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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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If you are pregnant or breastfeeding, hand expressing is a useful skill to have. You may want to hand express your milk for a number of reasons including if you have a sick or pre-term baby, because your breasts are full and engorged, to help increase your milk supply or to store some milk to offer…

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This patient information leaflet has not been converted to a web page and remains available as a PDF. It does not meet accessibility standards, but is essential to providing our services. A number of our patient information leaflets have pages that are to be completed by the patient: consent forms workbooks diaries e.g.

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https://www.laleche.org.uk/hand-expression-of-breastmilk/

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If you are pregnant or breastfeeding, milk expression by hand is a useful technique to learn. It's a handy way to relieve engorged breasts. You can also use it to stimulate milk production and provide milk for a baby who is not breastfeeding well or needs more milk.

Why hand expression?
If you use a pump
Practice helps
How breasts work
Before you start
Relax and get comfortable
How to hand express Step by step How long will hand expressing take? Hand expressing shouldn't hurt

Why hand expression?

Skin-to-skin contact with hand expression encourages the milk ejection reflex (MER) or 'let-down reflex'.

Mothers usually get more milk using hand expression alone or combined with pumping than using just a pump.

It requires no special equipment and is always available, even in emergencies.

It's convenient and free.

Hand expression is particularly useful if you need to express colostrum during late pregnancy (see Antenatal Expression of Colostrum) or in the first few days after birth. It makes it easy to save every drop of precious colostrum.

If you use a pump

Whatever pump you may use, combining pumping with hand expression can help you express more milk more effectively.

Breast massage and hand expression can be used at the beginning to get your milk flowing.

Breast massage while pumping increases the amount of milk you can express.

Continuing to hand express can release milk remaining, even after the pump flow has stopped.

And if your pump breaks down, or there is no electricity, you always have your hands.

Practice helps

How breasts work

When milk is removed more often, your breasts feel soft and comfortable and produce milk faster. When milk is removed infrequently, your breasts may feel full but produce milk more slowly. Frequent milk removal is the key to maintaining milk production whether you are breastfeeding or expressing. Expressing stimulates your breasts-though not as effectively as a baby-to make and release milk.

For more information on how milk production works, click here.

Before you start

Wash your hands. Have a suitable clean container available to collect your milk: colostrum can be expressed into a small (5ml) container or even onto a teaspoon for immediate feeding. Once milk production has increased milk may spray in several directions so a bowl, wide mouthed container or a bottle with a funnel might be more practical.

Relax and get comfortable

Milk tends to flow better when you are feeling comfortable, relaxed and warm. Tension or anxiety inhibits milk flow. Relaxation techniques can help increase the amount of milk you can express. The sound of running water may help, or you could practise in the bath or shower.

Seek privacy; try the breathing exercises you learnt for use during labour; visualise flowing milk. Have your baby nearby, or think of him. Use photos or recordings of your baby and smell his clothing. All these will help stimulate milk flow. Take a few deep breaths, drop your shoulders and release tension with each exhalation. Bending forward with your breasts suspended means gravity can help milk flow.

How to hand express

One basic approach

1. Start by encouraging milk flow in both breasts.

2. Then hand express from each breast until milk flow slows right down. If you need to increase milk production, continue expressing for a couple of minutes after milk flow has stopped.

3. Repeat these two steps at least twice more. You will find milk flow slows or stops sooner each time you repeat.

4. Most mothers adapt the above approach to suit themselves, so experiment to find what works best for you.

Step by step

Encouraging milk flow
Stimulating your milk ejection reflex (MER or 'let-down') is the key to expressing. It can take a few minutes. You may see drops of colostrum or breastmilk, or even experience a tingling sensation, but many mothers don't see any milk until they start actually expressing. Experiment with the following suggestions to find out what works best for you.

Massage your breast starting at the top, using a firm circular pressure on one spot. After a few seconds, lift up your fingers to move to the next area on the breast. Spiral around the breast towards the areola and nipple.

Stroke your breast from the top of the breast to the areola and nipple. Light stroking with fingers is one option, or use a soft item with a light tickle-like stroke. Continue this stroking motion from the chest wall to the nipple around the whole breast.

Shake your breast gently while leaning forward so gravity can help your milk flow.

Hand position

You can use either or both hands on one breast, or express both breasts at the same time. Hold your hand in the shape of a letter 'C', with your thumb and forefinger behind the base of your nipple, feeling for the change in texture of your breast. Move you fingers closer to, or away from your nipple to find the best place for you.

To express

Start with the pad of your thumb at the top of your breast, and your finger pads below.

Support your breast, then press the breast towards the chest wall to put pressure on the milk ducts.

Now compress the breast between your fingers and thumb to move the milk forward towards your nipple.

Release and repeat rhythmically: press-compress-relax (like a baby breastfeeding) until milk flow stops

Then rotate your hand around the breast a little and repeat. Do this for each section of your breast until it feels soft and comfortable. Keep your fingers and thumb opposite one another as you rotate.

Remember that when a baby breastfeeds, milk doesn't flow immediately, so it's normal for it to take a little time for milk to start flowing when you express. Switch back and forth between breasts as the flow slows to encourage further MERs.

This video has a good demonstration of hand expression of breastmilk

How long will hand expressing take?
Allow plenty of time at first: the whole process may take 20 or 30 minutes, but you can always stop and start again later if you need to. Frequent short sessions are usually more effective than infrequent, longer expressing sessions.

Switching between breasts several times as milk flow slows can help trigger further milk ejection reflexes. The more MERs you stimulate, the more milk you will be able to express and make.

Hand expression shouldn't hurt
Squeezing, pulling and sliding fingers along the skin can cause discomfort, bruising and skin burns. Pain or discomfort inhibit the MER and are signs that something needs adjusting. If your breast feels engorged or tender try warm moist heat immediately before expressing. Start expressing from the most comfortable areas.

Removing milk from areas around a blocked duct can reduce the discomfort, making it easier to express from the tender area later.

Written by Sue Upstone, Karen Butler and mothers of LLLGB.

Further Reading
The Womanly Art of Breastfeeding. LLLI. London: Pinter & Martin, 2010.
Breastfeeding Answers Made Simnple. Mohrbacher, N. Amarillo, Tx: Hale Publishing, 2010.

Antenatal Expression of Colostrum
Birth and Breastfeeding
Expressing Your Milk
Engorged Breasts - avoiding and treating
My Baby Needs More Milk
Sleepy Baby - why and what to do
Storing Your Milk
Working and Breastfeeding
Bottles and other tools

You can buy this information in printed form from the LLLGB shop.

LLLI Resources
The Power of Hand Expression

Copyright LLLGB 2016

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Hand Expression of Breastmilk - La Leche League GB

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If you are pregnant or breastfeeding, milk expression by hand is a useful technique to learn. It's a handy way to relieve engorged breasts. You can also use it to stimulate milk production and provide milk for a baby who is not breastfeeding well or needs more milk. Why hand expression?

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Antenatal Expression of Colostrum - La Leche League GB

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Mothers start to produce colostrum (early milk) while pregnant. Being able to express colostrum is a useful skill to have. Saving your expressed colostrum may also be beneficial if your baby is likely to need special care after birth. Why express while pregnant? Being familiar with your breasts and…

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Why Normalising Baby and Toddler Sleep is Essential

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Why Normalising Baby and Toddler Sleep is Essential

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Smokescreens that make us doubt ourselves and our babies.

Smokescreens that make us think that what we are doing is wrong or to blame for our child's wakeful patterns.

Smokescreens that make us think that everybody else's baby can just be put down to sleep.

Smokescreens that fog our connection and trust with our own children by making us question whether they truly *need* us or if we are being manipulated and need to break bad habits.

Smokescreens that make us think that the only reason we are tired is because our baby wakes and needs help in the night.

Smokescreens that tell you that if you accept that waking is normal than you must also accept that extreme sleep deprivation and exhaustion is your life.

Smokescreens that tell you that by finding acceptance in the normal waking, you must martyr yourself and your own mental well-being.

Smokescreens that tell you that the *only way* to function with whatever challenges your family face is to stop your baby's waking or calling to you in the night.

And they sap you of precious energy.

Body, mind and soul as they focus your energy so squarely on but one problem to be *fixed* ~ your baby's behaviour.

All of the tracking, timing, withholding, questioning, desperation, exhaustion that makes the connection between you and your child that much more hazy.
While you think they are asking for too much... While you think they shouldn't need you this way... While you think no other child needs this... While you think there is no other way... While you think this is unreasonable... While you think this is not sustainable...
Your smokescreens prevent you from ever exploring what else might work for your family.

By KNOWING what is truly normal you free some of your energy.

You free the anxious part that thinks you are doing it all wrong and your baby is broken.

By KNOWING what is truly normal, you also free yourself to recognise when things AREN'T normal and begin to focus in on the underlying causes instead of simply trying to fix the behaviour that was a symptom not the cause.

This also means, you KNOW that your child who has got other things at play, can rest in your connection and nurturing as you work it all through. There are no bad habits.

Understanding what is normal, also allows us to find a new level of respect and value in the behaviours we see in our children.

And once you find the freedom that is released through simply knowing what is normal, suddenly the shape of your problem will look different ...

Your exhaustion, your logistics, your life and well-being, they can come into sharper focus but WITH your baby's needs in mind, too.

And you begin to work with each other, as a team.

You begin to look outside of your little unit for the supports you need to feel well yourself.

Rest, respite, rejuvenating in ways that you've yet to imagine!

There are SO many possibilities for every family, if only we let go of all the things we *can't* or *won't* consider.

What CAN and WILL you consider?

And we need to let go of perfection ...

What is perfect anyway?!?

Certainly, not life.

And that doesn't mean there won't be joy but it does mean accepting the ups and downs, the raw and the real, the messy and imperfect.

Because behind all of the beauty and precious moments we experience nurturing and trusting our little ones, there is always the day to day of life.

Your solutions don't need to be perfect.

Your solution today to more rest and respite may need to evolve tomorrow, next week and again next month.

Life with little ones is like the flow of a river system forging its way to the ocean ...

You can fight against it, you can build dams and swim upstream...

You can resist...

You can question...

You can feel like it doesn't really have direction and you need to *take charge*...

But the truth is, through the hardest of circumstances, the river will flow and meander on and it WILL find the ocean in its own glorious time in its own perfectly imperfect way.

You can choose to trust your little ones just as we can trust a river knows its way to the ocean.

We can choose the path of least resistance and embrace it.

We can find our natural flow alongside them and forge a path together.

Connected through the good times and the bad.

Our babies need us.

It's that hard and that simple.

To read more ideas to get thinking about your situation, check out our content series on HOW to move beyond sleep training ❤️

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Why Normalising Baby and Toddler Sleep is Essential - The Beyond Sleep Training Project

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Smokescreens that make us doubt ourselves and our babies. Smokescreens that make us think that what we are doing is wrong or to blame for our child's wakeful patterns. Smokescreens that make us think that everybody else's baby can just be put down to sleep.

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Self-soothing. Possibly the biggest lie ever foisted on parents

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Self-soothing. Possibly the biggest lie ever foisted on parents

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First of three articles

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Real Self-Soothing (It’s not what sleep experts say it is)

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Real Self-Soothing (It’s not what sleep experts say it is)

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Second of three articles

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Part 2: Real Self-soothing.(It’s not what sleep experts say it is)

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Part 2: Real Self-soothing.(It’s not what sleep experts say it is)

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Third of three articles

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From The Beyond Sleep Training Project

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We recognise every day breastfeeding is an achievement and there's a point where it will come to an end be this in the first weeks or months of life or through until a child naturally weans on their own. Whilst TBSTP encourages waiting until a minimum of 18 months to wean - we discuss our perspective on weaning in further detail here and our rationale. We recognise that isn't always achievable or desirable for a multitude of reasons, and that each breastfeeding journey is as individual as each mother and child.

We do however believe that making informed decisions #informedisbest, and that decisions made honour and respect both mother and child.

Across the world, we see a variety of recommendations for breastfeeding, the WHO recommends breastfeeding for a minimum of two years or beyond [1]. In Australia, it is recommended, "that breastfeeding be continued until 12 months of age and beyond, for as long as the mother and child desire." [2]. In Western culture, breastfeeding rates vary greatly from biological norms and we should refer back to these norms when we approach weaning that occurs prior to when the child is biologically ready as it can be a difficult and emotional journey for the dyad. By not preparing parents with this information we are not giving you the chance to consider all your options.

Breastfeeding often offers the mother the quickest and easiest approach to get their child to sleep or back to sleep in the night. Most children will not naturally night wean until between 2-4 and the most gentle option for our children is child-led weaning. However, breastfeeding is a dyadic relationship and it needs to be one that's working for both mother and child and there is a vast range of reasons that child-led weaning is not an option. At the heart of our recommendation to wait until 18 months, is that this is the earliest point that a toddler may have the cognitive and developmental readiness to understand weaning - this, therefore, makes it a smoother and more gentle process than the undertaking of the same process with a 12-month-old who has less life experience, language development and cognitive function.

We also recognise that there is a plethora of misinformation on weaning including the linking of breastfeeding to dental cavities [3][4][5] and a pressure to stop feeding overnight from 6 months of age or when a baby reaches a certain weight. Leading to many mums feeling anxious, guilty or conflicted about night weaning. If you would like to continue breastfeeding your child at night but are finding it hard, we suggest exploring ways to get yourself some respite if possible and consider some other strategies that may help you through such as meditation, magnesium and getting a health check done to ensure your iron levels, thyroid function and other vital levels are not increasing your fatigue. If you are struggling, consider accessing some professional support as sometimes an individualised plan is needed to best serve your family.
Weaning a 12-18 month old
With consideration for the above, we do receive a number of questions about how to approach gentle weaning when a baby after they've reached 12 months of age.

We know how important respectful and gentle parenting are to the members of this group. If you do intend to attempt weaning prior to 18 months of age, we would recommend a consult with one of our recommended professionals to help make a plan for weaning if this is the decision you have made. There is not a one size fits all and it's great to have support when going through a big change such as this.
How can I wean my child?
Remember that for gentle weaning that we must allow time, a gentle approach may take months not weeks. Rapid weaning can cause mastitis or blocked ducts and can be traumatic for your child. A weaned baby may or may not improve sleep quality/wakeups and some parents find themselves in a very challenging position having weaned, and yet their child's sleep hasn't improved and they're left to find new ways to help settle their child back to sleep in the night that very often takes longer than breastfeeding and are more distressing for both mother and child.
Our Admin Team Top Tips*:

Don't offer, don't refuse

Consider layering/ stacking in other forms of comfort whilst still giving breastfeeds. This could be adding in a back rub, head stroke or a bottom or back pat during feeds. Other options are humming, singing, quiet music playing or a comfort item like a blankie or soft toy. You might need to experiment a bit to see what seems to work for your baby. Once these new comfort measures have been established they can be used during the transition of reducing the length of feed or offered instead of a feed.

Distraction, distraction, distraction - offer an alternative activity

Ensure that your child has their nutritional needs met elsewhere recognising that breastfeeding is more than just a nutrition source

Cover your breasts so they're less convenient for nursing (not with sticking plasters/bandaids) this may include wearing a top with a high neck, a t-shirt rather than a scoop neck or clothing that was not designed for breastfeeding.

Choose a spot in the house for nursing that's not in a room that you're normally in, always move to this spot when your child asks for a feed

Ask your child to have a feed for x number of sucks and count. But don't refuse if they continue. Or have a breastfeed for the amount of time it takes to sing a particular nursery rhyme

Try another method for getting your little one to sleep like a walk in the pram or a car trip - this will be best done by a method that has worked previously for your child so not to cause distress.

Ask your child to wait until something is finished before a feed i.e. I need to pack the groceries away before we feed, can you wait? Can you help Mummy to put these items in the drawer?

Offer a drink of water

Offer a snack - ensuring you have something that's available with little or no preparation

If there are consistent times of the day that your child has a feed, look to tackle one feed at a time.

Start by dropping the feed that your child is least interested in

Find some other ways to connect with your child for cuddles. Your little one will need reassurance that your love is not being taken away

Only offer one breast at feeds rather than two

Purchase a new sippy cup or drinking cup and make a big deal about how special this is

Read 'Nursies when the sun shines' or create your own weaning story (template to start you here)

Change your routine so that a feed is moved further away from sleep

Make a 'pop' noise with your lips as a cue to ask your child to stop feeding and unlatch

Nighttime may prove to be more challenging as many of the daytime tools can't be applied - Sarah Ockwell-Smith talks about her gentle approach here.

Consider trying things in 'bursts', this means attempting a new way to settle but if your child becomes distressed revert back to the usual way of settling them. Keep working to increase the length of the burst (while being guided by your child's response) this allows them time to build trust in this new transition. This technique is explained by Dr Tracy Cassels of Evolutionary Parenting.

*It is important to recognise that these tips will generally be easier to implement with each passing month of age.
Recommended Book Titles on Weaning

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TBSTP Perspective on weaning your child 1yo and beyond - The Beyond Sleep Training Project

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We recognise every day breastfeeding is an achievement and there's a point where it will come to an end be this in the first weeks or months of life or through until a child naturally weans on their own.

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Accepting the Reality of Infant and Toddler Sleep

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Accepting the Reality of Infant and Toddler Sleep

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From The Beyond Sleep Training Project

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The stress, strain, struggle and sacrifices made all because so few people know and recognise what has always been and always will be the way our tiniest most vulnerable humans find sleep normally.

I was told that new and expecting mothers don't want to know that babies continue waking for a couple of years. I was told I was scaring them unnecessarily and that it was the equivalent of telling horror birth stories to a pregnant mama as she prepared to birth.

I strongly disagree.

Knowing and accepting what IS likely to happen as your baby grows and develops is not a horror story. No one knows how your baby will find sleep in this world but one thing is for sure, they will need you and that is not something you need to fear. Instead of fear, it gives room to mentally, physically and practically prepare. It takes away the element of surprise. It removes the angst of 'shouldn't they be sleeping better yet?', 'why does my baby still wake?'

A birthing mother doesn't need to hear every horrific tale of every horrific thing that may or may not happen to her. That does nothing to help her towards her own journey. But it equally does not help to tell her that it will be easy, straight forward and you practically just sneeze and the baby falls out without pain/ discomfort.

A pregnant or new mother does not need to hear every detail of every form of sleep challenges she may or may not face in the years ahead with her child. But she equally doesn't need to sprint to some arbitrary finish line that someone has told her and think that her child's night-time needs will magically cease and her sleep will return to that of pre-baby.

Let's be real. Let's be honest and let's give new parents the very best chance to set themselves up with realistic expectations for the early time in their child's life where they will be needed just as much at night as they are by day. Let's stop infantilising families and trying to shield them from reality when in fact that is just blind-siding them.

I know this may seem like a pipe dream right now, but voices are rising. Parents and babies of the future deserve better than what is offered up in mainstream society today and a growing group of families in The Beyond Sleep Training Project are developing the evidence- base of what life looks like in a post-sleep training world. Little Sparklers will also be taking this work to effect change on a systemic level to ensure that the supports required to make life with little ones sustainable and rewarding.

When we know better, we can do better and so, for all of those in the know, it's our turn to share our voice, speak our knowledge and share with all we can the truths of normal infant and toddler sleep.

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Accepting the Reality of Infant and Toddler Sleep - The Beyond Sleep Training Project

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Imagine if we, as a society accepted normal infant and toddler sleep. I mean really accepted it, in all its glory. Every part of society, from every generation, every family, every profession, every community, every culture, every religion. What if we knew and accepted it

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Why don't babies sleep at night? You asked Google - here's the answer | Paul Kelley

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Every day millions of internet users ask Google life's most difficult questions, big and small. Our writers answer some of the commonest queries

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How they affect babies' sleep

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How do I help my baby sleep during the coronavirus pandemic?

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How do I help my baby sleep during the coronavirus pandemic?

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From the Pediatric Sleep Council

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How do I help my baby sleep during the coronavirus pandemic?

Routine and predictability can help your little one adjust to a new normal.

* Try to do things in the same (or similar) order each day. For instance, if nap time was always after lunch, try to keep nap time after lunch - even if it's not at the exact same time as before (or even each day).

* Try to keep your child's morning wake time consistent, even if it's a newly set wake time. The time a child wakes up in the morning helps set their internal clock for the rest of the day - which will affect things like when your child gets sleepy for naps and when your child is ready for bed at night.

* Hold on to some of the things that always worked to get your little one off to sleep, keeping your little one's bedtime routine as similar as possible. Even if you are all going to bed a bit later than usual, get that bedtime routine in to help prepare your child for sleep. If you can't do the exact routine you were doing before, keep some important elements of the routine that usually worked to settle your little one down. This could be a favorite song, cuddle time, or a favorite story. If your little one has a lovey, make sure that she has it at bedtime.

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How do I help my baby sleep during the coronavirus pandemic? | Baby Sleep Advice for Parents & Kids

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Routine and predictability can help your little one adjust to a new normal. * Try to do things in the same (or similar) order each day. For instance, if nap time was always after lunch, try to keep nap time after lunch - even if it's not at the exact same time as before (or even each day).

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All relevant for parents considering night feeds away from the breast

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Drinks for babies and young children

Not all drinks are suitable for babies and young children. Here's what to give to your child and when.

Breast milk

Breast milk is the only food or drink babies need in the first 6 months of their life.

It should continue to be given alongside an increasingly varied diet once you introduce solid foods from around 6 months.

The World Health Organization recommends that all babies are breastfed for up to 2 years or longer.

Breastfeeding up to 12 months is associated with a lower risk of tooth decay

Formula milk

First infant formula is usually based on cows' milk and is the only suitable alternative to breast milk in the first 12 months of your baby's life.

Follow-on formula is not suitable for babies under 6 months, and you do not need to introduce it after 6 months.

First infant formula, follow-on formula or growing-up milks are not needed once your baby is 12 months old.

Cows' milk can be introduced as a main drink from 12 months.

Read more about the types of infant formula.

Non-cows' milk formula

Goats' milk formula is available and produced to the same nutritional standards as cows' milk formula.

Goats' milk formula is not suitable for babies with cows' milk protein allergy. It's no less likely to cause allergies in babies than cows' milk formula as the proteins they contain are very similar.

You should only give your baby soya formula if a health professional advises you to.

'Goodnight' milk

'Goodnight' milk is not suitable for babies under 6 months old. This type of formula is not needed, and there's no evidence that babies settle better or sleep longer after having it.

Water

Giving water as a drink to babies under 6 months is not recommended. Speak to your GP or health visitor for advice before giving water to your baby.

From around 6 months you can start introducing water with meals.

When preparing formula for babies under 6 months, you should not use water straight from the mains tap in the kitchen as it's not sterile. You'll need to boil the tap water first and then let it cool down. Water for babies over 6 months does not need to be boiled.

Bottled water is not recommended for making up infant formula feeds as it may contain too much salt (sodium) or sulphate.

If you do have to use bottled water to make up a feed, check the label to make sure the sodium (also written as Na) level is less than 200 milligrams (mg) per litre.

The sulphate (also written as SO or SO4) content should not be higher than 250mg per litre.

Like tap water, bottled water is not sterile, so it will need to be boiled before you use it to prepare a feed.

Always use boiled water at a temperature of at least 70C when you prepare a feed. Remember to let the feed cool before you give it to your baby.

Read more about how to make up baby formula.

Cows' milk

Cows' milk can be used in cooking or mixed with food from around 6 months but should not be given as a drink to babies until they're 12 months old. This is because cows' milk does not contain enough iron to meet your baby's needs.

Whole milk should be given to children until they're 2 years old because they need the extra energy and vitamins it contains.

Semi-skimmed milk can be introduced once your child is 2 years old, as long as they're a good eater and they have a varied diet.

Skimmed and 1% milk are not suitable for children under 5 years old because they do not contain enough calories.

Lower-fat milks can be used in cooking from 1 year old.

Unpasteurised milk

Young children should not be given unpasteurised milk because of the higher risk of food poisoning.

