there is now the option of having therapeutic ultrasound treatment to shift blockages. Very often, when home remedies are not working, ultrasound treatment means women can avoid the need for antibiotics.

Here is a description by chiropractor Nina van Dyk of how therapeutic ultrasound works. Nina, whose practice is in Hampstead https://www.hampsteadchiropractic.co.uk/nina-van-dyk/, has a master's degree in chiropractic and a post graduate master's in advanced chiropractic paediatrics. She is also as a very experienced breastfeeding mother of two.
Therapeutic ultrasound for treating blocked ducts and mastitis
Therapeutic ultrasound is a great tool for easing inflammation; it can be used for breast engorgement, to clear blocked ducts and for mastitis.
How does it work?
Ultrasound therapy works by emitting an ultrasound wave: tiny piezoelectric crystals (which change shape through an electrical charge) are emitted from the sound head. This micro massage, and the small oscillation of the particles, increase the movement of fluid in the tissue and cell membrane, pushing and pulling on the cell, rapidly changing pressure and moving the ultrasound waves through the tissues.

Ultrasound waves control inflammation by speeding up healing, reducing pain and improving tissue extensibility. They increase local vasodilation and blood flow, helping cells to heal. Capillary pressure and cell permeability are also increased, while painful nerve signals are dampened down.
Is treatment painful?
The treatment is very comfortable; patients only feel gentle heat. Often the blockages in the ducts clear during the procedure and there is a noticeable difference when palpating breasts afterwards. It is not uncommon for patients to leak milk during a treatment due to the heat.
How long does each appointment last?
Taking a history usually takes about 20 to 30 minutes. How long each treatment lasts depends on the size of the affected area: an area of around 1 to 2 inches takes 10 minutes. The first appointment usually lasts about an hour and subsequent ones, around 40 minutes. Our patients generally recover after 1 to 4 sessions. If there is no improvement, we refer patients to a breast surgeon, who can arrange for a diagnostic ultrasound, to check for a galactocele or breast abscess.
Can I bring my baby?
Babies can come and stay in their pushchair, but it is not possible for their mother to hold them during the treatment, so most mums don't bring them. It is important for the patient to breastfeed no later than 20 minutes after a treatment, so her baby will need to be close by.
Additional treatments and strategies
Therapeutic ultrasound works best when combined with lymphatic drainage massage, lymphatic taping, using an electric massager at home, as well as manual massage, applying heat compresses and breastfeeding frequently. The rugby hold and the laid back/baby-led breastfeeding position can be very helpful for clearing blockages.
The importance of getting additional support from an IBCLC Lactation Consultant or Breastfeeding Counsellor
When a mother is suffering from mastitis and/or blocked ducts, it is vital she gets support from an IBCLC lactation consultant or breastfeeding counsellor who can help her work on attachment and positioning and check her baby for a tongue tie.

Physiotherapists and chiropractors who use ultrasound are trained to identify red flags and often work closely with other health care professionals, such as IBCLCs or GPs, to ensure the best and most appropriate care is given, in order to prevent recurrences of blockages and inflammation.

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In recent years, a new form of treatment has become available to breastfeeding mothers who are experiencing blocked ducts and mastitis. In addition to the usual self-help steps, such as applying heat, and doing lots of breast massage, there is now the option of having therapeutic ultrasound treatment to shift blockages.

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Gentle osteopathic treatment can release and balance the strains which can cause breastfeeding difficulties. The main aim is to establish an effective latch, help the baby nurse as efficiently as possible and generally make breastfeeding a positive experience for both mum and baby.

Far from the 'clicks' and 'cracks' expected from osteopaths, osteopathic treatment using the cranial approach is gentle, safe and effective for babies and children. Cranial osteopathic practitioners use specialised palpation and knowledge of anatomy and physiology to identify and correct disturbances of tissue mobility, not only in and around the joints of the skull but also throughout the body. Very specific, skilled, light pressure is applied where necessary to assist the natural ability of the body to release stresses and tensions.

There are many factors that may contribute to difficulties in breastfeeding. There may have been a long second stage, a difficult presentation, the cord around the baby's neck, or an instrumental intervention (forceps or ventouse). In any of these instances, osteopathic treatment is usually concentrated on mechanical strains of the head, face or throat which may occur during delivery.

After their birth, babies may be excessively sensitive around the back of the head and neck. Often these are the contact areas mothers are shown to bring the child to the breast for feeding. If this is painful for the baby, they may resist and be unable to relax enough to latch on. This can be most distressing for both mum and baby. Very quickly the baby will learn to associate the approaching breast with pain and become fearful. With pressure from hospital staff, this can sadly be a time when new parents give up on breastfeeding.

In this situation other breastfeeding positions can be used that do not require any pressure along the back of the baby's head or neck, such as the side-lying position or the laid back, baby led position.

Common areas that affect feeding include the base of the skull, jaw, tongue and neck muscles. The base of the skull must withstand substantial forces during the delivery. Parents may notice their child prefers one breast to the other. This may be due to a mechanical restriction at the top of the neck similar to a 'crick' neck, causing pain on turning to one side. In this delicate area, there are also nerves that supply the tongue which, if affected, will make sucking difficult and uncoordinated.

The jaw may be restricted and compromise an effective latch as the baby is unable to open their mouth sufficiently. The anterior neck muscles may also cause imbalance. Increased tension in this area will affect neck movements such as extending the neck and will hinder proper swallowing/suckling coordination.

'Tongue tie' is when the frenulum of the tongue is taut and does not allow the baby to extend the tongue adequately for an effective latch. This is not caused by a difficult birth, but an osteopath will check for this as well. If necessary, a simple procedure, called a frenulotomy, can be performed by a tongue tie practitioner, to free the tongue. Cranial treatment following a frenulotomy will then encourage the baby to open their mouth adequately to enable an effective latch and swallow.

Midwives are not always experts in breastfeeding and may encourage formula feeds in order for the baby to be discharged. If there are difficulties in feeding, please be sure to consult a breastfeeding specialist - before leaving hospital if possible.

Any questions or if you are not sure if osteopathy can help you or your baby, please do not hesitate to contact the osteopath first. Often home visits can be arranged particularly in the early days following birth.

For a list of osteopaths who have trained at the Foundation for Paediatric Osteopathy, completing a minimum of two years specialising in children, go to:

Article by Anna Scullard BOst, MSc Paed Ost

Mobile: 07866 476 756 email: annascullard@gmail.com﻿

Here's a study into osteopathic treatment for breastfed babies: Efficacy of an Osteopathic Treatment Coupled With Lactation Consultations for Infants' Biomechanical Sucking Difficulties - PubMed

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Gentle osteopathic treatment can release and balance the strains which can cause breastfeeding difficulties. The main aim is to establish an effective latch, help the baby nurse as efficiently as possible and generally make breastfeeding a positive experience for both mum and baby.

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by Cordelia Uys

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Here's some information I've put together for women who know they're going to be having a caesarean birth. Women due to give birth via caesarean are often told that not experiencing the hormones of labour will affect their milk production, and that their mature milk will come in later. But in the almost 20 years I've worked with pregnant women and new mothers, first as a birth doula and then as an NCT breastfeeding counsellor, I haven't observed this. My belief is that having a caesarean birth can make it harder to do lots of skin-to-skin, both straight after the birth, and in the following days, and it is reduced skin-to-skin contact that can delay the onset of mature milk production.
Skin-to-skin in the operating room
Despite innumerable studies showing how crucial those first two hours of uninterrupted skin-to-skin are for mother and baby bonding, and for milk production, it's still not common for hospitals to allow immediate skin-to-skin after a caesarean. The excuse is often that the operating room is too cold, despite research showing that when a baby is placed in skin-to-skin contact on their mother's chest, her body will warm her baby up very effectively.
Thermal synchrony
In fact, via a phenomenon known as thermal synchrony, if a mother of newborn twins places one baby on each breast, her breasts will warm up to different temperatures, depending on each baby's needs.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1890034/
Even in a cold operating theatre, all that's needed is for the baby to be dried by patting them down as soon as they emerge. They can then be placed straight on to their mother's chest, with a blanket or towel covering their body.

It can be helpful to put your surgical gown on backwards beforehand, so that it's easier to open when your baby is placed on your chest. Because it can be harder to administer the anaesthetic with the gown on backwards, some hospitals might prefer that you put the gown on as normal, but just tie it loosely. Make sure to ask that they are careful where they place the monitoring equipment, so that your chest is free.
There's rush to weigh your baby
As long as both mother and baby are well, they can then stay in skin-to-skin contact while the incision is being sutured. There's no rush to weigh the baby - that can wait.
If immediate skin-to-skin is not possible - please don't despair
If you are not able to have immediate skin-to-skin with your baby, please tell your health care professionals that you would like to have it as soon as possible. If you and your baby have to be separated, skin-to-skin will provide a magical and powerful way of reconnecting, and calming you both.
Skin-to-skin with fathers or partners
If you are not well enough to hold your baby straight after their birth, skin-to-skin with your partner will provide them with a lot of valuable comfort and closeness.
Ask to meet your doctors in advance
If you are having a planned caesarean birth, if possible, I would recommend that you ask for a meeting in advance with both the surgeon and the anaesthetist, so you can tell them how important skin-to-skin is to you. You could print out a few of the studies below. A client of mine did this and was able to get her doctors to agree to immediate skin-to-skin, even though it's not the hospital's usual policy.
Research on skin-to-skin
This film and these articles on skin-to-skin following a caesarean might help to know what to ask for:
https://www.unicef.org.uk/babyfriendly/news-and-research/baby-friendly-research/research-supporting-breastfeeding/skin-to-skin-contact/ https://www.youtube.com/watch?time_continue=2&v=0jCjk73Xpn8 The Natural Caesarean - Newbury Doula https://evidencebasedbirth.com/the-evidence-for-skin-to-skin-care-after-a-cesarean/?fbclid=IwAR1u3-sKZfDTqH6JIB1Kg2Q3YgwzpkhzH0QqPmdmsxpQ21TuPNqQxLNkNe8 The continued importance of skin to skin on the postnatal ward and at home
Once you're on the postnatal ward, and in the first week or two at home, try to ensure that you continue spending the majority of your time in skin-to-skin with your baby. If possible, it's really helpful to have a friend or relative with you who can pass the baby to you, as bending down and picking your baby up out of a cot is difficult in the first few days after a caesarean.

Frequent skin-to-skin contact in those early days will speed up the onset of your mature milk production. It will also allow you more easily to notice your baby's early feeding cues and therefore breastfeed them more often, which is also really good for stimulating your milk supply.
Weighing your baby at 24 hours
There is research showing that when babies are born by caesarean, it's best practice to use their weight at 24 hours old as the reference for weight loss (when they're weighed by the midwife on Day 5), rather than their birth weight. This is because babies take on board some of the intravenous fluid given to their mother during the procedure, and this artificially inflates their birth weight. They then pee out that extra fluid in the first 24 hours.
https://www.ncbi.nlm.nih.gov/m/pubmed/29356561/

If you can't weigh your baby at 24 hours, please be aware that they might have a greater weight loss on Day 5, than one would expect for a baby born vaginally, for whom a 5-7% weight loss is normal.
A mother's experience
My client Emily Winterbotham writes: " I was lucky to have a wonderful doula who helped me prepare my birth plan around a caesarean because my son was breech. When I nervously presented my birth plan to Queen Charlotte's hospital in advance, they said my requests for delayed cord clamping, skin-to-skin, lowering the screen to see our son born were all standard practice. Obviously, we were prepared for the fact that things can go wrong and some of our preferences might not be possible. Ultimately though, feeling supported by the hospital meant that we had a wonderful c-section birth even though I had actually gone into labour a week ahead of my planned c-section. Alexis left my chest just once after birth - to go on his dad's chest as I was shaking a bit - but then he went straight back on from theatre to recovery. The midwife in recovery was a delight (helped by the fact that it was very late at night by then as we had been waiting a while, and so were the only ones there) and helped me get Alexis latched on in recovery at my request. Alexis was only taken away for a quick weigh and check about 1.5-2hrs after birth. My milk came in the night I came home, so three days after birth.
On the mobility and picking the baby up point: I was worried about that as people talk about it a lot re c-sections. The day after was very tough (largely due to lack of sleep due to anaesthetic for me and the fear of the cut), but you're in hospital then anyway. But two days after I had a shower and though fragile, felt fine to bend down and was moving pretty normally from then on. I know that's not everyone's experience, but I really felt great within 72 hours. All in all, we had a beautiful birth, so it can be done!"
The reason Queen Charlotte's is so supportive of skin-to-skin after a caesarean birth is that a senior midwife called Jenny Smith, who worked at QCH, pioneered what she calls Jentle caesarean births:
https://vimeo.com/373107346?fbclid=IwAR18LDpI8TXk2VXXK5mBrW1bjw9-1NI1KuMBEXCSLpOD2k4UyRyDCQqXR04
Wishing you all the best for the birth of your baby or babies.

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Here's some information I've put together for women who know they're going to be having a caesarean birth. Women due to give birth via caesarean are often told that not experiencing the hormones of labour will affect their milk production, and that their mature milk will come in later.

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How to protect your breastfeeding journey if your baby is receiving supplemental feeds. 

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How to protect your breastfeeding journey if your baby is receiving supplemental feeds. 

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There are some excellent Apps that can help you stay on track with pumping; many are free, for example: https://apps.apple.com/gb/app/the-best-baby-tracker/id985523028 When to pump? The best time to double pump is shortly after a breastfeed.

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What to do if your newborn isn't latching

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What to do if your newborn isn't latching

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by Cordelia Uys

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It's not uncommon for newborn babies to take a while to learn to latch, especially if they are born a bit early, or if their birth was stressful. It can be extremely distressing for a new mother if her baby isn't latching, but please be assured that given some time and patience, the vast majority of babies will learn to latch.

I n the meantime, there are some crucial actions that need to be taken:

1. Feed your baby.

2. Make sure your breasts are getting very frequent stimulation.

3. Do lots and lots of skin to skin with your baby.

4. Reach out to an IBCLC lactation consultant or breastfeeding counsellor for help with latching and positioning your baby.

Establishing your milk supply

What is really critical and time sensitive, as well as making sure your baby is getting fed, is for you to do lots of hand expressing, so that your breasts get the message that they need to start making mature milk.

For the first 2 or 3 days after a baby is born, their mother will be producing colostrum (the first milk). Colostrum production is hormonally driven, meaning it's produced whether a mother puts her baby to the breast or not. However, from around Day 3, breastmilk production switches to being locally controlled, meaning it works on a supply and demand basis. In order to establish lactation, it's essential for colostrum, and then mature milk, to be removed from both your breasts at least 8 to 12 times in 24 hours.
Hiring a hospital grade double pump
I would recommend hiring a hospital grade double pump as soon as possible, just in case your baby still isn't latching by Day 3, so you can start pumping as soon as your mature milk starts coming in, which normally happens on Day 3 or 4.

It's imperative to pump with a hospital grade double pump as regular pumps will not be powerful or gentle enough for 8 to 12 pumping sessions in 24 hours. Double pumping (removing milk from both breasts simultaneously) provides much more stimulation than single pumping and saves precious time.
Hospital grade double pumps can be hired from
Ardo Breast Pumps: https://www.ardobreastpumps.co.uk/shop/products/rent-a-breastpump/?gclid=EAIaIQobChMIuZvixpeZ7gIV2ZTVCh3PgwfaEAAYASAAEgJiEfD_BwE

Medela: https://www.medela-rental.co.uk/?gclid=EAIaIQobChMIjciF7ZeZ7gIVibTtCh1tzAhrEAAYASAAEgLAlPD_BwE

Alternatively, the Spectra S1 is a Korean-made hospital grade double pump that can be bought online, and which gets excellent feedback from experienced pumpers.
Make sure the breast shields fit you properly https://www.verywellfamily.com/ways-to-tell-if-your-breast-pump-flanges-fit-2758354
Feed your baby

On Days 1 and 2, you can hand express your colostrum and feed it to your baby via a syringe. Colostrum comes in very small quantities, but that's fine because babies' tummies are very small in the first couple of days.
Finger feeding colostrum
Here's a film showing how to finger feed a baby using a syringe:
https://www.instagram.com/p/CC0UANfAgQ1/?igshid=e3rws0j65c9m&fbclid=IwAR2KKYLG5N7_TS2_JnNGCnlhUI7gi8o1_YIX94Hrk_AdQ-aZDEmnL2ZAqZ8 Paced bottle feeding
Once your mature milk comes in, you can switch to regular double pumping, and feed that milk to your baby using the paced bottle feeding method. The traditional way of bottle feeding puts babies at risk of overfeeding and gets them used to a fast flow, which in turns means they are likely to reject the breast, which has a much slower flow. Paced bottle feeding is essential in order to protect breastfeeding: https://www.youtube.com/watch?v=UH4T70OSzGs&list=UL9WhI4nIcWn4&index=3
Bottles
The type of bottle and teat you use aren't as important as making sure to ALWAYS practise paced bottle feeding. However, it is easier to practise paced bottle feeding with a bottle that isn't too big or too fat. Look for a bottle that has around a 150ml maximum capacity, and one that resembles Kate Moss in shape, rather than Beyoncé.
https://breastfeeding.support/best-bottle-breastfed-baby/ Donor milk
Rather than giving a baby infant formula, the World Health Organisation recommends pasteurised donor milk for babies whose mothers aren't immediately able to express enough milk to satisfy their baby's needs. For more information about obtaining donor milk please contact the Hearts Milk Bank: https://heartsmilkbank.org/
Volumes
In the first week, the volumes a baby needs will increase day by day. To give you a very rough idea, on Day 1, a baby's maxim stomach capacity is circa 5ml per feed, on Day 2 it's circa 10ml per feed, on Day 3 it's circa 20 to 30ml per feed, and it increases by 10ml per day until plateauing at around 60-80ml by Day 7. The volumes a baby needs will also depend on how frequently they're feeding and will often vary from feed to feed.

Here's a link from kellymom about how much milk a baby might need after the first week:
How much expressed milk will my baby need? Feeding frequency
It's fine for your baby to feed more than 12 times in 24 hours, but you want to make sure that he or she is not feeding fewer than 8 times in 24 hours.
Wake your newborn baby if they're sleeping longer than 3 hours (approximately):
A newborn baby who isn't getting enough milk can lack the energy to wake up for feeds.

How to tell if your baby is getting enough milk
Nappies:
Your baby's pees and poos are a very important indicator of how well breastfeeding is going:

Please keep close track of your baby's pees and poos as they will indicate whether your baby is drinking enough milk: https://www.justonenorfolk.nhs.uk/media/2447/p2p-nct-whats-in-a-nappy.pdf

In the first week, it can be helpful to take photos of your baby's poos to show to your midwife.

Weight loss in the first few days is normal:

Your baby's weight will of course also be a good indication of whether she's getting enough.

When they're weighed by the midwife on Day 5, it's normal for babies to have lost up to 7% of their birth weight if they were born vaginally, and up to 10% if it was a caesarean birth. It can then take 2 to 3 weeks for babies to regain their birth weight:
https://kellymom.com/bf/normal/weight-gain/
If your baby isn't producing the expected amount of wet and dirty nappies, or their weight gain isn't as expected, please contact your GP or health visitor.

Pumping plan
Hand expressing If your baby isn't latching at all, in order to establish and maintain your milk supply, it is essential to remove milk from both your breasts at least 8 to 12 times in 24 hours:
While you're still producing colostrum (usually until around day 3 or 4) you need to hand express, as colostrum comes in small volumes and therefore can't be collected in a pump. It's recommended to hand express for around 10 minutes on each breast every hour or two during the day, and for around 15 to 20 minutes on each breast roughly every 3 hours at night. Regular removal of colostrum, and then mature milk, from your breasts is essential in order to establish and maintain your milk production.

You can collect the drops of colostrum directly from your nipples with a syringe and feed them to your baby. Alternatively, you can hand express on to a sterilised spoon, or into a small sterilised cup, and then suck up the colostrum with the syringe.

Here's an excellent film explaining hand expressing:
Hand Expressing Milk | Newborn Nursery | Stanford Medicine Double pumping
If your baby still isn't latching once your mature milk comes in, you can move from hand expressing to double pumping with a hospital grade double pump.

You need to aim to double pump at least 8 times in 24 hours

In order to establish and maintain your milk supply, the recommendation is to double pump with a hospital grade double pump, at least 8 times in 24 hours, including once at night between 2am and 4am, when your prolactin (the hormone that makes milk) levels are highest.

You will need to work out how long to pump for; the standard recommendation is approximately 20 to 30 minutes, but any amount of pumping will be beneficial to your supply.

Please don't worry if you don't produce much milk for the first few days. There will be times of the day when you produce less milk. One breast often produces more milk than the other. It's frequent stimulation that is really important in establishing and maintaining milk supply.

Here's an excellent film explaining how to do hands on double pumping - massaging while pumping makes a difference to the volumes of milk women are able to produce:
https://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html
The four minutes of hand expressing on each breast, at the end of a pumping session (as described in the film) are really good for stimulating milk supply.

Pumping bra:

You can buy or make for yourself a self-expressing bra which will make double pumping easier, as you can pump hands-free. Make sure the bra isn't too tight or pressing the breast shields into your flesh.

Here is a photo of a mother with the sports bra she adapted:

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It's not uncommon for newborn babies to take a while to learn to latch, especially if they are born a bit early, or if their birth was stressful. It can be extremely distressing for a new mother if her baby isn't latching, but please be assured that given some time and patience, the vast majority of babies will learn to latch.

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Cordelia on how to apply a nipple shield

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Cordelia on how to apply a nipple shield

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How to feed a baby with a syringe using your finger

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How to feed a baby with a syringe using your finger

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Breastfeeding with flat or inverted nipples

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Breastfeeding with flat or inverted nipples

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Nipples (and breasts) come in all shapes and sizes and not always in matching pairs. Not all nipples protrude like half a cherry on a cup cake. Some nipples may be quite shallow or flat, perhaps level with the areola (the darker skin around the nipple), others can be dimpled or folded, very long or wide. Some nipples are inverted or retracted-where the nipple points into the breast instead of sticking out. This article looks at whether flat or inverted nipples can affect breastfeeding and how to deal with any challenges.

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Can you breastfeed with inverted nipples or flat nipples?

Many mothers can breastfeed with flat or inverted nipples because breastfeeding relies on a baby having a big mouthful of breast to stimulate the milk glands behind the nipple rather than simply being a matter of hanging on to a nipple. However, while some babies find breastfeeding with inverted nipples or flat nipples quite straightforward, others find it more difficult. Potential issues include:

Latching

The way a baby attaches to the breast is often referred to as latching. A protruding nipple can be easier for a baby to find and grasp and guides a baby's latch. However, a flatter, short shanked nipple may be quite difficult for a baby to find and grasp, especially at first while a baby is learning to breastfeed. The after effects of birth medications or birth trauma can also be causes of difficulty latching or coping with variations in anatomy.

Knowing when to suck

The stimulus of a nipple deep in a baby's mouth triggers the sucking reflex by stroking the baby's hard palate. Faced with a soft, flat nipple, a baby may feel confused and disorientated. Barbara Wilson-Clay explains:

Some parents may notice that the baby will suck strongly on a finger, pacifier or bottle nipple, but appear apathetic, disinterested or frustrated by the breast. This may be because the nipple is not elastic or everted [protruding] enough to reach back to stroke the palate. When this happens the baby doesn't know what to do next. The baby may bob back and forth and seem unable to "locate" the nipple, may pull away and cry, or may fall asleep each time the breast is offered. Skilled help from an IBCLC and close follow-up from the physician will make it easier to overcome this challenge.

Forming a teat

If the nipple is flat and the breast tissue is very firm instead of soft and stretchy, a baby may find it difficult to shape the breast into a teat shape to suckle and stay latched. If a baby is premature, has low muscle tone (floppy) or has high muscle tone, a small mouth, poor latch or has a restrictive tongue-tie, it may compound his difficulties.

Sore nipples

If a baby doesn't have a big mouthful of breast as well as the nipple in their mouth (a shallow latch), a mother's nipples can rub against a baby's hard palate and quickly become sore. Careful attention to the way a baby is held (positioning) can help with this and certain positions may be more helpful than others when a mother has flatter nipples. Reclining while breastfeeding with baby on their tummy may help some mothers, or for others, a more upright position such as cross cradle may give more control for a deeper latch. A couple of weeks of continuous sucking (or pumping with a good pump) can gradually draw out flat or inverted nipples permanently and improve comfort levels for some mothers.

Ongoing nipple pain

Occasionally pain might continue even when breastfeeding is going well because the nipple has undergone major changes or because the bands of tissue that are inverting the nipple stay tight and may crack or blister (Mohrbacher, 2020 p741) .

Risk of low milk supply or low weight gain

If it is difficult for a baby to get a deep latch due to the shape of his mother's nipples, there is a higher risk of having a low milk supply. This is because the breasts may not be emptied thoroughly and efficient breast drainage is the stimulus for a good milk supply. If this is the case, a baby could be at risk of low weight gain.

Sometimes when a baby latches to an inverted nipple, it can compress the buried nipple rather than squeezing the breast tissue behind the nipple as usual. This can prevent the baby getting any milk and will also be painful for the mother. In this situation a breast pump may be helpful as this will tend to draw the nipple out rather than squeezing the buried nipple (Mohrbacher. 2020 p 740).

How flat is a flat nipple?

There is a wide variation of normal, but some authors describe an average nipple diameter as 16mm and height as 7mm. However, whether there will be any problems for your baby if your nipples are much flatter (or much larger) than average will depend on the size of your baby's mouth, how stretchy the breast tissue is and whether you have good help to get breastfeeding started.

What is an inverted nipple?

When a nipple is inverted it points into the breast or lies flat on the breast instead of protruding outwards. This may be due to short milk ducts, tight bands of connective tissue pulling the centre of the nipple into the breast or an absence of connective tissue supporting the nipple. Pressing on the areola either side of and about an inch behind your nipple (sometimes called "the pinch test") can reveal whether a nipple is inverted. An inverted nipple will pull into the breast (retract) but everted or protruding nipples stay out like a cherry on a cake. If you can coax the nipple out, that's a good sign that your baby will be able to do the same if he is latched well.

There can be different degrees of inversion or retraction from mild to severe, descriptions in the breastfeeding literature include;

Retracted.⁶ Some nipples appear "graspable" but on stimulation e.g. with the pinch test, pull into the breast which can make latching difficult. The degree of retraction might be minimal or moderate to severe affecting whether an infant can pull the nipple forward during breastfeeds or not (Wambach and Spencer, 2021 p64).

Pseudo-inverted (Core Curriculum, 2012. p271) or simple inversion (Wambach and Spencer, 2021 p64). Nipples may look inverted but become erect on stimulation which should not present a problem to the breastfed baby.

Dimpled nipples. A dimpled or folded nipple is a partially inverted nipple where only part of the nipple protrudes. This nipple may extend during a breastfeed but after the feed it folds back over and may become damp and sore inside. Patting the nipple dry after a feed or holding it open until it is dry can help avoid soreness or skin breakdown.

Inverted, truly inverted or complete inversion. The inverted nipple that is retracted both before and after stimulation is not common but where present it makes it more difficult for a baby to latch (Core Curriculum, 2012; Wambach and Spencer, 2012 p 64).

Inverted nipples may resolve

Nipples continue to develop during pregnancy under the influence of hormones so that many inverted nipples turn out (evert) by the end of pregnancy and may even protrude a little further with each subsequent pregnancy (Wambach and Spencer, 2012 p 64). If a baby can manage to latch and feed regularly this can loosen the adhesions that keep some nipples inverted. A good pump may also do this.

Tips for breastfeeding with flat or inverted nipples

Some babies may not have any difficulties breastfeeding with inverted nipples or flat nipples. But some will. Paying careful attention to latch and positioning can help your baby breastfeed successfully. Useful articles providing general information to help all babies latch include Breastfeeding Tips for Newborns, Latching Tips, Breastfeeding Positions for Newborns and Why Skin to Skin? Further tips include:

#1 A natural birth (and a breast crawl)

Where possible, a baby will be better able to master latching after birth if he isn't too sleepy and disorientated from drugs such as strong pain killers that have crossed the placenta. Also, in certain positions, a baby's natural breastfeeding instincts and reflexes are primed which helps them to breastfeed. Letting a baby crawl to the breast when first born (and at other times during the first few weeks) can also help with this (Mohrbacher 2020). For videos see Why Skin-to-Skin?

#2 Getting a good latch

A breastfeeding specialist such as an IBCLC lactation consultant can help to get breastfeeding off to a great start and can help you one-to-one with latching techniques and helpful positions whether reclining or using more upright holds. Ideas to help a baby latch to a flat or inverted nipple include:

Help baby to use their reflexes

Holding a baby in skin-to-skin contact to breastfeed, removing scratch mittens and trying reclining positions can enable a baby to use their feeding reflexes to help them latch.

Shaping or flattening the breast

In more upright breastfeeding positions, variations of breast shaping, sometimes called an assisted latch, nipple tilt, flipple or breast sandwich may help a baby get a deeper latch. Ensure your fingers are far enough back from your nipple so your baby can get a big mouthful of breast. See Latching Tips for a description and video clips. You may need to continue to support the breast through the feed if the latch is fragile.

A nipple shield

A nipple shield can help some babies to latch to a very flat or inverted nipple. See Nipple Shields Good or Bad? for further information about shields. If used, it's important that the nipple shield fits well. Listen for your baby's swallows and keep an eye on his weight gain and dirty nappies to ensure he is getting enough milk. Pumping regularly will protect your milk supply until you're sure feeding is going well. Wetting the shield can help keep them in place either with breast milk or some mothers use a little lanolin around the edges of the shield. Avoid using a shield during the first few days before your milk comes in as thick and sticky colostrum doesn't flow well through a shield; hand express instead and feed this to your baby by cup, spoon or syringe.

#3 Try to bring your nipples out before a feed

Some flat nipples or inverted nipples can protrude with a little stimulation and provide the latching focus a baby is looking for. To bring out the nipple before a feed try:

Stimulation

Rolling the nipple between your finger tips, cold stimulation, or letting baby lick and bob about on the breast can help a flat nipple become erect or protrude.

Pulling back on the breast tissue or areola during a latch

Pulling back on the breast tissue as baby gapes to latch can help a nipple to protrude more (Mohrbacher, 2020 p739).

The "nipple nudge"

This involves pushing up into the breast through the areola and behind the nipple to help expose the nipple for the latch i.e. push it inside out.

Commercial gadgets

In addition to using a breast pump prior to feeding, there are a number of purpose built gadgets that can help bring out a nipple before a feed. See below for further details.

#4 Keep breasts soft

Nipples can flatten out when breasts are very full or engorged and nipples that were already quite flat may seem to disappear completely. It can help to practice latching in the days before your milk comes in while your breasts are still soft. A little hand expressing, pumping or reverse pressure softening can help soften an engorged breast so your baby can latch.

#5 Avoid bottles and dummies

Bottles and dummies differ from the average human nipple and are very differently shaped to a flat nipple. Using bottles and teats can cause nipple confusion or bottle preference for some babies and can be a particular issue for the baby who is learning to breastfeed with inverted nipples or very flat nipples. A baby may quickly favour the bottle-particularly if he associates the breast with frustration and hunger. Try using a cup, spoon or syringe for top-ups to keep your baby well fed if he can't latch. If you do need to use a bottle see our Tips to Bottle Feed a Breastfed Baby.

Preferring one nipple over another

If one nipple is inverted or very flat and the other sticks out, a baby may prefer the easier breast with the protruding nipple. A nipple shield on the inverted nipple helps some mothers to use both breasts. Alternatively, pumping the side baby refuses can stimulate the milk supply to supplement back to your baby and it may help evert the nipple. Some mothers allow milk production from the side with the inverted nipple to dry up while continuing to feed on the other breast. The breast that is still used will compensate by increasing milk production.

Gadgets to evert nipples

If the ideas in #3 above do not help to evert nipples before a breastfeed, and baby is struggling to latch on, the use of breastfeeding gadgets may help some mothers. Devices that temporarily draw out the nipple may be particularly helpful when a mother has flat nipples or pseudoinverted nipples. Some devices have been designed to provide more sustained suction over a longer time period (weeks to months) to modify the nipple shape when nipples are inverted or tethered. Bear in mind the success or otherwise of some of these devices hasn't been proven, and care should be taken not to cause nipple damage by over use of suction.

A breast pump

A breast pump can help pull out a flat or inverted nipple and can help stretch and break any underlying adhesions with repeated use. Sometimes however the adhesions under the nipple will remain tight and repeated pumping or latching could create cracks or blisters (Mohrbacher, 2020 p741).

Suction devices

Various commercial suction devices (nipple everters) are available to buy and it is possible to make a homemade version using a syringe. Popular commercial brands often cited in breastfeeding books include Supple Cups, Latch Assist, Evert-it Nipple Enhancer and the Niplette. Some of these specific brands may not be available outside USA. Follow manufacturers safety instructions carefully and read customer reviews for further information. As noted above, care must be taken not to cause nipple damage by too much suction.

Homemade device: the modified syringe

The authors of The Womanly Art of Breastfeeding discuss making your own suction gadget from a plastic syringe that is a little larger in diameter than your nipple:

Take the plunger out. Using a serrated knife, cut the needle end off and put the plunger in the "wrong" end. Now you have a little suction device with a smooth end that you can put over your nipple. Pull out on the plunger far enough to draw your nipple out, but not so far that it's uncomfortable, and keep the suction up for about a minute

Commercial devices

Lactation consultant Catherine Watson Genna provides more comprehensive information about suction devices in Selecting and Using Breastfeeding Tools Improving Care and Outcomes.She notes that:

The Evert-it Nipple Enhancer is a commercial version of the homemade syringe to temporarily evert flat nipples.

The Latch Assist uses a bulb syringe device to evert flat nipples prior to a feed and is based on the same principle as using a breast pump briefly before a feed.

Supple cups are small flexible cups made of silicone. The cups attach to the breast by suction and the negative pressure inside the cup draws out the nipple. One small study showed positive results when the cups were worn for up to four hours a day after 37 weeks of pregnancy in women with inverted nipples, and prior to a breastfeed postnatally in women with flat nipples.