Goats' and sheep's milk

Goats' and sheep's milk are not suitable as drinks for babies under 1 year old as, like cows' milk, they do not contain enough iron and other nutrients babies this age need. As long as they're pasteurised, they can be used once your baby is 1 year old.

Soya drinks and other milk alternatives

You can give your child unsweetened calcium-fortified milk alternatives, such as soya, oat or almond drinks, from the age of 1 as part of a healthy balanced diet.

Babies and young children under 5 years old should not be given rice drinks, because of the levels of arsenic in these products.

If your child has an allergy or intolerance to milk, talk to your health visitor or GP. They can advise you about suitable milk alternatives.

Rice drinks

Children under 5 years old should not have rice drinks as a substitute for breast milk, infant formula or cows' milk as they may contain too much arsenic.

Arsenic is found naturally in the environment and can find its way into our food and water.

Rice tends to take up more arsenic than other grains, but this does not mean that your baby cannot eat rice.

In the UK, there are maximum levels of inorganic arsenic allowed in rice and rice products, and even stricter levels are set for foods intended for young children.

Do not worry if your child has already had rice drinks. There's no immediate risk to them, but it's best to switch to a different kind of milk.

Fruit juice and smoothies

Fruit juices, such as orange juice, are a good source of vitamin C. However, they also contain natural sugars and acids, which can cause tooth decay.

Babies under 12 months do not need fruit juice or smoothies. If you choose to give these to your baby, dilute the juices and smoothies (one part juice to 10 parts water) and limit them to mealtimes.

Giving fruit juice and smoothies at mealtimes (rather than between meals) helps reduce the risk of tooth decay.

From 5 years old, you can give your child undiluted fruit juice or smoothies. Stick to no more than 1 glass (about 150 ml) a day, served with meals.

Squashes, flavoured milk, 'fruit' or 'juice' drinks and fizzy drinks

Squashes, flavoured milk, 'fruit' or 'juice' drinks and fizzy drinks are not suitable for young babies. They contain sugar and can cause tooth decay, even when diluted.

For older babies and young children, these drinks can fill your child up so they're not hungry for healthier food. Instead, offer sips of water from a cup with meals.

Fizzy drinks are acidic and can damage tooth enamel so they should not be given to babies and young children.

Diet or reduced-sugar drinks are not recommended for babies and young children.

Even low-calorie drinks and no-added-sugar drinks can encourage children to develop a sweet tooth.

'Baby' and herbal drinks

'Baby' and herbal drinks usually contain sugars and are not recommended.

Hot drinks

Tea and coffee are not suitable for babies or young children. If sugar is added, this can lead to tooth decay.

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Drinks and cups for babies and young children

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Not all drinks are suitable for babies and young children. Here's what to give to your child and when. Breast milk is the only food or drink babies need in the first 6 months of their life. It should continue to be given alongside an increasingly varied diet once you introduce solid foods from around 6 months.

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From the Scottish Book Trust

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Book List: Night-time books for babies and toddlers

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We are a national charity bringing the benefits of reading and writing to everyone in Scotland.

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From the Institute of Health Visiting

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Validate your membership/access to the iHV Champion hub here to receive your password. Not a member? Join here. Upcoming Training and Events Use the arrows to scroll through upcoming events Featured Online Resources The iHV is closely following the advice and reports of the UK Government - and share some of the latest Government guidance here: We always seek to ensure our activities and publications comply with the UNICEF BFI - and do not take sponsorship from formula milk industry.

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From Sleep Scotland

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All humans wake throughout the night - there is no such thing as 'sleeping through the night'

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Compare to the adult sleep pattern

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Supporting mothers who breastfeed: A guide for trainee and qualified doctors 

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Supporting mothers who breastfeed: A guide for trainee and qualified doctors 

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This short guide (less than 100 pages) was written by an NCT Breastfeeding Counsellor as part of a national breastfeeding initiative. It covers most of the learning outcomes in brief and straightforward text and is an up-to-date and reliable source for building your wider knowledge base.

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Dr Suzanne Zeedyk is a Dundee-based expert in baby's brain development and how they make connections. She sometimes refs breastfeeding, but also lots on why babies need closeness. If you ever have the chance to hear this woman speak live - go!

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Dr. Suzanne Zeedyk is a research scientist fascinated by babies’ innate capacity to connect. Suzanne’s core aspiration continues to be strengthening awareness of the decisions we take about caring for our children — because those choices are integrally connected to our vision for the kind of society…

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An option for lesbian, adoptive and surrogate parents. This is one couple's story.

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One lesbian couple explains why having both mothers breast-feed was a positive way to start their parenting journey.
Jane*, 30 and Sarah*, 34, have just finished weaning their daughter Lily*, now 8 months old. As a lesbian couple who wanted to be equal parents from the start they both breast-fed Lily from birth.

When Sarah was pregnant they heard about the concept and popularity of induced lactation with lesbian couples in Sweden. With both mothers breast-feeding, they share the task of meeting the demands of a newborn and can both start bonding with the baby from early on. The couple decided to give it a try. Sarah planned two months off work after the birth, combining paternity leave with annual leave - making it logistically possible.

A woman who has not carried a child can create a milk supply as long as she has working mammary glands. Induced lactation is more common in the USA but is known about in the UK in the context of adoption (breast-feeding can help adopted babies and young children who have attachment issues), re-lactation (when a woman is forced to stop breast-feeding due to illness or other unforeseen interruptions), surrogacy (when a mother who has used a surrogate to carry her child wants to breast-feed) and wet nursing. However now lesbian communities are hearing about it, and some are attempting it.

Jane found The Newman-Goldfarb Protocol online - an American method used to induce lactation. It is possible to induce a milk supply simply using a breast pump but it's not easy to achieve a decent supply without the assistance of drugs. Jane's best chance of success was to go on the combination pill, providing the oestrogen and progesterone needed to build breast tissue. A month later she would come off the pill and go onto domperidone, an anti-emetic (anti-sickness) drug which has a side effect of increasing lactation, then start breast-pumping regularly with an electric breast pump. Timing this to just before Sarah was due to give birth, Jane planned to put their baby Lily onto her breast at three days old (allowing Sarah's primary milk supply to come in first), stimulating milk flow and building her supply. Jane ran the Protocol past her GP who prescribed the pill and verified that it was safe to take domperidone whilst breast-feeding, and she started the process six weeks before their due date. "I was pumping for about 20 minutes, four or five times a day. It seemed like nothing was happening. It was quite dispiriting but then, after a week, a drop of milk appeared!" Slowly her supply increased, and after about a month Jane was producing about 25mls from each breast each time she pumped.

Lily was born in hospital and was put on Sarah's breast at 20 minutes old. Then Sarah needed stitches, which took some time. While this happened Lily was crying so Jane put her to her breast and the baby fed without a problem. On their first night at home Sarah's milk had not come in yet and despite her feeding and feeding Lily was screaming with hunger. Jane fed her and she went to sleep. "We were really happy that Lily got what she needed and that was that," Jane recalls.

"This is a great success story," says Emma Pickett, a lactation consultant in London and breast-feeding counsellor with The Association of Breast-feeding Mothers. "It's hard work to get a full milk supply built up with induced lactation. It takes a lot of physical and emotional commitment." Emma has many lesbian clients and has advised a few couples on induced lactation, but none have managed to follow it through. "One of the fears is that the birth mother's milk supply is threatened in the first six weeks. But there's no reason why you can't protect her milk supply by expressing using a breast pump."

Luckily, once it came in, Sarah's milk supply was strong. Because breast milk production is based on demand the couple carefully maintained both their milk supplies by balancing the feeds. "I'd feed Lily first," says Jane, "then if she was still hungry I'd pass her to the big guns!" As Lily got older Jane's milk supply would not sustain a full feed but was enough to comfort her. This meant Sarah could get good stretches of sleep at night and breaks in the day, so neither parent suffered the extreme sleep deprivation common with having a newborn. "We feel that our start to parenthood was easier than it might have been," says Sarah.

The couple found responses from other people were varied. Their midwives had never come across the concept of induced lactation before and avoided engaging with it. But midwives knowledge and expectations vary considerably and many others would have been open to it. "I would be doing a lot of signposting, says Judy*, a midwife in the southwest who has practised for 30 years, and has come across induced lactation before. "To me it seems like a really obvious thing to do - share the parenting. So many men say, 'I wish I could breast-feed the baby. All this burden is on her, I want to take some of it away.'"

At first Jane found it tricky explaining to her boss that she needed to pop away from her desk to pump in the lead up to the birth. "Once he understood he was supportive," she recalls, "some friends and family admitted they felt uncomfortable about us both breast-feeding at first but didn't say so until they were over it."

"We've had loads of supportive and positive reactions from other parents," says Jane. "The main attitude has been 'I wish my husband could breast-feed too, I'm so jealous!'"

The couple plan to have another child, and Jane will carry this time. "I'd really like Sarah to breast-feed too. I did half the nights - that one is going to come back! I'd much rather share that role and have the help."

Jane and Sarah are now both equally bonded to Lily. "She doesn't express a preference about who she goes to for comfort," says Sarah. "This was one of several strategies that we put in place in order to try and make sure Lily has two primary parents and it worked well. It's been great for me and lovely seeing Jane and Lily also bond from the start."

All breast-feeding support services will be able to advise on induced lactation.

National Childbirth Trust NCT: www.nct.org.uk

Association of Breastfeeding Mothers: www.abm.me.uk

This article was printed in issue 6 of We Are Family magazine, Summer 2014. Details may have changed - please do not rely on this information solely when making decisions - do your own research, make your own checks and get legal or health advice as appropriate.
* names have been changed to protect identities

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One lesbian couple explains why having both mothers breast-feed was a positive way to start their parenting journey. Jane*, 30 and Sarah*, 34, have just finished weaning their daughter Lily*, now 8 months old. As a lesbian couple who wanted to be equal parents from the start they both breast-fed Lily from birth.

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A padlet by a colleague of mine with a range of articles on breastfeeding related topics

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A padlet by a colleague of mine with  created just in case you or someone else needs to know the science and all the rest of it. A selection of serious and not so serious bits of information and videos

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An exhaustive and well-respected breastfeeding info website, although the sponsorship and some US-specific info cake make it less appropriate for sharing.

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Active Listening - an article from Perspective - NCT's journal 

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Active Listening - an article from Perspective - NCT's journal 

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A Padlet for NCT Practitioners. Password   NCTP-ALS

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Having meaningful conversations with mothers

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Having meaningful conversations with mothers

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UNICEF document laying out important communication points and techniques.

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Feeling good about how we feed our babies

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Feeling good about how we feed our babies

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A website exploring pressures, barriers and feelings about feeding

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Many women suffer from shame, guilt and embarrassment surrounding decisions about how they feed their babies.

Sometimes we feel like we have to our decisions to others. We feel like we have to show that we made the right decision . When we do this, other people can feel like we are saying they made the wrong decision .

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Do you feel that other people have strong opinions about how you feed your baby?

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Many women suffer from shame, guilt and embarrassment surrounding decisions about how they feed their babies. Sometimes we feel like we have to our decisions to others. We feel like we have to show that we made the right decision . When we do this, other people can feel like we are saying they made the wrong decision .

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Differences between empathy and sympathy

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Differences between empathy and sympathy

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Seven infographics

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Motivation is life changing. Your life is changing every day. What happens today, you wouldn't have imagined a few months ago. What would tomorrow bring? You might only find out tomorrow.

Change is either changing for the better or it is slowly changing for the worse.

"Change happens in an instant. It happens the moment you decide to change."

Motivation is derived from the verb "motivate," which means "move." It is the burning desire that compels you to take action. It is so deeply intertwined with what you believe to be true and right in life that it moves you from a simple desire to a moment of decision. Have you ever watched a working dog? The only motivation is YOU.

You are going to be different tomorrow. Stop feeling stuck. When you decide to be different, you will find motivation seeping into thoughts and into your actions. Motivation causes you to take action, it becomes an inner drive fueling you forward.

We all believe something. When was the last time you asked yourself, "What do I believe? What role does faith play in my life? Why was I placed on this earth? What is my purpose in life?"

Remembering that motivation is a verb meaning to "move" or take "action." Family, friends, co-workers and the people all around us are key motivators for how we act. Surround yourself with great people and you will surround yourself with great motivation.

So, how to find life motivation? These 21 motivational words will inspire you:

1. Goals

It should be no surprise that goals motivate us and inspire us. The most powerful goals are self-directed goals. Self-directed internal goals. They include understanding your priorities and purpose in life, knowing what you believe to be most important and using those goals as a daily guide for how you will choose to live your life.

2. New

Choosing to learn something new every day will give you a reason to grown and change. This could be something as simple as driving to work via a different route or signing up for guitar lessons.

3. Challenge

Challenges are frequently seen as some sort of contest like the final four during March Madness. Challenges draw out the best in us. A simple challenge might be to decide to go to bed fifteen minutes earlier for thirty days to see if it improved your daily productivity.

4. Truth

Truth does not waver. Something either is true or it is not. Truth provides a firm foundation to stand on. Truth strengthens, encourages, and will guide you correctly.

5. Determination

You've met them. Those rare individuals who are determined to continue regardless of how difficult the circumstances. Determination literally means you are willing to put a "stake" in the ground. It is not a casual choice. There are very few things humans will determine to mark as permanent placeholders for their beliefs.

6. Laughter

Laughter heals the soul. Why is it that children laugh hundreds of times a day and adults laugh only _____ times. Laughter occurs when something unexpected happens that causes your brain to emit a signal to your lungs to expel short burst of air causing you to make audible noises that are a signal of joy all across the world.

7. Perseverance

Perseverance reminds me of a road or a bridge - a specific course or path we all walk down. When you feel hopeless and lost, that is when perseverance counts the most. Perseverance is consciously choosing to stay on your path even in the midst of incredible difficulties.

8. Freedom

Having a sense of control or autonomy over your time and your actions is a powerful motivator. Freedom liberates you to dream and imagine and create. Freedom of stress is one of the most sought after psychological goals.

9. Tenacity

Tenacity is a word originating with the meaning of adhesiveness. There are frequent times you will find you need to "stick together". Tenacity never gives up. It never lets go. Willpower lives in the core of your being. Willpower moves you, motivates you and causes you to take action for good or for bad. This inner drive is the control center for many of the decisions you will choose to make moment to moment.

10. Faithful

Faithfulness is a rare quality in today's world. It is choosing to remain reliable, trusted and constant. It carries a sense of attachment and devotion to people, causes, organizations and beliefs. Faithfulness is a foundational motivator.

11. Endurance

This word literally means to have the ability to endure suffering over long periods of time. Grit is stone broken down, but it is still stone. It speaks to the indomitable toughness it can take to push through life's most difficult trials. Endurance when accepted can build character, patience, wisdom, empathy and compassion.

12. Novel

Novelty is also one of the most unexpected motivators. When you experience something for the very first time or you see something you have never seen before you may find yourself swept away with emotion. The birth of a child. An unexpected gift. A surprise ending to a difficult moment in life.

13. Tragedy

Life is full of heartache and indescribable pain. War, illness, death, divorce, financial problems, and injustice. Tragedy regardless of the pain is full of opportunities to learn and grow and find renewal and hope. Tragedy shows you are never alone.

14. Learning

Any gap in understanding will motivate you to want to fill that knowledge gap. If you want to know more about leadership - read books by great leaders. To learn how to train a dog - hire a dog trainer and take lessons. The incremental acquirement of new knowledge becomes a self-motivating driver.

15. Anticipation

The act of looking forward to something important happening in your life. When you are just given a glimpse of a future success or opportunity the anticipation releases an incredibly powerful chemical called dopamine into your system. Everything you have ever wanted in your life you were first motivated to strive for attaining it because you anticipated the feeling of importance it would mean to you. Dopamine is the brain chemical of anticipation.

16. Courage

Lt. Col. (retired) Dave Grossman shared a single quote of where the bravery of being an Army Ranger came from for him. He said, "Courage is just being willing to take one more step." Sometimes the only motivation you need is to take just one more step.

17. Hope

When used as a noun hope only a feeling, but when used as a verb hope becomes the focal point of your motivation. Sometimes in life all you have is hope. And, in those moments hope will be more than enough.

18. Time

Time is not merely a framework for how the minutes, hours and days pass by - each day is like having a blank canvas sitting in an art room filled with unlimited options. Improving your motivation through improving your time management will require you to reduce the number of choices you have to let into your life. You will find simplicity and peace in narrowing your focus and increasing your energy and attention only on accomplishing the tasks that bring motivation and meaning in your life.

19. Love

The foundation of life is love.. There is no way to create a life of meaning without love. There is no motivation, no reason to move or change or engage in life without love. The foundation of motivation is love.

And, Three That Might Surprise You

20. Brain

The prefrontal cortex is the thinking part of the brain. This is where life happens! In this space just behind your forehead, ideas are created, thoughts are pondered, imagination grows (or dies), judgments are made. This part of the brain is highly specialized in humans; this is where you define meaning, plan for the future, and imagine. Your values, priorities, purpose, goals, drive, learning, love, and hope all live here. Motivation is a decision.

21. Attention

You experience the depths of motivation when your attention focused so intently on completing a task or a project or a hobby that challenges you to such a point that time stands still. When you are in that moment - swept away from stress and worry - concentrating with full attention - you don't need motivation - you are experiencing motivitation. At that moment you are motivated. You are in the process of taking action. And, in those amazing moments you realize the life-changing power of motivation. You understand the difference between existing and thriving. And, in that moment - life oozes out of you. And, motivation is contagious.

22. Time Management

Your personal time management skills affect the levels of motivation you experience in life. Dr. JoAnn Dahlkoetter is a sports psychology expert and coach to Olympic athletes, as well as being a world-class athlete in her own right. She says, "It starts with a dream; motivation comes from within. It has to be an inner desire, an inner fire, a willingness to achieve something you are passionate about."

Far too many people only focus on the hard parts of life that motivation can guide us through. By improving your time management you can create daily blocks of time to focus your time and attention on the part's of life that motivate you.
Action Steps:

Assess your current schedule

Determine which activities motivate you and which activities drain you of energy

Take time to think about what you really want out of life (preferably away from work or home)

Clarify what you want in life by writing down personal or professional goals

Create a plan of action - prioritize or sequence the individual action steps you need to take to accomplish your new goals

Use a pen and paper to schedule when you will take these actions.

Then take action.

Remember "motivation" comes from the word "motive" which means to "move" - or to take "action."

You can find more time management techniques here: 10 Practical Ways to Improve Time Management Skills

More Motivational Tips

Featured photo credit: Lethicia Matos via unsplash.com

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7 Intricate Differences Between Empathy And Sympathy

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Motivation is life changing. Your life is changing every day. What happens today, you wouldn't have imagined a few months ago. What would tomorrow bring? You might only find out tomorrow. Change is either changing for the better or it is slowly changing for the worse. "Change happens in an instant.

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Empathy vs. Sympathy: How to Practice Empathy and Fuel Connection

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Empathy vs. Sympathy: How to Practice Empathy and Fuel Connection

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“I’m a fixer. I hear a problem and I want to jump to a solution. I’ve been working on trying to linger in the listen mode. It feels really awkward sometimes, but the value – oddly enough – is greater connection with the other person. I get to just be and connect with the other person in a new and different way. It’s so interesting and also takes the pressure off of me to come up with a solution. I’ve been “practicing” this for a couple years and it’s still hard! Work in progress.”

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"Rarely does an empathic response begin with at least," says Brown. Check out this Facebook interaction I came across the other day. Notice how a comment like this drives disconnection. The person says, "I'm sorry," which is a good start, but then goes into comparing her suffering to her friend's suffering. And no one benefits, or gets closer, as a result.

In this context, this response seems ludicrous, right? And it is. But it's also a really common way to respond to other people's problems. It's irresistible to try and put a silver lining on it, with or . I know I am guilty of it. My excuse is that I am "helping them" see the bright side. And while that certainly has a place, when people are being vulnerable about a problem, it's normally way more effective to practice true empathy.

Could she bring up her own experience and be more empathetic? Of course! Here's what that could look like:

Comment: "I am so sorry. I got a big bill for a kidney stone a few years ago and I can relate to that terrible feeling. I am thinking of you!"

Just a small difference and this comment now fuels connection. It puts them on the same team, with shared feelings. Instead of trying to fix it by offering a different perspective, the fix is to assure the other person that those feelings are valid and that they are not alone. That is what differentiates empathy vs. sympathy.

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Empathy vs. Sympathy: Understand the Crucial Differences and Why Empathy Drives Connection * Six Seconds

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"Rarely does an empathic response begin with at least," says Brown. Check out this Facebook interaction I came across the other day. Notice how a comment like this drives disconnection. The person says, "I'm sorry," which is a good start, but then goes into comparing her suffering to her friend's suffering.

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A cartoon by Lunarbaboon

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A short, memorable animation

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Not specifically about Peer Support, but a piece of research based on the experiences of 700 UK which came up with a solution which..... sounds very much like what PS can offer.....

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Breastfeeding and Health Care Experiences are a group of 440 mothers, all of whom breastfeed their children; approximately half of the group are health care professionals (HCPs) or breastfeeding peer supporters and all are citizen scientists with Parenting Science Gang. The group worked together to design, run and analyse research on breastfeeding and health care experiences.

This group is interested in the vital role that health professionals play in supporting mothers to breastfeed successfully.

Research on Breastfeeding and Healthcare Experiences:

The group collaborated with Dr Gavin Brookes at Lancaster University, creating a survey asking mothers who wanted to breastfeed, to share their experiences of healthcare in the UK. Over 700 mothers responded. The group are still analysing the results, using a technique called Corpus Linguistics; we are delighted to share some preliminary findings with you.

The group members have created a card summarising the results, with busy HCPs in mind (see image below). On the back is a list of useful evidence-based resources for HCPs to access up-to-date information on breastfeeding and medication.

Preliminary Results:
Issues

the early days are crucial.

"throw away" comments can make or break breastfeeding for many mums.

lack of time for staff a major factor.

tongue tie seems to be commonly missed or down-played.

problematic latches and the effective transfer of milk were a significant issue but often the focus was on treating weight loss, thrush, mastitis or nipple damage rather than the underlying problem.

What worked / what mothers wanted

Listening to the mother is the most important thing.

The success stories normally happened when one person listened to the mother about the whole situation and worked through everything step by step.

HCPs need to be ready to listen to what mothers want/need before offering any advice.

HCPs working with mothers shouldn't be afraid to admit they don't always know the answer and be willing to look in to it

Download a copy of our card, based on our preliminary results of analysis of our survey of over 700 mothers' stories of breastfeeding and healthcare in the UK.

More on breastfeeding and healthcare

Read our blogs on breastfeeding and healthcare to find out more about the subject and our research process.

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Breastfeeding and Health Care Experiences are a group of 440 mothers, all of whom breastfeed their children; approximately half of the group are health care professionals (HCPs) or breastfeeding peer supporters and all are citizen scientists with Parenting Science Gang. The group worked together to design, run and analyse research on breastfeeding and health care...

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A simple knitted breast pattern to produce a useful prop for peer support work.

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I'm not a 'Nipple Nazi', I'm a breastfeeding counsellor

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I'm not a 'Nipple Nazi', I'm a breastfeeding counsellor

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A good reflection of the work and motivation of breastfeeding supporters.

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By Emma Swales, an NCT Breastfeeding Peer Supporter
I never knew how important breastfeeding would become. After having my first daughter, I was astounded that feeding my baby could be so challenging. The first few months were heart breaking.

Not many healthcare professionals understood why I was so upset about topping up, or the sense of failure I felt doing it. I sought support from charites including NCT, which supplied me with correct info as well as a listening ear.

I became interested in supporting others like me in those early months and enrolled on an NCT Breastfeeding Peer Supporter training course. I learned why breastfeeding is so challenging. How parents are given conflicting advice. How myths make breastfeeding seem unachievable. And the many other ways a baby can be fed without formula. The more I learned, the more my passion grew.