The Niplette uses a syringe to remove air from a hard plastic cup to create a vacuum around the nipple. The syringe is then removed and the cups can stay on for several hours providing sustained pressure to help evert the nipples and encourage the ducts to lengthen. This product cannot be used in late pregnancy as the pressure will remove colostrum, fill the cup with fluid and break the vacuum, the Niplette could also potentially increase the risk of premature labour. (Watson Genna, 2009)

Breast shells

Worn inside the bra these used to be recommended to provide pressure around the base of the nipple to encourage it to protrude. However a research study found they weren't helpful and shells caused pain, discomfort, skin problems, and embarrassment. Another study also found no advantage to using breast shells. Some mothers may find them useful but if used, breastfeeding charity La Leche League GB says:

If you decide to try breast shells, wear them for no longer than 30 minutes before feeds to reduce the risk of nipple soreness due to lack of air circulating around the nipple and blocked ducts due to pressure. You may need a bra with a larger cup size than normal. Breast shells need to be washed daily and any milk collected should be discarded because of the risk of bacterial growth.

The Hoffman technique or Hoffman exercises

This technique involves placing a thumb either side of the base of the nipple and pressing into the breast while you move your thumbs apart and stretch the nipple. It can be tried in pregnancy as long as it isn't painful but the research by Alexander et al did not find the exercises were beneficial.

Your partner

Your partner may be able to help draw out your nipples with gentle oral suction.

Other nipple variations

Other nipple variations are possible in addition to flat or inverted nipples. A mother may have quite different nipples on each breast. Very large or long nipples can fill a baby's mouth and not leave any room for a good mouthful of breast tissue. However after a few weeks, baby's mouth will have grown to accommodate these normal nipple variations. An IBCLC lactation consultant can be a helpful partner to get breastfeeding working smoothly with more unusual nipple anatomy.

Summary

Some babies can breastfeed quite happily with flat or inverted nipples, but others, such as a premature baby or a baby with a small jaw or poor tongue function may find it very difficult. If your baby can't latch, hand expressing initially, followed by frequent pumping will stimulate your milk supply and provide a supplement to keep your baby well fed until you can get skilled help with positioning and latch. Latching may naturally improve once your baby's mouth has grown or your nipple becomes more stretchy. It's a good idea if possible to avoid bottles and dummies while your baby learns to breastfeed so that he doesn't develop a preference for the bottle teat.

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Breastfeeding With Inverted Nipples and Flat Nipples

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Nipples (and breasts) come in all shapes and sizes and not always in matching pairs. Not all nipples protrude like half a cherry on a cup cake. Some nipples may be quite shallow or flat, perhaps level with the areola (the darker skin around the nipple), others can be dimpled or folded, very long or wide.

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The size and shape of nipples and breasts vary widely between women. These differences have little to do with the ability to breastfeed-though if one or both nipples are flat or inverted some mothers find that establishing breastfeeding takes a little extra time and patience in the early days.

Inverted nipples? Many nipples will protrude when stimulated. If you think yours may be inverted, try placing your thumb and finger on opposite sides of the areola (the darker area of skin surrounding the nipple) and squeezing gently inwards. A nipple that stands out when stimulated is not inverted. Sometimes nipples may be partly inverted, looking dimpled or folded. Severely inverted nipples usually retract deeply when compressed or stimulated.

It's common for nipples to change shape during pregnancy, gradually protruding more. After your baby is born, your nipples may appear flatter but babies often lick the nipple to stimulate it before latching on. Your nipples may also appear flatter if your breasts are very full or engorged.

Causes

Inverted nipples may be caused by:

Tiny bands of connective tissue connecting the nipple to the inner breast tissue

Short milk ducts

Less dense connective tissue beneath the nipple than in women with protruding nipples

Treatment

There is no agreement about whether it is helpful to treat inverted nipples. The Royal College of Midwives believes that a diagnosis of flat or inverted nipples serves only to damage a mother's confidence in her ability to breastfeed. While individual mothers sometimes find one of the treatments suggested overleaf for inverted nipples helpful, no controlled studies have shown any particular treatment to be effective. Whether or not you try the techniques overleaf, do learn how to hand express milk. You may also like to try expressing your colostrum in the last four weeks of pregnancy. Any colostrum you collect can be frozen and given to your baby after the birth if needed. Antenatal Expression of Colostrum provides more information.

Good attachment is the key

Whatever breastfeeding specialists think about the different treatment options, they all agree that getting a deep latch is crucial. Babies breastfeed-not nipple feed-so with effective positioning and attachment your baby can learn to nurse well even if you have flat or inverted nipples. When a baby takes in a large enough mouthful of breast he will be able to feed effectively, so the shape of your nipples may not be an issue at all. Reading La Leche League books and leaflets before your baby is born will help you learn about breastfeeding and how to avoid common difficulties. Try to attend an LLL Meeting too-pregnant women are always welcome.

Comfortable breastfeeding

Comfortable positioning and attachment are important for all mothers. You will have time to practice with your baby while your breasts are soft before your milk comes in. Whether or not you have flattish nipples, start as soon as possible by holding your baby in skin-to-skin contact right after the birth. The earlier you start, the easier it is. laid-back or 'natural' positions can be a great help in encouraging your baby to latch on well, as well as being comfortable for you.

If your baby isn't nursing well

Hand express or pump to stimulate your breasts to make milk. Aim to express as often as your baby would be feeding, about 8-12 times in 24 hours. Your expressed milk can be offered by spoon, cup or syringe while you both learn how to breastfeed. Avoid using bottles or dummies as they may cause nipple confusion, making matters worse.

Soften your breast

Breastfeed as often as you can. When your baby bobs his head and licks the nipple, he naturally makes it easier to latch on. If your breast is full and hard, you can use reverse pressure softening to move fluids away from the nipple area so your baby can latch on well. Apply gentle steady pressure with your fingertips on the areola around your nipple for about a minute. You can also press with the sides of your thumbs or fingers. Denting the breast at the edge of the areola with a finger and placing your baby's chin in the dent may also help. Gently hand express a little milk if needed.

Stimulate your nipples

If your baby's head bobbing and licking isn't enough to stimulate your nipples, try:

Rolling your nipple gently between your thumb and finger

Touching your nipple with a cold moist cloth

Try using a breast pump

With some deeply inverted nipples, when a baby tries to breastfeed, he compresses the buried nipple beneath his mother's areola. If simpler techniques of stimulating your nipples before a feed fail, an automatic electric pump may be needed to provide suction to draw the nipple out before a feed. Once may be enough, or you may need to pump before each feed for a few days or perhaps weeks.

Nipple shields

A nipple shield is a thin, silicone teat that can be placed over a mother's nipple and may help a baby who is having difficulty learning to breastfeed. Nipple shields can be used temporarily to help establish breastfeeding. They come in different sizes-a comfortable fit is very important.

It is very important to seek skilled help with positioning, attachment and any other problems if you are already using nipple shields or planning to use them. Whilst a nipple shield can be a useful tool it should be regarded as only a temporary solution-continue to offer your baby some time in skin-to-skin contact every day without a nipple shield so he has the opportunity to latch on if he is able.

Practicalities

First breastfeeds
Breastfeed early and often after your baby's birth to minimize engorgement. Many babies have no difficulty feeding from mothers with inverted nipples, so start off by putting him to the breast and see how he gets on. If he latches on well and you are comfortable he will get plenty of practice and will probably continue to feed well after your milk comes in and your breasts feel fuller.

If your baby won't breastfeed
Don't panic! A baby usually starts to suck spontaneously if he can snuggle up close to his mother's bare chest for periods of time. Try letting your baby lie on your body as you recline so that both his chest and tummy are against you. This kind of contact, sometimes known as Biological Nurturing™, usually stimulates a baby's instinct to attach and suckle well at the breast. In such positions babies can also latch on when sleepy or in light sleep. Watch for signs your baby is stirring and gently encourage feeding.

Practical tips
Getting a deep latch
Help your baby get a deep mouthful of breast using the following tips:

Bring baby to breast, not breast to baby. Relax comfortably with your breast in its natural position

Keep your baby's whole body close against your body

Help your baby approach the breast 'nose to nipple' with his chin on or close to the breast. Keep his body tucked in close as he attaches and feeds but make sure he can tip his head back easily to open his mouth wide

As your breast touches his tongue, it will push his lower jaw open wider. If you are sitting up, as he opens his mouth to take the breast pull his body in firmly against you and give a little push between his shoulder blades

This will help him open his mouth very wide to get his top lip over the nipple area to latch on, resulting in a bigger and better mouthful of breast

His lower jaw will be tucked into your breast well away from the base of your nipple and his nose will be free. Active sucking is triggered when your breast tissue reaches the back of his mouth

Once your baby is attached you can make small adjustments to maximise your own comfort. If you're sitting up to feed, try shifting your weight back onto your tail bone and reclining your body back a little to open up a space for your baby. This allows more of his weight to be supported by your body and less by your arms. Gravity can help him stay attached deeply.

You can als o experiment with different holds to help you find what works best for you. An LLL Leader can help you find the most effective approach. You can find more detailed information by reading our page Positioning & Attachment.

Some women like (or need) to hold their breast when nursing. They flatten their breast as they would a big sandwich they were offering to the baby, matching it to the oval of his mouth. This can help their baby grasp more breast tissue. It doesn't matter if fingers are closer to the upper jaw but try to keep the "lower jaw fingers" out of your baby's way.

Exaggerated latch
To help get an even deeper latch you could try placing your thumb or finger near the base of the nipple where the middle of your baby's upper lip will be, lined up with his nose. As you press, your nipple will tilt away from your baby, presenting him with your breast rather than your nipple. As he opens wide, snuggle him in close and use your thumb or finger to tuck the breast into his mouth. Your nipple will be taken in last and unroll in his mouth. You can then slip your finger out.

Seek Support

Many mothers experience challenges with breastfeeding and find attending LLL meetings supportive. They will give you the chance to see that, whatever challenges you may face, breastfeeding can become a rewarding experience. If there is no LLL group in your area, you can still contact an LLL Leader for support.

Treating inverted nipples

Various techniques can be used to draw out nipples-though research on their effectiveness is inconclusive. If using devices, it is important to follow the manufacturer's instructions.

The Hoffman Technique
This technique is used during pregnancy. With a thumb on each side of the base of the nipple, press in firmly against the breast tissue and at the same time pull your thumbs away from each other. If this feels comfortable, repeat five times each morning, moving your thumbs around the base of the nipple. If you experience pain this technique may not be appropriate for you.

The Nipplette™
The Nipplette™ is a device that uses suction to help a nipple protrude. It consists of a transparent nipple mould from which air is sucked using a small syringe. The device is placed over the nipple area for increasing time each day during the first six months of pregnancy. One device is needed for each inverted nipple. The manufacturers do not recommend use in the last three months of pregnancy. While breastfeeding, limit use to a few minutes to draw out the nipple immediately before breastfeeding.

Breast shells
Sometimes, two-piece breast shells are suggested to apply steady pressure to encourage flat or inverted nipples to protrude. Whilst individual mothers report that using breast shells is a help, research has found them to be ineffective. They can be worn during pregnancy or before breastfeeds. If you decide to try breast shells, wear them for no longer than 30 minutes before feeds to reduce the risk of nipple soreness due to lack of air circulating around the nipple and blocked ducts due to pressure. You may need a bra with a larger cup size than normal. Breast shells need to be washed daily and any milk collected should be discarded because of the risk of bacterial growth.

Other concerns
Sore nipples
You may experience some discomfort in the first couple of weeks of breastfeeding as your baby gradually draws your nipple out. This is temporary and different from nipple damage and soreness caused by a baby who isn't latching on well. Pat your nipples dry after feeds, replace breast pads frequently and change wet bras. Your aim is for comfortable, relaxed feeds for you and your baby. So seek skilled help if you do experience nipple damage.

One breast preference
Differences in your nipples can lead to your baby preferring one breast to the other. You can encourage your baby to breastfeed on the least preferred side by putting your baby to the breast when he is in light sleep, offering it first at feeds and by breastfeeding frequently. Some mothers express from the least preferred breast to maintain milk production. However, some babies are quite determined in their preferences and end up breastfeeding from only one side. If this happens, milk production from the preferred breast will increase to meet your baby's needs as the other breast produces less. Any lop-sidedness will be temporary.

When further help is needed

If you have flat or inverted nipples and then experience additional challenges such as a premature birth or a thrush infection, seek help from your midwife or LLL Leader.

Written by Karen Butler, Sue Upstone & mothers of LLLGB. Photos courtesy Lois Rowlands and Kate Riley.

Further Reading
Antenatal Expression of Colostrum Beginning Breastfeeding Comfortable Breastfeeding
Engorged breasts - avoiding and treating
Hand Expression of Breastmilk
Is My Baby Getting Enough Milk?
My Baby Won't Breastfeed Nipple Confusion Nipple Shields Sleepy Baby - why and what to do

From LLLI
Inverted nipples don't stop breastfeeding

Books
The Womanly Art of Breastfeeding. LLLI. London: Pinter & Martin, 2010.

References
Breastfeeding Answers Made Simple. Mohrbacher, N. Amarillo, TX: Hale Publishing, 2010.
Biological Nurturing; Laid-back breastfeeding for mothers DVD. Colson, S. et al. 2012.
An Introduction to Biological Nurturing; New angles on breastfeeding, Colson S. Amarillo, TX: Hale Publishing, 2010.
Supporting Sucking Skills Watson Genna,C. Burlington, MA: Jones & Bartlett, 2012.
How to do Biological Nurturing
This information is available to buy in printed form from our Shop.

Copyright LLLGB 2016

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The size and shape of nipples and breasts vary widely between women. These differences have little to do with the ability to breastfeed-though if one or both nipples are flat or inverted some mothers find that establishing breastfeeding takes a little extra time and patience in the early days. Inverted nipples?

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Helpful for healing cracked or damaged nipples

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NOVOGEL Gel Breast Pads PADS X(2) | eBay

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NOVOGEL Gel Breast Pads. Also available on Prescription as NOVOGEL 7.5cm circle. Remove the Novogel gel pad before feeding and keep clean. NOVOGEL PROMOTES SUCCESSFUL BREAST FEEDING. Novogel starts to work straight away and makes Breastfeeding comfortable again.

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Moist wound healing for cracked or damaged nipples: 

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Moist wound healing for cracked or damaged nipples: 

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Here is an examination of studies into how to treat cracked nipples:⁣ ⁣ https://www.breastfeedingnetwork.org.uk/moist-wound-healing/ Although there is not enough research into this topic, anecdotally, many women report that moist wound healing works well for them. Please see the BfN link (above) for detailed information.

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When the breastfed baby keeps falling asleep at the breast:

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AKA "The Power nap"

We all know it's totally normal for breastfeeding babies to fall asleep when they've finished their dinner. We know that in the first few days after birth it's also not unusual for baby to "forget" what they're were doing and take a quick snooze mid-feed, particularly if they're a little jaundiced or have had a more tiring delivery. If you try and move them they will suddenly spring back into action. Eyes open, hand comes back to mouth - rooting ensues. Baby was taking a power-nap whilst waiting for more milk, they were It's probably easier to ask the question -I had an interesting discussion last week over on "Occupy Breastfeeding". I do though think we have to acknowledge when a latch The Global Beastfeeding project has uploaded some great clips,
But what about when baby is consistently falling asleep before they're full?
It tends to go like this - baby drinks the first milk ejection or letdown, a nice suck/swallow ratio can be seen and this tends to be the part of the feed everyone watches.
As this naturally slows down, instead of pausing and then starting to drink with a regular swallow pattern again - baby adds more and more sucks for each swallow, becoming slower and slower until they're asleep.
Except they're not.

I hear lots of solutions to resolve this. Strip the baby down, blow on them, use a cold wet cloth to rouse them (yikes!), change a nappy. Much doesn't tend to work for long though and so it goes like this:
mum blows on baby not ready to leave the restaurant thank you very much.
baby takes three sucks
baby goes back to sleep
mum blows on baby
baby sucks a few more times
baby goes back to sleep
mum blows on baby
baby ignores blowing
mum blows AND tickles hands
baby suck a few more times
baby falls back asleep
mum undoes baby grow a bit, blows and tickles hands
and so on and so forth

A big reason babies fall asleep at the breast or bottle, is when the flow (for whatever reason) becomes too slow to be worth staying awake for. Lots of sucking without swallowing lots of milk, isn't a sensible idea for a small human with limited energy supplies - they want bang for their buck.
We know this as if we take a "power-napper" and increase milk flow, baby's eyes spring open! Oh we're back in action? Nice one, I'll wake up then...

Of course, in a symptom solving society the answer seems obvious - increase milk flow, breast compress and switch feed. Indeed short-term this can help, particularly for the sleepy newborn or baby who is a little early/small and simply running out of energy too soon.
A common reason for many "breast hangers" is a shallower than optimal latch, resulting in reduced milk transfer.

I love seeing breastfeeding in all sorts of positions and attachments, I'm not for a second suggesting we only show "optimal" images - this mum has clearly overcome a difficult time getting baby latched and feeding well and the resulting photo is glorious.