I breastfed my first daughter for over two years, until I was pregnant again. As before, I ran into trouble. But this time I got NCT help a few days in. A volunteer sat with me for hours, helping me achieve a pain free feed. Even though it was a role I did myself, that one-to-one support was so valuable. I could not have achieved my aspiration of extended feeding without NCT and I am so proud to be part of their team of volunteers, helping those who want to breastfeed achieve their target however they decide to feed their babies.

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By Emma Swales, an NCT Breastfeeding Peer Supporter I never knew how important breastfeeding would become. After having my first daughter, I was astounded that feeding my baby could be so challenging. The first few months were heart breaking. Not many healthcare professionals understood why I was so upset about topping up, or the sense of failure I felt doing it.

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Article on the 'Baby Cafe' style of Peer Support Groups

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Article on the 'Baby Cafe' style of Peer Support Groups

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But many relevant points about PS in general

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15k Accesses

39 Citations

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Metrics

Abstract

Background

Whilst 81 % of UK women initiate breastfeeding, there is a steep decline in breastfeeding rates during the early postnatal period, with just 55 % of women breastfeeding at six weeks. 80 % of these women stopped breastfeeding sooner than they intended, with women citing feeding difficulties and lack of adequate support. As part of efforts to increase breastfeeding continuation rates, many public and voluntary organisations offer additional breastfeeding support services, which provide practical support in the early postnatal period and beyond. This paper focuses on the qualitative experiences of UK users of Baby Café services to examine their experiences of breastfeeding and breastfeeding support.

Methods

The study was based upon in-depth interviews and focus groups with users of eight Baby Café breastfeeding support groups across the UK. Thirty-six interviews and five focus groups were conducted with a total of fifty-one mothers using the service. Interviews and group discussions were analysed using N Vivo software to draw out key themes and discussions.

Results

Whilst each mother's infant feeding journey is unique, reflecting her own personal circumstances and experiences, several themes emerged strongly from the data. Many women felt that they had been given unrealistic expectations of breastfeeding by professionals keen to promote the benefits. This left them feeling unprepared when they encountered pain, problems and relentlessness of early infant feeding, leading to feelings of guilt and inadequacy over their feeding decisions. Mothers valued the combination of expert professional and peer support provided by Baby Café services and emphasised the importance of social support from other mothers in enabling them to continue feeding for as long as they wished.

Conclusions

The research emphasises the need for realistic rather than idealistic antenatal preparation and the importance of timely and parent-centred breastfeeding support, particularly in the immediate postnatal weeks. The findings suggest that effective social support, combined with reassurance and guidance from skilled practitioners, can help women to overcome difficulties and find confidence in their own abilities to achieve their feeding goals. However, further work is needed to make sure such services are readily accessible to women from all sectors of the community.

Peer Review reports

Background

Exclusive breastfeeding until six months of age is recommended by the World Health Organisation [ 1] as providing short and long term health benefits for both mothers and children. Whilst UK rates of breastfeeding initiation have risen from 62 % in 1990 to 81 % in 2010 [ 2], there remains a steep decline in breastfeeding rates during the early weeks, with 55 % of women still breastfeeding at six weeks and just 34 % at six months. The UK lags behind other western countries such as in Scandinavia, where 80 % of Norwegian mothers [ 3] and 68 % of Swedish mothers [ 4] are still breastfeeding at six months. Rates of exclusive breastfeeding are even lower, with just 23 % of UK women exclusively breastfeeding at six weeks and only 1 % by six months [ 2]. Much of this drop-off is unplanned, with 80 % of women who stopped feeding during the first six weeks saying they would have liked to continue for longer [ 2].

Problems such as inability to latch, sore or painful nipples and insufficient milk supply are frequently cited reasons for early breastfeeding cessation [ 2]. Women are often unprepared for the physical challenges of early breastfeeding [ 5] and feel that they are left to 'learn the hard way' due to lack of time, expertise or practical assistance from health professionals [ 6]. However, the broader causes are more complex, with breastfeeding prevalence linked to demographic and socio-cultural factors, such as mother's age, ethnicity, education, profession, level of deprivation and personal or familial breastfeeding experience [ 2, 7]. A long history of UK formula feeding and negative attitudes towards breastfeeding in public means that many women may not have had first-hand exposure to breastfeeding and may lack practical experience and support from relatives or friends [ 8]. Embodied experience of seeing friends or family successfully breastfeeding, or having breastfed a previous child, are important factors in motivating women to initiate and continue breastfeeding [ 8, 9]. Conversely women from communities where formula feeding is seen as the norm are more likely to view breastfeeding as difficult and potentially embarrassing [ 10, 11], and see the breast as a primarily sexual object [ 9]. For younger mothers, breastfeeding is often not widely accepted within their social circles and formula is seen as offering an 'easier' solution that enables them to share the burden of feeding with other family members [ 11, 12].

Health promotion messages focusing upon the 'breast is best' message are often perceived as prescriptive and unhelpful in the lived reality of everyday relationships, where competing goals of immediate family well-being are often valued over the long term health benefits of exclusive breastfeeding [ 13]. Mothers frequently experience conflicting advice and pressures from health professionals, partners, family and friends to conform to social norms and expectations of 'good motherhood' [ 14] whether this be supplementation with formula where the baby is perceived as not gaining adequate weight, or to continue breastfeeding despite personal discomfort. Idealistic representations of breastfeeding during the antenatal period may mean that women do not prepare for the need for postnatal support [ 15]. Unrealistic promotion of breastfeeding as 'natural' and unproblematic [ 15] can lead to feelings of failure if women do not experience the breastfeeding relationship as harmonious or pleasurable [ 16, 17]. Failure to continue breastfeeding can lead to 'shattered expectations' [ 18] and feelings of guilt and failure, in a society where breastfeeding is highly promoted in the public health agenda [ 13, 14]. Mothers perceive moral judgement on their feeding methods regardless of how they feed their babies, for example by 'risking' the health of their babies by formula feeding [ 12, 19] or exceeding limits of what some consider to be 'acceptable' breastfeeding behaviour, such as breastfeeding in public or for extended periods of time [ 20].

Whilst the health benefits of breastfeeding are now widely acknowledged, the lived reality of women's everyday experiences means that idealistic feeding goals may be impractical [ 21]. Recent approaches to infant feeding support suggest the need to move away from ideas of one-off 'choices' to breastfeed to explore women's experiences and decisions throughout their feeding journeys [ 15, 21]. A shift in health policy has been recommended away from breastfeeding promotion, and towards providing practical and ongoing 'mother-centred' feeding support in the early postnatal period and beyond [ 15]. The need to focus upon relationship building and practical breastfeeding support is now widely recognised in both research and policy [ 22, 23].

Various types of 'additional' breastfeeding support are currently available in the UK, including one-to-one support from midwives, health visitors, qualified breastfeeding counsellors or lay peer supporters [ 24, 25], breastfeeding support groups [ 26], and telephone helplines [ 27]. Evidence for the effectiveness of these interventions is mixed, with recent UK trials showing limited positive results [ 28]. However, evidence suggests that women often value these services and they provide pyscho-social benefits for the mothers, peer supporters and professionals involved [ 25]. A recent Cochrane review of 52 trials of support for healthy breastfeeding mothers [ 29] found an overall effect of extra breastfeeding support (including all forms, lay and professional) in increasing the duration of both exclusive and any breastfeeding. Face-to-face support was found to be more effective than telephone support, and proactive support was found to be more effective than interventions where the mothers were required to initiate contact themselves [ 29]. However a qualitative study of women's experiences of group based or individual peer support found that women preferred a group-based approach which normalised breastfeeding, and provided flexibility and a greater sense of empowerment and self-control [ 30]. One-to-one peer coaching was perceived as more intrusive and a greater risk to self-confidence, and lacked the net social and interactional gains of a group situation [ 30]. A systematic review of evidence from randomised control trials concluded that peer support interventions did not have a significant effect on increasing breastfeeding rates in high income countries, particularly the UK [ 24].

Timing of support plays a key role, with evidence from a 2006 maternity survey [ 31] suggesting that additional support in the first ten days after birth has a significant effect on breastfeeding rates. The sharpest drop-off in breastfeeding occurs during the first two days, so support during this initial period is crucial [ 32]. Intensity of support is also important with evidence suggesting that interventions involving several contacts between mother and supporter are more effective than one-off episodes of care [ 24, 29]. Between four to eight contacts seems to provide an optimum effect [ 29], allowing the support to intervene at key points during the infant feeding journey [ 21]. Multi-channel interventions that are tailored to local contexts and populations, and involve both antenatal and postnatal contacts and continuity of care, are more likely to be effective [ 25, 33]. However the success of these interventions is dependent on local conditions, including health service resources, motivation of staff and integration with mainstream services [ 26]. Engagement of mothers with support services can also be problematic. Older, more highly educated mothers are more likely to seek help with breastfeeding difficulties [ 34], whilst pro-active approaches may be perceived as pressurising and impact on women's sense of self-efficacy [ 15, 30].

This article focuses on the qualitative experiences of UK users of the Baby Café network of community based breastfeeding support services. These services offer a combination of expert one-to-one support from skilled professionals, combined with group-based social support from volunteers, peer supporters and other breastfeeding mothers. The paper examines women's experiences of breastfeeding in contemporary Britain, support from health professionals, friends and family and the experience of accessing and using this particular model of breastfeeding support. The study identifies which elements of this support are seen to be effective and why, and considers how such services can be integrated with other forms of support to influence breastfeeding outcomes.

Methods

Settings and participants

The study was based upon in-depth interviews and focus groups with users of eight breastfeeding support groups, which were part of a UK network of 'Baby Café' services. The social model of support on which the service is based aims to combine mother-to-mother support in a welcoming, but protected, café style environment, with direct access to expert practical support for breastfeeding and referral pathways for additional clinical care where required. Services are delivered to a specific set of quality standards and group facilitators are either health professionals (e.g. midwives or health visitors) with specific experience or training in supporting breastfeeding women, or Association of Breastfeeding Mothers / Breastfeeding Network / La Leche League / NCT qualified breastfeeding counsellors, many of whom are also International Board Certified Lactation Consultants (IBCLC). Services are located in accessible community settings (e.g. children's centres, health centres or community halls) and are available free of charge to all mothers needing support with infant feeding.

The study was designed and conducted in accordance with the Social Research Association's ethical guidelines and research procedures. The study protocol was approved by the NCT ethical review committee prior to commencing the research, including review by two external academic advisors. An Evaluation Steering Group consisting of internal and external stakeholders, including support group facilitators, oversaw the conduct of the research, meeting four times throughout the duration of the project to advise on design, data collection and analysis.

The eight sites were selected to represent a variety of locations, settings, types of facilitator (health professional/breastfeeding counsellor) and length of time they had been running. Two sites were located in inner London, two in outer London, one in rural South East England, and one in a city and two in towns in Northern England. Support group facilitators were contacted in advance by the lead researcher (RF) to ask if they wished to take part in the project and other local staff informed of the research. In total nine sites were approached, with one declining to take part as the facilitator felt that their cramped location in a busy health centre would make it unsuitable for conducting potentially sensitive interviews.

Each site was visited separately on two occasions by the lead researcher (RF) to conduct individual interviews and focus groups. Participation was voluntary and respondents were given information sheets regarding the research and required to sign consent forms, understanding that all information would remain confidential and anonymous and they were free to withdraw from the research at any time. Thirty-six interviews and five focus groups (with between three and seven participants) were conducted with a total of fifty-one mothers using the service. Interviews and focus groups were chosen as suitable methods to elicit women's feelings, behaviours and experiences. Individual interviews allowed for more in-depth exploration of sensitive issues, whilst focus groups were able to generate discussion of key issues and emerging themes.

The study was based upon convenience sampling and thus any mother present at the groups on the day of the visits was eligible to take part. The researcher used her judgement in not approaching women who were very obviously upset or struggling with acute breastfeeding difficulties, however several of these women did approach the researcher later in the session to speak about their experiences. In total sixty-three mothers were approached with fifty-one agreeing to participate. Mothers were given a choice of taking part in individual or group discussions (with seven taking part in both). The sample size was determined by availability of participants, with some Baby Cafés attracting a larger number of mothers than others. However at the end of the data collection period it was felt theoretical saturation had been reached and no further visits were required.

Data collection

Interviews were conducted by RF during the support group sessions (n = 41) or by telephone at a later date (n = 6). Five focus group discussions were facilitated by RF, either in a separate room during the Baby Café session (n = 3) or in the main room after the session had ended (n = 2). Focus groups were not possible at three locations due to lack of time or space. Interviews were conducted in a busy support group environment and therefore tended to be relatively brief, lasting between 6 and 52 min (mean = 27 min). Interviews were sometimes disrupted or terminated prematurely by staff arriving to provide episodes of support to the women, or by the baby's requirements. Focus groups lasted between 35 and 78 min (mean = 52 min) and were less prone to disruption.

Interviews were semi-structured, allowing mothers to lead the discussion and spontaneously raise topics of importance to them. The interview schedule covered a broad range of topics relating to mothers' experiences of breastfeeding and breastfeeding support, including their expectations versus realities, positives and negatives of breastfeeding, problems they had encountered, support they had received from health professionals, friends and family, experiences of seeking 'additional' breastfeeding support and using Baby Café.

Data analysis

All interviews and focus groups were digitally recorded and transcribed verbatim, then analysed using NVivo software [ 35] to draw out key themes and discussions. Transcripts were coded initially by RF using an inductive approach to draw out key themes emerging from the primary data. Transcripts were then re-read in more detail by members of the research team (RF, SM & MN) to refine these themes and coded further to produce higher level concepts emerging from the research. These codes were then checked by a second independent researcher VB (employed by NCT but not involved in the research project) and the interpretation of data discussed during face to face meetings and agreed between members of the research team (RF, SM & MN). Codes were cross-referenced to draw out common or contrasting examples and illustrative quotes to support the wider theories [ 36]. This type of analysis produces a rich qualitative description, detailing individual experiences and adding depth to inconclusive quantitative evidence on the effectiveness of breastfeeding support interventions.

Results

Whilst each mother's infant feeding journey is unique, reflecting her own personal circumstances and experiences, several themes emerged strongly from the data. Particularly for first time mothers, antenatal preparation was often described as setting unrealistic expectations of breastfeeding, leading to feelings of failure where this did not work out as expected. Both primiparous and multiparous women shared feelings of pressure, guilt and blame regarding their feeding experiences, and reported conflicting advice and varying levels of support from health professionals, friends and family. All women interviewed for the study were currently receiving additional breastfeeding support via Baby Café services and valued both the expert and social support provided, including the use of other mothers and peer supporters as 'breastfeeding role models'.

In this section we firstly present the site and participant characteristics, before discussing these themes in more detail within the context of wider literature on the subject. The results are presented in two main sections: experiences of breastfeeding and experiences of additional breastfeeding support.

Site characteristics

The sites selected for the research aimed to cover a variety of locations, types of facilitator and length of time they had been established. All groups ran weekly (excluding public holidays) and were staffed by qualified facilitators, trained peer supporters and volunteers. Further characteristics of each Baby Café are shown in Table 1 below.

Table 1 Characteristics of each Baby Café site

Participant characteristics

The study included both 33 primiparous and 18 multiparous women aged between 23 and 44 (mean age = 35). Mothers tended to be highly educated and in employment and all but one were living with a partner. Ten participants were born outside of the UK. Unsurprisingly the support groups located in inner London attracted the widest diversity of ethnicities and nationalities, reflecting the characteristics of the local population. Participant characteristics are shown in Table 2 below.

Table 2 Participant characteristics

Experiences of breastfeeding

In this section findings in relation to experiences of breastfeeding are presented under four sub themes: antenatal education, realistic experiences, postnatal care and support from friends and family

Antenatal education: Unrealistic expectations

In line with findings of previous studies, many of the women interviewed felt that they had been given unrealistic expectations of breastfeeding by professionals keen to promote its health benefits [ 6, 15, 18] and expressed anger about the lack of preparation they had been given for potential difficulties.

In the beginning I expected it to be easy, because when you go to the antenatal classes and you watch these videos and you think 'oh yeah it comes naturally', it looks so easy, but then when comes to the real baby, it's not like that, you have to work at it (Mother, age 29, first baby)

It's a complete shock, you know, and your emotions are all over the place. No-one tells you. They don't tell you that breastfeeding can be so difficult and you don't realise... Maybe no-one can tell you, maybe it's just impossible to ever really prepare you for what it's going to be like (Mother, age 38, first baby)

Dominant discourses that portray breastfeeding as 'easy' and 'instinctive' left mothers with feelings of guilt and inadequacy at their inability to master a supposedly 'natural' skill.

I just remember being on the postnatal ward and feeling like everyone around me had their babies firmly attached to their boob except me, I just had her screaming and I was thinking 'Oh God, it's all gone wrong, what am doing? Is it just me?' I mean I'm an intelligent person. Millions of women feed their babies this way. Why am I finding it so difficult? (Mother, age 31, first baby)

Lack of control over the situation contrasted with women's views of themselves and undermined their sense of self-efficacy.

I don't know if it's the era that we live in now that women, maybe because we're having babies older and we're having our careers before our children, we have different expectations of how things are supposed to work and we're used to a life where we're totally in control and now all of a sudden we're not (Mother, age 36, first baby).

Such experiences underline the need for realistic antenatal education [ 15, 21] to adequately prepare mothers for the realities of breastfeeding and strategies for coping with the demands of a new baby.

If I knew what was to come or what I could expect to happen then I wouldn't have freaked out so much. Because even with all the information that I had I was very, very unprepared, I wasn't prepared for the pain, or the bleeding nipples, or the cluster feeding. I didn't know that babies could feed for six hours! I just didn't know it was possible (Mother, age 28, first baby)

Realistic experiences: Pressure, guilt and blame

Women felt that there was still a great deal of pressure upon mothers to breastfeed, but that this was not always backed up by adequate practical support. This led to guilt about making the 'correct' feeding decisions and how to do the 'best' for their baby [ 37].

I think there is a great deal of pressure, you know 'breast is best' and all that and I couldn't help but feel that I was sort of, I wasn't doing my job properly, if I didn't at least give it my absolute best shot (Mother, age 34, first baby).

I think it took four or five weeks for her to regain her birth weight....and you kind of feel really guilty, don't you? Like maybe I'm making the wrong choice here - maybe I'm being selfish by not giving her a bottle (Mother, age 30, second baby).

Mothers felt they had to justify their decisions in order to maintain a sense of their own moral position as a 'good mother' [ 14, 38].

You get the feeling that mixed feeding is kind of looked down upon, but I just felt I wasn't producing enough milk, he was a big baby and he was always hungry, I felt it was the right thing to do (Mother, age 37, first baby).

Mothers may also frame their feeding decisions within a context of 'biographical repair' [ 38] perhaps making up for previous 'failed' feeding experiences.

My first baby I was feeding for one month. I didn't have the support at the time. I was twenty and far away from my family. I couldn't understand the pain. Now I am older and more mature. I know that the baby is more important than the pain, somehow it's easier (Mother, age 25, second baby)

I know it sounds silly but I've got a great sense of pride and achievement because I didn't manage so well with [Baby 1] and I've managed a lot better with [Baby 2]. I feel like I'm doing better for my baby because I know it's the best thing for him. I know that I'm providing that. When I stopped early last time I felt like I'd let him down (Mother, age 24, second baby)

Postnatal care: Conflicting advice and undermining of confidence

Many women expressed dissatisfaction with routine postnatal care, reporting that advice was often inadequate, contradictory and undermined their confidence in their feeding abilities [ 6, 39, 40]. In particular the notion that 'breastfeeding shouldn't hurt' was found to be unhelpful where women were experiencing problems with sore and cracked nipples.

In the hospital they kept repeating that it shouldn't be painful, if you are doing it right it shouldn't hurt. And that wasn't particularly helpful, because it was painful for me (Mother, age 32, first baby)

'Disconnected encounters' [ 41] with health professionals could leave women disheartened and afraid to ask for further support.

They said "Oh if you've got any issues, just call us", so I called somebody and the lady that came, she wasn't a midwife, she was a nursery nurse or something, this older lady and she just kind of snapped at me "Well of course of hurts if you've never done it before!" (Mother, age 28, first baby)

Staff could give very contradictory messages, promoting breastfeeding on the one hand, but also quick to resort to alternative feeding methods.

I think they're understaffed in hospitals, they just don't have the time to sit with you, and it takes a lot longer to spend the time to get you breastfeeding, rather than handing you a bottle...(Mother, age 33, first baby)

The midwives, obviously, are very focused on the babies putting on weight and not having to go back into hospital, so they just push you to top them up with formula (Mother, age 24, second baby)

Mothers felt that they had to be very determined to achieve their feeding goals in the face of pain and limited support, often relying on their own embodied knowledge that something 'wasn't right'.

They weren't doing home visits on Christmas day so I just felt totally abandoned. I took her back into hospital on Boxing Day and insisted that they helped me. I thought things weren't right with her... she wasn't feeding and kept getting really upset. I kept on calling them and asking them to come and help me, but you have to just be so determined to do it. It's a real struggle (Mother, age 31, first baby).

Such experiences emphasise the need for adequate resources and training of healthcare staff to support breastfeeding women and the importance of mother-centred and personal interaction skills [ 15]. Women particularly valued professionals who were supportive, non-judgemental and enabled them to make their own decisions and build upon existing support from friends and family [ 13, 41].

The midwives in hospital were really good because I just felt like I wasn't alone and they kind of supported my husband to support me, he helped me once we got home with positioning and, you know, he would say, oh you remember about this position, why don't you try that sort of thing (Mother, age 33, first baby)

Women also valued the opportunity to build personal relationships, emphasising the need for continuity of care in the antenatal and postnatal periods [ 25, 33].

I think my midwife has been very supportive and very helpful, she was the midwife that happened to be doing the antenatal classes that we went to in the NHS so that was good because we'd already developed a relationship. She was also a very practical midwife, so it was actually the sort of person I needed to say it quite bluntly on occasions (Mother, age 31, first baby)

Support from friends and family

It is well recognised that mother's immediate social and cultural circles have a strong influence on her decisions to initiate and continue breastfeeding [ 8, 9, 21]. Participants in the study came from a variety of cultural and social backgrounds with different histories of infant feeding practices. Mothers whose immediate family and friends had not breastfed themselves, or had bad experiences of breastfeeding, were sometimes unsupportive of their decision, or attempted to undermine their efforts.

When I first tried to breastfeed my mother was quite shocked because she didn't feed, she doesn't agree with the idea of breastfeeding, you know like 'if I was meant to breastfeed, to have something sucking on my nipples, then I would have been born a cow' (Mother, age 27, first baby)

All me friends were formula fans, and they were all like 'oh, just stop doing it' I was like 'oh no, I want to carry on'. But everything from friends was like 'you can stop, you can stop ... just get some get formula and you can stop' (Mother, age 29, first baby)

Even women who may initially have felt social pressure to breastfeed found that once they reached a certain point in their feeding journey, there was an equal pressure to 'move on' to formula as part of a 'normal' progression, highlighting continued negative conceptions in UK society of women who breastfeed for extended periods of time [ 20].

I think, in my NCT group now, there's only one other mum still breastfeeding and they all say, you know, if you give her formula, you'll get a better night's sleep, and that kind of thing, so it's hard to...there's pressure on people to breastfeed, but there's also pressure on breastfeeding mums not to... (Mother, age 34, first baby)

I don't have any family around here, apart from [partners] family. They've been really unhelpful, to the point where I've got really frustrated with them 'Oh, she's still having it, she's six months now, you don't have to breastfeed her, she just needs her food now' 'why are you still breast feeding her all the time?' (Mother, age 26, first baby)

Other mothers found that partners, friends and family had been key in supporting them to keep going when they encountered breastfeeding issues.

Well, in the end it was my mum, when I was having problems, she remembered the problems that she'd had feeding me, because I was her first, and that the only thing that had got it started for her was nipple shields, so she went out and bought some nipple shields for me, because no one had suggested that I try them. No one at all. But that was what I needed to actually get it to work (Mother, age 31, first baby)

However even supportive partners and other family members could question mother's determination to breastfeed where they perceived the mother as not coping well or were concerned about her welfare.

My in-laws were going 'give her a bottle, it's not worth it' and [partner] was so worried about me. There was a day when we got the breast pump and I was sat in the bed in tears, and [partner] was knelt beside me trying to express milk from my left boob, and I've got her on the other boob and my nipples were red raw bleeding...every time I could see her coming, I pulled back a bit, and it killed, it was so painful...but we wanted to do it such a lot, we just kept going (Mother, age 26, first baby)

Feeding decisions are not individual one-off choices but situated within mothers personal social and cultural situations, with various 'significant others' [ 13] playing an important role in decisions about breastfeeding initiation and continuation [ 15]. Therefore it is important to continue to work to change wider cultural perceptions of breastfeeding and offer 'family-centred' support that works within women's own social networks to support them at pivotal points within their feeding journeys [ 13].

Experiences of 'additional' breastfeeding support

In this section we present the results relating to women's experiences of additional breastfeeding support provided by Baby Café services. The results are presented under five sub-themes: seeking breastfeeding support, expert support, social support, breastfeeding role models and breastfeeding as a journey.

Seeking breastfeeding support

All women involved in the study were attending a Baby Café breastfeeding support group at the time of the interviews and were therefore likely to be those who were more determined to breastfeed and possessed the 'social capital' [ 42] to seek support and advice. Some of the mothers had already sought support from other services such as telephone helplines.

What I did beforehand was I rang the Breastfeeding Helpline and they were really, really good as well, and that's kind of what made me think you know what, there's different responses to how you feed your baby, conventional formula versus breastfed, and I thought I need to find a place to go to where I've got likeminded people and that grew my confidence to be honest as a new mum and as a breastfeeding mum (Mother, age 30, first baby)

Whilst contact with other breastfeeding support services may sometimes have been the impetus to attend, women valued the face-to-face element of contact with a skilled breastfeeding professional [ 29].

You need that one to one; you need to see somebody face to face. Sometimes, doing it on the phone, what you're telling somebody, it might not be exactly how it is...Somebody like [group facilitator] can say 'Well, actually, I can see that...What you need to do is change this, or that...you just can't get that on the phone... (Mother, age 35, first baby)

Where Baby Cafés were well embedded within the local health service, or combined with other forms of support such as peer supporters on hospital wards, women often found it more straightforward to seek support [ 25].

Well you got a leaflet about all the support groups from the hospital and when the health visitor came to have a check she mentioned the group and told me about how good it is, so when I was struggling I thought I'd try it out (Mother, age 35, first baby)

It was one of the Breast Buddies (peer supporters) at the hospital who suggested it, because I was saying to her 'oh, I think I've had enough...I think I'm just going to give up and go onto bottles' and she was like 'no no no, go to the Baby Café and have a chat with them first' (Mother, age 27, first baby)

Convenience was also a factor, with women often preferring services in a familiar location that they may be visiting for other purposes.

I've heard about this place. I knew things were going on here, because I used to come and see my midwife next door. And they have other groups going on so you can just pop in and say hello, it's not just all about the breastfeeding (Mother, age 30, second baby)

Many of the women were initially anxious about attending a group situation and unsure of what to expect.

I was nervous the first time, yeah. Not knowing what it were like...I thought it would be like a café in the middle of town, that was my visualisation of it, you know, and all these people sat there. It's just the unknown I suppose, you're not really sure what to expect (Mother, 27, first baby)

You're tired because you've only just given birth and your child can't feed and you know, you're suddenly, it's the very first time you're supposed to just get your boobs out in public ... it can be quite nerve-wracking and yeah, I totally see why people are put off to be honest (Mother, 30, first baby)

Reticence about first attending may particularly affect younger or less confident mothers, who might feel that they do not 'fit in' with the other mothers.

I was feeling I had the baby too early. I just look around and there was old mothers at mature age. I was really feeling, not maybe embarrassed, but anxious about them. Like maybe I shouldn't be here, I'm never going to find any mother in my age (Mother, 25, second baby)

However once they had made the initial effort mothers often felt that the group provided a supportive environment to increase their sense of breastfeeding self-efficacy.

I think it gives you a sort of safe haven to start if you're a bit uncomfortable about doing it in public, to do it where other people understand what it's like to feel self-conscious and to struggle and, you know, but it's still a public place and so you get that bit of confidence (Mother, age 31, first baby)

Expert support

Reasons for attendance ranged from appreciating general support and reassurance to needing help with breastfeeding 'crises', where women often felt on the brink of being unable to continue.

I can honestly say at ten days old, I hadn't slept, I was full of milk, [baby] was screaming, I walked in and just sat there and cried for two hours and just said if somebody doesn't sort this out I am going home and I am going to give her a bottle (Mother, age 29, third baby)

For some women the visit to the Baby Café was seen as a 'turning point' in their breastfeeding relationship.

I was struggling for him to latch on. Couldn't get any help from anywhere, I was absolutely end of my tether, beside myself, and on the verge of giving up, so I got a friend to bring me up here and [facilitator] took one look at him and diagnosed a tongue tie, arranged for me to have it snipped and gave me some tips on positioning. Within minutes, I thought 'You know, actually, I think I can do this' (Mother, age 36, first baby)

A metasynthesis of women's perceptions and experiences of breastfeeding support found that women valued an 'authentic presence' where they developed a trusting relationship or rapport with the supporter, who took time to ensure their needs were met, provided an empathetic and caring approach and affirmation of the mothers own abilities [ 41].

I've always got the help. Always. No matter how silly the question is, they've always got an answer. And its nice because they do remember your name, they do remember your baby, and it just feels, it feels nice (Mother, 35, first baby)

Expert knowledge and experience is also seen as key, with women valuing the presence of a skilled facilitator [ 30].

I think the advice you get here is so much better than that you get from GP's or health visitors, who sometimes don't seem to know that much about breastfeeding. They are experts in their field and they are mums themselves, which is always, experience speaks volumes (Mother, age 34, first baby)

Social Support

The informal atmosphere of Baby Café and the provision of refreshments were seen as providing a more socially acceptable environment in which to discuss their concerns [ 30].

I was a bit kind of apprehensive when I first started coming along 'cos I don't know, I don't trust Health Visitors so I was thinking it would be kind of a bit kind of clinical because it was held in a health centre. Yeah, but I was just really pleased the first day I came, I really enjoyed it and it just felt really welcoming (Mother, age 33, first baby)

I think that the minute you walk in and somebody says 'hello' with an open arm and a cup of tea and a biscuit and when you're a new mum and you're not sleeping well, you've got feeding issues, you're tired, you just want somebody to say 'would you like a cup of tea and tell me all about it' (Mother, age 31, first baby)

Involvement of partners or other supporters also increased mother's sense of self-confidence.

We thought fathers were not allowed to stay here, but then [facilitator] said 'no, we welcome dads as well' so...he stayed and was chatting to everyone, and I felt really comfortable (Mother, age 29, first baby)

Social support from other mothers was seen as an important component of the service, providing benefits over and above 'professional' assistance with breastfeeding [ 30].

To be honest, most of the support I get on a day to day basis is from other mums. That's been the key support in getting through the first three months, just getting out and seeing people (Mother, age 32, first baby)

This was particularly the case for women who were isolated from friends and family.

I find it really helpful because there's nobody else to ask...I mean all my family's back in Sri Lanka, so I don't have my mum or a sister whatever to rely on, to ask for simple things, because when it's your first child you don't know what to do (Mother, age 35, first baby)

Breastfeeding role models

The social model of the service meant that women could attend regularly if they wished and created a space for the sharing of infant feeding experience. Mothers found it helpful to be around other breastfeeding women, especially those with older babies who were further on in their feeding journey. This role modelling had a positive impact on those women who were still at the stage of getting breastfeeding established, and gaining confidence about feeding in public places;

I do think it's quite important, that here, you can speak to other mums with older babies and see it does get better, because if you're all sat here with newborns, all crying, all saying you can't do it. You want to see that it will get better, to speak to a mum that says its better (Mother, age 30, first baby)

I got really nice help from the previous peer supporter that was here. She had an older baby and when you have a younger baby, it was nice to see an older baby breastfeed successfully...Oh! She does it with such comfort, makes it seem so effortless. It was a really nice thing to see... (Mother, age 34, first baby)

Such environments also played an important role in normalising the feeding of older babies, for mothers who wished to follow the guidance of complimentary breastfeeding for two years and beyond [ 20].

I kind of want to go past a year now and to come here and meet other people who like openly are like "Oh yeah, I'm still feeding my three year old" I'm a little bit like "Are you? Okay, great". I'm shocked, I will admit it, I'm a little bit shocked, but I'm also like "Okay, other people are doing this, I can do it too" (Mother, age 30, first baby).

Breastfeeding as a journey

Many of the women interviewed for the study were already in later stages of their breastfeeding journey and looking back upon the initial 'investment and adjustment' period [ 15] with the benefit of hindsight. This gave them a chance to reflect upon their feeding journeys, considering what had made a difference at pivotal moments.

I think in the grand scheme of things they weren't really anything too major, it was all major in my own head because the pain was unbearable so like latching, unlatching, being in the shower was extremely painful, the water touching...and then of course, you know, he was feeding around the clock, you know, hour and a half for a feed, you know, your whole life is breastfeeding. But once you feel more confident, I think groups like this encourage you to just feed your baby in public, that kind of thing and once you know that you can go out and feed your baby then you can get your life back again (Mother, age 30, first baby)

Mothers found that they had often made peace with their feeding decisions and overcome some of the early challenges.

It's got a lot easier now, but he's still not having enough, so I give him the bottle as well. But I'm still breastfeeding, so it's going well. He latches on well. He's happy and I'm happy (Mother, age 32, first baby)

However breastfeeding constantly brings new challenges, for example in relation to weaning or returning to work, emphasising the importance of ongoing support [ 23]. Such support is necessary to enable women to meet (or even extend) their breastfeeding goals, and increase continuation rates in line with WHO standards [ 1].

I was always dead set on breastfeeding, but I've gone through spits and spurts of 'Oh can I keep this up?' because it is quite a demanding role, and coming here has made me think I actually can, because you can see all the mums here, you can speak to them. I'd always said 'Right, when she goes into her own room at three months then I'll stop', but I haven't stopped, I said 'At six months I'll stop', and she's almost that, I'm not planning to stop. My next goal's a year (Mother, age 29, first baby)

Discussion

The research shows that despite continued efforts to increase UK breastfeeding initiation and continuation rates, mothers still face substantial social, cultural, practical and physical barriers to successful breastfeeding [ 2, 13, 20]. Whilst policy and best practice such as the UNICEF Baby Friendly Initiative are steadily improving standards of care for breastfeeding mothers in UK hospitals [ 22], understaffing and lack of resources mean that women are not always able to access the support that they require from routine health care [ 6]. Prevalence of formula feeding amongst recent generations means that women may lack cultural support or practical breastfeeding expertise within their immediate social network [ 8, 9]. Antenatal contacts that set unrealistic expectations of the breastfeeding relationship can leave mothers unprepared for the lived experience of the early weeks and common breastfeeding problems [ 15, 18].

Whilst evidence on the effectiveness of 'additional' breastfeeding support interventions is limited [ 24, 28, 29], qualitative findings suggest that these can have a positive impact on women's infant feeding journeys and contribute to the duration and quality of their feeding experiences [ 30, 31]. This study has focused upon one particular form of community-based support provided in the form of weekly Baby Café drop-ins facilitated by skilled health professionals or breastfeeding counsellors, with the help of trained peer supporters. Findings suggest that women value the social aspect of the Baby Café service and gain a great deal from interactions with other breastfeeding mothers, as well as from specialist expertise to address specific feeding difficulties [ 30]. Group environments normalise breastfeeding and can contribute to increased duration, providing ongoing support and assistance during the 'pivotal points' in a woman's infant feeding journey [ 13] and enabling them to form continuing relationships.

However breastfeeding groups such as Baby Café tend to attract older, more advantaged mothers and those with a strong initial commitment to breastfeeding [ 30]. Motivation to breastfeed can be an important factor in accessing support services, with evidence from the 2010 Infant Feeding Survey [ 2] showing that whilst the majority of women received information about voluntary breastfeeding organisations, only a minority accessed them. The women interviewed for this study showed a strong commitment and determination to breastfeed, often continuing despite initial or ongoing difficulties and possessing both the motivation and 'social capital' to seek out additional support.

Conversely those women who lack initial commitment to breastfeeding or role models amongst their immediate social circles may be more likely to cease breastfeeding rather than proactively seek support. Group environments may appear daunting to younger or less confident women, particularly where they perceive themselves as not 'fitting in', or lacking in confidence to breastfeed in public or seek professional advice. Thus such interventions ideally need to combined with alternative forms of support, including proactive contact from peer supporters in the antenatal and immediate postnatal periods [ 25], and additional telephone and one-to-one support where required. Community support services need to be well integrated with local health and social care systems and promoted effectively to ensure that all women are able to access support when they need it.

Strengths and limitations

The strengths of this research are that it provides an in-depth qualitative examination of women's experiences of breastfeeding and using a particular form of community based breastfeeding support (Baby Café), adding depth to inconclusive evidence on the effectiveness of such interventions from UK randomised control trials.

The limitations of the study include a risk of bias due to the researchers being employed by NCT rather than an independent evaluator. This risk is minimised through the active involvement of external academic advisors on NCT's Research Advisory Group, who have commented at all stages of the research and the fact that the research team are not involved in the delivery of NCT or Baby Café services. However it is recognised that their position within the organisation may influence their perceptions of breastfeeding support.

The research was conducted within a Baby Café setting, with group facilitators present (though not directly involved in the interviews / focus groups). Therefore mothers may have been less likely to report negative opinions or experiences of Baby Café services. The study sample is not intended to be representative of UK mothers as a whole, but of those accessing a particular support service. While the sample is diverse in terms of ethnicity, first language and place of birth, it is biased towards older mothers and those with higher levels of education and employment. Such groups are a) more likely to initiate breastfeeding, b) more likely to seek out support for breastfeeding difficulties and c) more likely to be willing to be involved in research interviews. Thus findings of the research cannot be generalised to the overall population and highlight the need to attract a more diverse range of mothers to such services or find alternative means of support for mothers from less advantaged populations.

Conclusion

The research emphasises the need for realistic rather than idealistic antenatal preparation and the importance of timely and parent-centred breastfeeding support, particularly in the immediate postnatal weeks. The findings suggest that effective social support, combined with reassurance and guidance from skilled practitioners, can help women to overcome difficulties and find confidence in their own abilities to achieve their feeding goals. However, further work is needed to ensure that services such as Baby Café are readily accessible to women from all sectors of the community.

References

1. 1.
World Health Organization. Global strategy for infant and young child feeding. Geneva: WHO; 2003. WHOWHA55/2002/REC/1 Annex 2.

2. 4.
Sveriges Officiella Statistik och Socialstyrelsen. Amning och föräldrars rökvanor. Barn födda 2007 [Breastfeeding and smoking among parents of infants born in 2010]. Stockholm, Sweden: Sveriges Officiella Statistik; 2009. Available from: https://www.socialstyrelsen.se/Lists/Artikelkatalog/Attachments/18809/2012-8-13.pdf.

3. 21.
Hoddinott, P., Craig, L. C., Britten, J., & McInnes, R. M. A serial qualitative interview study of infant feeding experiences: idealism meets realism, BMJ Open. 2012;2(2):e000504. doi: 10.1136/bmjopen-2011-000504.

4. 22.
UNICEF UK Baby Friendly Initiative. The Baby Friendly Initiative. 2012. Available at www.babyfriendly.org.uk

5. 25.
Ingram J. A mixed methods evaluation of peer support in Bristol, UK: Mothers', midwives' and peer supporters' views and the effects on breastfeeding. BMC Pregnancy and Childbirth. 2013;13:192. doi: 10.1186/1471-2393-13-192.

6. 29.
Renfrew MJ, McCormick FM, Wade A, Quinn B, Dowswell T. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database Systematic Review. 2012;5.

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Acknowledgments

The authors would like to thank the mothers, peer supporters and facilitators who took part in the interviews and focus groups for this research. They would like to thank Catherine Pardoe and Julie Williams, Baby Café founders, for their assistance in the design and conduct of the study and the Evaluation Steering Group members, Jennie Yelverton, Margaret Reid, Charles Gray and Helen Hunter for their input at all stages of the research. Thanks are also due to Vanita Bhavnani for her independent review of the transcript coding, Lynn Balmforth for her assistance with library services and NCT for providing the funding for this research to take place. They would also like to thank the reviewers Rhona McInnes and Rachael Spencer for their helpful input on improving the content and structure of the article.

Author information

Affiliations

NCT, Alexandra House, Oldham Terrace, London, W3 6NH, UK

Rebekah Fox

, Sarah McMullen

& Mary Newburn

Authors

1. Rebekah Fox

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2. Sarah McMullen

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3. Mary Newburn

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Corresponding author

Correspondence to Rebekah Fox.

Additional information

Competing interests

The research was funded by NCT as part of an internal evaluation of Baby Café services. Baby Café is part of the NCT charity group and provides a network of breastfeeding drop-ins that are funded locally through community fundraising or as a commissioned health service.

Authors' Information

RF is Senior Research and Evaluation Officer at NCT, SM is Head of Research and Quality at NCT, MN is NCT's Strategic Ambassador.

Authors' contributions

RF contributed to the design of the study, conducted data collection and analysis, and drafted the paper. SM contributed to the analysis and writing up. MN initiated the study and contributed to the design, analysis and writing up. All authors read and approved the final manuscript.

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# data[].attributes.attachment_link.title
UK women's experiences of breastfeeding and additional breastfeeding support: a qualitative study of Baby Café services

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Whilst 81 % of UK women initiate breastfeeding, there is a steep decline in breastfeeding rates during the early postnatal period, with just 55 % of women breastfeeding at six weeks. 80 % of these women stopped breastfeeding sooner than they intended, with women citing feeding difficulties and lack of adequate support.

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One mum's story

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'I'm a second-time mother, and I had breastfed my two-year-old throughout my pregnancy and planned to tandem feed. I felt I would be even more confident with breastfeeding second time round and would not require any support. However, the tandem feeding became an emotional and physical struggle. My toddler increased her feeding, and wanted to feed like a newborn. I found positioning two children difficult and tiring. I questioned my ability to continue.

'A few days after my home birth, I received a courtesy call from an NCT breastfeeding peer supporter; coincidentally she had also tandem fed. She reassured me that it was normal for a toddler to increase their feeds, and that this is normally a short-term thing.

'She reminded me that I was doing something wonderful for both my children, and that they would share a special bond. We briefly discussed feeding positions and techniques to distract my toddler when my newborn was cluster feeding.

'She recommended that when I recovered from the birth I visit a Baby Café, in order to meet other mums who had also tandem fed. In the meantime, we agreed she would call again in a couple of weeks to see how I was getting along and offer solutions to any further problems.

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From mum to peer supporter: one NCT member's story - NCT Matters

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'I'm a second-time mother, and I had breastfed my two-year-old throughout my pregnancy and planned to tandem feed. I felt I would be even more confident with breastfeeding second time round and would not require any support. However, the tandem feeding became an emotional and physical struggle.

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The Physiological basis of Breastfeeding

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The Physiological basis of Breastfeeding

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Academic article which covers anatomy, reflexes and milk composition

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The physiological basis of breastfeeding - Infant and Young Child Feeding - NCBI Bookshelf

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Breast milk contains all the nutrients that an infant needs in the first 6 months of life, including fat, carbohydrates, proteins, vitamins, minerals and water (1,2,3,4). It is easily digested and efficiently used. Breast milk also contains bioactive factors that augment the infant’s immature immune…

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1. Right timing

The most important thing is to do what feels right for you and your toddler (NHS, 2017a). If you aren't sure whether the time is right or it's what you want, talking to a breastfeeding counsellor can help. Whenever you choose to stop breastfeeding, support is available - see our contacts page for more details.

If you'd like to cut down or stop breastfeeding, it's good to plan this for when your family is not expecting any major changes. When there's nothing like a house move or starting preschool ahead of you.

If you start the transition and it doesn't go smoothly, you could take a break and try again later. You might do this if your toddler is ill and they really need the comfort of breastfeeding.

2. Natural term weaning

The World Health Organization recommends breastfeeding up to two years old and beyond (WHO, 2013). Some mums are happy to be led by their child and continue to breastfeed until their little one chooses to stop. This is sometimes called natural term weaning.
If you take this approach, you can probably expect a toddler to cut down feeds gradually over months, or longer, until eventually they stop completely. Again, do what feels right for you and your child.

3. Gradual transition

As stopping breastfeeding can sometimes be an emotional time for you and your toddler, it can help to cut down breastfeeds gradually over time. This will also help your body adjust and prevent your breasts from becoming too full. If your breasts are too full, it could lead to mastitis - a painful and potentially serious infection in the breast (NHS, 2017c).

You could start by replacing a specific breastfeed of the day with a suitable alternative milk. This must be formula milk if your child is under one year old but it can be cow's milk or similar if they are older than one (NHS, 2017a; La Leche League GB, 2017). Over time, you can gradually cut out more breastfeeds one by one.

4. Offer alternatives

If your child is over one year old, the chances are they're keen to try alternative milks out of a cup, like cow's milk. Drinking from a cup is better for children who are older than one year as it prevents comfort sucking on a bottle, which can lead to tooth decay (NHS, 2017b).

You can also try introducing them to other milks like soya milk, almond milk or oat milk, to see whether they have a preference. Do note that children under five should not drink rice drinks (NHS, 2017b).

Toddlers often enjoy a cup of milk and a snack as an alternative to a breastfeed. It's important to offer an alternative milk rather than simply replace a breastfeed with a snack. This will help prevent dehydration and aid digestion.

5. Change your routine

When you are reducing breastfeeds, it can help to introduce a new routine so the old routine doesn't remind them of breastfeeding (ABM, 2018). For example, if your little one likes to lie in bed for a morning breastfeed, you could try getting up swiftly and having breakfast together instead.

At night if you would like to cut out a bedtime feed, you could encourage your partner to put your toddler to bed. You may find your toddler easily accepts a different bedtime routine. They might like a warm cup of suitable milk and a bedtime story instead, before brushing their teeth and saying goodnight.

6. Distraction and postponement

You might be surprised at how easy it is to distract toddlers (ABM, 2018). You could use distraction on your toddler to postpone a breastfeed when you're out, for example. Often they will accept a change like this quite easily, especially if you're consistent - perhaps by saying 'when we get home' or 'at bedtime'.

You may be able to distract your toddler with an offer of an exciting activity like a trip to the park instead of a breastfeed.

7. 'Don't offer, don't refuse'

This method can help cut down breastfeeding gently and lead to your child stopping breastfeeding gradually over time (ABM, 2018). All you need to do is no longer actively offer breastfeeds. Don't refuse it if your toddler asks for a breastfeed but, at the same time, simply stop offering them breastfeeds like you might have previously.
As your toddler gets older, more energetic and involved in activities, you might notice they naturally stop asking as often. This method can lead to you gently and gradually stopping breastfeeding.

8. Explain the changes

Some parents find it helpful to explain the transition from being a baby to being a toddler to their child. Some use storybooks to help explain. Others like to chat or sing to their little one about the changes.

Stopping breastfeeding is part of the process of growing up for your little one and there are plenty of books available on the subject for toddlers. If, for example, your toddler still breastfeeds frequently at night and you would like to cut these feeds out, you could read them a storybook on this. Some children will be fine with this transition and accept it as part of growing up.

9. Comfort and cuddles

As well as fulfilling nutritional needs, breastfeeding is one way of offering your toddler emotional support and comfort (La Leche League GB, 2016; NHS, 2017a). If you're gradually cutting down breastfeeding or stopping breastfeeding, it might help to give your little one extra cuddles and comfort. They will appreciate it if you can spend some extra time playing together, chatting to them or sitting reading with them.

10. Agree a timeframe

If you want to stop breastfeeding your older toddler or pre-school child completely, they may agree to stop after a specific date - like their next birthday. This will depend on your child having a concept of future time. You might need to reinforce by reminding your little one about the stop date as the occasion gets nearer.