Perhaps this baby had just fallen asleep at the end of a lovely feed and slipped shallow as mum moved to take the pic? Who knows, it doesn't really matter as long as we can acknowledge that whilst it's a stunning picture, that latch as we see it won't work for many. why is the typical term, healthy baby persistently falling asleep before they're full?
To some a shallow latch won't be a huge deal, particularly in the early days. Some can compensate well, especially when demands are small and milk supply is abundant. Some mums are happy to feed half hourly day and night as baby gets older, or hold them upright or sling-wear to compensate for the colic, wind or reflux. We're re-framing this as "normal", but for some mums, tapas style eating around the clock isn't always sustainable. Some will experience mastitis from the regularly ineffective breast drainage, whilst for others the tiny mouth causes problems for baby if not for mum. From reducing the transfer, to gulping air a myriad of symptoms can follow.
I'll take it as a compliment to be accused of "being very big on latch" (I'm still not entirely sure whether the pun was intended, but I chuckled anyway). I think we underestimate mothers to suggest they're going to stop breastfeeding en-mass because whilst they believed until now everything was completely fine, someone pointing out it doesn't quite look like a textbook may prompt them to abandon the breast and reach for the bottle. If whatever your doing is working for you and your baby, run with it!
I propose though, mums are more likely to stop breastfeeding when despite telling everyone they have some concerns, they're pacified that it's just a (never ending) growth spurt, or their baby is fine with a teeny tiny mouth and perhaps she just has insufficient glandular tissue or baby has an allergy?
WATCH THIS CLIP - when additional milk is given, we can see the shutters ping open.
This was the stunning image posted. Mum looks radiant but oh my days look at that teeny latch. is shallow - because we seem to have a nation of people who can't recognise the difference or who believe it doesn't matter and I don't think it's really helping anyone. If we saw a heap of well attached babies, the odd shallow latch wouldn't need a mention - but we see so few breastfeeding images and we've lost so many skills around feeding... including exploring why latch matters for many. Here is a still from their clip showing a deep latch versus shallow latch or "nipple hanging".

In action this means we can't see the corners of baby's mouth:

The problem I think is the myth that refuses to die. The pain myth. How often do we hear the two key questions?

As though these are the only markers of effective feeding.

***Newsflash: Babies can have an incredibly shallow latch and not cause pain.***

These babies will typically have slower gain, and/or feed super frequently or for long periods to compensate. Not all though, sometimes mum has so much milk, baby is full after drinking the milk that pours out with the first milk ejection (lactose rich milk) resulting in typical or above average gain.

In order to cause damage a baby has to to:

a) Have enough of something in their mouth to damage it

b) Be doing a compensatory action that causes damage. Whether that's pushing the nipple up to the hard roof of their mouth, pinching and trapping it, rubbing their tongue against it or sucking extra hard like a vacuum cleaner.

Sometimes a baby's suck is so disorganised they don't generate enough suction to cause pain to anything - it's weak and ineffective, like a sock in a washing machine. These babies may also have initial early latching problems and trouble staying on the breast (lack of effective suction). Sometimes mum is show positions to try and compensate for this which gets baby on, but not necessarily transferring milk as well as they could.

All of this also fails to recognise that the very mechanics of breastfeeding, mean that even if a baby doesn't latch "optimally", the act of suckling (creating a seal and rippling the tongue) - will assist in shifting them in to a deeper latch.

Normalising the weeny latch as "fine" doesn't really I suspect help many beyond the early weeks - we need to up our game in terms of breastfeeding education to help parents recognise when their baby is latched and drinking well, versus hanging out eating tapas style.

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When The Breastfeeding Baby Keeps Falling Asleep Before They're Full

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We all know it's totally normal for breastfeeding babies to fall asleep when they've finished their dinner. We know that in the first few days after birth it's also not unusual for baby to "forget" what they're were doing and take a quick snooze mid-feed, particularly if they're a little jaundiced or have had a more tiring delivery.

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Gestational diabetes and colostrum harvesting: 

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Gestational diabetes and colostrum harvesting: 

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Colostrum harvesting is collecting colostrum from the breast. Colostrum is the first secretion from the mammary glands, rich in antibodies. It is a sticky liquid from the nipples which is made before the milk has 'come in' (before breast milk is produced). It is produced from around the 20th week of pregnancy, up until the first few days after the baby has been born.

Colostrum is easily digested and is packed with proteins, vitamins, minerals and salt which helps prevent dehydration and help boost the baby's immune system. Colostrum helps the passing of meconium (the baby's first bowel movement) which also assists in preventing jaundice.

Antenatal colostrum harvesting is when the mother collects or expresses the colostrum from the breast during pregnancy before the baby is born and freezes it for use after birth.

The frozen colostrum is taken to the hospital and stored until it is required, where it can be defrosted and fed to the baby.

The link between diabetes and colostrum harvesting

Many babies born to diabetic mothers can have low blood sugar levels after birth putting them at risk of neonatal hypoglycaemia and jaundice.

Neonatal hypoglycaemia (low blood sugar levels) is the biggest post-birth complication we see in our support group, even when the mother's blood sugar levels have been well controlled.

To raise blood sugar levels the baby needs to feed as much as possible. Even though many mothers manage to successfully breastfeed, some babies still require further top-up feeds and some have difficulties feeding and therefore require bottle or cup feeds. In more concerning situations, babies born to gestational diabetes mothers may need an NG tube or a glucose/dextrose infusion.

The best thing to raise blood sugar levels in the baby is colostrum. If you choose not to breastfeed or cannot for any reason, the formula can be used to raise blood sugar levels instead.

Increased risk of neonatal hypoglycaemia

Babies born to diabetic mothers have very likely been subject to high blood glucose levels whilst growing in the uterus at some point. In response to processing these high blood glucose levels from the mother during the pregnancy, the baby overproduces its own insulin to compensate.

Once born, the baby may still overproduce insulin amounts in their body, struggling to regulate their own insulin production and causing low blood glucose levels.

The baby may struggle to raise their blood sugar levels without additional help and so this is where additional colostrum top-up feeds can really help.

Things that can be done to help control babies born to diabetic mothers' blood glucose levels after birth

1. It is really important to try to gain control and keep blood glucose levels stable throughout pregnancy, especially towards the end and during labour. Avoiding any high readings becomes extremely important right at the end, so don't be tempted to give in to temptations in those last few days, thinking "oh it won't make much difference now I'm so close to the end!". Despite what you may be told, avoid energy drinks or high sugar foods which may be suggested such as flapjack during labour. Keeping your blood sugar levels stabilised gives the baby the best chance to normalise their own insulin production and blood glucose levels before they are born

2. Harvesting colostrum so that you have some readily available should baby require top-up feeds

3. Have skin to skin and try to initiate breastfeeding as soon as possible, ideally straight away

4. Feed baby as regularly as possible, ideally every 3 hours. If you have a sleepy baby then you may need to strip the baby down, change their nappy etc. to help rouse them and encourage them to feed. If you have any difficulties breastfeeding then don't be afraid to ask for help and support from the midwives and nurses. Some hospitals have breastfeeding consultants, support workers and specialist breastfeeding midwives.

Experienced breastfeeding mothers benefit too

Many ladies who are experienced breastfeeding mothers do not understand the need for expressing colostrum before birth. Firstly, each and every baby can be very different, along with different complications such as issues with latching and/or tongue tie, preventing them from breastfeeding. GD babies can be very sleepy and may also struggle to latch, wake for feeds or feed effectively. Some babies may feed well from the breast but still require additional feeds on top of regular breastfeeds to keep blood sugar levels stable.

Colostrum v's formula

Formula will raise blood sugar levels, however, research suggests that breastfeeding colostrum has a better effect on raising blood sugar levels than formula:

RESULTS: Infants who were breastfed in the delivery room had a significantly lower rate of borderline hypoglycaemia than those who were not breastfed in the early postpartum period (10% versus 28%; Fisher's exact test., P = 0.05,). Likewise, infants breastfed in the delivery room had significantly higher mean blood glucose level compared to infants who were not breastfed in the delivery room (3.17 versus 2.86 mmol L(-1), P = 0.03). Additionally, breastfed infants had a significantly higher mean blood glucose level compared to those who were formula fed for their first feed (3.20 versus 2.68 mmol L(-1), P = 0.002).

CONCLUSIONS: Early breastfeeding may facilitate glycaemic stability in infants born to women with gestational diabetes.

Can't I just breastfeed or express when the baby is born?

Yes, of course, you can breastfeed when the baby is born and we actively encourage this. However each baby is different, some babies may have difficulty feeding for many reasons and some may need additional top-up feeds on top of breastfeeding. Expressing can be difficult and having a supply harvested ready for use can be helpful and reassuring should your baby need it.

Lactation aiding foods/drinks and sweet things to increase sugar amounts in colostrum are not necessary

Colostrum itself is extremely potent and sweet (we call it 'liquid gold'). Your normal GD-friendly diet is best and you don't want to cause any unnecessary high blood sugar levels for yourself and your growing baby. Stay well hydrated by drinking plenty of fluids.

Please note that whilst lactation cookies, teas, oats, fenugreek etc. may be advocated to assist milk production, there is no evidence to support these things increasing colostrum production during pregnancy.

You will still have gestational diabetes at this time and so it is important to not risk eating or drinking things that could cause high blood sugar levels, in fact, this could have a detrimental effect on your baby's blood sugar levels after birth and so should be avoided.

When to start colostrum harvesting

After 36 weeks is the usual time for mothers with gestational diabetes, based on induction or planned delivery of around 38 weeks+. But giving yourself 2 weeks before the baby is due or planned is a good idea. It is advisable to speak with your diabetic team regarding when would be the best time for you.

It is not advised to express in order to collect colostrum before this time as expressing may induce contractions early.

However, if you are leaking colostrum then do not waste it! All colostrum is full of goodness and so this can be sucked from the nipple with a sterile syringe and frozen. If you start to get strong Braxton Hicks or contractions then stop expressing. If you are leaking lots through the day, then you may want to purchase some milk collection shells so that every little drop of colostrum can be saved, rather than letting it soak into breast pads and be wasted.

There is no harm in advising women with diabetes in pregnancy at low risk of complications to express breastmilk from 36 weeks' gestation Prof Della A Forster et al. 2017

Will my diabetic team or midwife discuss colostrum harvesting with me?

Some diabetic teams will advocate colostrum harvesting, giving out supplies or packs for colostrum harvesting, along with guidance and support on how to express. Other teams may look at you like you've grown another head when you mention it! Just like with everything else related to gestational diabetes, advice, support and information can vary dramatically from one hospital to another.

In a survey Gestational Diabetes UK ran in 2016, from 1,308 answers 77% (1,005 ladies) were not happy with the information and support giving around colostrum harvesting at their hospital

If you wish to harvest colostrum ready for birth, then speak with your diabetes team and breastfeeding specialists and if they are unaware, then explain the benefits and reasons why. As long as they have space in a freezer for your colostrum to be stored during your labour, then there should be no reason why you can't harvest.

Some may suggest that they would prefer to use formula instead of colostrum if the baby requires top-up feeds. This is your decision and if you wish to use colostrum instead, as long as it has been stored correctly, there is no reason for the formula to be used instead.

Harvesting colostrum

Some Mums may find they leak colostrum, others will need to express to extract colostrum from the breast.
Please do not panic or worry that you are not leaking colostrum or do not notice any difference in your breasts. This does not mean you will not be able to harvest colostrum.
Equipment needed

Sterile syringes should be used to collect the colostrum and is what are recommended for use in the UK.

1ml sterile syringes are best for collecting colostrum which can be bought in pharmacies or online. We find 1ml the best as each syringe can be defrosted and used without any wastage.

Capped syringes (syringes with caps or lids) are not necessary but may be preferred to eliminate contamination risks. However, these can be hard to get hold of and quite expensive.

Ask for some syringes

In the first instance ask your diabetic team or midwife if you could have some syringes. Sterile syringes without caps will serve the same purpose as long as the filled syringe is placed inside the wrapper or a clean plastic bag (like a sandwich/freezer bag) and chilled or frozen straight away. Or you could ask your hospital for some syringe caps.

Your diabetic team/midwife may be able to supply syringes for free so it is worth asking! Some teams even offer colostrum harvesting packs such as these

ask your diabetic team if they provide colostrum harvesting packs or syringes for free

If your hospital cannot provide you with syringes for colostrum harvesting and you need to purchase some syringes, then head over to Drops of Gold where you can purchase everything from just syringes to whole colostrum harvesting kits!

How to harvest colostrum - antenatal expressing of colostrum

Step 1. Always wash your hands before you start expressing.

Expressing after a shower or bath can be extremely beneficial to colostrum harvesting. Some ladies also find a warm compress such as a hot flannel or holding a hot water bottle to the breasts aids colostrum harvesting.

Make sure you have your colostrum harvesting equipment ready to hand such as your sterile syringes, sterile spoon or pot.

Step 2. Sit in a comfortable position. You need time, space and to be able to relax. Some mothers find it helps to sit in the baby's nursery or to look at scan pictures of their baby.

Step 3. Gently massage your breast, massaging from the back of your breast towards the nipple. Use kneading, circular and stroking movements to massage. You should be gentle when massaging, you can use one or both hands and it should not cause any discomfort. Some mothers find it works well to massage whilst in the shower or bath.

Step 4. Find the correct place to press using your thumb and index finger.

This is usually a few centimetres back from the base of the nipple, or move up slightly until you find where the breast feels firmer and a change in the texture of the breast tissue is felt.

Cup the breast using the 'C shape' position with the thumb and finger.

Step 5. Using the pads of your fingers rather than the fingertips, press back into the breast, squeezing gently for a few seconds and then releasing.

Your fingers should not touch the nipple, they should work on the outside of the areola but should not tug, squeeze, pinch or drag your nipple.

Squeeze and release, squeeze and release. Continue to repeat this motion to mimic the action of a baby sucking.

(This picture shows beads of colostrum forming on the nipple, but it may take many, many attempts before any colostrum is seen - do not let this put you off! This is completely normal)

Step 6. If any beads of colostrum form they can be collected in 3 different ways depending on how much colostrum is produced.

6a) Beads of colostrum on the nipple: The easiest way to collect colostrum which is forming beads on the nipple is to suck it directly from the nipple into a sterile syringe. This can be fairly tricky and you may need a little help in sucking up the colostrum.

Have a sterile syringe ready to use. DO NOT pull the plunger out. To use the syringe it must have the plunger pushed fully into the syringe.

Place the tip of the syringe over the bead of colostrum and with your other hand, gently pull up the plunger slightly (but only enough to suck up the bead of colostrum).

If the colostrum is pulled too far down the syringe, flick the syringe to remove any air bubbles and very gently push up the plunger. This will push the colostrum back nearer the top BUT do this carefully! Many ladies have done this, pressed too hard and lost all the colostrum out the end of the syringe.

Continue expressing and keep adding to the syringe each time a bead forms.

6b) Slightly more flow can be expressed onto a sterile spoon

If you are getting more flow than just beads forming, you may want to try expressing directly onto a sterile spoon which involves catching the droplets with the spoon.

Once you have some on the spoon, you can then use your syringe to suck up the colostrum.

Use the same technique mentioned above to suck up the colostrum and move the colostrum up the syringe to the top.

6c) Heavier flow can be expressed into a sterile pot

If you're lucky enough to get larger volumes of colostrum then you may find it easier to express straight into a sterile container. This involves holding your breast over the container and allowing the colostrum to flow or drop into it.

Once you have finished expressing, the colostrum can then be sucked straight into a sterile syringe.

Step 7. After expressing in this position for a while, move your hand around to hold the breast in the 'C position' from another angle and repeat the squeeze and release motions again.

Step 8. Repeat the whole process on the other breast.

Step 9. When you have finished expressing, replace the syringes into their wrappers or place a cap on them.

Step 10. Label your syringes with your name, hospital number and most importantly the date.

Many ladies have forgotten to do this in the past which has resulted in wasted colostrum.

You can continue adding to the same syringe for 48 hours (as long as it is kept refrigerated) but the date you first expressed is the date that should be written on the syringe.

Step 11. Refrigerate or freeze your colostrum. Use a Tupperware box or a suitable freezer bag to store your colostrum.

Don't let your hard work and efforts go to waste! Make sure your colostrum is stored correctly until you need it.

For further details on storing colostrum, please read below.

*Please note: The mother in the video above is expressing breast milk and so please do not expect this amount of milk to flow. Colostrum can be very thick and sticky and may form in very small droplets, rather than 'squirting' out when expressing. This is completely normal! We recommend collecting colostrum in small syringes (1-2ml) so that small top-up feeds can be defrosted as and when needed to avoid any wastage of defrosted colostrum

Further guidance on hand expressing

Hand expressing is advised for antenatal colostrum harvesting. Hand expressing is when you use your hand to massage and squeeze the breast to extract colostrum as the guide above explains.

Further guidance on hand expression can be found through the many links below.

Please remember, you will not be expressing milk as breast milk will not 'come in' until after the baby is born. Also don't expect great amounts of colostrum unless you're really lucky! You may only manage a bead or two, but don't give in...the more you express, the more you collect!.. Every drop of liquid gold counts!

Colostrum will not 'run out' or be used up by the time your baby is born, you will continue to produce colostrum until your milk comes in, so please do not worry that your supply will disappear by expressing.

Here is a video to demonstrate how to hand express, but please note that the recommendations around freezing are different in the UK. Sterile syringes are the preferred way to store harvested colostrum - this can easily be given straight into the baby's mouth when required. These should then be clearly marked with your name and date

Here is another video showing expressing, this shows a lady actually expressing from the breast, but please bear in mind that colostrum is much thicker and stickier than breast milk and so it doesn't tend to flow from the breast like this and another video here from UNICEF.