This page was last reviewed in October 2017

Further information

Our support line offers practical and emotional support in many areas of pregnancy, birth and early parenthood: 0300 330 0700.

You might find attending one of our Early Days groups helpful as they give you the opportunity to explore different approaches to important parenting issues with a qualified group leader and other new parents in your area.

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby.

NHS Choices breastfeeding information.

Visit our breastfeeding support page.

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Ten tips for gently stopping breastfeeding your toddler

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The most important thing is to do what feels right for you and your toddler (NHS, 2017a). If you aren't sure whether the time is right or it's what you want, talking to a breastfeeding counsellor can help. Whenever you choose to stop breastfeeding, support is available - see our contacts page for more details.

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Why babies need loving contact to thrive

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Why your baby is only happy in your arms

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"He sleeps really well but only when he's laying on my chest, he hates his moses basket" "She cries every time we lay her on her play mat" "He hates going in his pram, he cries the second we put him in it".
If I had a pound every time I heard these from a new parent I'd be a very rich lady by now! What amazes me though is that society in general doesn't get it, they don't get why so many babies need to be held by us to settle and what perplexes me even more is that we do spend so long trying to put them down! We spend more than time though, the 'putting babies down' industry is worth millions, rocking cribs, battery swings, vibrating chairs, heartbeat teddies and the list goes on..................having been a first time parent who bought all four of the items listed above I am embarrased to admit now it honestly didn't enter into my head that perhaps the answer was to *not* put my baby down and I certainly didn't consider why these things might help. It took me a long time to understand and empathise with my baby, to see the world through his eyes so to speak.
"Empathy: the intellectual identification with thoughts, or attitudes of another." or vicarious experiencing of the feelings, "Birth suddenly disrupts this organization. During the month following birth, baby tries to regain his sense of organization and fit into life outside the womb. Birth and adaptation to postnatal life bring out the temperament of the baby, so for the first time he must do something to have his needs met. He is forced to act, to "behave." If hungry, cold, or startled, he cries. He must make an effort to get the things he needs from his caregiving environment. If his needs are simple and he can get what he wants easily, he's labeled an "easy baby"; if he does not adapt readily, he is labeled "difficult."" - Dr. William Sears.
To empathise with our newborns feelings we need to put ourselves in their place, to imagine experiencing their world - but which world? The world they have spent most of their life in, their 'womb world' or the world they are in now - our world. To fully understand we must appreciate the enormous transition they have made - a concept known to many as 'The Fourth Trimester' -some make the womb to world transition easily, others less so and it is this latter group in particular "the clingy babies" we can learn so much from through this concept.

So lets quickly compare the two different 'worlds' your baby has lived in:

Pretty different huh? On top of this the big thing to understand is that in utero the baby's world was constant, each day was the same, the stimulation didn't change, but now they are born each day is different - ever changing, ever stimulating!

The concept of the fourth trimester helps us to understand the transition a newborn must make over their first few weeks earthside and once we understand we find so many ways we can help - but to me the most important facet of the fourth trimester is parental understanding and empathy, once that exists everything else will flow naturally.
Movement
Here are some common newborn calming techniques that tend to work quite well, but remember each and every baby is different, if you don't already know, you will soon learn what your baby likes best and that's what matters, that it is unique to *your* baby. Prescriptive 'do this/don't do this' baby calming lists don't help anybody - because they forget they are dealing with individuals - both parents and babies! Some things on this list will be inappropriate for you and your baby, some simply won't work, some you won't like - and that's OK! because really it isn't about these tips it's about you and your baby getting to know each other!
Skin to Skin Contact
The womb is a constantly moving space, Braxton Hicks would squeeze your baby at the end of pregnancy and each time you moves your baby was wobbled around inside. Imagine how walking upstairs feels for a baby in utero! Babies tend to love movement but so often we put them down somewhere completely still. You could try dancing, swaying from side to side, going for an exaggerated quick walk or bumpy car ride.
Bed-Sharing
Such a brilliant baby calmer! Being in contact with your warm, naturally (un)scented, skin is heaven for a baby, it helps to stabilise their body temperature, heart rate and stress hormones and stimulates the release of oxytocin - the love and bonding hormone - in you both. Topless cuddles, shared baths, baby massage and bedsharing are all great skin to skin experiences for your baby and you.

Sharing a bed with your baby is an amazing way of getting more sleep for everyone, babies are generally much calmer and sleep more easily if they sleep with you in your bed, yet it is such a taboo topic and although 60% of parents will share a bed with their baby at some point it's a subject that makes society very uncomfortable, but...it is an *amazing* baby calmer! It's really important that you think about how bedsharing will work and follow some important safety guidelines HERE.
Swaddling
For more on bedsharing and other ways to improve your newborn's sleep, watch my free webinar here:

Imagine how snug your baby was at the very end of your pregnancy inside of you - now imagine how strange it must feel to them after they have been born and have so much space around them! The absolutely best thing you can do is to envelop your baby in your arms, but for times when you don't want to or indeed can't then swaddling is an option. Swaddling is becoming increasingly popular, however there are important safety guidelines to be followed if you choose to swaddle your baby, if you are breastfeeding please make sure feeding is established before swaddling and take care not to miss your baby's hunger cues if you are feeding on demand:
** The American Academy of Paediatrics recommends swaddling for babies 0-14wks. Babywearing

Never swaddle over your baby's head or near his face

Never swaddle your baby if he is ill or has a fever

Make sure your baby does not overheat and only swaddle with a breathable/thin fabric

Only swaddle your baby until he can roll over**

Always place your baby to sleep on his back

Do not swaddle tightly across your baby's chest

Do not swaddle tightly around your baby's hips and legs, his legs should be free to "froggy up" into a typical newborn position.

Lastly start to swaddle as soon as possible, do not swaddle a 3 month old baby if he has not been swaddled before.

Wearing your baby in a sling is one of the ultimate ways to keep them calm and happy. It increases the time a baby spends in a state of "quiet alertness" - a time of contentment when they learn the most. When a baby is in utero they spend 100% of their time in physical contact with us - yet the moment they are born this is estimated to drop to only 40%! Babywearing also means 2 free hands!

Choose your sling carefully. A good sling will be easy to use and will support both yours and your baby's spine whilst not placing any pressure on your baby's growing hips - newborns should always be carried facing inwards with a "frog leg" pose, not a crotch dangle pose so commonly used by commercial baby carriers. Also seek to carry in an 'in arms' position - i.e: how your baby would be held if you were holding them!

Babywearing is a great way for dads to bond with babies!
Position
It is quite common for a baby to cry once placed in a sling, this does not mean that they hate the sling - it just means that you need to move, so get dancing! As with swaddling,babywearing is becoming increasingly popular, however there are important safety guidelines to be followed, the TICKS acronym below neatly sums them all up:

The "tiger in the tree" position below, taken from baby yoga, is often magical, stopping a crying baby in an instant!
Feed
Noise
Babies love sound, but for many not the sound you might think. For many babies a hoover is much more calming to a baby than a lullaby. A special white noise recording, such as , can be played on loop whilst your baby sleeps to help keep them calm.
Deep Bathing
If your baby is hungry nothing will calm him, so watch for his hunger cues. Feeding is always better if it is baby led, not led by a routine - whether you are breast or bottle feeding. Remember as well that your baby may not always be hungry for a full feed, they may want a quick drink, a quick snack or just some comfort sucking. Babies also find sucking the ultimate relaxation and comfort tool. Sucking helps a baby's skull bones to return to their normal position after birth as well as providing them with comfort and security. If you are not breastfeeding you might find your baby will relax when given a dummy/pacifier.
Outside
The womb is a wet, warm place. The world as we know it is dry and cold! Sometimes a nice deep, warm bath can stop a baby's tears in seconds - even better if mummy or daddy goes in the big bath with baby too as skin to skin contact is a wonderful baby calmer.
What have you found calms your newborn? The NEWLY UPDATED Gentle Sleep Book - out now! If you would like to understand and learn how to improve your baby's sleep WITHOUT cry-based conventional sleep training, this is the book for you! p.s: Come and chat with me on Facebook, Twitter and Instagram Or watch my videos on YouTube You can also sign up for my free parenting newsletter HERE.
If all else fails many babies stop crying the minute they hit the open air - I'm not sure if this is because we are usually moving (e.g.: walking over cobbles with the buggy/ bouncing in a sling and the drone and movement of a car) or because of the change in air - but it works!

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The Fourth Trimester - AKA Why Your Newborn Baby is Only Happy in Your Arms

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"My baby is only happy in my arms, the minute I put her down she cries" "He sleeps really well but only when he's laying on my chest, he hates his moses basket" "She cries every time we lay her on ...

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Multiples and other early babies may not be able to feed directly at the breast at first. Here's one mum's story of establishing breastfeeding after 8 weeks of bottles.

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Why you might want to put the baby books down

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Why you might want to put the baby books down

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School of Health & Social Care, Swansea University

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Why you might want to put the baby books down...

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From the Australian website 'Raising Children' - but not all the pages and videos are as good.

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Baby-led attachment is letting baby follow their instincts to find the breast and attach. It can help you get started and overcome breastfeeding challenges.

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Overdiagnosis and industry influence: how cow’s milk protein allergy is extending the reach of infant formula manufacturers

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Overdiagnosis and industry influence: how cow’s milk protein allergy is extending the reach of infant formula manufacturers

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A lengthy but fascinating read from the BMJ

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Cochrane Reviews are internationally recognised as the highest standard in evidence-based health care. This one details the lack of evidence for treatments such as ointments.

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Many breastfeeding women experience painful nipples and this is a common reason for stopping. That's a great shame as it can be a lovely, as well as beneficial, experience and leading authorities such as the World Health Organization recommend that babies should be exclusively breastfed for the first six months. If you, or a woman you're supporting, is experiencing nipple pain from feeding then you're probably wondering what's the best thing to do. We tend to do several things when making choices about our health - we seek advice from others, including friends and family, health professionals and online communities; we might (think twice!) 'Google' it; and we look at the shelves in the local chemist to see what products promise.

There's nothing like a common problem to spawn a whole industry of products offering solutions. If you are a breastfeeding woman who's feeling sore, should you part with your money for glycerin gel dressings, ointments, or breast shells with lanolin? How do you know if you should trust the claims? You might like to know the latest independent evidence on this to help you decide.

Here it is, from a Cochrane review, which set out to bring together the best available evidence from of treatments for painful nipples in breastfeeding women. There were four , all of which included teaching all the mothers about correct positioning. In addition, they evaluated five interventions: glycerine pads, lanolin breast shells, lanolin alone, expressed breast milk, and an all-purpose nipple ointment.

Here's what they found

Applying nothing, or expressed breast milk, may be as good or better than applying an ointment, such as lanolin, for both nipple pain and healing

Regardless of the Something done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. , for most women, nipple pain reduced to mild levels 7 to 10 days after giving birth

How good is the evidence?

The were well-designed , but they were small and they compared different things, so overall there isn't enough good evidence to allow confident conclusions about any particular . Women should be encouraged by the finding that nipple pain resolves for most within ten days.

Avoiding nipple pain

Poor latching or positioning can cause nipple trauma so it's important that new mums are helped to get going with breastfeeding from the start. Earlier have showed that this help can come from health professionals and/or peer supporters. Face-to-face support and scheduled, rather than reactive, visits to support breastfeeding make success more likely.

Old problem, old solutions?

It seems, then, that solutions that are as old as the problem itself, time and our own milk, are possibly the best. Did women always know this? I spent some years looking at aspects of women's health through letters, diaries and medical books from the 16 th and 17th centuries. They reveal a lot about attitudes to breastfeeding and a bit about the practicalities.

Medical men hotly debated whether mothers should feed their own babies or hire wet-nurses, what breast milk was made from (many thought converted menstrual blood), if the early milk we know as colostrum was suitable nourishment and whether it was alright for breastfeeding women to have sex. Women, meanwhile, must have quietly shared their knowledge about it in conversation with each other, but some of this they recorded in household 'receipt' books and in their diaries.

Alice Thornton recorded in her diary the troubles she had with breastfeeding and then, in 1660, her delight at being given "the blessing of the breast as well as the womb" when she was able to feed her son William. He died after two weeks and she breastfed her next child for an unusually long period. A generation before Alice, Elizabeth, Countess of Lincoln, felt so guilty about hiring wet-nurses to feed her babies (a common practice amongst the upper classes) that she wrote a small pamphlet encouraging women to breastfeed their children. She attributes her feeding choices to poor advice, distaste for breastfeeding, failure to recognize it as her duty and 'being overruled by another's authority', probably that of her husband.

How did they promote successful breastfeeding?

A standard element of breast care after birth was to apply warm cloths, to ease pain, keep out cold and prevent milk from curdling. Medicines and topical treatments were sometimes used to encourage milk flow and products were often chosen for their with milk or milk-producing animals, such as powdered cows' hooves and udders, dairy products and milky-veined plants.

Friction was thought to stimulate milk production (ouch!) but more commonly suggested were ointments made of greasy substances such as butter, applied warm on a piece of lint. Advice was given on getting the baby to latch on, though I rather hope Isaac Archer's attempt to help his wife overcome the difficulties by trying to get a puppy to latch on was unusual. Pain and infection was often mentioned. Nipple shields were used and nipples painted with all manner of substances from ox marrow to leaf gold! Reminders of the importance of good hygiene were rather cancelled out by recommendations to apply animal dung, the hot excrement of a child or leaves steeped in the woman's husband's urine!

If breast milk itself was used to treat painful nipples, it didn't make it into the records I came across, but this simple could well have been tried by women whose experiences are now lost to us. Perhaps they too could have told us that time itself is a very good healer. It can be hard to do nothing, when doing 'something' can make us feel more in control, but sometimes it's the best thing of all.

Featured image: Credit: Wellcome Library, London A woman lying down breast-feeding her baby. Etching by F. Bartolozzi after G. Guercino.

Links:

Dennis CL, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. 2014, Issue 12. Art. No.: CD007366. DOI: 10.1002/14651858.CD007366.pub2.

Balogun OO, O'Sullivan EJ, McFadden A, Ota E, Gavine A, Garner CD, Renfrew MJ, MacGillivray S. Interventions for promoting the initiation of breastfeeding. Cochrane Database of 2016, Issue 11. Art. No.: CD001688. DOI: 10.1002/14651858.CD001688.pub3.

McFadden A, Gavine A, Renfrew MJ, Wade A, Buchanan P, Taylor JL, Veitch E, Rennie AM, Crowther SA, Neiman S, MacGillivray S. Support for healthy breastfeeding mothers with healthy term babies. Cochrane Database of 2017, Issue 2. Art. No.: CD001141. DOI: 10.1002/14651858.CD001141.pub5.

Page last updated 30 April 2019

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Simple help for painful nipples in breastfeeding women - Evidently Cochrane

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Many breastfeeding women experience painful nipples and this is a common reason for stopping. That's a great shame as it can be a lovely, as well as beneficial, experience and leading authorities such as the World Health Organization recommend that babies should be exclusively breastfed for the first six months.

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Another useful article with some positive quotes, links and suggestions

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Birth Boot Camp® Amazing Childbirth Education Classes

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Breastfeeding your baby is one of life's most precious relationships. While we place a lot of emphasis on the birth (especially since birth can impact the breastfeeding relationship), no doubt, breastfeeding is an act that will take far longer and have lasting health impact for both the mother and her baby.

Breastfeeding is particularly important for babies and women who experience cesarean birth. Breastfeeding provides closeness, bonding, infant nourishment, and a hormonal cocktail that benefits both mom and baby.

Here are some tips and information about breastfeeding after cesarean. In fact, this information is beneficial to any mom and any baby, no matter how they birth! Breastfeeding is incredible!

Advocate for Skin to Skin Contact

Skin to skin contact is known to help facilitate breastfeeding. We love the idea that being on mama's chest is the "natural habitat" for the newborn human infant. Truly, this is their happy place and where they want to be. This is true immediately after the birth and for months afterwards.

Skin to skin advice is supported by other experts. Skin to skin helps regulate temperature, blood sugar, and of course, gives easy access to your breasts for a baby that needs to nurse frequently.

Keep Baby Close

One thing that can be a big obstacle to nursing any baby is early separation from their mother, the source of breastmilk. This separation is a problem no matter the mode of delivery, but long separation from baby, often of about four hours, is very common after a cesarean birth.

Advocating for gentle care for you and your baby and a prompt return of your baby, or even better, no separation if possible, is one of the first and most important steps for nursing after cesarean delivery. In fact, helping the mother initiate breastfeeding with 30 minutes after the birth is one of 10 steps to baby friendly care - for ANY birthing woman. There are no exceptions for babies born via cesarean section.

Cameo describes how she was able to have her baby breastfeed soon after birth, despite some common struggles specific to cesarean section birth.

"After my cesarean, I got labor shakes really bad. I wasn't comfortable even holding my baby for fear of dropping her but I wanted to breastfeed her. After about 45 minutes of my mom holding her, I asked for my baby back and a nurse helped me get my daughter in the football hold despite all my shaking. Literally the second she started nursing, all the shakes went away. It was amazing." Cameo Sherman, Birth Doula, Bowie, MD

It is not unusual for a mother to need some help from others in that initial latch, particularly if their hands are not free to hold their baby. Staff, family, or a trained doula can help in this role so that the mom who births via cesarean section can still nurse her baby soon after birth.

Preparation for Breastfeeding is Key

Preparation for breastfeeding is imperative. While it is a natural process, and your baby is born knowing how to suck, it takes work and training for both mom and baby to master the rest of the skills needed for breastfeeding. If you know you are having a cesarean, it can help to know some of the potential barriers that may arise, how your hospital handles cesarean birth and immediate postpartum care, and who can help you postpartum. A more mother-friendly or "gentle" cesarean is a great option, if possible.

Melissa's quote, below, is powerful because it shows how easy it is to be blindsided by the realities of cesarean birth and how lack of support (even when you don't know to ask for it) makes such a big difference.

"I don't think my breastfeeding struggles were directly related to having a cesarean, but more a lack of support and not knowing to ask for help. I was able to nurse as soon as I was out of surgery, but I was so out of it, drugged up, and shaky, it definitely wasn't a special moment for me, and was more awkward and forced than it should have been."

Melissa Kosloski, Childbirth Educator,

Women DO breastfeed after cesarean. It is possible. Caryn, who had three cesarean sections before her two VBAC births, tells an incredible story about how the breastfeeding relationship changed with each of these cesarean births and what she did to help make it more positive.

Caryn says,
"With my third baby, even though he was a planned cesarean, I was bound and determined to get this thing right! He was taken away from me just as the others, but I spent a little more time holding him in the recovery room before he was taken away. I kept calling them until they finally brought him to me. Since it was planned and not late at night, I was a little more awake during our first nursing session. This time it seemed so much different! I did not once give him a bottle while I was in the hospital. In fact, in the 15 months that I went on to breastfeed my third child, he only took a bottle once!"

Caryn Westdyk, Childbirth Educator in Carrollton, TX

Planning and preparation really does make a difference in breastfeeding!

Enlist Partner Support

Support is key for any successful breastfeeding relationship and can come from any direction. The support of your partner is particularly imperative. If mom's partner is offering bottles to the baby, this can be so detrimental to the breastfeeding mother. The words of family, nurses, care providers, and friends are all powerful whether negative or positive. Seek out and embrace those people who show support. This is even more important after cesarean.

Cameo's experience beautifully illustrates this point.
"After my cesarean, I needed a lot of help from others. I had my mom and sister take turns staying with me at the hospital so they could get my baby out of the bassinet and give her to me and put her back in when needed. Once home, that became my husband's job. I also discovered side-lying to be a wonderful way to nurse at night so I could get rest without her laying on my incision." Cameo Sherman, Birth Doula, Bowie, MD

Cameo got help before she even left the hospital and continued to have this support even after she returned home. Oh, how things would be different if every woman had this kind of help breastfeeding after cesarean!

Co-Sleeping Can Be Helpful

Sleeping near your baby is something that many women find helpful for breastfeeding. Having to wake frequently throughout the night, march down a hallway, and nurse your baby, wakes everybody up and often results in a baby that is upset by the time you get to them.

This is even more true in the early days of recovery after a cesarean section. Though a common way to give birth, it is a serious abdominal surgery that requires healing and rest. If being closer to your baby helps your breastfeeding relationship, consider it! Melissa says:

"I co-slept initially out of necessity. My husband deployed when our oldest was a week old. Getting up multiple times a night to get baby out of the pack n' play was really tough while trying to recover from surgery. Having him laying next to me made night nursing feasible! Bed share, get a co-sleeper, or sidecar a crib to make your life easier!"

This post has some great tips for co-sleeping safely.

Find Your Own Success!

When you talk to hundreds of women who have breastfed their babies, you find that the definition of "successful breastfeeding" is not universal. Everyone has different experiences. For one woman successful breastfeeding may mean exclusive breastfeeding until six months and a nursing relationship that extends to two years.

We have seen women struggling with insufficient glandular tissue (IGT) who work incredibly hard to keep their babies at the breast but simply must supplement with something besides their own breastmilk in order for their baby to grow healthy and strong.

This quote from Ebon'nae Piggee after her unplanned, emergency cesarean is so beautiful and shows how successful she was and how hard she worked to breastfeed her baby.

"I had always heard the phrase "breast is best", so I KNEW I wanted to breastfeed my baby. Yet, after an induction gone wrong; I ended up being rushed into the OR for an emergency Cesarean. With it being my first pregnancy, I didn't research nor consider having a Cesarean. I had no defenses nor preparation for the pain, hormonal delays, and emotional disarray my body or my baby would be up against after the surgery. I woke up after surgery wanting to nurse my child, but having NO clue and NO support (besides an unsure nurse) through the process.

I did the best I knew how with the little info I'd read online to latch my baby on my breast, but after a day or so he seemed to reject the breast completely. Unfortunately, he'd been receiving bottles of formula in the hospital nursery. I was not prepared for the pain of a Cesarean. I couldn't stand and It hurt to laugh. I blew up like a marshmallow man, from all the fluid retention. Every time I'd put my baby to my breast he would scream and cry and so would I. I felt so guilty that I didn't have a seamless breastfeeding experience, but still I went on to pump for about six months."

Ebon'Nae Piggee, Childbirth Educator, Desoto, TX

Ebon'Nae is an example of nursing success against the odds. She was still able to give her baby the gift of breastmilk. Successful breastfeeding looks different to every woman. Set your own goals. Get the help you need. And know that your best is more than enough- it is amazing.

Breastfeeding After Cesarean is Empowering

Women experience cesarean birth for a variety of different reasons. For some it is planned and wanted. For others it is a traumatic experience that took them by surprise.

No matter your birth, breastfeeding can be incredibly empowering. It shows us the miraculous things that our bodies can do- not only can we grow a human within ourselves, we can grown them outside of us too! There is something awe inspiring about watching a baby double and triple in size while being fed only milk from mother.

Lauren, who experienced a planned home birth turned to cesarean describes this perfectly.

"I felt like everything was out of my control, ending up with a cesarean. Breastfeeding felt powerful and calm. In that moment there was still something I could do for my cesarean baby, right here, right now. Breastfeeding was something I could plan to do regardless of how the birth went. Breastfeeding returned me to my mother power in the face of sterilized and medical birth."

Lauren McClain, Childbirth Educator, Bowie, MD

Breastfeeding after cesarean is possible and often a healing experience.

Build your support network, seek for help, decide what makes the relationship successful for you, and re-discover the empowerment that is possible after birth.

You can have an amazing breastfeeding experience after cesarean!
Photo credit: remysharp / Foter / CC BY-SA, Photo credit: Marie in NC / Foter / CC BY, Photo credit: Kelly Sue / Foter / CC BY-SA

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Breastfeeding After Cesarean - Birth Boot Camp® Amazing Childbirth Education Classes

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Breastfeeding your baby is one of life's most precious relationships. While we place a lot of emphasis on the birth (especially since birth can impact the breastfeeding relationship), no doubt, breastfeeding is an act that will take far longer and have lasting health impact for both the mother and her baby.

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If you think you may be having a c-section, read up and get prepared with these helpful suggestions

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KellyMom.com - Breastfeeding and Parenting

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Breastfeeding after a Cesarean Birth - KellyMom.com

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Educate yourself and arrange for breastfeeding help Find a La Leche League group near you! Try to attend at least one meeting before your baby is born. Ask questions! Talk to the lactation consultant (LC)--assuming your hospital has one on staff--and ask that she meet with you as soon as you get out…

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Breastfeeding Babies born around 36 weeks

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Breastfeeding Babies born around 36 weeks

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One of the best (and most up-to-date) articles I've read describing the unique issues with babies born at 'late pre-term'.

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A baby born between 34+0 weeks and 36+6 weeks gestation is defined as a late preterm baby. A baby born between 37+0 weeks and 38+6 weeks is defined as an early term baby. The average length of a twin pregnancy is 36+4 weeks. Many twin babies are born between 36 and 38 weeks gestation due to the NICE guidelines.

For babies who are born at this time, establishing breastfeeding can be quite difficult. They are often well enough to remain on the postnatal ward with their mothers , which is great as they do not have to go to special care. But as such they often get treated the same as a full term baby and are left to "demand feed".

The problem is that these babies often do not "demand" enough and prefer to sleep, although I prefer the term "cue-based feeding" or "baby-led feeding". They are often too sleepy for the mother to be able to follow their lead completely. And if they do not feed enough, they get even sleepier and harder to rouse to feed. Also a lot of slightly early babies are not physically strong enough or coordinated enough to fully breastfeed, often until around due date or even a bit after. They have a few sucks, take on a little milk, and then fall asleep before they have had their fill.

This can lead to real problems! Babies can lose weight, or jaundice can set in. Mum's milk supply may not be stimulated enough, or she may lose her hard-earned milk supply if she was pumping in NICU. After a week or two it is decided the babies need supplementing, but the lack of breast milk may mean they need to use formula.

These problems are also experienced by parents of more premature babies as they are often discharged around what would have been 36-37 weeks gestation with minimal breastfeeding support. They are often given the chance to "room in" for a couple of days to practise feeding and looking after their baby or babies full time, and this is often the first time the breastfeeding mother is allowed to follow her babies' lead.

These families need lots of support. They need good quality face-to-face breastfeeding support after discharge. They need to be shown the subtle cues their baby makes to show that they need a feed; stirring, mouth opening, turning head from side to side, and the later cues including stretching, moving arms and legs, trying to bring hand to mouth. Crying and agitation are late cues. (Maria Biancuzzo, Dec2018) They should be encouraged to feed their babies frequently. Dr Tena Fry said in her interview with Maria Biancuzzo: "If a baby's eyes are open they should be offered food". Parents also ned to be supported to understand when their baby is not cueing frequently enough. We would suggest not to let a baby of this gestation go longer than 3 hours from the start of each feed to ensure they have a minimum of 8 feeds in 24 hours.

Parents should also be shown how to ensure the babies are latching on well to feed. And tandem feeding positions can be discussed to help with the intensity of breastfeeding new baby twins. Also breast compressions are a very useful tool to help transfer a bit more milk to the babies during the feed, and to remind them to keep feeding when they get a bit sleepy towards the end of the feed. Sometimes a baby of this gestation may have trouble latching directly on to the breast. Babies who are a little early sometimes latch better and feed more efficiently when using nipple shields. Close attention should be paid to milk weight gain and nappy output if shields are used as they can inhibit milk transfer.

Parents may need support with continuing to pump for top ups if the babies are not ready to fully breastfeed. And they need to be shown how to tell that their baby is developmentally ready and feeding efficiently enough to move away from 3 hourly feeds and on to baby-led, cue-based feeding. The problem is each baby is different. Some will be ready to fully breastfeed at 36 weeks, others at 42 weeks, and everything in between. But mums often continue to supplement and schedule far longer than they need to. We would normally look for each baby to be putting on weight as expected, generally waking themselves for feeds before the 3 hour schedule, and having a good proportion of "active feeding" during a breastfeed. Then if mum is pumping for top ups this can be gradually phased out. They will be safe to move on to baby-led feeding. If parents are using formula to top up this can be gradually phased out. See our guide here

Ideally each family would be guided by somebody highly qualified such as an IBCLC or experienced breastfeeding counsellor. This is a scenario that deserves specialist breastfeeding support in the home on discharge from hospital , to ensure they can maximise the breast milk intake of their babies.

Kathryn Stagg IBCLC 2019

Cue-Based Feeding for Late Preterm Infants: 5 Facts You May Not Know

The Baby Friendly Initiative

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Breastfeeding babies of 36 or 37 weeks gestation

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A baby born between 34+0 weeks and 36+6 weeks gestation is defined as a late preterm baby. A baby born between 37+0 weeks and 38+6 weeks is defined as an early term baby. The average length of a twin pregnancy is 36+4 weeks. Many twin babies are born between 36 and 38 weeks gestation due...

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Tips for breastfeeding whatever your nipple shape

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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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Options for combining breastfeeding with medical treatment

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Drugs in Breastmilk factsheets - The Breastfeeding Network

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These factsheets have been compiled by our Drugs in Breastmilk information service team of pharmacists. If you are unable to find the information you are looking for below, or you still have questions, you can contact the team by sending a private message via our Facebook page or via email. Please provide as much information as possible (age […]

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Another NCT BFC who has made a study of this topic pulled together this selection of links.

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Physiology, hormones, and a whole lot more!

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By Kelly Bonyata, BS, IBCLC

To understand how to effectively increase (or decrease) milk supply, we need to look at how milk production works...
For the most part, milk production is a "use it or lose it" process. The more often and effectively your baby nurses, the more milk you will make.
In the Beginning...

Endocrine (Hormonal) Control of Milk Synthesis - Lactogenesis I & II

Milk production doesn't start out as a supply and demand process. During pregnancy and the first few days postpartum, milk supply is hormonally driven - this is called the endocrine control system. Essentially, as long as the proper hormones are in place, mom will start making colostrum about halfway through pregnancy (Lactogenesis I) and her milk will increase in volume (Lactogenesis II) around 30-40 hours after birth.

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During the latter part of pregnancy, the breasts are making colostrum, but high levels of progesterone inhibit milk secretion and keep the volume "turned down". At birth, the delivery of the placenta results in a sudden drop in progesterone/estrogen/HPL levels. This abrupt withdrawal of progesterone in the presence of high prolactin levels cues Lactogenesis II (copious milk production). Other hormones (insulin, thyroxine, cortisol) are also involved, but their roles are not yet well understood. Although biochemical markers indicate that Lactogenesis II commences approximately 30-40 hours after birth, mothers do not typically begin feeling increased breast fullness (the sensation of milk "coming in") until 50-73 hours (2-3 days) after birth.

These first two stages of lactation are hormonally driven - they occur whether or not a mother is breastfeeding her baby.

Established Lactation...

Autocrine (Local) Control of Milk Synthesis - Lactogenesis III

After Lactogenesis II, there is a switch to the autocrine (or local) control system. This maintenance stage of milk production is also called Lactogenesis III. In the maintenance stage, milk synthesis is controlled at the breast - milk removal is the primary control mechanism for supply. Milk removal is driven by baby's appetite. Although hormonal problems can still interfere with milk supply, hormonal levels play a much lesser role in established lactation. Under normal circumstances, the breasts will continue to make milk indefinitely as long as milk removal continues.

By understanding how local/autocrine control of milk synthesis works, we can gain an understanding of how to effectively increase (or decrease) milk supply.

What does current research tell us about milk production?

Current research suggests that there are two factors that control milk synthesis:

Milk contains a small whey protein called Feedback Inhibitor of Lactation (FIL) - the role of FIL appears to be to slow milk synthesis when the breast is full. Thus milk production slows when milk accumulates in the breast (and more FIL is present), and speeds up when the breast is emptier (and less FIL is present).

The hormone prolactin must be present for milk synthesis to occur. On the walls of the lactocytes (milk-producing cells of the alveoli) are prolactin receptor sites that allow the prolactin in the blood stream to move into the lactocytes and stimulate the synthesis of breastmilk components. When the alveolus is full of milk, the walls expand/stretch and alter the shape of prolactin receptors so that prolactin cannot enter via those receptor sites - thus rate of milk synthesis decreases. As milk empties from the alveolus, increasing numbers of prolactin receptors return to their normal shape and allow prolactin to pass through - thus rate of milk synthesis increases. The prolactin receptor theory suggests that frequent milk removal in the early weeks will increase the number of receptor sites. More receptor sites means that more prolactin can pass into the lactocytes and thus milk production capability would be increased.

Both of the above factors support research findings that tell us:

FULL
Breast
=
SLOWER
Milk
Production

EMPTY
Breast
=
FASTER
Milk
Production

Research indicates that fat content of the milk is also determined by how empty the breast is (emptier breast = higher fat milk), rather than by the time of day or stage of the feed.

How does milk supply vary throughout the day?

Earlier researchers observed that milk volume is typically greater in the morning hours (a good time to pump if you need to store milk), and falls gradually as the day progresses. Fat content tends to increase as the day progresses (Hurgoiu V, 1985). These observations are consistent with current research if we assume the researchers were observing babies with a fairly typical nursing pattern, where baby has a longer sleep period at night and gradually decreases the amount of time between nursing as the day progresses.

Storage capacity: Another factor that affects milk production and breastfeeding management is mom's milk storage capacity. Storage capacity is the amount of milk that the breast can store between feedings. This can vary widely from mom to mom and also between breasts for the same mom. Storage capacity is not determined by breast size, although breast size can certainly limit the amount of milk that can be stored. Moms with large or small storage capacities can produce plenty of milk for baby. A mother with a larger milk storage capacity may be able to go longer between feedings without impacting milk supply and baby's growth. A mother with a smaller storage capacity, however, will need to nurse baby more often to satisfy baby's appetite and maintain milk supply since her breasts will become full (slowing production) more quickly.

Think of storage capacity as a cup - you can easily drink a large amount of water throughout the day using any size of cup - small, medium or large - but if you use a smaller cup it will be refilled more often.

What does the research tell us about increasing milk supply?

Milk is being produced at all times, with speed of production depending upon how empty the breast is. Milk collects in mom's breasts between feedings, so the amount of milk stored in the breast between feedings is greater when more time has passed since the last feed. The more milk in the breast, the slower the speed of milk production.

To speed milk synthesis and increase daily milk production, the key is to remove more milk from the breast and to do this quickly and frequently, so that less milk accumulates in the breast between feedings:

EMPTY
Breast
=
FASTER
Milk
Production

In practice, this means that a mother who wishes to increase milk supply should aim to keep the breasts as empty as possible throughout the day.

To accomplish this goal and increase milk production:

1. Empty the breasts more frequently (by nursing more often and/or adding pumping sessions between nursing sessions)

2. Empty the breasts as thoroughly as possible at each nursing/pumping session.

To better empty the breasts:

Make sure baby is nursing efficiently.

Use breast massage and compression.

Offer both sides at each nursing; wait until baby is finished with the first side before offering the second. Switch nursing may be helpful if baby is not draining the breast well.

Pump after nursing if baby does not adequately soften both breasts. If baby empties the breasts well, then pumping is more useful if done between nursing sessions (in light of our goal to keep the breasts as empty as possible).

Are you having problems with oversupply?

Mothers who are working to remedy oversupply usually need to decrease supply without decreasing overall nursing frequency or weaning baby. One way to accomplish this is by "block nursing" - mom nurses baby as frequently as usual but restricts baby to one breast for a set period of time (often 3-4 hours but sometimes longer) before switching sides. In this way, more milk accumulates in the breast before mom switches sides (thus slowing milk production) but baby's nursing frequency is not limited.

See also:
Frequently Asked Questions about Milk Production I'm confused about foremilk and hindmilk - how does this work?
Anatomy of the human breast. Diagram by DT Ramsay, RL Hartmann, PE Hartmann

Note: the graphics above are copyrighted. Do not use without express written permission.

Many thanks to Denise Fisher of Health e-Learning for the valuable feedback!

Additional information

How the breasts make and deliver milk from AskDrSears.com

Examining the Evidence for Cue Feeding Breastfed Infants by Lisa Marasco, BA, IBCLC and Jan Barger, MA, RN, IBCLC

Human Milk and Lactation by Carol L Wagner, MD

References

Cox DB, Kent JC, Casey TM, Owens RA, Hartmann PE. Breast growth and the urinary excretion of lactose during human pregnancy and early lactation: endocrine relationships. Exp Physiol. 1999;84(2):421-34.

Cox DB, Owens RA, Hartmann PE. Studies on Human Lactation: The Development of the Computerized Breast Measurement System. June 1998. Accessed May 28, 2004.

Cox DB, Owens RA, Hartmann PE. Blood and milk prolactin and the rate of milk synthesis in women. Exp Physiol. 1996 Nov;81(6):1007-20.

Cregan MD, Mitoulas LR, Hartmann PE. Milk prolactin, feed volume and duration between feeds in women breastfeeding their full-term infants over a 24 h period. Exp Physiol. 2002 Mar;87(2):207-14.

Hartmann PE, Prosser CG. Physiological basis of longitudinal changes in human milk yield and composition. Fed Proc. 1984 Jun; 43(9): 2448-53.

Hurgoiu V, Marcu A, Sopon E, Olariu M. Dynamics of the composition of lipids in human milk during lactation. [French]. Pediatrie. 1985 Apr-May;40(3):201-5.

Ingram J, Woolridge M, Greenwood R. Breastfeeding: it is worth trying with the second baby. Lancet. 2001 Sep 22;358(9286):986-7.

Marasco L, Barger J. Cue Feeding: Wisdom and Science. Breastfeeding Abstracts. 1999 May;18(4):28-29

Mohrbacher N. Breastfeeding Answers Made Simple. First Edition. Amarillo, Texas: Hale Publishing; 2010. 390-401.

Neville MC, Morton J. Physiology and endocrine changes underlying human lactogenesis II. J Nutr. 2001 Nov; 131(11): 3005S-8S.

Neville MC. Anatomy and physiology of lactation. Pediatr Clin North Am. 2001 Feb; 48(1): 13-34.

Neville MC, Morton J, Umemura S. Lactogenesis. The transition from pregnancy to lactation. Pediatr Clin North Am. 2001 Feb; 48(1): 35-52.

Peaker M, Wilde CJ. Feedback control of milk secretion from milk. J Mammary Gland Biol Neoplasia. 1996 Jul;1(3):307-15.

Perez-Escamilla R, Chapman DJ. Validity and public health implications of maternal perception of the onset of lactation: an international analytical overview. J Nutr. 2001 Nov;131(11):3021S-4S.

Ramsay DT, Kent JC, Owens RA, Hartmann PE. Ultrasound imaging of milk ejection in the breast of lactating women. Pediatrics. 2004 Feb;113(2):361-7.

Walker M. Physiology of the Breast During Pregnancy and Lactation. In: Walker M, editor. Core Curriculum for Lactation Consultant Practice, Sudbury, Massachusetts: Jones and Bartlett; 2002. 27-34.

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How does milk production work? * KellyMom.com

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To understand how to effectively increase (or decrease) milk supply, we need to look at how milk production works... For the most part, milk production is a "use it or lose it" process. The more often and effectively your baby nurses, the more milk you will make.

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A tiny adjustment makes all the difference.....

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A tiny adjustment makes all the difference.....

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An article by Emma Pickett IBCLC including many common adjustments to improve the latch

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A dad at my breastfeeding support group this week had a bit of an epiphany. 'It's never felt like this before,' his wife had said. We'd spent just 3 or 4 minutes together. I'd mentioned one or two things about the way she was holding her baby. It was enough to make all the difference.

Just like in golf, he noted, with a tiny change to swing and position the game had been transformed.

As a lactation consultant, you study for hours and hours and pages and pages and pages. You know lots of things you may not talk about from month to month. But there are twenty or so things you say nearly every day.

So many mums have their experience transformed by a tweak. They are sore, dreading each feed, wondering how things will ever change and one comment - that may not even be 20 words long - can make all that go away in an instant.

It's one reason why even a rushed midwife or GP can turn breastfeeding around with the right training, even if they don't always have the time to devote to a long support session.

Here are a few of my favourite tweak considerations:
​
1. Get a glass of water. Take a drink. Notice how you tip your head back and your chin comes away from your chest? Now try to take a drink with your chin pointing down towards your chest. Not so easy. Try and do that every time you drink, and I think you'll find you take less, give up sooner that you might otherwise and probably get a bit windy. So, tweak number one is hold your baby in a position where they can lift their chin away from their chest. If you are using a cradle hold or a cross-cradle hold, that means you might need to have them further away from the feeding breast's armpit and slid more across towards the non-feeding breast. We talk about 'nose to nipple' because that's encouraging the baby to reach towards the nipple with their head tilted back. If you are using a rugby hold, super important the baby isn't too far forward so they end up curling around the breast with their chin hunched towards their chest.

2. Don't hold the baby's head too high on the back of their head or push the baby's head towards the breast. Babies are clever at protecting their breathing (why we don't need to press our fingers into the breast near baby's nose). And nature has given them a reflex which means when someone pushes on their head, they'll be very unhappy about attaching in case they can't rescue themselves when breathing becomes restricted. They may even push back and shallow the latch and sometimes even refuse to feed entirely. So, support baby's head by holding around the base of the skull - supporting around their shoulders and chin and ears area - but no higher. Imagine Elvis towards the end of his career in Las Vegas with those diamond encrusted collars. You're holding your baby's Elvis collar and no higher. And even then, as gently as possible. Just enough to support baby's head without being too bossy or firm. You might even be using a position where this isn't a risk at all - you might be lying down or using a reclined position where your hand is nowhere near baby's head.

3. Beware the cushion myth. I am not kidding when I say that most people I meet using breastfeeding cushions are using them in a way that makes their life harder for themselves. The gap between your lap and the natural fall of your breast is probably very different from your mate's. It's going to depend on the length of your torso, the size of your breast, the way your breasts fall, the height of your lap which varies with your chair. It's also going to depend on the shape of your baby. So how on God's green Earth did we all get the message that the same size of breastfeeding pillow fits everyone?

Again and again and again, taller mums are slumping forward and hunching over their baby lying on their cushion. 'This cushion must be right. I just have to contort myself to get to it!'

And shorter women also think that the cushion is surely the answer, so they put baby on the cushion and umm, there's no space between their breast and the cushion for baby to fit. They often end up lifting their breast so baby can fit underneath. They might then have to hold their breast throughout the entire feed, compressing ducts and causing hand pain and usually not holding the breast in the same position the whole way through a feed so things wobble around.

Or folks might put the baby on the cushion and baby is a few centimetres too far away from them with sometimes not even the chin and chest making contact with mum at all.

Cushions can be handy to support mum's arms, but it doesn't normally work that the baby can't be held by mum and is entirely on the cushion.

What often works even better is no pillow at all and mum leaning back a bit. Check out: http://www.mothering.com/articles/natural-breastfeeding/

4. Baby needs to be clooose. If you can see the buttons down the front of baby's sleep suit, they are probably too far away. If baby's arm is trapped between you, they are being pushed too far away. If there's a big blob of your clothing and a breast pad between you, they are probably too far away. I once supported a mum who found night time feeds much more painful. She was sitting in the same chair to feed as she did in the day and was using exactly the same position but at night it was pinchy and uncomfortable. It turns out the difference was that the baby was wearing a sleeping bag at night. Just a few extra millimetres of padding meant that baby's chest and chin was a little bit further away from mum's body and the nipple wasn't going back far enough into baby's mouth. Baby's chin needs to be close into the breast. It's not going to work if the baby's chin isn't touching the breast at all. And the chin can't touch if the chest is too far away.

It's common for a mum to say, "Wow it doesn't hurt anymore!" followed by "I haven't been having them close enough!"

5. Mums are fiddling around and 'checking the latch'. It's completely understandable that when someone tells you the baby's mouth should be a certain way and the bottom lip should be flanged out like a fish lip, you think you are supposed to check! But the minute you push your baby's cheek out of the way and have a bit of a rummage, you've made some adjustments. Better to go with a look at the baby as they approach the breast and the mouthful you saw them take and how it feels. And how the nipple looks when it comes out of baby's mouth (might be elongated but shouldn't be squashed and flattened at the end.) If the baby is close enough, you usually can't see the lips at all. The rounded part of baby's cheek is in contact with the breast and the lips are hidden.

6. And while we are talking about lips, the top lip doesn't need to flange out and do the fish lip thing. It can rest in a neutral position. An excessively flanged top lip can even be the sign of a shallow latch. I've met several mums who have been told that the top lip should stick out and even flip it out themselves to make that happen. Curled in isn't ideal but it doesn't need to flip out.

7. Babies are sinking. Mums might start with baby on a squishy pillow and as the feed goes on, gravity does evil things and the baby starts to sink. The movement might be imperceptible but it's enough to pull the baby away from the breast. That pregnancy pillow filled with beans that the manufacturers claimed was super for breastfeeding? Meh. If it's bean-filled, it's likely to sink. That favourite feather filled bed pillow? Going to sink. Holding all the weight of your baby on your arms and hands and sitting bolt upright? You are going to sink. You are not designed to hold the weight of your baby in that position for minutes and minutes throughout the day. It's a big clue if you finish a feed rubbing your wrist and thinking, 'phew, glad that's over!' Gravity is your enemy. You need to find a position which you can sustain. That might be the right cushion for you (or more than one) or again, it might be about leaning back. Babies also latch better when they are anchored. If they feel themselves slipping, they may even clamp down and things can get even more sore.

8. What's the bottom cheek doing? Not many of us have nipples that come out from our body at precise right angles. So why do so many of us feed a baby as if that's true? The baby is precisely 'tummy to mummy' and lying on a breastfeeding cushion as if our nipples are pointing directly in front of us. In fact, most women have nipples that point slightly down (or off to one side and down). But we put baby into the 'right angle' position anyway. What ends up happening is that the top cheek (which mum can see in a cross-cradle or cradle position) is nice and close to the breast and rounded. However the bottom cheek can be centimetres away from mum's body with an unhelpful gap for air to get in and a shallowed latch. Get someone to check that the bottom cheek is touching the breast too. Look at your natural body shape. Your baby may need to look up towards your shoulder rather than at the back of the chair. You may be able to see both of their eyes.

9. Ear/ Shoulder/ hip in alignment. Get that glass of water again. Twist your neck and try to take a drink. It's rrrreally hard. And if what you were drinking was gradually getting thicker and fattier, again, you're likely to be taking in air and giving up sooner than you might. Baby can't lie on their back and twist their neck towards you to come to the breast. We want the ear and shoulder and hip to all be pointing in the same direction. Even a baby with a twisted torso and the twist is around the hips can run into problems.

10. Look at your body. Look, that mum over there in Costa seems to be able to drink her coffee (yes, you can drink coffee) and is just supporting her baby on one arm! How the heck! Can I do that? You know how hairdressers' clients turn up to their appointments with a celebrity photo and say, 'make me look like that!' That sometimes happens in breastfeeding too. 'Can I hold my baby like that mum I saw?'

Sometimes the answer is yes and sometimes it's no. Your humerus is the bone that goes between your shoulder and your elbow. Sometimes your humerus bone and the height of your breast isn't ideal for particular positions. Long humerus and high firm breast? You may not be able to do the cradle hold. I mean seriously - you may NEVER be able to do the cradle hold. The baby will be too low. Short humerus and long low breast? You may not be able to do the position that that woman in Costa can do and drink coffee. You might always need a hand to support the breast if you want to do the cradle hold.

It's not all about the pictures in that breastfeeding book or what your mates are able to do. It's about the shape of your body and the shape of your baby. Do you need to factor in wheelchair arms? Do you need to think about how your breast texture changes in the day? It's all very individual. Trying to make it work like everyone else does it can be unhelpful - which is why getting face-to-face help tailored to you can be so useful.