Can I use a breast pump?

If you are getting a heavier flow of colostrum then breast pumps can cause a lot of wastage as colostrum is so sticky and can get stuck in the breast pump tubes.

If you are really struggling to get any droplets to form then you may find using a breast pump is enough to encourage your colostrum to bead or form droplets. Personally, I could only harvest colostrum by using an electric breast pump. It was just enough to get beads of colostrum to form for me to suck up.

Breast pumps should be used with caution antenatally due to the expression being stronger than with hand expressing. If you decide to use a breast pump then use it sensibly and stop expressing if you notice any tightenings or contractions.

Storing colostrum

You should only store colostrum in a sterilised container, ideally a sterile syringe. Ensure the syringes you use are sterile before using. Coldwater sterilisation is the best method for non-sterile syringes.

Label every syringe with your name and the date it was collected, hospital stickers from your handheld notes are great for this if you have spares!

How long to store colostrum for

in the fridge for up to 48 hours at 4ºc or lower (store in the main part of the fridge, not the door). You can add to the same syringe for a couple of days before freezing but you should date it as the first date collected

for two weeks in the ice or freezer compartment of a fridge

for up to six months in a freezer

Colours and consistency of colostrum

Colostrum can vary dramatically in colour, from dark orange/brown, and yellow/cream to pale/clear.

Please do not panic if yours does not look the same colour as the examples are shown here, or if yours changes colour and consistency over a few expressing sessions, this is normal.

Consistency can be very thick and sticky, or more watery and thinner.

All colostrum is packed with the goodness your baby needs, so please do not worry. If you express and get pink colostrum then this may mean that some blood may be present. Small amounts of blood are not harmful to the baby and so they should not be discarded. If you have any concerns then please speak to a medical professional.

Frequency of colostrum harvesting and the amount required

Collect as much as you would like and are able to. Bear in mind that a newborn baby's tummy is the size of cherry on Day 1, the size of a walnut by Day 3 and the size of an apricot by 1 Week. You don't need huge amounts, but any harvested colostrum will not go to waste.

Some mothers have used expressed colostrum when returning home from hospital and some even use it for the first stages of weaning at 6 months or for teething lollies! Colostrum has many uses including using it to ease sore nipples from feeding or in skin or eye infections of baby. It really is liquid gold!

You can express colostrum as often as you feel comfortable doing so. Most mothers prefer to express daily after a warm shower or bath.

ARGH...I've been trying for ages and I'm not getting any colostrum!

Don't panic!

It is not easy expressing and harvesting colostrum and many (in fact the majority) really struggle to do it.

It may take many days of trying and a lot of frustration before you even see a bead of colostrum!

If you're happy to continue then keep trying every day. If it's stressing and upsetting you then stop putting pressure on yourself. Only you can choose if you wish to continue or not. It is is not necessary to harvest colostrum and so please do not feel that you HAVE to do this.

Many mothers that have tried expressing colostrum have found that they have had better breast feeding experiences compared to previous births where they've struggled to breastfeed. This is obviously not a given, but even if you struggle to actually collect colostrum, know that the process is helping prepare your body for feeding your baby. If you collect some colostrum then it's a bonus!

Not being able to harvest colostrum has NO indication of lack of milk production or how well breast feeding will go

The amount of colostrum harvested, or lack of, prior to birth does not mean that you will not be able to breastfeed or express once your baby has been born. I repeat, it has NO impact or indication of a lack of milk production. Please do not feel that if you can't express colostrum that you will not be able to breast feed or produce milk.

Tips:

1. Try expressing after a warm bath or shower

2. Hold warm flannels or even a hot water bottle wrapped in a cover or towel on your breasts before expressing to increase circulation. You can also purchase breast warming pads which may be helpful

3. RELAX, Relax, relax - stressing will not help, if you can do it great, if you can't it is not the end of the world and it has no relation to whether you will be able to breastfeed or not OR how much milk you will have

4. Massage your breasts before expressing

5. Don't touch the nipple during expressing or try to express too close to the nipple - many ladies say that they have sore nipples following trying to express. It shouldn't hurt. Pulling fingers back to the outside of the areola then forwards really milks the ducts

6. Drink plenty of fluids

7. Looking at scan pictures, sitting in your nursery or baby's room, rocking something like a toy like you would your baby, thinking of your baby and listening to a newborn baby cry have all been great tips to help!

8. Ask for help! Speak with midwives, your health visitor, local breastfeeding peer supporters and lactation consultants in your area for tips and advice on expressing. There are lots of people out there who can help you, but you may have to go online and search for local specialists. Try The Breastfeeding network or La Leche League

Is it safe to harvest colostrum when taking Metformin?

Yes - Metformin is often used in women who have PCOS. PCOS causes insulin resistance and so many mother's with GD may have PCOS. Both PCOS and insulin resistance can be linked to low milk supply. For further information regarding metformin and PCOS please read more here

More helpful links:

Research
Importance of early first feed for babies of diabetic mums

Background

Infants of women with diabetes in pregnancy are at increased risk of hypoglycaemia, admission to a neonatal intensive care unit (NICU), and not being exclusively breastfed. Many clinicians encourage women with diabetes in pregnancy to express and store breastmilk in late pregnancy, yet no evidence exists for this practice. We aimed to determine the safety and efficacy of antenatal expressing in women with diabetes in pregnancy.

Methods

We did a multicentre, two-group, unblinded, randomised controlled trial in six hospitals in Victoria, Australia. We recruited women with pre-existing or gestational diabetes in a singleton pregnancy from 34 to 37 weeks' gestation and randomly assigned them (1:1) to either expressing breastmilk twice per day from 36 weeks' gestation (antenatal expressing) or standard care (usual midwifery and obstetric care, supplemented by support from a diabetes educator). Randomisation was done with a computerised random number generator in blocks of size two and four, and was stratified by site, parity, and diabetes type. Investigators were masked to block size but masking of caregivers was not possible. The primary outcome was the proportion of infants admitted to the NICU. We did the analyses by intention to treat; the data were obtained and analysed masked to group allocation. This trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12611000217909.

Findings

Between June 6, 2011, and Oct 29, 2015, we recruited and randomly assigned 635 women: 319 to antenatal expressing and 316 to standard care. Three were not included in the primary analysis (one withdrawal from the standard care group, and one post-randomisation exclusion and one withdrawal from the antenatal expressing group). The proportion of infants admitted to the NICU did not differ between groups (46 [15%] of 317 assigned to antenatal expressing vs 44 [14%] of 315 assigned to standard care; adjusted relative risk 1·06, 95% CI 0·66 to 1·46). In the antenatal expressing group, the most common serious adverse event for infants was admission to the NICU for respiratory support (for three [<1%] of 317. In the standard care group, the most common serious adverse event for infants was moderate to severe encephalopathy with or without seizures (for three [<1%] of 315).

Interpretation

There is no harm in advising women with diabetes in pregnancy at low risk of complications to express breastmilk from 36 weeks' gestation.

Funding

Australian National Health and Medical Research Council

Prof Della A Forster, PhD

Lisa H Amir, PhD

Effects of early breastfeeding on neonatal glucose levels of term infants born to women with gestational diabetes

It has been recognised that babies of diabetic mothers are at greater risk of hypoglycaemia and as such, an early feed is recommended. This study was carried out to ascertain both the impact of an early feed and to establish what type of feeding provided the best option to reduce the risk of hypoglycaemia. The researchers found that infants who were breastfed in the delivery room had a significantly lower rate of borderline hypoglycaemia than those who were not breastfed in the early postpartum period and the researchers concluded that an early breastfeed may facilitate stable blood glucose levels in the infants of mothers with gestational diabetes.

Neonatal hypoglycaemia in infants of diabetic mothers Management of Infants of Diabetic Mothers The Confidential Enquiry into Maternal and Child Health (CEMACH). Diabetes in pregnancy: caring for the baby after birth. Findings of a National enquiry: England, Wales and Northern Ireland. CEMACH London; 2007

Results: Eighteen (47%) infants developed hypoglycaemia (blood glucose level less than 2 mmol/L) during the first 2 h of life. There was no difference in the cord blood glucose levels between infants with or without hypoglycaemia (3.7 ± 1.1 vs 4.5 ± 1.1 mmol/L, respectively). Infants of mothers with diabetes diagnosed prior to 28 weeks gestation were at a higher risk of developing hypoglycaemia (8 of 10 vs 10 of 28, OR 7.2, 95%CI 1.3-40.7). Hypoglycaemic infants were of significantly higher birthweight, and were more likely to be born to Caucasian mothers and by Caesarean section. Raised maternal fructosamine blood level, the need for insulin treatment or the infant's haematocrit were not different between infants with or without hypoglycaemia.

Conclusions: In well-controlled diabetic mothers, the incidence of early hypoglycaemia in infants is still high, particularly in those mothers who had a longer duration of diabetes. Cord blood glucose level did not identify the infants with hypoglycaemia.

Hypoglycemia rates in the first days of life among term infants born to diabetic mothers Colostrum Versus Formula Supplementation for Glucose Stabilization in Newborns of Diabetic Mothers Nutritional Factors That Affect the Postnatal Metabolic Adaptation of Full-Term Small- and Large-for-Gestational-Age Infants Hypoglycemia and the breastfed neonate Metformin before and during pregnancy and lactation in polycystic ovary syndrome
Hypoglycaemia of the Newborn, copy of the literature, from WHO (World Health Organization), with 10 pages of references

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Colostrum harvesting * Gestational Diabetes UK

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Colostrum harvesting is expressing and collecting colostrum whilst pregnant. Colostrum is hugely beneficial to babies born to diabetics. Learn more here...

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Please let your GP know about GPIFN, a new website set up by two GPs to help health professionals provide their patients with evidence-based breastfeeding support: 

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Please let your GP know about GPIFN, a new website set up by two GPs to help health professionals provide their patients with evidence-based breastfeeding support: 

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A Website to Assist Primary Care Practitioners with Best Practice in Infant Feeding

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Here's an excellent film on hand expressing colostrum, which will be helpful IF YOUR BABY DOESN’T LATCH IN THE FIRST FEW HOURS, or if breastfeeding is painful for you. If this is the case, you will need to hand express on each breast at least 8 times in 24 hours, to make sure your milk supply is adequately stimulated. I usually suggest hand expressing for 5 minutes on each breast every hour that the mother is awake, and for 10 of 15 minutes on each breast if the mother wants to sleep for 2 or 3 hours. The reason hand expressing is better when a mother is still producing colostrum, is that if she uses a pump, the volumes of colostrum are so small that most of the colostrum will just get smeared on the flanges of the pumpsets.

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Here's an excellent film on hand expressing colostrum, which will be helpful IF YOUR BABY DOESN’T LATCH IN THE FIRST FEW HOURS, or if breastfeeding is painful for you. If this is the case, you will need to hand express on each breast at least 8 times in 24 hours, to make sure your milk supply is adequately stimulated. I usually suggest hand expressing for 5 minutes on each breast every hour that the mother is awake, and for 10 of 15 minutes on each breast if the mother wants to sleep for 2 or 3 hours. The reason hand expressing is better when a mother is still producing colostrum, is that if she uses a pump, the volumes of colostrum are so small that most of the colostrum will just get smeared on the flanges of the pumpsets.

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This material was developed by Jane Morton, MD and produced for educational purposes only. Reproduction for commercial purposes is prohibited. Utilization of the materials to improve care of pregnant women and their newborns is encouraged with proper citation of source.

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This material was developed by Jane Morton, MD and produced for educational purposes only. Reproduction for commercial purposes is prohibited. Utilization of the materials to improve care of pregnant women and their newborns is encouraged with proper citation of source.

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Here's a film on how to finger feed colostrum to your baby with a syringe:

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Here's a film on how to finger feed colostrum to your baby with a syringe:

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It can be quite overwhelming when a mother’s milk comes in, which is normally somewhere between day 2 and day 4.  Please have a look at this link, on dealing with engorged breasts. Applying cold cabbage leaves to breasts between feeds, and warmth just before a feed, can really help during this period, which usually only lasts 24 hours or so. Please also see my article on primary engorgement:

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It can be quite overwhelming when a mother’s milk comes in, which is normally somewhere between day 2 and day 4.  Please have a look at this link, on dealing with engorged breasts. Applying cold cabbage leaves to breasts between feeds, and warmth just before a feed, can really help during this period, which usually only lasts 24 hours or so. Please also see my article on primary engorgement:

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Here's a link to an explanation of reverse pressure softening, a technique which can be very helpful if a woman's breasts are so engorged that her baby can't latch:

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Here's a link to an explanation of reverse pressure softening, a technique which can be very helpful if a woman's breasts are so engorged that her baby can't latch:

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Check out stylish,
functional breast pump bags
and accessories from
our sponsor Sarah Wells Bags.

by K. Jean Cotterman RNC, IBCLC. Reprinted with permission from the author.

More health care providers are observing that mothers receiving multiple intrapartum IV's experience delay in expected postpartum fluid shift. Increased edema during the puerperium complicates engorgement, increases sub-areolar tissue resistance, distorts the nipple and interferes with comfortable, efficient latching. Edema may appear early, or later, within 48-96 hours, often lasting 10-14 days. (This may depend on both the quantity of IV fluid given and the time of infusion in relation to placental delivery, the stimulus for lactogenesis II.)

Reverse pressure softening (RPS) is a simple intervention that has proven very helpful in the first 14 days postpartum. RPS uses gentle positive pressure to soften a 1-2 inch area of the areola surrounding the base of the nipple, temporarily moving some swelling slightly backward and upward into the breast. RPS may be applied by the health care provider, and/or taught to the mother/significant others, if necessary, over the telephone.

Interstitial fluid volume increases 30% above normal before edema becomes visible. ( Guyton) To contain edema, areolar tissues must expand, limiting their ability to extend the nipple well into the baby's mouth. Early proactive use of RPS causes no harm and may facilitate increased milk transfer, reduce risk of nipple trauma, and help resolve engorgement.

Conversely, pumping may attract edema into the flange area, especially at maximum vacuum settings. Areolar tissue may then appear "thickened", seeming to "bury" the subareolar ducts. Then, neither infant tongue action, fingertip expression nor the pump itself removes milk very successfully.

RPS is best performed immediately before each attempt to latch, for as many feedings as needed:

The mother may prefer to apply RPS herself, or the HCP, with her permission, may apply RPS.

facing the mother, or

from slightly behind the mother, reaching over her shoulders

or place his/her fingers over those of the mother, to reinforce pressure.

The firmer or more swollen the areola, the more time is needed to achieve pliability.

RPS often forms temporary "dimples" or "pits", but edema soon re-enters the pits after pressure is released.

Positioning the mother with severe edema flat on her back during RPS delays re-entry of swelling, allowing a longer window of time for latching.

Firmly but gently, press steadily on the areola, right at the nipple base.

Pressure should not be firm enough to cause pain. Avoid discomfort with less pressure for longer intervals.

Press inward toward the chest wall for a full 60 seconds or longer (10-20 minutes or more if needed. This is a good time for instructions.)

Any finger combination may be used. (See diagrams)

Mothers may find short nails with curved fingertips of both hands the most effective method.

One-handed methods are convenient if the other hand is busy.

HCP's may find straight-fingers or two-thumb methods more convenient.

Use the flats of two thumbs or the first several fingers on each hand lengthwise above and below the nipple, creating a 1-2 inch long depression.

Continue to alternate in opposite quadrants, with repeated 2 minute periods of pressure, partially overlapping the first set of pits, to keep edema displaced from the entire area at the base of the nipple.

After RPS, additional fingertip expression to further soften the areola is much easier, more comfortable and more productive. Creating a special niche for the chin often permits deeper latching.

Two handed, one-step method
Fingernails short, fingertips curved;
each one touching the side of nipple.

Two handed, two-step method
Using 2 or 3 straight fingers on each side, first knuckles touching nipple. Move ¼ turn. Repeat above & below nipple.

Two thumbs, two-step method (Step 1). Using straight thumbs, base of
thumbnail even with side of nipple.

Two thumbs, two-step method (Step 2).Move ¼ turn. Repeat above & below nipple.

One handed "flower hold"
Fingernails short, fingertips curved,
placed where baby's tongue will go.
(To see your areola better,
try using a hand mirror.)

Soft ring method
Cut off bottom half of an artificial nipple to place on areola to press with fingers.

Benefits of RPS include:

Steady stimulation of nerves under the areola automatically triggers the milk ejection reflex, propelling milk forward in the breast, nearly always within 1-2 minutes or less.

Excess interstitial fluid is temporarily moved in the direction of natural lymphatic drainage.

Displacing milk slightly backward into deeper ducts relieves over-distention of subareolar ducts, reducing latch discomfort and facilitating milk transfer.

Areolar elasticity is freed for

extending the nipple more deeply into baby's mouth

responding to the rippling of the tongue.

Guyton, AC, Basic Human Physiology: Normal Function and Mechanisms of Disease, 2nd Ed., W. B. Saunders Co. Philadelphia, 1977, p. 321.