11. Give the baby more space for their tongue on the breast. You may have heard people talk about baby getting more of a mouthful of breast below the nipple than above. Or seeing some areola above the top lip and less (or none) below the bottom. If the baby has more space for their tongue on the breast, they have a chance of scooping more breast into their mouth and the latch being deeper. When the nipple is going in, picture it pointing towards the roof of baby's mouth rather than pointing down the back of their throat. Even just a little bit of re-angling can make things easier.

12. Don't make your baby eat cotton. Breastfeeding clothes also assume we're all the same. If you find them a faff - as you pull open a teeny slit to find your nipple hidden in there somewhere - I'm pretty sure your baby does too. If they ping back so the baby's nose and cheek comes back into contact with fabric again, maybe rethink. I've even seen babies with fabric in their mouths with a look of resignation that says, "This is the best I'm going to get". Cheap vest tops you can pull out of the way are very sensible. You can layer more than one so different bits are covered. And a bulldog clip is useful for securing fabric (not your chin holding your clothing and preventing it from flopping down onto baby's face).

As I say, some of that really isn't complicated. It's what we talk through on the breastfeeding helplines and what we point out every day in breastfeeding support groups. While at the same time NOT saying that it's 'normal' to be pain at 10 days or your nipples just need to get used to things. If you feel breastfeeding is just all too hard, remember you could be seconds away from fixing things.

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'Breastfeeding is just like golf! A tiny adjustment makes all the difference'

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A dad at my breastfeeding support group this week had a bit of an epiphany. 'It's never felt like this before,' his wife had said. We'd spent just 3 or 4 minutes together. I'd mentioned one or two things about the way she was holding her baby.

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If you're worried about milk supply, someone may suggest lactation foods. Here's a quick clear page about the issues.

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A helpful demo of breast compression to keep a baby feeding. But notice how this baby's cheek dimples as he feeds - indication of a shallow and/or ineffective latch...

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College of Human and Health Sciences, Swansea University

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Over the course of her breastfeeding journey, it is almost inevitable that a mother will encounter the terms "foremilk" and "hindmilk". There is certainly no shortage of confusing and conflicting advice on the concept, which has led to a lot of misunderstanding.

In The Breastfeeding Answer Book, "foremilk" and "hindmilk" were defined as follows:

"Foremilk" is the milk the baby receives when he begins breastfeeding, which is high in volume but low in fat (1).

"Hindmilk" is the milk near the end of the feeding, which is low in volume but high in fat (1).

Actually, the terms "foremilk" and "hindmilk" only really refer to samples of breastmilk taken right at the beginning of a feed ("foremilk") and samples of breastmilk taken right at the end of a feed ("hindmilk"). Even then, the advantage of using these terms is debatable. A photo on

Why?

Wikipedia "helpfully" shows two 25ml samples of human breastmilk: "foremilk" on the left and "hindmilk" on the right:

The problem with showing a sample of breastmilk from the start of a feed together with a sample of breastmilk from the end of a feed is that it tells us nothing about what happens to the breastmilk in between the two samples. Mothers end up mistakenly believing that their breasts make two different types of milk, and wonder how long they must feed for before the "foremilk" magically switches over into "hindmilk" (2).

So if the terms "foremilk" and "hindmilk" are misleading and there's no "magic switch" from one to the other, what really happens?

Since The Breastfeeding Answer Book was published in 2003, research in human lactation has advanced (2), so we now understand more about how breastmilk is produced:

Your breasts make just ONE type of milk

There is no magic switch between two different types of milk over the course of a feed. In fact, The answer lies in what happens to the
there is no sharp distinction between breastmilk at the start of a feed and breastmilk at the end of a feed (3). "Milk does indeed change consistency during a feed - but this happens gradually rather than suddenly" (4).

Why does the consistency of breastmilk change over the course of a feed?

fat in breastmilk when breastmilk is

Your breasts are continuously making just one type of milk, containing 'sticky' fat globules that tend to stick to each other and to the milk ducts in the breast as breastmilk is produced (2,3,5).

Breastmilk produced between feeds moves down towards the nipple and collects in the breast, leaving increasing amounts of fat globules 'stuck' together further up the milk ducts (3).

When let-down occurs, the milk ducts dilate (5) and the milk is ejected from the breast. The milk removed at the beginning of a feed may be lower in fat because the fat globules are still 'stuck' further up in the milk ducts (6). As the feed progresses, multiple milk ejections occur (5) and the breast is emptied, more and more fat globules become dislodged and the breastmilk increases in fat (3,6). This has the overall effect of a gradual increase in fat content of breastmilk in each breast independently as milk is removed.

How do we know that the increase in fat is gradual?

Studies involving several mothers have been conducted in which samples of breastmilk were taken at intervals over the course of a feed. The evidence from these studies suggests that the fat content of breastmilk increases gradually as the breast becomes progressively emptier over the course of a feed (7,8).

It's much easier to explain this gradual increase in fat content using pictures...

...so, revealing the crazy lengths I'm prepared to go to so I can prove a point, I visited The Countess of Chester Hospital, where several wonderful people enabled me to take consecutive small samples of breastmilk from one breast only over the course of one pumping session, and professionally photograph the results. The samples were then taken to the Cheshire and North Wales Human Milk Bank, where the fat content of each sample was analysed.

This is the snapshot we got of the gradual increase in fat content of my milk over the course of one pumping session:

Note the gradual colour change of each breastmilk sample. This is the gradual increase in fat content from the beginning of a feed (test tube 1) to the end of a feed (test tube 12).

Remove test tubes 2-11, and the result is a picture similar to the one on Wikipedia:

This shows a sharp contrast between the breastmilk at the When breastmilk is left to stand for a while, it separates into two layers. This very beginning and the breastmilk at the very end of a feed only - it tells us nothing about what happens to the breastmilk in between the two samples. Only the photo containing all 12 test tubes shows the complete picture: a gradual increase in fat content.

isn't the separation of "foremilk" from "hindmilk"; it is simply the fat in the milk rising to the top, not the separation of two different kinds of milk (4).
So what's that stuff that rises to the top of expressed breastmilk?

The reason this separation doesn't occur in a bottle of cow's or goat's milk you buy in a shop is that this milk has been homogenised. "

Whole homogenised milk is identical in fat and nutrient content to whole standardised milk however it has undergone a process known as "homogenisation" which breaks up the fat globules in the milk. This spreads the fat evenly throughout the milk and prevents a creamy layer forming at the top." (9)

After a while, the breastmilk in our test tubes separated into two layers (click on the image to open a larger version in a new window):

Again, removing test tubes 2-11 shows
Note that the breastmilk in test tube 1 does, in fact, contain a layer of fat.

Note also the increasing thickness of the fatty layer that collects at the top of the breastmilk from test tubes 1-12. This further demonstrates a gradual increase in fat content from the beginning of a feed (test tube 1) to the end of a feed (test tube 12).

only a sharp contrast between the thin fatty layer that rises to the top of the breastmilk at the very beginning, and the much thicker fatty layer that rises to the top of the breastmilk at the very end of a feed.

This photo tells us Before I continue, I must stress that this is just a snapshot of
nothing about what happens to the breastmilk in between the two samples. Remember: only the photo containing all 12 test tubes shows the complete picture: a gradual increase in fat content.

Showing us pretty pictures is nice, but how much fat did the breastmilk samples actually contain?

my breastmilk. It is unlikely that the results shown here will be an exact reflection of what happens to every mother's breastmilk. However, it does provide a rough idea of what happens, so here are the results of the analysis of each sample of my breastmilk:

If looking at raw data isn't your thing, here's a line
TS = Total Solids, ie. the bulk of the rest of the milk
Protein, carbohydrate, fat and TS values are in grammes per 100ml

graph showing the amount of protein, fat, carbohydrates and total solids present in each of my 12 breastmilk samples (fat content is shown in red).

The graph clearly shows there was a gradual (if slightly wobbly) increase in fat content as the breast is emptied. Quite plainly, there is no arbitrary "magic switch" between two different types of breastmilk during a feed.

Remember, though, that all of this is just a tiny piece in a vast breastfeeding jigsaw...

Although it is true that the fat content does gradually increase as the breast is emptied, it is important to understand that the difference in fat content between milk at the beginning of a feed and milk at the end of a feed can vary greatly from mother to mother. Not only this, but it can vary greatly over a 24 hour period, even among individual mothers (2). The difference in fat content can also depend to some degree on the amount of time elapsed between each feed (this is truer the younger the baby is) - another reason why it might not be a good idea to wait for your breasts to "fill up" before a feed.

the higher the fat content of the milk

the lower the difference in fat content between the breastmilk at the beginning and end of a feed (2,3)

This is not simply a case of the longer the feed, the higher the fat content: if there is a shorter gap between feeds (such as during periods of cluster feeding), the milk at the beginning of a feed may not necessarily be low in fat (2,10).

"Babies can show a wide variety of feeding patterns, suckling for varying lengths of time and at varying intervals over the course of a day, and maintain a healthy weight" (4,10)

Whilst fat is important, we can and do get far to preoccupied with the issue of fat content - take another look at the graph showing the amount of protein, fat, carbohydrates and total solids present in each of my 12 breastmilk samples:
The most important thing to remember is this:
In the vast majority of cases, as long as you are:

breastfeeding on cue

and allowing your baby to come away from the breast spontaneously at the end of a feed,

there is no need to worry about what's in the breastmilk your baby is getting. ALL of the components of breastmilk are essential for the growth and the physical and mental development of your baby, not just its fat content.

_________________________________________________________

If you liked this article, please consider making a small donation to Cheshire and North Wales Human Milk Bank (a charity which does a fantastic job of getting breastmilk to our most vulnerable babies), without whom this article could not have existed.

Lynda Coulter (Cheshire and North Wales Human Milk Bank) for very kindly agreeing to analyse the samples of my breastmilk.

Janet Beech and Linda Gendler (Cestrian Ward, The Countess of Chester Hospital) for entertaining my mad idea and helping to co-ordinate the experiment.
Becca Williamson (Bosom Buddy breastfeeding peer supporter) for being my extra pair of hands.

Jenni Ross (Medical Photography, The Countess of Chester Hospital) for taking such excellent photos of my breastmilk samples. This article has been republished as a guest blog on
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Acorn Pack
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Foremilk and Hindmilk: In Quest of an Elusive Arbitrary Switch.

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Over the course of her breastfeeding journey, it is almost inevitable that a mother will encounter the terms "foremilk" and "hindmilk". There is certainly no shortage of confusing and conflicting advice on the concept, which has led to a lot of misunderstanding.

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Clear info that cuts through the scare stories

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A little knowledge can be a dangerous thing. This has never been so true as in the ongoing debate about foremilk and hindmilk and their impact on breastfeeding. The misunderstandings around these concepts have caused anxiety, upset, and even led to breastfeeding problems and premature weaning.

The 2003 edition of The Breastfeeding Answer Book defines these terms this way:

"The milk the baby receives when he begins breastfeeding is called the 'foremilk,' which is high in volume but low in fat. As the feeding progresses, the fat content of the milk rises steadily as the volume decreases. The milk near the end of the feeding is low in volume but high in fat and is called the 'hindmilk'" (Mohrbacher and Stock, p. 34).

It goes on to explain that by simply letting the baby "finish the first breast first"-switching breasts when the baby comes off the breast on his own rather than after a set time-the mother can be sure her baby receives the "proper balance of fluid and fat." Since this book was published, research has expanded our understanding of foremilk and hindmilk and answered many of the common questions mothers have about these concepts.

What worries? Confusion about foremilk and hindmilk has led to all sorts of uncertainty. Are there two distinctly different types of milk? Does the baby need to breastfeed for a specific number of minutes before foremilk suddenly turns to hindmilk? Can a baby miss out on hindmilk altogether if he breastfeeds for too short a time? If this happens often, will his weight gain suffer? Sometimes healthcare providers get into the act, telling breastfeeding mothers they should watch the clock to make sure their baby breastfeeds "long enough to get the hindmilk," with the number of minutes recommended varying by adviserWhat do we really need to know about foremilk and hindmilk? And is there any reason to worry?

The truth about foremilk and hindmilk. Research has found this concept is not as simple as it sounds. It is true that fat sticks to the milk ducts in the breast and the percentage of fat in the milk increases during a breastfeeding as the fat is released from the ducts during milk ejections. But the reality of this seemingly simple dynamic is not always as it seems.

There are not "two kinds of milk."Despite this common belief, there is no "magic moment" when foremilk becomes hindmilk. As the baby breastfeeds, the increase in fat content is gradual, with the milk becoming fattier and fattier over time as the breast drains more fully.

The total milk consumed daily-not the hindmilk-determines baby's weight gain. Whether babies breastfeed often for shorter periods or go for hours between feedings and feed longer, the total daily fat consumption does not actually vary.

Foremilk is not always low-fat. The reason for this is that at the fat content of the foremilk varies greatly, depending on the daily breastfeeding pattern. If the baby breastfeeds again soon after the last feeding, the foremilk at that feeding may be higher in fat than the hindmilk consumed at other feedings.

How does this work? Interestingly, foremilk and hindmilk are concepts that really only make sense when longer intervals such as two to three hours or more occur between feedings. The longer the time gap between feedings and the fuller a mother's breasts become, the greater the difference in fat content between her foremilk and hindmilk. These differences in fat content can vary greatly over the course of a day even among individual mothers. For example, when a long breastfeeding gap occurs during the night, at the next feeding a mother's foremilk will be lower in fat than during the evening when her baby breastfeeds more often.

What really matters. Research indicates that there is no reason to worry about foremilk and hindmilk or to coax a baby to feed longer. As long as a baby is breastfeeding effectively and the mother does not cut feedings short, baby will receive about the same amount of milk fat over the course of a day no matter what the breastfeeding pattern (Kent, 2007). This is because the baby who breastfeeds more often consumes foremilk higher in fat than the baby who breastfeeds less often. So in the end it all evens out.

What's most important to a baby's weight gain and growth is the total volume of milk consumed every 24 hours. On average, babies consume about 750 mL of milk per day (Kent et al., 2006). As far as growth is concerned, it doesn't matter if a baby takes 30 mL every hour or 95 mL every three hours, as long as he receives enough milk overall (Mohrbacher, 2010). In fact, researchers have found that whether babies practice the frequent feedings of traditional cultures or the longer intervals common in the West, they take about the same amount of milk each day (Hartmann, 2007) and get about the same amount of milk fat. Let's simplify breastfeeding for the mothers we help and once and for all cross foremilk and hindmilk off our "worry lists."
References
Hartmann, P.E. (2007). Mammary gland: Past, present, and future. in eds. Hale, T.W. & Hartmann, P.E. Hale & Hartmann's Textbook of Human Lactation. Amarillo, TX: Hale Publishing, pp. 3-16.

Kent, J. C. (2007). How breastfeeding works. Journal of Midwifery & Women's Health, 52(6), 564-570.

Kent, J. C., Mitoulas, L. R., Cregan, M. D., Ramsay, D. T., Doherty, D. A., & Hartmann, P. E. (2006). Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics, 117(3), e387-395.

Mohrbacher, N. Breastfeeding Answers Made Simple: A Guide for Helping Mothers. Amarillo, TX: Hale Publishing, 2010.

Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book, 3rd edition. Schaumburg, IL: La Leche League International, 2003.

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Worries About Foremilk and Hindmilk - Nancy Mohrbacher

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A little knowledge can be a dangerous thing. This has never been so true as in the ongoing debate about foremilk and hindmilk and their impact on breastfeeding. The misunderstandings around these concepts have caused anxiety, upset, and even led to breastfeeding problems and prem

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'Semi-demand feeding' can be a simple key to giving your baby the start they need.

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We all love and need to eat! It makes us feel good and gives us the energy to do things in life.
Human babies are no different in this need. They want to eat when fuel is needed and then feel content. Where they do differ from adults though is in their ability to get their food.

Once out of the womb, human babies are dependent on adults to create the right conditions to enable them to feed. If this is breastfeeding, the baby needs to be in full body contact with its mother's body, on its tummy in an alert state (not too groggy after birth) so it can step, crawl, push, feel, smell and see its way to the breast. If the feeding is to be by bottle, the baby needs holding in an appropriate manner so it can drink safely from it.

We as adults all recognise that babies need feeding soon after birth. Birth, after all, means the ending of the constant food delivery system that baby's been used to for many months. The drip-feeding from mother to baby via the placenta and umbilical cord has to be replaced quickly so that blood sugar levels stay steady. This is why - in Baby Friendly hospitals in particular - there's an emphasis on getting babies to feed within the first hour.

Why then do I come across - on the national telephone helplines, in groups, in private practice - so many situations where, within the first week, the baby has either become very jaundiced and sleepy, or very unsettled and crying a lot, weight gain is stalling or even still sliding down, mother may feel her breasts have never become very full, and baby is being topped up with formula out of desperation? What happened after the laudable effort to get baby breastfeeding quickly after birth?

I feel it lies in a continuing misunderstanding of the frequency of newborn feeding. The word 'frequent' is used a lot. But how frequent is frequent? Nils Bergman says it could well be hourly in the first days. Jill Bergman reminds us that the stomach empties a milk meal in 60 minutes; that the sugar content of milk lasts just 60 minutes; that the proteins in human milk come in low concentrations which also need topping up every hour; and that the normal sleep cycle of a baby from deep to light sleep states is also approximately every 60 minutes. It's known that a full-term baby can use its brown fat stores for several hours after birth if for any reason access to the breast is limited. But by day 2 of life, the baby needs to be receiving additional fuel from the breast and from then on needs to feed a lot. Very often though, a lot of asking to be fed is interpreted as something inadequate about mother's milk quality or production; and mothers may be counselled to rest after the effort of labour. These are misguided concerns and can be very detrimental for the future of the breastfeeding journey.

The baby, nevertheless, is primed to want to ask to feed a lot. S/he's been anticipating the necessity to feed frequently and has been doing a lot of practice in the womb. At 15 weeks gestation, swallowing starts; at 21 weeks, tongue cupping (like it would be around a breast) has been observed; at 22-24 weeks the baby is doing consistent swallowing of amniotic fluid. The volumes it swallows are big compared to when it starts swallowing colostrum after birth. These volumes of colostrum are small: for some it's 2-10 mls per feed, for others it's 5-7 mls per feed on day 1. For the baby who has been accustomed to bigger swallows in the womb, it's a real incentive to keep going back to the breast to ask for more - and this is just what the breasts need for stimulating the onset of full milk production within 72 hours of birth. So even if the feed volumes seem small, if the baby goes to the breast a lot, then the small amounts add up to an appropriate amount of intake. By day 2 the intake may be 5-15 mls per feed with an average total of 150mls per day; by day 3 it's increasing to approximately 15-30mls per feed totalling an average intake of 250mls per day. As can be seen, there are some babies who will need to feed more often to get an overall adequate amount of milk.

Which babies need more attention paid to how often and how effectively they feed? The baby who arrives early, a baby who is a lighter weight, a baby who is producing high amounts of bilirubin, the baby of a mother who had gestational diabetes or who is diabetic - these babies have compromised reserves (less brown fat stores) and increased demands. Babies born earlier than 39 weeks (and especially those 34-37 weekers) have immature systems which means that they're at much greater risk of under-nutrition, hypoglycaemia and jaundice. We know in addition that these will compromise their breastfeeding skills: babies need energy in order to be able to feed robustly so as soon as they're not getting enough fuel (for any of the reasons above), they feed even less well. How often do we hear of the baby who can just about get to the breast but falls asleep almost immediately?

Unfortunately, even though early and smaller babies are most at risk, they're not the only ones. Full-term babies can quite quickly drop into this risky place of not getting enough calories. These well-known and often used phrases - "be led by your baby", "feed on demand", even "responsive feeding" - can unwittingly cause insufficient breastfeeding for a baby. Separation of mother and baby - even if it's just into a bedside cot - takes baby away from the habitat it needs to achieve breastfeeding. Jill and Nils Bergman have written extensively about the need of the human infant to be in the mother's chest zone, in order for it to signal and then follow-through its intention to breastfeed. The baby not on mother (or on some other aware adult's body) may do some wiggles or head-turning or a bit of grimacing or move its eyes under its eyelids and then drift back to sleep again - and that is a feeding opportunity missed. The full blown cry or very obvious hands in mouth aren't every baby's signal and it can be easy to miss the more subtle signals of a less alert baby, especially in cultures where a sleeping and quiet baby is preferred. As the minutes tick by and baby's energy flags a little more, the cues may become even less obvious - so it's confusing for a mother to be "led by her baby" if the baby appears to be 'saying' nothing.

I believe we need to be explicit with new parents about the importance in the earliest days of life of keeping baby adequately energised. They need to be aware of possibly quite subtle signs from their baby of wanting to feed; and that if a baby is sleeping more than expected (the birth could be having an impact here), then it's vital to get milk into baby. This is "semi-demand feeding", when parents observe their baby closely, step in and make the decision themselves to feed baby, getting those all-important calories in, using a spoon or finger-feeding tube or syringe if baby is too sleepy to actively breastfeed.

This is where breastmilk production needs to happen too. Mother needs to be expressing in order to facilitate the normal course of breastmilk production if baby is already not stimulating her breasts appropriately. Hand-expressing colostrum (which has more fat by this method) on to a spoon is ideal; and if it's done more than 5 times daily in the first 3 days of life, the rate of breastmilk production is influenced for up to 8 weeks.

In addition, unlimited skin-to-skin will help to achieve better attachment, meaning good latching and effective milk transfer. But good attachment only really works if the calories are going in to baby quickly and repeatedly in the first hours and days after birth. If there's any compromise for baby in how well it feeds - due to separation, birth interventions, size, earliness, jaundice, musculo-skeletal effects from in utero positioning or birth - then mother needs to follow the Three Keeps, neatly summarised in The Womanly Art of Breastfeeding: keep baby fed, keep baby close, keep milk flowing out of the breast.

Feeding every 60-90 minutes may seem a lot to start with - so women need support and encouragement and skilled assessement of good positioning, their breasts and the state of the baby. It can help if parents are reminded to think of the breast replacing the frequency of food passing through the umbilical cord; and if they can be reassured that as baby's energy levels are kept high through lots of milk giving, the feeding frequency will tame down somewhat - then mothers will always try to do what they know their baby needs.

Let's ditch "3 hourly" from our breastfeeding vocabulary. Let's instead encourage parents to be vigilant - to be "semi-demand feeders" if necessary - and to feed babies really little and often with the hopeful result that lactation specialists will see fewer and fewer infants who simply need more milk. Calories, breastmilk production and good attachment are what all babies need, frequently (perhaps hourly for some), effectively and comfortably at the start of life.

Sources:
Nancy Mohrbacher, 2012.
Jane Morton, GOLD 2010; GOLD 2016.
Jill Bergman, 'Hold your Prem', 2010.

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We all love and need to eat! It makes us feel good and gives us the energy to do things in life. Human babies are no different in this need. They want to eat when fuel is needed and then feel content. Where they do differ from adults though is in their ability to get their food.

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What does - and doesn't suggest that there might be a milk supply issue.

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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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A 38 minute 'Quick Start' video featuring a lot of laid-back techniques. But the site will try to sell you other products....

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Natural Breastfeeding - Love to Love Breastfeeding

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Hand-expression can have benefits that make it a valuable addition or alternative to pumping

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Diana West, BA, IBCLC

Originally published January 2015 and republished with the express permission of the author.

I was a new mother struggling with low milk production and a baby who wouldn't nurse when the first effective "consumer grade" breast pumps were invented. I'd been renting a hospital-grade pump to remove my milk, but the idea of owning a good quality pump that was more portable enticed me to buy a double-sided electrical model. It looked so cool! It was in a black bag designed to look like a briefcase so it could be carried to work discreetly. I wasn't working, but I loved the way it made me feel efficient and smart. I was in the first wave of breastfeeding mothers to flock to this type of pump, and millions have been sold over the years.

Knowing what I've learned since those days, my heart sinks to think I put such stock in a cool looking pump when my own two hands could have done a better job. But expressing my milk by hand never crossed my mind then. My impression of hand expression in those days was as a last resort when a good pump wasn't available. My mind has changed quite a bit since then.