Permission is hereby given to reproduce and distribute this article as long as the original wording and my authorship and credit for diagrams by Kyle Cotterman are retained. You may contact me at: mellomom@juno.com

See also:

Engorgement at KellyMom

Too Swollen to Latch On? Try Reverse Pressure Softening First by K. Jean Cotterman, RNC, RLC, IBCLC, from Leaven, Vol. 39 No. 2, April-May 2003, pp. 38-40.

Cotterman KJ. Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement. J Hum Lact 2004 20: 227-237.

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Engorgement Help: Reverse Pressure Softening * KellyMom.com

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More health care providers are observing that mothers receiving multiple intrapartum IV's experience delay in expected postpartum fluid shift. Increased edema during the puerperium complicates engorgement, increases sub-areolar tissue resistance, distorts the nipple and interferes with comfortable, efficient latching. Edema may appear early, or later, within 48-96 hours, often lasting 10-14 days.

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When we're so used to new mums worrying about low milk supply, it's easy to forget what life is like for women at the other end of the spectrum.

Imagine a baby with the natural urge to come to the breast but when they get there they find it overwhelming, distressing and unsafe.

Imagine a young baby who chooses NOT to breastfeed when they need comfort and reassurance.

Oversupply can be miserable for everybody concerned and it doesn't help when you're surrounded by people telling you how lucky you are.

It's important that we know what oversupply can look like, what to do about it and what it's not. There is an epidemic of confusing oversupply and its accompanying symptoms for 'colic' and 'reflux'. There are many babies right now being dosed with infacol, lactase drops, Gaviscon and reflux treatments, when the issue is simply that mum has too much milk or that improvements can be made with an adjustment to positioning.

It's not clear why some mums seem to produce more milk than their babies need. In some cases it might be as a result of expressing with powerful modern electric breast pumps (and mums getting the message that regular pumping is part of normal breastfeeding). Perhaps they have more prolactin than average or large amounts of glandular tissue. Often there's no obvious cause.

The problems will normally start to show themselves after the first week or so. It may be that some feeds are less of a problem (perhaps nights are easier) or that every feed is a struggle. A baby will look like someone dealing with a large volume of liquid being pushed down their throat which is not surprising as that's often what's happening. You may hear spluttering and choking. A baby may break off to take a breath (and mum may notice a spray of milk). A baby may cry or be obviously distressed and grumpy.

This baby will probably not feed for long. They may not need to because they are getting what they need in such a short time. As a result, these are the babies of mums who really don't need the 'advice' to 'feed for at least 20 minutes or baby won't reach the fattier milk' and a great demonstration of the fact that you can't make rules about how long a feed should last.

Sometimes a baby may break off prematurely when actually they could have done with a bit more. If this is going on it will be reflected in the baby's weight gain and these are the babies who are more likely to have mucousy green frothy nappies or have some digestive discomfort. These are the babies who are going to develop the symptoms that look a lot like 'colic'.

Colic isn't a very useful word. It's a term used as a threat to new parents. It's the thing we fear but we don't really know what it is we are fearing. Unhappiness and lots of crying seems to be the basic summary but normal healthy otherwise happy newborns will have periods in an ordinary day where they are fussy and unsettled. It's normal for a baby to cry on and off for most of an evening. It's normal for a baby to only be calmed on the breast and want to feed almost constantly for several hours. It's normal for parents for feel desperate and confused and perhaps worry that either there's a problem with milk supply or their baby is behaving unusually because something is wrong. If they are calmed on the breast (even if only for a short time and they don't actually appear to be swallowing much) then that sounds like normal evening fussiness. One definition of colic (Wessel's definition) is three hours of crying, three days in a row, three weeks in a row. By that definition, no one can say that a week old baby has colic or even a two week old baby. Normal evening fussiness may not develop in the first couple of weeks. A common call to the helpline goes like this: "Help! When we first got home from the hospital, our baby slept in the Moses basket in the evening and we ate dinner and watched TV and then we all went to bed together at 11ish. Now my baby cries most of the evening. He wants to feed constantly from about 6pm to 10pm. I haven't even got time to eat dinner or go to the toilet. Is this colic?" That doesn't sound like colic but normal cluster feeding or growth spurt behaviour and normal behaviour for a baby in the first few weeks of life. The parents who get the evening shift are luckier than the ones who get the 1am-4am slot.

It's also normal for babies to be windy. The reality is that a large group of mums perceive their babies to be windier and fussier than average but we can see that statistically that doesn't make sense. If lots of babies have periods of being fussy and windy and unsettled, that IS normal. We need to check latch and positioning because when there's a problem that means an opportunity for air to get in. It's surprising how many babies struggling with wind and digestive pain are more comfortable once changes are made: the gape has improved; the tongue is placed correctly on the breast; the head is tilted with the chin burying into the breast and once that cheek is touching the breast (on both sides). It's also normal for babies to be grumpy just before they poo. You'd think this natural process would be nice and easy but no.

However beyond what's normal, babies dealing with oversupply and overactive letdown are more likely to be windy and more likely to be dealing with digestive discomfort.

How would we know it was due to oversupply? We'll see that classic behaviour on the breast of the bobbing on and off and struggling with faster flow. We may also find a baby who is more likely to get hiccups, get trapped wind, produce explosive poos and bring up milk after a feed.

Bringing up milk after a feed isn't the reflux we worry about. The word reflux just means 'a flowing back'. It's normal for some milk to come back out when little babies have immature sphincter muscles at the top of their stomach. If they take in too much milk, a bit comes back up again. That's not a negative, that's a safety mechanism that prevents stomach stretching and overfeeding. Plus the baby gets breastmilk with all its lovely growth factors and immunological factors sliding past on the way down and on the way back up again! When an air bubble comes out, sometimes milk comes out. The milk surrounding the trapped air bubble will come out too. All perfectly normal. Messy but normal.

When it's not just milk coming out but acid too and a baby is in pain, that's the reflux that we might worry about. A baby bringing up with a look of surprise on their face rather than a look of pain doesn't need medication. These are the babies with a "laundry problem" rather than a "medical problem". Unfortunately it's the laundry problem babies that are sometimes still finding themselves in the GP surgery. Parents are worried that too much milk is coming up and they want to stop it happening. Sometimes these are parents focused on intervals between feeds and believing that that the small amount of milk coming out is preventing them from reaching the 3 or 4 hours their baby book says should be the aim. GPs may provide Gaviscon - a thickener that stops the stomach contents from lifting up through the oesophagus - but as we already know this may not be the ideal if this process is actually a safety mechanism. Gaviscon has other side effects: the thickening continues through the system and these babies may start to develop constipation and certainly have firmer stools. We end up seeing babies in genuine pain with constipation due to medication that was trying to solve a problem that wasn't actually a problem in the first place. When you give a baby infant Gaviscon, you are giving them sodium alginate and magnesium alginate which form a gel in the stomach when they come into contact with stomach acid and thickens the stomach contents. Let's not do that unless we really need to, not to avoid normal posseting.

When babies spit up, it can look a lot. Mums talk about 'the whole feed' coming back up. This is unlikely to be the case. If you get 1 fluid oz (30ml) of cow's milk out of the fridge and spill it down the front of a baby gro, I think you'll be surprised how far it will go. They will be drenched. If a baby is taking in 60-80ml and even 20 mls comes out, that's still going to look like a lot but the majority is left happily behind. It can be normal for a baby to posset after EVERY single feed. This still isn't a baby in need of medication. Another problem with giving Gaviscon is delivering it to a breastfeeding baby. The manufacturers suggest mixing the powder with cooled boiled water to make a paste and then giving it AFTER a feed using a syringe or spoon. I worry that many mums will be tempted to give a bottle (with potential impact on latching or milk supply) just to deliver this medication. Plus giving a young baby something in a spoon when they will usually still have a tongue thrust reflex is an impossible mission. Syringe feeding a sleepy baby (breastfeeding contains hormones like oxytocin and cholecystokinin which encourage drowsiness) is likely to be an aspiration risk. This may well mean feeds end early and babies are broken off before the right amount of high fat content milk has been reached.

So please let's not give Gaviscon to babies that bring milk back up but aren't in pain doing so.

If 'colic' or 'reflux' is to do with oversupply, it can be fixed. Colic is usually used to describe babies with digestive discomfort. They may raise their legs while crying or we may hear their tummies rumbling. They may be red in the face or rigid with discomfort. It has been suggested that these babies have issues with their gut flora and probiotics may help. They may have hypersensitivity of nerves in the gut and the underlying cause is not known, though babies will usually grow out of it between 3 and 4 months. Some of these babies may have food intolerances. A reaction to dairy protein is a possibility though that will usually be accompanied by other symptoms such as a skin condition, unusual stools (which may even be blood flecked) and weight gain issues. Mums who smoke are more likely to have babies with colic.

Increasingly, companies are marketing products at these understandably desperate mums. Gripe water is an old-fashioned remedy which historically contained nearly 4% alcohol (and various herbs, bicarbonate of soda or ginger). We now realise giving babies a raft of mysterious untested ingredients seems like a bad idea when we know so much more about gut flora and the relationship of our vital friendly bacterias to the Ph of our gut. Most of us know now that it's not wise to give young babies herbal teas or plant extracts but if the product is being made by pharmaceutical companies then we inherently trust it. Mums are being told to use 'colic drops' that often contain lactase. The theory is that babies are reacting to lactose and need help digesting it. Lactose is the sugar naturally found in all breastmilk (it's not about dairy intake) and true lactose intolerance is very very rare. To give lactase drops, we're spoon feeding those young babies with the tongue thrust again. This time when they are hungry and hoping for breast.

At least if a mum gives Simeticone drops (which help air bubbles to clump together to leave the body more easily) it can come directly from the dropper. Although I'm not sure we have research on giving babies 'natural orange flavour' several times a day.

I know there are mums who find some of these products useful. Of course, babies with genuine acid reflux find thickeners helpful. I know there are mums who like giving droppers and other products. They feel it helps. I'm not down on everything on the shelves in Boots the Chemist.

I'm just saying that if you suspect oversupply or positioning and attachment might be your issue, get some breastfeeding support before going down to the pharmacy or to the GP. Let's try and solve the underlying problem rather than fiddling around with spoons and exposing our babies to unnecessary chemicals.

Chemicals can be wonderful but let's save them for the babies who can't have their issues resolved after a fifteen minute chat with a lactation consultant or breastfeeding counsellor.

If your baby is gulping and choking and it appears to be about the volume of liquid going down their throat; if your letdown pain is quite strong; if you pump a large amount in a very short time; if you get extremely engorged and uncomfortable inbetween feeds - these could be clues that oversupply is an issue. You may hear baby clicking which indicates a loss of seal and can be associated with a large volume of milk. Baby may slip off or attempt to shallow the latch to cope with the flow.

What can be done about it? First of all, let's check that some of these issues aren't about positioning and attachment problems rather than oversupply. Babies may protest, shallow their latch, be fussy, slip off and wiggle around when mums just need to position them in a different way. We'll assume you've had positioning checked and it's clear there's too much milk. Let's also check you haven't been removing your baby from the breast prematurely which can also result in some of the lactose overload problems and fussiness associated with oversupply. Ideally baby will come off the breast when they choose to do so or when they have stopped actively feeding and swallowing. If you are not sure what swallowing looks like, this video can help: https://www.youtube.com/watch?v=7giyNvlCW18 It's also true that babies with tongue ties (especially posterior tongue ties that are often missed by healthcare professionals) are sometimes the babies struggling at the breast - bobbing on and off and choking and spluttering. Babies with tongue restrictions will have problems grooving the tongue and swallowing the bolus of liquid effectively. If your baby is fussy, it's a good idea to get their tongue assessed alongside a general check of latch before you start any kind of supply adjustment.

How old is baby? If baby is under six weeks, you might be in a group of mums who start off with overproduction but things settle down as the body gets used to your baby's natural levels of intake. Your body regulates from the higher prolactin baseline to the one that will become the norm for the rest of your time breastfeeding. So it may well be that your supply eases without you having to do anything at all. If we fiddle around with your supply in the early weeks and then you experience this shift, things might go too far the other way so it may be wise to hold on and see. That doesn't mean that you can't do anything though if your baby is really struggling with fast flow.

Milk comes out because of your milk ejection reflex (the oxytocin arriving in the breast and contracting muscles to push the milk down through your ducts) and your baby's ability to remove milk using their tongue and create negative pressure inside their mouth. It's not much about gravity. But if liquid is flooding into your throat and you are UNDERNEATH the flow, that's more likely to be overwhelming. You won't feel safe taking a breath. You are more likely to feel out of control and feel the need to break off. When we feed babies in a cradle hold, cross-cradle hold or rugby hold and they are under the breast, it's understandable they feel more overwhelmed. If we lean back so the baby is more above the breast, this is likely to prevent the milk pooling in the back of their throat and hopefully they will feel less out of control.

You could get them on in their usual position but then scoot your bottom forward and lean back - just make sure you have back support for yourself. You could also use positions where the baby is seated, perhaps with one leg astride each side of yours and their mouth level with the breast. By changing position, we're hopefully going to result in the baby staying latched on properly throughout the feed. This is going to mean less air getting in and less windiness, colic and possetting. This technique can mean that mums are more at risk of blocked ducts or even mastitis. Once you come back to the neglected breast after a gap of time, flow may be particularly overwhelming so this is a good time to use that technique where the first milk floods off into a cloth before the baby attaches properly. After the first feed back on that side, it's a good idea to check that no firm areas remain and the breast has been drained effectively. You may have firm areas If mums have a history of mastitis (and that may not be unusual if mums have a history of overproduction), the idea of block nursing can be a scary one. An alternative option is to use natural remedies that reduce milk production. Applying cabbage leaves to the breast can reduce supply (which is one reason we want to be cautious in recommended this to brand new engorged new mums). Sage is also a useful herb. I once spoke to a breastfeeding supporter who claimed she spoke to more mums with supply problems after Thanksgiving and Christmas and all the sage and onion stuffing. That sounds a bit unlikely unless they are serious stuffing fans but sage does appear to have an effect. If you are not ending breastfeeding, you'll need to be cautious. Kellymom.com (Sadly there aren't fixes for every baby with colic symptoms or reflux symptoms. Some of these families are going to need medication and all the support they can get. However let's just check that babies we know aren't part of the trend of

I've heard of mum pumping before every feed to take off the faster milk. This really isn't sensible as you're stimulating your supply and telling your body to keep production at this level. One option might be to get the letdown started and then you could let the faster milk flood off into a muslin cloth before reattaching baby but this wouldn't be fun in the long term. Some mums also get results by pressing on their breast with the side or heel of their hand at the begnning of a feed and blocking off a section of their breast but again this isn't wise in the longer term and it could increase your risk of blocked ducts.

If changing positioning doesn't help things and your baby is a couple of months old, it could be time to consider reducing your supply on purpose. We know that when the breast is full, this slows milk production. A fuller breast stretches the prolactin receptors in the alveoli so more prolactin can't be received. A fuller breast accumulates a whey protein known as FIL (feedback inhibitor of lactation) and this seems to slow milk synthesis.

Before we play around with supply, we want to make sure that this isn't a baby struggling with other issues such as weight gain. It is true that some mums with significant oversupply could still have a baby with weight gain problems. If a baby is taking in a large volume of milk, they may be filling up before they get to the higher fat content milk. They may have frothy green mucousy stools and be particularly gassy from getting the larger doses of lactose which we find in the lower fat content milk. When lactose is in large quantities, baby may not be able to digest it all effectively. It may travel through the gut undigested and this faster transit can result in greener poos. Undigested lactose can move into the large intestine and start to ferment and produce extra abdominal gas. Good bacteria are important part of digestion so it makes sense that we are concerned that babies with digestive problems are potentially struggling with gut flora issues. If we take the edge off your supply, they should hopefully start to receive proportionally more of the higher fat content milk.

However it's not sensible to intentionally reduce your milk supply without proper supervision if your baby has green stools and weight gain problems. This can also be a sign of insufficient milk supply. A baby may also bob on and off the breast and protest when the flow is too slow. This is a time to talk to a lactation consultant or an experienced breastfeeding supporter. It's important to note that green poo can be a normal coloured poo for a happy healthy baby. We're only going to worry if it's frothy, mucousy and accompanied by other symptoms.

A way to reduce supply, when we are confident that is the problem, is to use a technique called block nursing. This means the baby stays on one breast for a block of time. This isn't because we aim for them to have slower milk for a few feeds in a row but because it means the neglected breast will accumulate milk and the body will receive signals to reduce production. If you aren't already doing single-sided feeding (offering only one breast for each feed), you can start with that. If that doesn't improve things, you could then spend 24 hours experimenting with two feeds on each breast. That's going to mean something like 4-6 hours with all the feeds being on the same side. The neglected breast may become engorged and even a little bit uncomfortable and this will send messages to reduce production. Then you swap and the other breast gets its turn to be fed from for a block of time. After 24 hours of blocking, you could then return to single sided feeding and see if things are any easier. In some extreme cases, mums may need to block on one side for three feeds or even more.

before a feed and even lumps which may just be the glandular tissue full and distended under the skin. All the way along, let's use our instincts. If a baby is indicating that they aren't happy staying on one breast and they need more, this may be a time to abandon this method and try something else and check our thinking. Some mums also reduce their milk supply using pseudoephedrine, an ingredient in decongestant and cold and flu medicine. Birth control pills containing oestrogen can also reduce supply. However I hope no one is starting off with decongestants and hormonal contraception without proper guidance and having tried other remedies first.

http://kellymom.com/bf/can-i-breastfeed/herbs/herbs-oversupply/) recommends taking ¼ teaspoon of dried sage three times a day for up to three days. It can be combined with food or drank with vegetable juice.

misdiagnosing colic and reflux when actually the problem is latching and positioning or oversupply and it can be sorted with some skilled help. I have known many mums and babies who have had 'colic' and 'reflux' disappear overnight with after a short conversation on latching or a couple of days of supply adjustment. But that doesn't make the pharmaceutical companies any money, does it? And our GPs may not have the 15 minutes to spare nor the training in breastfeeding to resolve an issue that could be pretty straightforward.

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"You've got so much milk! You're so lucky!" "No, I'm bloody not": oversupply, 'colic' and 'reflux'

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When we're so used to new mums worrying about low milk supply, it's easy to forget what life is like for women at the other end of the spectrum. Imagine a baby with the natural urge to come to the breast but when they get there they find it overwhelming, distressing and unsafe.

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Forgive me for asking but...

Do you REALLY have low milk supply?

This is a very important place to start. Please bear with me. I don't mean to doubt your situation and be annoying patronising lactation consultant woman but it's crucial to note that the MAJORITY of new mothers who fear they have low milk supply DO NOT.

The majority of women who start to use formula because they worry they aren't making enough or baby isn't getting enough DO NOT HAVE A PROBLEM.

I cannot emphasise this enough.

Every day mothers panic and end breastfeeding or start using formula and there is not an underlying problem with their milk supply. But of course - once they start using formula without correct support, they often will start to send signals to their breasts to really reduce supply.

· You do not have low milk supply just because your baby won't go the X number of hours between feeds that the book on your coffee table tells you they should. Or your mother-in-law. Or the X number of hours your friend's baby is going between feeds.

A normal happy healthy baby who has a gorgeous mummy with a normal healthy milk supply might get hungry an hour after the last feed, or 90 minutes, or 45 minutes or two hours. They might be cluster feeding and hardly want to come off the breast at all. They might be having a growth spurt and feed every hour for a day.

· You do not have low milk supply because your breasts have stopped leaking. Some mothers leak less than others. MOST mothers notice that leaking reduces at the weeks go by and the teeny tiny sphincter muscles responsible tighten.

· You do not have low milk supply because your breasts feel softer than they used to. The excessive fullness we experience in the early days of breastfeeding is about vascular engorgement (blood and lymph) and it's about the body inefficiently storing unnecessary amounts of milk between feeds. As time goes by, the breasts get cleverer at storage (don't forget milk is also made while a baby is actually feeding). There is also less blood and lymph needed in the breasts as breast tissue growth slows down. At the beginning, it's often very obvious which breast is going to be fed from next. That feeling goes. And many mothers mistakenly connect it with a reduction in milk supply. We are not all supposed to continue feeling heavy and full throughout our breastfeeding experience. Don't ever think 'I'll wait to let my breasts fill up!' Noooooo. This shows a misunderstanding of how lactation works to a spectacular degree. When breasts are fuller, milk production slows down. When breasts are emptier, milk production increases. Emptier softer breasts may well be making a heap more milk in a 24 hour period than the engorged full versions.

· You do not have low milk supply because your baby feeds for a short time. Plenty of babies get everything they need in under ten minutes. Probably not five - but sometimes a feed might even be five minutes long. Lots of babies use their tongue and jaw muscles super efficiently and gulp and glug and slow down as the milk gets fattier and thicker and then come off happy. It might take them nine minutes or nineteen. A baby might start off life needing 30 minutes to drain a breast (when we say 'drain', breasts are never completely empty, it just means the baby has taken out all the milk they usefully want to). As a baby gets older, this can dramatically reduce. It doesn't mean less milk is going in. If a small sleepy jaundiced baby falls asleep very quickly at the breast without some solid minutes of good swallowing, that's a different story. Overall however, a longer feed does not always mean a better one.

· You do not have low milk supply because you have small breasts. Large breasts are a combination of fatty tissue and glandular tissue. You cannot tell much about someone's milk production by the size of the breasts. If you are really worried your breasts don't 'look right', we'll come back to this later.

· You do not have low milk supply just because your baby wakes up a lot. Plenty of young babies feed with similar intervals day and night. Plenty continue waking every 2-3 hours for a while.

· You do not have low milk supply because your baby won't 'go down' after a feed. So you feed your baby and they drop off to sleep on the breast. You move them to the Moses basket and they wake up as if you just placed them on a sheet of molten lead. And they seem to be rooting again. This happens because being next to you skin-to-skin was nice and cosy and relaxing and warm and it smelt good. The Moses basket is cold and NOT YOU. You probably triggered the Moro startle reflex when you moved them. You probably moved them about 15-30 minutes after a feed when the hormone cholecystokinin had dropped in their blood stream causing them to be more wakeful. Your teeny primate mammal baby finds the breast a lovely place to be. They like to suck to relax themselves. Babies like second helpings. This does not mean you are not making enough milk.

· You do not have low milk supply because your baby will take milk out of a bottle after a feed. Put a teat against a young baby's palate and you trigger that baby's sucking reflex. Babies will usually continue to take milk beyond the point that they need it. This is one of the reasons we see links between bottlefeeding and obesity.

You do not have low milk supply you cannot feel your 'letdown' reflex (milk ejection reflex). Some women feel an electrical tingle at the point the milk lets down. Some don't. Crucially some feel it for the first few weeks and then it fades. This fading sometimes worries people. It does not mean anything has changed with your milk supply and it is perfectly normal for the sensation to go.

· You do not have low milk supply because you don't pump very much milk. Pumping and breastfeeding are surprisingly unrelated. Your baby removes milk in a completely different way. Plenty of women with healthy milk supplies fail to pump much at all. Their bodies can't be tricked into eliciting the milk ejection reflex (or 'letdown'). Plus pumps don't always work. Suction goes as valves get old.

These are the things that REALLY tell you a mother might have low milk supply:

· Weight gain problems. A newborn is born and then loses weight. They regain birth weight at around two weeks. They then put on about 150-200g a week after that. That slows down after around four months. If your newborn loses more than 10% of their body weight, we might pay attention but we'll also want to look at things like your birth. Did you have a drip in labour that filled you and your baby with fluid? Did your gorgeous newborn look a wee bit like the Stay Puft marshmallow man in their first photos? That fluid elevated the birth weight and as it comes out again in the first few days, we might see more of a weight drop. That doesn't necessarily mean feeding or supply is a problem. However we wouldn't want your baby to lose weight after about day five or lose weight a second time. It might take some babies three weeks to get back up to birth weight.

Have a look at the chart in your red book. Notice how we have birth weight line and then a space where the curvy lines don't go and they start again at week two. Just because your baby was born on the 75th percentile, that doesn't mean we would expect them to definitely re-start on the 75th after that two week gap. That's why the lines don't continue. That's why we have that space. We start again at two weeks. Your baby might be on the 50th then. They then ideally will roughly stick in the same vicinity. But babies wobble around a bit. They might dip below. They might get close to the 25th. And then they might bob back up again. We don't expect all babies to hug a line exactly. This chart is a guide. It's about averages. It's not about mathematical certainties.

· Nappies. In the early days (first four weeks), we look at poo and pee. After your milk has come in (around day two to five), we'd expect to see six wet nappies in 24 hours and three poos the size of a £2 coin or bigger. After week four, some babies' poo rate can slow right down. This doesn't mean anything is wrong. Some babies can skip several days between poos and this isn't anything to do with milk transfer or supply. However if someone tells you it's OK for a ten day old baby not to poo for a few days, don't believe them. We'd need to investigate that situation. Only later on do we relax.

Weight gain and nappies. That's it. Those are the only things that tell us about milk supply. You may hear people say that 'babies should be settled after a feed' but some babies get wind or need to poo or have reflux or wake up and want second helpings. Let's be careful about even saying that. Let's look at weight gain and nappies.

So let's now assume you do have low milk supply. How many of you are still with me? I'm sorry if you are. I'm sorry if your baby only put on 60g last week and 90g or less or nothing the week before that and they are slipping down the percentiles. I'm sorry because I know how scary that can feel. Nothing feels like it matters more. There are things we can do.

1. Find people.

Find people who know about breastfeeding. Someone who tells you just to use formula in this situation is not who you need. If that's all they can offer you, they don't know about breastfeeding and you need someone else. You need someone who understands how lactation works. These people may actually still tell you to use some formula in some situations (or donor breastmilk) but they will do so alongside telling you how to protect and develop your milk supply. You also need people close to you to look after you. If you are going to do all the other stuff on this list, you need to have people who love you who will cook your dinner and run you a bath sometimes. And text you just before the weigh-in clinic next week to say they are thinking of you.
2. Breastfeeding M.O.T.
Someone like a breastfeeding counsellor or IBCLC (lactation consultant) should check your latch. You might not be sore and your nipples might not be misshapen after a feed but something still might be going wrong. Your latch needs checking. Is baby's chin deep into the breast? Is baby's body close to yours? Is baby's ear/ shoulder/ hip in a line?

They shouldn't just check your latch but look at your breastfeeding management. Are you feeding enough? Maybe your baby doesn't show cues very strongly and someone told you to wait for them and you're sometimes going four hours between feeds? Maybe you need to feed more frequently?

They may also need to take a closer look at your baby. Is there a reason why baby may not be transferring milk effectively? Is this someone who can look at baby's tongue, jaw and palate? Are they familiar with the term 'tongue tie' and especially 'posterior tongue tie'? Would they know what to do if there was one? That might mean suggesting an exaggerated latch or different positions or it might mean referring you to a tongue tie specialist.

When are you changing sides? Too quickly? (and baby is missing the fatty milk). OR did someone tell you to stick on one side forever to get that 'hind milk' and the baby is on 45 minutes without doing a heck of a lot? Maybe you need to change sides at 20-30 minutes instead and get baby a greater volume of milk overall and fatty milk overall. Both of these habits can cause weight gain problems. Get someone to help you recognise what swallowing looks like so you'll know when to change sides and when good feeding has finished.

3. Google ' breast compressions'. You'll get to a video and handout from Dr Jack Newman. You can finish a feed with breast compressions and get an extra dose of fatty milk into baby.

4. You have 3 sides and 4 sides. This is ' switch nursing'. Try and go back to the first side. There will be milk there. The more breastfeeding you do, the more milk you will make. The second time you return to that breast, the milk will be fattier and richer and you'll send great signals to your body to make more.

5. Find time.

If you are going to build up your supply, get help. You can't devote time to switch nursing and skin-to-skin when you have to go to Tesco to buy milk and pick up another child from school. If this is 'Operation Milk supply', who can help you? You'll read people talking about a 'babymoon'. Go to bed, they say. Just you and the baby. Feed lots. If that sounds appealing, go for it. Personally my babymoon would involve the sofa and box sets and crisps. However there's no point in babymoooning until next Christmas if your latch and breastfeeding management are the issues. Get that checked first.

6. Using a pump.

Baby feeding effectively is first choice but pumps can be useful. You can pump on an emptier breast to send even more signals to your milk supply. But we're not going to take a baby off the breast do be able to pump.

You don't need to wash and sterilize a pump every time you use it. Pop it in a plastic bag and put it back into the fridge between pumping sessions. 10 minutes is ample. If you are pumping for 30 minutes and 'nothing is coming' out, you are not getting a letdown and you are not doing yourself any favours. Use hand expression before and after (google 'Marmet hand expression') and prepare the breasts with warm compresses and massage if you can. You can take an hour and do some 'cluster pumping' or 'power pumping'. Pretend to be a baby having a cluster feed. Pump for ten minutes. Break for five. Pump again and repeat.

Just check your pump is the best one available. If it's second hand or you have had it a while, it might need servicing or replacement parts. You also might want to consider hiring a hospital grade double electric pump from someone like www.ardobreastpumps.co.uk to give yourself the opportunity to pump both sides together as effectively as possible.

Pumping shouldn't hurt. Make sure your flanges are the right size - that means they are the right diameter for the size of your nipple. Don't think that cranking up the suction will automatically do better things. And don't think, "I don't want to pump because I will empty my breasts and baby will have less milk." Certainly they might be less appreciative if you pump just before a feed is due and you leave them with an emptier breast full of thicker fattier milk but pumping overall will increase milk supply and stimulate milk production. You are not 'taking their milk away'.

You might also be someone who always gets better results with just using hand expression so stick with that.

Of course, you might not want to pump at all and just focus on feeding baby more effectively and frequently.

7. Galactagogues.

Taking herbs and medication that increase milk supply. Not right for everyone but some women really feel they helped. You need to read about side effects and dosage on sites like kellymom.com. Fenugreek, blessed thistle and goat's rue are popular. Some doctors prescribe domperidone in certain situations. These are never a substitute for good breast emptying and a breastfeeding MOT.

8. The science part.

In a book, this bit would be under a little flap as we're only talking to a small group of people.

Did you have breast surgery?

Are your breasts very widely-spaced or asymmetrical, or very tubular with a bulging areola? Did they not really change much in pregnancy (or puberty)?

Do you have PCOS? Some women with PCOS (not all) have a reduced milk supply.

These are times when it's worth finding an IBCLC and getting technical.

Some doctors will do hormonal testing for you. There are medications that can help develop breast tissue especially in pregnancy.

What about your thyroid levels? This is something relevant for more people than you might realise. If you are trying everything and low milk supply continues to be a problem, ask your doctor to check your thyroid levels. There are sometimes medical reasons mothers have a low milk supply and doctors and lactation consultants may be able to help you. These are not the most common reasons why people have low milk supply by a long shot. Hence the need for the flap.

Most people who genuinely have low milk supply got themselves into a pickle with using artificial nipples or not breastfeeding enough or breastfeeding ineffectively. And it can almost always be reversed.

Also remember that just because you had low milk supply in your first breastfeeding experience, it doesn't mean a subsequent lactation will also be a struggle. The development of all that breast tissue first time round often helps.

Hold in your mind the fact that women can relactate after not breastfeeding at all for several weeks. We CAN send signals to increase supply again in the vast majority of cases. There are tons of us in real life and online who want to support you.

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Forgive me for asking but... Do you REALLY have low milk supply? This is a very important place to start. Please bear with me. I don't mean to doubt your situation and be annoying patronising lactation consultant woman but it's crucial to note that the MAJORITY of new mothers who fear they have low milk supply DO NOT.

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Once a mother's milk comes in, if her baby is struggling to latch, or breastfeeding is painful, in order to maintain her milk supply, the recommendation is to start double pumping with a hospital grade double pump, at least 8 times in 24 hours, for about 20 to 30 minutes per session: 

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Once a mother's milk comes in, if her baby is struggling to latch, or breastfeeding is painful, in order to maintain her milk supply, the recommendation is to start double pumping with a hospital grade double pump, at least 8 times in 24 hours, for about 20 to 30 minutes per session: 

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This material was developed by Jane Morton, MD and produced for educational purposes only. Reproduction for commercial purposes is prohibited. Utilization of the materials to improve care of pregnant women and their newborns is encouraged with proper citation of source.

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This material was developed by Jane Morton, MD and produced for educational purposes only. Reproduction for commercial purposes is prohibited. Utilization of the materials to improve care of pregnant women and their newborns is encouraged with proper citation of source.

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When giving a bottle of milk, it's very important always to practise paced bottle feeding: 

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When giving a bottle of milk, it's very important always to practise paced bottle feeding: 

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Paced Bottle Feeding For The Breastfed Baby

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Paced bottle feeding is a method of bottle feeding that is designed to mimic breastfeeding. There are many reasons families might decide to try it. Some mothers find that when they return to work and their babies are receiving breastmilk or formula from a bottle in childcare, their babies become less interested in breastfeeding at home and some may even refuse the breast.

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Here's a leaflet on neonatal jaundice, which over 50% of babies will develop on around Day 3 or Day 4. Jaundice can make babies very sleepy, and they may need to be woken for feeds. In the early days, it's best not to let a baby go much longer than 3 hours between feeds: 

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Here's a leaflet on neonatal jaundice, which over 50% of babies will develop on around Day 3 or Day 4. Jaundice can make babies very sleepy, and they may need to be woken for feeds. In the early days, it's best not to let a baby go much longer than 3 hours between feeds: 

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By Kelly Bonyata, BS, IBCLC
It is very common for babies to be fussy and nurse very often in the evenings, particularly in the early months.
My daughter had a fussy time every evening for a couple of months (yes, it does go away!). I spent weeks camped out on the end of the sofa with a constantly nursing and/or fussy baby every evening from about 6 to 10 PM. With my son, we didn't have the luxury of being able to sit down. Alex was unhappy and crying unless he was upright and being walked around at this time of day (and sometimes this only helped him to be less unhappy). He would occasionally have a very fussy time during the day, too. Nursing rarely helped to calm his fussiness (unlike with my daughter), so I usually didn't have that tool to work with (though I always tried). His fussiness was such that I looked into other causes (such as food sensitivity), but we never determined any reason for it and he was all smiles the rest of the time. The fussiness gradually went away between 3 and 4 months, as is the norm, but the first few months were hard. Nowadays, the typical comment that I hear about him is "Is he always this happy?" So remember: this, too, will pass...

Cluster feeding, also called bunch feeding, is when babies space feeding closer together at certain times of the day and go longer between feedings at other times. This is very common, and often occurs in the evenings. It's often -but not always- followed by a longer sleep period than usual: baby may be "tanking up" before a long sleep. For example, your baby may nurse every hour (or even constantly) between 6 and 10 PM, then have a longish stretch of sleep at night - baby may even sleep all night.

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Cluster feeding often coincides with your baby's . Baby will nurse a few minutes, pull off, fuss/cry, nurse a few minutes, pull off, fuss/cry... on and on... for hours. This can be VERY frustrating, and mom starts wondering if baby is getting enough milk, if something she is eating is bothering baby, if EVERYTHING she is doing is bothering baby... It can really ruin your confidence, particularly if there is someone else around asking the same questions (your mother, your husband, your mother-in-law).

This behavior is NORMAL! It has nothing to do with your breastmilk or your mothering. If baby is happy the rest of the day, and baby doesn't seem to be in pain (as with colic) during the fussy time - just keep trying to soothe your baby and don't beat yourself up about the cause. Let baby nurse as long and as often as he will. Recruit dad (or another helper) to bring you food/drink and fetch things (book/remote/phone/etc.) while you are nursing and holding baby.

Does this mean that baby needs more milk than I can provide?

No. Don't give baby a bottle - supplementation will only tell your body that you need LESS milk at this time, and that will not help matters. Also, keep in mind that formula fed babies experience fussy periods in the evening, too - fussy evenings are common for all young babies, no matter how they are fed. The Academy of Breastfeeding Medicine spells this out in their supplementary feeding guidelines:

There are common clinical situations where evaluation and breastfeeding management may be necessary, but supplementation is NOT INDICATED including... The infant who is fussy at night or constantly feeding for several hours.

Why do babies fuss in the evening?

One frequently-heard explanation for baby's fussiness in the evenings is that milk volume tends to be lower in the evening due to the natural cycling of hormones throughout the day. However, Dr. Peter Hartmann, a breastfeeding researcher, has said that in the women he has studied, milk volume is not low at this time of day. Even if milk volume is lower in the evening, fat content is typically higher in the evening (particularly if baby is allowed to control this via cue feeding), so the amount of calories that baby is getting should not be significantly different. Milk flow can be slower in the evening, which may be frustrating for some babies.

Doctors often attribute evening fussiness to baby's immature nervous system (and the fussiness does end as baby gets older, usually by 3-4 months). However, Dr. Katherine Dettwyler (who does research on breastfeeding in traditional societies) states that babies in Mali, West Africa and other traditional societies don't have colic or late afternoon/evening fussiness. These babies are carried all day and usually nurse several times each hour.

So perhaps none of these explanations is a complete answer to baby's evening fussiness. For many babies, the fussy time seems to be characterized by a need to have small quantities of milk at frequent intervals, combined with lots of holding, cuddling and movement. Babies who are offered as much expressed milk or formula as they will take by bottle [note: this practice will decrease your milk supply!] often behave in exactly the same way in the evenings. Baby takes a small amount and dozes (and fusses), then a little more, and so on. Perhaps babies "remember" mom being very active during her pregnancy at these times, and want to be held, rocked, and nurtured constantly again.
Perhaps babies simply need to nurse more often at this time - rather than consume more milk.
Soothing techniques for the fussy times

Wear baby in a sling or baby carrier. This will free one or both hands for other tasks (fixing dinner, caring for other children) while you hold, soothe and nurse your baby.

Change of pace. Let dad have some "baby time" while mom takes a shower or simply gets some time to herself to relax and regroup after a long day.

Go outside. Relax baby (and mom too) with a walk, or just sit and enjoy the outdoors. Try this a little before baby's regular fussy time.

Soothe with sound. Sing, hum, talk, murmur shhhh, listen to music, or use 'white noise.' Try different types of sound, different styles of music and singers with different types of voices.

Soothe with rhythmic motion. Walk, sway, bounce, dance, swing, or even try a car ride.

Soothe with touch. Hold or bathe baby, try baby massage.

Reduce stimulation. Dim lights, reduce noise, swaddle baby.

Vary nursing positions. Try side lying, lying on your back to nurse with baby tummy to tummy, etc.

Nurse in motion (while rocking, swaying, walking, etc.).

Combine rhythmic motion with soothing sounds.

Avoid scheduling, even more so in the fussy evening hours.

More soothing techniques.

More resources for fussy babies

@ KellyMom

@ other websites

Helpful books

The Happiest Baby on the Block: The New Way to Calm Crying and Help Your Baby Sleep Longer
by Harvey Karp, MD

The Fussy Baby Book: Parenting Your High-Need Child From Birth to Age Five
by William Sears, MD and Martha Sears, RN, IBCLC

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Cluster Feeding and Fussy Evenings * KellyMom.com

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It is very common for babies to be fussy and nurse very often in the evenings, particularly in the early months. My daughter had a fussy time every evening for a couple of months (yes, it does go away!).

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If breastfeeding is painful even though your baby seems to have a good latch, your baby might have TONGUE TIE:

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If breastfeeding is painful even though your baby seems to have a good latch, your baby might have TONGUE TIE:

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Here’s an article about the over-diagnosis of reflux disease: 

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Here’s an article about the over-diagnosis of reflux disease: 

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Revised
Reflux, spitting up or possetting are all names used to describe babies bringing back some of the milk that they swallowed earlier. Some spitting up is quite normal in young babies, this may simply be how they deal with too much milk or anything that doesn't agree with them .

Reflux is very common

Reflux -full name gastroesophageal reflux (GER)-in newborns is very common. In Breastfeeding and Human Lactation, the authors explain that infants with reflux are generally happy and thriving babies who spit up at least once or more per day most days. One study found 73% of babies spit up in their first month of life and that babies who were exclusively breastfed spit up less often than infants who received mixed feeding.

Unless your baby has the more severe symptoms of gastooesophageal reflux disease (GERD) discussed below, the only problem with a lot of spitting up might be that you have more laundry to do.

Why do babies spit up?

Dr Jack Newman, Canadian paediatrician and breastfeeding expert explains how spitting up regularly may have a protective function if the baby is otherwise happy and gaining weight:

Breastmilk is full of immune factors (not just antibodies, but dozens of factors that interact with each other) that protect the baby from invasion by bacteria and other microorganisms (fungi, viruses, etc.) by forming a protective layer on his mucous membranes (the linings of the gut, respiratory tract and other areas). This protective layer prevents micro-organisms from invading the body through these mucous membranes. A baby who spits up gets extra protection, first when the milk goes down to the stomach, and again when he spits it up.

Vomiting due to illness or other medical reasons is not the same as reflux and will be more forceful and your baby will seem poorly, contact your health care professional if you have any concerns.

Causes of reflux in babies

Although some spitting up is normal, and may have a protective function, certain factors may worsen symptoms.

1. Immature sphincter muscle?

Reflux is sometimes attributed to an immature sphincter muscle which is said to strengthen as the baby grows through their first year . However author Linda Palmer describes this "immaturity" as a perfectly normal phenomenon considering 70% of babies have a "weak" lower esophageal sphincter saying: "This is not an error; it is normal". And fellow author Maureen Minchin says the oesophageal sphincter is "beautifully evolved".

2. Cows' milk allergy and reflux

Studies have shown a link between reflux and having an allergy or intolerance to cows' milk protein (Palmer, 2015). There could also be a sensitivity to some other food allergen, excess caffeine or second hand smoke ( Kelly Bonyata, 2011). If a mother tries removing dairy products from her diet, the symptoms of reflux will improve if her baby is sensitive to cows' milk protein. See Milk Allergy in Babies and Elimination Diet for further information.

If a baby is reacting to his mother's diet it makes little sense to move to formula as an answer. The cows whose milk is modified into industrial formula also eat foods that could be potential allergens such as grasses (grains), corn, soy, or wheat (Palmer, 2015).

3. Fast flow and oversupply

Babies may spit up more if they're getting too much milk (often called oversupply) or too much milk too quickly. If your baby gulps and gasps or lets go of the breast just after you have a let-down because the flow seems too fast for him, you could try taking him off the breast for a moment or two until the flow slows a little. A container or towel can catch the milk and once the flow has slowed your baby may be better able to cope with his feed. For more coverage on the subject of true oversupply and fast flow see #4 below and our article on oversupply.

4. Tongue function

How well a baby can handle milk flow can depend on whether they have a deep latch and a good tongue function. Your IBCLC lactation consultant can check whether your baby's latch, positioning or tongue function could be improved or whether any steps need to be taken to manage your supply. The tongue moving in the right direction is thought to set the stage for the swallowing reflex down the oesophagus and into the stomach and beyond. Alison Hazelbaker says being tongue-tied could interrupt this reflex action and could lead to sluggish digestion, inflammation, gas, trouble pooping and may cause symptoms of reflux, colic or secondary lactose intolerance in babies . Poor tongue function may lead to excessive swallowing of air according to some practitioners. American surgeon Scott Siegel calls this aerophagia induced reflux (AIR) and calls for more research .

Is reflux in newborns the same as acid reflux in adults?

No, most infant reflux and silent reflux (when the regurgitated milk comes part way up the oesophagus then goes back down to the stomach) is not acidic . Author Linda Palmer explains:

Milk (human, formula, or cow) is quite alkaline, as opposed to acidic, and baby tummies themselves are low in acid, compared to child or adult stomachs. Half of all infants visibly spit up at least once per day. Even more babies experience silent reflux, which is when stomach contents spill only partway up the throat and go down again without coming out of baby's mouth. Most infant reflux is not highly acidic and likely not uncomfortable nor damaging to esophageal tissues.

This ties in with Dr Jack Newman's reasoning above that spitting up is probably beneficial (and normal) due to all the protective factors in breastmilk washing up and down the food pipe. Rarely, babies suffer from more severe forms of reflux. It also ties in with studies that have not found acid reducing medication effective .

Severe forms of reflux

A rare form of reflux called gastro-oesophageal reflux disease (GERD) may cause pain and other problems .

Some babies with allergy can suffer from an inflamed oesophagus (eosinophilic esophagitis) causing reflux and difficulty swallowing (Minchin, 2015).

In a small number of cases, reflux is a sign of something more serious such as a blockage (e.g. pyloric stenosis)

What is GERD?

The acronym for gastro-oesophageal reflux disease is GORD or GERD depending where you are in the world and how you spell oesophagus. Sources suggest only one in 300 infants actually has GERD needing treatment yet the number of babies given acid-reducing medication tends to be very much higher than this figure .

Symptoms of GERD

There isn't a set of symptoms that is definitely diagnostic of GERD in babies. Of the potential symptoms and signs associated with GERD many can have other causes giving potential for GERD to be over diagnosed. Symptoms often described include:

1. Bringing up large amounts of milk after most feeds, or frequent burping or hiccups-symptoms that could also be due to allergy or normal baby behaviour.

2. Poor weight gain or other feeding difficulties such as pulling at the breast and fussing, refusing to feed or conversely, feeding continuously for comfort-small volumes of milk are said to act like an antacid. Note; these symptoms are also seen with low milk supply.

3. Being in pain or fussy and irritable between feeds, having difficulty sleeping, lying flat or waking with screams. Or back arching and twisting the neck between feeds (Sandifer's Syndrome). Note: unexplained crying can be from other causes and may not be due to abdominal pain . Underweight babies can present as "fussy" due to hunger (see below).

4. Associated breathing problems, chest infections, pneumonia, asthma, wheezing or apnea-note similar symptoms may sometimes be seen with allergies.

5. A sore throat, or inflammation to the food pipe with gagging, choking, coughing or difficulty swallowing, may have hoarse sounding cries. May have bad breath or acid damage to teeth. Some of these symptoms could also be related to allergy or oversupply.

Fussy baby, hungry baby?

A baby fussing during feeds, pulling at the breast, refusing the breast, not wanting to lie flat, or being fretful can have other causes. A possible reason can be if your baby is not getting enough milk and is not gaining weight normally, and Dr Jack Newman notes that symptoms of reflux may be associated with low milk supply. Oversupply and food allergy can also be confused with not enough milk and rigid approaches to a perception of "oversupply" can quickly become "not enough milk" (Newman, 2014). True oversupply can sometimes cause symptoms of lactose overload. Other causes for fussing in babies are described in Fussy Breastfed Baby. If you are not sure what is making your baby fuss, always check with your health professional and find an IBCLC lactation consultant to help you if it could be connected to feeding issues.

Helping reflux

Frequent small feeds, keep baby upright, burp baby

General suggestions include:

1. Upright positions for feeding, carrying and gentle handling. Try frequent smaller breastfeeds rather than large feeds further apart (Womanly Art of Breastfeeding, 2010)

2. Conversely breastfeeding in a laid back position may help (Wambach & Riordan, 2015)

3. Look at mum's diet and consider if an Elimination Diet could help if allergies are involved

4. If oversupply is suspected check positioning, tongue function and breastfeeding management with your lactation consultant

5. Burping your baby regularly may help prevent milk travelling back out with gas bubbles

6. Baby lying on his left side may be more comfortable (Minchin, 2015).

7. Comfort sucking on an empty breast

Thickened feeds not recommended

Breastfeeding authors Wambach and Riordan discuss the drawbacks of thickening milk feeds to help reflux:

Occasionally providers will suggest thickened feedings with cereal. When cereal is added to breastmilk, enzymes break it down very quickly, and it is an ineffective thickening agent. Furthermore, thickened feedings have not been found to be effective. The frequency of reflux episodes may be reduced, but exposure of the oesophagus to acidic gaseous material is increased, probably because thickened gastric contents do not clear as quickly (Bailey et al, 1987). In addition use of cereal-thickened feedings is associated with coughing in infants with GERD (Orenstein et al., 1992).

Author Maureen Minchin describes thickeners as food additives carrying risks that should have no place in the treatment of complicated reflux. She shares that in 2012 commercial thickener "Simply Thick" was linked to the deaths of seven babies.

Medication

Medications such as antacids prescribed by your doctor can reduce the acidity of gastric secretions and offer short term acid reduction and symptom relief for GERD. However as discussed above, most baby reflux is not acidic and medication will not be helpful for normal reflux:

In the case of infants, most reflux is buffered by frequent feeds and seldom is of acid pH,19 which seems to have been largely ignored by prescribers of medication.

The largest randomized, controlled study to date in infants showed that for symptoms purported to be those of GERD, a PPI [proton pump inhibitor] was no better than placebo.

The Breastfeeding Network in the UK has a reflux information sheet discussing suitable medications when truly needed. However adverse events associated with some medications may outweigh their benefits ( Vandenplas 2009). For example reflux medications and simple antacids can cause constipation in babies (Palmer, 2015 p 179) or may affect digestion and result in food intolerances (Minchin, 2015). If medication for GERD doesn't help, contacting a lactation consultant may help rule out any other causes for fussiness that may be connected to breastfeeding.

Colic remedies?

The symptoms of colic (unexplained crying and tummy ache in an otherwise healthy baby) have similarities with reflux or silent reflux. Parents may come across suggestions to try gripe water or Infacol for a fussy baby (traditional "cures" for colic). Author Linda Palmer warns that gripe water may contain a lot of sugar and "cures nothing" and re simethicone drops (Mylicon, Infacol) she says studies indicate "they work no better than placebos".

Probiotics?

Probiotics are live bacteria and yeasts that are widely promoted as having health benefits when these "friendly bacteria" are added to our diet. There is more about probiotics generally on the NHS website which points out that there is little evidence for many of the health claims surrounding them. Could probiotics help reflux in babies? In her book author Linda Palmer says although probiotics may be useful for healing a baby's damaged gut in certain circumstances, they are not a cure for colic and reflux. There is still much to learn about probiotics and how they could affect babies for better or worse. For a discussion of the pros, cons and unknowns about probiotics for babies see Are Baby Biotics Bugging You? by Maureen Minchin or her book Milk Matters which is reviewed here.

Cranial Work

Some parents have felt that baby massage and cranial osteopathy helped with their babies' symptoms of colic and reflux ( NCT, 2017).

Summary

Spitting up is a normal event for babies and doesn't usually cause them a problem although more severe forms are possible e.g. GERD. Certain underlying causes such as allergy, oversupply, lactose overload and poor tongue function can make reflux worse. Working with an IBCLC lactation consultant alongside your health professional can help find ways to reduce reflux or identify other possible reasons for an otherwise healthy breastfed baby to be miserable and fussy.

1. A ring of muscle between the stomach and the food pipe preventing spillage of the stomach contents

2. Tongue-Tie Morphogenesis, Impact, Assessment and Treatment, Alison Hazelbaker, 2010, p 89

3. Pyloric stenosis is the narrowing of outlet between the stomach and small intestine. It causes projectile vomiting and is more common in formula fed babies. Author Maureen Minchin says there is considerable evidence that it is due to inflammation and damage from cows' milk.

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Reflux in Newborns - Breastfeeding Support

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Revised Reflux, spitting up or possetting are all names used to describe babies bringing back some of the milk that they swallowed earlier. Some spitting up is quite normal in young babies, this may simply be how they deal with too much milk or anything that doesn't agree with them .

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Research showing colic remedies don't work: 

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Research showing colic remedies don't work: 

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Using Infant Massage to Relieve Colic | Isis Parenting