I now see hand expression as far more powerful than pumping in many ways.Research has shown that it can be more effective at removing milk in the first days after birth when the colostrum is thick and the breasts are swollen. ¹ Pumping colostrum leaves only sprays on the side of the bottle that are hard to give to the baby, but hand expression into a spoon saves every drop. Hand expression can also be used as a technique during and after pumping to increase caloric content 2 and remove more milk. ³ It can be more reliable than a pump when electricity is scarce. It's quieter than a pump when privacy is needed. It's certainly less expensive than a pump. But I think the most powerful aspect of hand expression is the way it affects our perception of our breasts and what they can do.

Many young women have an uncomfortable relationship with their breasts before they become mothers. They're usually aware of the sexual aspects of their breasts before they think about their ability to make milk. As an erogenous zone, women often feel it's more appropriate for their partners to handle their breasts than to touch them themselves. There can be a delicate balance between breasts as sexual power and targets of sexual vulnerability.

Many women have discovered that learning how to hand express during pregnancy helps them feel more comfortable touching and handling their breasts. I jokingly call this "making friends with the girls" when I suggest the idea to a client. That usually makes her laugh and lightens the mood, but there's some real truth to it. One study found that learning hand expression during pregnancy increased mothers' confidence and readiness for breastfeeding. ⁴ Another study found that it increased not only breastfeeding confidence, but also how long they breastfed. ⁵ Experimenting slowly with hand expression to figure out what it takes to get drops of milk can be empowering, especially during pregnancy before there's any pressure to express milk for the baby.

In my experience, there's no one right way to hand express. When I was nursing my first baby almost 20 years ago, I remember being taught the Marmet Method of Milk Expression, which was developed by Chele Marmet, one of the pioneers of the lactation consultation field. Over the years, there have been several other official methods, many of which are now demonstrated on YouTube. But I think hand expression methods are best used as a starting point to figuring out what works best on your own individual breasts. We're all different, and what works for you might be different than what works for me. The one movement that I find helps no matter what else you do is to move the skin over the breast tissue instead of sliding your fingers over the skin. You'll also almost always get milk to spray by compressing just behind the areola where there's a sort of "sweet spot."

Getting to know the landscape of your breasts and the way they work can help you start to think of them as your breasts. You may feel a slowly growing pride as you see that they can feed and soothe your baby. You'll start to appreciate their superpower. After a few days of nursing, you may realize that your breasts are your connection to this baby with whom you are falling so deeply in love. That's the power of hand expression.

Resources
LLLI Hand Expressing LLLGB Hand Expression of Breastmilk LLL USA, Working and Breastfeeding: My Experience with Hand Expression Stanford School of Medicine demonstration video: Hand Expression of Breastmilk. Maya Bolman, IBCLC and Ann Witt, MD, FABM, IBCLC. The Basics of Breast Massage and Hand Expression.
The Womanly Art of Breastfeeding, 8th edition. Schaumburg, IL: La Leche League International, 2010, 292-293.

¹ Ohyama M, Watabe H, Hayasaka Y. Manual expression and electric breast pumping in the first 48 h after delivery. Pediatr Int. 2010 Feb;52(1):39-43.

² Morton, J., et al. "Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants." Journal of Perinatology 32.10 (2012): 791-796.

³ Morton J, Hall JY, Wong RJ, Thairu L, Benitz WE, Rhine WD. Combining hand techniques with electric pumping increases milk production in mothers of preterm infants. Journal of Perinatology 29.11 (2009): 757-764.

⁴ Forster DA, McEgan K, Ford R, Moorhead A, Opie G, Walker S, McNamara C. Diabetes and antenatal milk expressing: a pilot project to inform the development of a randomised controlled trial. Midwifery. 2011 Apr;27(2):209-14.

⁵ Flaherman VJ, Gay B, Scott C, Avins A, Lee KA, Newman TB. Randomised trial comparing hand expression with breast pumping for mothers of term newborns feeding poorly. Arch Dis Child Fetal Neonatal Ed. 2012;97:F18-23.

Diana West, BA, IBCLC, is an LLL Leader and one of the co-authors of the LLLI books The Womanly Art of Breastfeeding and Sweet Sleep. She is co-author with Lisa Marasco, MA, IBCLC, of The Breastfeeding Mother's Guide to Making More Milk, and with Dr. Elliot Hirsch of Breastfeeding After Breast and Nipple Procedures. She is also author of the Clinician's Breastfeeding Triage Tool and Defining Your Own Success: Breastfeeding After Breast Reduction Surgery.

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The Power of Hand Expression | La Leche League International

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Diana West, BA, IBCLC Originally published January 2015 and republished with the express permission of the author. I was a new mother struggling with low milk production and a baby who wouldn't nurse when the first effective "consumer grade" breast pumps were invented. I'd been renting a hospital-grade pump to remove my milk, but the ...

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Another video from 'Raising Children'

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Video transcript

Narrator: Getting a good attachment is an important step towards getting breastfeeding working for you and your baby. Becoming skilled at it can take time. Having you and your baby calm and relaxed is the first key step towards getting a good attachment to the breast. One thing that can help is to recognise the things your baby does to tell you he's ready for a feed, like turning his head from side to side with his mouth open.

To start the feed, hold your baby in close, along your forearm so that her chest is touching yours. Remember to bring your baby to your breast and not your breast to your baby.

Narrator: Bring your baby's nose directly opposite your nipple. As your baby tips her head back, her top lip brushes over your nipple. This encourages her to open her mouth wide. When her mouth is wide open, hug your baby to your breast and she can take your breast into her mouth with her chin leading. When your baby attaches well, she will have a large mouthful of breast in her mouth and your nipple will be positioned far back in her mouth, towards her soft palate. Breastfeeding will more likely feel comfortable and she can get the milk she needs.

So here is how it will look to you. Bring your baby's nose directly opposite your nipple. Allow your baby's head to tip back. As it does, her top lip will brush over your nipple. This encourages her to open her mouth wide. Sometimes it can take a few goes to get the timing right. So you can encourage her to open her mouth wide again by brushing your nipple over her top lip.

When her mouth is open wide, quickly hug her onto your breast directing your nipple towards the roof of her mouth. This helps achieve a deep attachment where your nipple is deep inside your baby's mouth towards her soft palate.

When your baby is attached well to your breast, her chin will be touching your breast and her nose is clear or only just touching your breast. Her lips are flanged out, not sucked in. There will be more of your areola showing above your baby's top lip, as compared to her lower lip.

You also know you have good attachment if there is no pain, although it is common for some mums in the early weeks to feel some nipple pain that ceases after the initial attachment.

At the start of the breastfeed, your baby sucks will be fast and shallow as she gets the milk flowing, by triggering the reflex that allows the milk to flow. After this, she will do groups of deeper, slower, suck and swallows.

Swallowing can be identified by a soft tick sound and also by a pause in her chin when it drops down to its lowest position when she has a mouthful of milk. The longer the pause in her chin, the bigger the mouthful. Rest periods between sucking are a normal part of breastfeeding too. As the breastfeed continues, the groups of sucks and swallows gradually become shorter and the rest periods longer.

Most of the time a baby will come off on her own accord when she is finished with that breast.

If you feel nipple pain beyond the initial attachment, you can try attaching your baby again. To break the attachment, avoid pulling your baby away from your breast. This could cause more pain and damage your nipple. Instead, break the attachment by inserting a clean finger into the corner of your baby's mouth between her gums. Gently but firmly press down on her lower gums and remove her from the breast.

Every mother and baby have slightly different ways of attaching to the breast. Doing what works best for you and your baby is important. So long as breastfeeding is comfortable and your baby is getting enough milk, exactly how you position and attach your baby doesn't matter. You can find out more about whether your baby is getting enough milk in our common questions video.

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Breastfeeding: getting a good attachment

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Good attachment is key to successful breastfeeding, but how do you make it happen? This video shows you how to do mother-led attachment to the breast.

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Detailed referenced article exploring issues around sleep training, habits and expectations.

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COULD it be that parents typically receive advice about their babies' sleep which doesn't improve night waking, undermines breastfeeding, worsens sleep distress for the whole family, and even places certain vulnerable babies at increased risk of behavioural and developmental problems in later childhood? Right now, given the widespread promotion of sleep training by our maternal and child health services and infant sleep businesses, daring to ask this question may be construed as outrageous, even dangerous.

The belief that we need to entrain the biology of an infant's sleep through extinction or graduated extinction methods in order to make life manageable for mothers (see Table) arose in the 1950s and 1960s, when the new psychology of behaviourism (now known as the "first wave of behaviourism") swept the English-speaking world.

First wave behaviourism was quickly adopted in the care of mothers and babies, at a time when easy, workable breastfeeding was in demise. I was obliged to study "mothercraft" as a Year 9 Queensland schoolgirl in the 1970s, where we drew clocks illustrating the 4-hourly feed routine, and learned the same first wave behavioural principles that characterise sleep training today:

"Good sleeping habits should begin in the earliest months of life, for habits learnt in babyhood are likely to last into childhood.

"So much sleep is needed because his body is growing quickly and his brain is developing very fast and his nervous system develops best when he is asleep. If he does not have sufficient sleep and rest, he will not grow so well, he will be nervous and fretful, and when overtired will not eat his meals well.

"Some form of routine is good for the baby because .... good habits are formed which will last him all his life. His nervous system develops best in calm, unchanging surroundings ...

"Do not play or talk to the baby ... when he is supposed to be going to sleep. Do not awaken the baby to show him to visitors."

Queensland Maternal and Child Welfare Service school handouts, 1974

With the rise of the evidence-based medicine movement from the 1990s, this government-sponsored approach to infant sleep was picked up as a researchable package, and subsequently promoted as evidence-based.

But does the research really prove sleep training's efficacy?

Senior figures continue to argue forcefully that it does, despite the failure of large randomised controlled trials to back these claims ( here, here and here), and despite systematic reviews showing no improvement in night waking, nor reliable impact on maternal mental health ( here, here, here and here). Parents continue to be warned that their child is at risk of poorer sleep and cognitive development if they allow "bad sleep habits" to persist, yet large studies fail to show that sleep training improves sleep habits in later childhood, or that longer sleep durations are linked with improved developmental outcomes ( here, here and here). Many parents do not want to use first wave behavioural approaches, but are led to believe it's necessary for their own mental health and for their baby's best outcomes.

Over the past decade, sleep training programs have been wrapped in the language of "responsive parenting", "secure attachment" and "gentleness". These words acknowledge the importance of responding to the baby's cues for secure attachment and optimal brain development: few health professionals recommend leaving infants alone to cry for indefinite periods these days. But parents soon discover that these sleep programs nevertheless promote patterns of not responding directly to, or ignoring, various baby cues over and over throughout the day and night (see Table), resulting in parent-baby communication confusion.

The UK has a cultural tendency to delay responses to the baby from birth. London newborns whose parents practice delayed responses cry for about half an hour in the night at 2 weeks of age, with a greater chance of a 5-hour block of uninterrupted sleep at night by 3 months of age. But this occurs in the context of the worst breastfeeding rate in the world. London babies also cry twice as much as those of Copenhagen parents, who have high breastfeeding rates and a cultural tendency to more responsive care ( here and here). Both not breastfeeding and cry-fuss problems are linked with increased risk of postnatal depression.

In the meantime, sleep training ignores underlying factors that lead to excessive night waking. First wave behavioural strategies may worsen night waking over time, due to disruption of the circadian clock caused by an emphasis on long daytime naps ( here and here). Sleep training not only fails to identify those breastfeeding problems, which commonly result in excessive night waking in the first months of life, but worse, it undermines breastfeeding success due to feed spacing.

In my 30 years of general practice experience, a great deal of iatrogenic anxiety and distress results from first wave behavioural advice in infancy. This heightened sleep anxiety is predicted by the adult sleep science, which tells us that a focus on sleep worsens sleep.

But most health research originates in tertiary settings, or is driven by career researchers in university settings, and does not translate into clinical practice in the community. Moreover, as argued by John Ioannidis, Professor of Medicine at Stanford University, published research findings are often false; interpretative biases affect even systematic reviews. The Open Science Collaboration claims that two-thirds of published research in the psychological sciences is unreliable. I mention these concerns not to devalue our scientific endeavours, but to emphasise the importance of an open mind and vigorous debate.

There is a link between sleep problems in infancy and sleep and behavioural problems in later childhood in a subgroup of individuals ( here and here), and also evidence that sleep architecture changes rapidly in the first few months of life. These findings are assumed to prove that families should sleep train in the first months to prevent "bad sleep habits" and impaired capacity to learn in later childhood. But the link between unsettled behaviour in the first months and sleep and behavioural problems in later childhood could also be explained by the early application of first wave behavioural approaches, which are culturally mainstreamed and which disrupt parent-baby communication, altering developmental trajectories and placing susceptible individuals at risk ( here and here). The exquisite neuroplasticity of the first months of life equally suggests that this may be a particularly risky time in which to attempt sleep training.

Leading primary care researcher Professor Trisha Greenhalgh explores the impact of research rhetoric on policy. When sleep training advocates claim that their programs "increase sleep", they are illustrating the power of research rhetoric. Sleep training helps a baby under 6 months of age lie in the cot without signalling for an extra half an hour at night. But parents commence sleep training because they are led to believe it will decrease the frequency of night waking, which is most often not the case ( here, here, here and here).

We experience the power of research rhetoric when a single, methodologically flawed study concerning first wave behavioural interventions for infants of average age 11 months makes the international news, alongside photos of newborns and the headline Controlled crying not emotionally harmful to babies - and then appears as an app for parents ( here and here). "Evidence-based" has become, as Professor Ioannadis argues, a marketable brand, and we see this operating in the profitable infant sleep industry.

A joint Mayo Clinic and Stanford University team argue that when a "Big Idea" has been found to fail in the research despite extensive investigation, proponents often continue to call for improved methodologies and more financial investment, when a resetting of the focus and innovation is required. According to the Open Science Collaboration, in the face of discredited findings, an ideological response "discount[s] the arguments, discredit[s] the sources, and proceed[s] merrily along". This is happening in the world of infant sleep research.

Neuroprotective Developmental Care approach to parent-baby sleep ( the Possums Sleep Program) has been developed in the severely underfunded and devalued backwaters of clinical primary care research. It applies a generalist's lens to integrate the neuroscience, psychological attachment, third wave behaviourism, lactation science, adult sleep science and evolutionary biology literatures ( here, and here).

In the same way that we've flipped our approach to infant allergy, recognising that the widespread prescription of maternal elimination diets for unsettled behaviour in breastfeeding babies over the past 2 decades has actually predisposed our children to allergy, or in the same way we've flipped our approach to obesity, recognising that calorie- reduction diets may actually increase weight gain, it's time to flip our approach to parent-baby sleep.

At the very least, parents should have the opportunity to choose between options when they come seeking help for baby sleep problems.

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Babies and sleep: a matter of choice | Possums for parents with babies ™ - Official Site

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COULD it be that parents typically receive advice about their babies' sleep which doesn't improve night waking, undermines breastfeeding, worsens sleep distress for the whole family, and even places certain vulnerable babies at increased risk of behavioural and developmental problems in later childhood?

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What really happens when mums breastfeed and co-sleep

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Researchers propose ‘breastsleeping’ as a new word and concept

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p(image-right). !http://news.nd.edu/assets/176054/200x/bed_sharing_300.jpg(Bedsharing)! As far as titles in academic journals go, it’s quite the atte…

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Would sold foods make your baby sleep better?

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Would sold foods make your baby sleep better?

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Sleeping like a baby. Ekaterina Pokrovsky/Shutterstock

New research claims that giving babies solid foods at just three months old will help them sleep. Though this may sound appealing to exhausted new parents, unfortunately there is a large gulf between the headlines and the data.

Much of the published evidence in this area actually shows the opposite, that what a baby eats has nothing to do with their sleep. In 2015 we found that neither breast nor formula milk, timing of solids introduction, nor the amount of solids eaten affected how often babies woke up at six to 12 months.

Another study has found that the common practice of adding rice cereal to a bottle before bed (which should be avoided as it can cause choking) has no impact on sleep at four months old. While a third found that early introduction of solids was associated with less sleep at 12 months old.

The recent study is an excellent example of how statistically significant differences and real world differences can be miles apart. The authors themselves note that no difference in waking was seen until five months old, despite one group having solids from three months.

From then, babies in the early introduction group may have technically slept more, but this amounted to an average of just seven minutes more a night. At its maximum (six months old) the difference was 16 minutes. Most babies in the study still woke up once or twice a night whatever they were fed. And given these figures are based on the self-reporting of sleep deprived parents - which often does not match up to sleep recordings - this is not a basis for making major changes in infant feeding practices.

There is no physiological reason why introducing solid foods early would help a baby sleep. First, babies (after the first few weeks) do not simply wake at night because they are hungry. Just like adults, they wake because they are cold, uncomfortable or simply want comfort. The difference being that they cannot always soothe themselves back to sleep.

Second, even if it were for hunger, the most sensible solution would be to offer additional milk, as it will give more energy, fat and protein than any other food you can give a baby. The aim of the trial from which this data came was not to increase overall energy intake, but to test how introduction of allergenic foods at three versus six months affects the development of allergies (which it did not).

The parents were advised to give very small amounts of allergenic foods (such as one egg, 25g fish and 100g yogurt spread over a week - just a few spoonfuls a day) alongside rice, cereals, fruit and vegetables. All of these foods are lower in calories than breast or formula milk but take up more room, meaning babies might even eat a little less as they get used to weaning - a potential explanation for the larger sleep gap at six months as the standard group got used to food.

Solid sleep

Less than half of the parents in the early introduction group stuck to the protocol. A variety of reasons were given but a major issue with introducing solids early is that babies are simply not physiologically ready. At three months, many may only just have good head control. They won't be able to sit up properly. They still have a gag reflex that pushes food out of their mouth. Earlier introduction of solids can be messy, time consuming and demoralising, as babies simply aren't equipped to be eating solids so soon.

OLJ Studio/Shutterstock

Research shows that the earlier a baby is weaned, the longer it takes them to eat anything other than a few tastes. One study found if babies were given solids before four months it took them six weeks on average to eat just 100ml of food per day, but it was just 12 days for those weaned at the recommended six months.

The guidelines to introduce solid foods at six months are there for good reason. There is no deficit to growth or nutrient status in waiting until six months to introduce solid foods, but there is an increased risk of gastrointestinal and respiratory illnesses in infants given solid foods before then.

Introducing solids too early can lead to a reduction in breastmilk intake (and its associated antibodies), introduction of contaminants, and can cause digestive difficulties as babies do not develop all the enzymes needed to properly digest solid foods until between four and six months old.

It should also be noted that the babies in the study were a very specific group. Nearly all were breastfed until six months old - 97%, compared to just 34% in the UK population. Research shows that breastfeeding through introduction to solid foods is important in reducing allergy development, but often early introduction of solids increases risk of stopping breastfeeding.

Great care must be taken in generalising these findings. The research begs the question, does introducing solids early - with all its associated risks - really carry more weight if it comes with a few minutes of sleep every night? It seems to me that we should be asking why parents are struggling with sleep so much and seek better ways to support them instead.

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Giving your baby solid food early won't help them sleep better

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New research claims that giving babies solid foods at just three months old will help them sleep. Though this may sound appealing to exhausted new parents, unfortunately there is a large gulf between the headlines and the data. Much of the published evidence in this area actually shows the opposite, that what a baby eats has nothing to do with their sleep.

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School of Health & Social Care, Swansea University

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Positive info about feeding expressed milk or formula

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Emma Pickett
IBCLC, Lactation Consultant and Breastfeeding Counsellor

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Responsive Bottle-Feeding - Attachment Parenting UK

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We know bottle feeding isn’t just about the milk. It’s also about holding the baby in a particular way & responding to cues.

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What Men can do to support Breastfeeding

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What Men can do to support Breastfeeding

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Dads, family members, friends, colleagues...all can play a part.

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Why is there still this stigma attached to mothers who breastfeed in public? Where does this disapproval come from?

It's worth remembering that many mums breastfeed in public with no problems at all, never receiving any negative comments or even a raised eyebrow. But we know new mums worry about it and a minority do experience problems.

We live in a society where breasts are primarily sexual. Breasts are perceived as being about attraction and when our breastfeeding rates are so low, breastfeeding isn't always seen as 'normal'. Some imagine a new mother is being provocative and sometimes the fear of potentially seeing a breast is more the worry than the reality. Breastfeeding rarely shows anything, but people fear otherwise.

Many people in the UK didn't get to breastfeed for as long as they wanted to. Or they may have lived at a time when breastfeeding wasn't promoted and bottlefeeding was seen as the way forward. When they see a mum breastfeeding in public that can sometimes bring up feelings which cause them to subconsciously behave strangely. It certainly isn't just men who have problems with breastfeeding in public. When we hear of the rare cases of people making comments, it can often be a woman.

It's also about new motherhood generally too. The public often rolls its eyes at a new baby being restless in public or a new baby in a public space. We often forget that babies are little people who are allowed to be part of family life, feel emotions and eat when they're out and about.

And for the record, what are the benefits of breastfeeding for mum, baby and dads too?

How long have you got? The benefits for baby are immense and lifelong. We are learning more every day about the constituents of breastmilk and the amazing things they can do. In the short term, the baby that is breastfed is less likely to experience colic and gastroenteritis and be re-hospitalised in the first year of life. They are less likely to have infections and allergies. The Lullaby Trust also explains how breastfeeding reduces your baby's risk of cot death. Even if a baby only receives some breast milk, they will receive antibodies tailor-made by that by their mother to help protect against infections in the environment. Breastmilk contains stem cells. It contains something called alpha lactalalbumin which is a protein that kills cancer cells. This is perhaps one of the reasons that breastfeeding is connected to reduced risk of childhood cancer.

For the mother, it protects against breast and uterine cancer and osteoporosis. There is also evidence that suggests it protects against diabetes for both mother and baby. It also has a protective effect against developing postnatal depression. You can read more about the research around breastfeeding on the UNICEF Baby Friendly website.

For the dad, it means a baby that's less likely to get unwell, a partner that receives protection, less faff when travelling, loved ones who can stay in bed at night, less cost, less impact on the environment.

Breastfeeding is much more than a medicine and some food. It's also nature's way of creating a secure trusting comforted baby with bonds to its parents, protected against the world when its immune system is just getting started. It's true that not every mother can breastfeed exclusively. And when someone can't breastfeed, there are ways to bottlefeed in a way that are as responsive as possible. But for the vast majority, breastfeeding works out with access to the right support, both in terms of breastfeeding expertise and particularly in terms of support at home.

Read more from Emma about supporting breastfeeding here.

Visit the Association of Breastfeeding Mother.

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How can men support breastfeeding? | The Book of Man

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Why is there still this stigma attached to mothers who breastfeed in public? Where does this disapproval come from? It's worth remembering that many mums breastfeed in public with no problems at all, never receiving any negative comments or even a raised eyebrow.

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More ideas on positive ways to deal with visitors...and a link to another article about making the most your babymoon.

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For my last 2 babies, my midwife had a piece of paper she taped to my front door before she left after the birth. Announcing to visitors that there was a new baby in the house, it shared birth facts such as weight, length, name, date, etc. That part was nice but what I really loved was the part about what visitors could do. Informing them that a new baby means help is needed and that their visit should be brief, this little piece of paper taped to my front door encouraged those that loved us and wanted to celebrate with us to keep their voices low, limit their time, understand if we needed to be alone, and give them ideas of how to help such as offering to do the dishes, sweep a floor, run the vacuum, or take the bigger kids to the park. In short, it helped our visitors figure out how to be the best kind of visitors and I discovered that I didn't mind having people stop by as much as I did with my older kids simply because they helped more and were more understanding of our needs. Knowing they already saw a notice of sorts on the front door before they came in made it easier for me to respect my own boundaries, excusing myself to rest or not feeling awkward about them asking if they could help with something around the house.

There are far too many expectations on families when they have a new baby. Respecting the postpartum recovery and the important bonding that needs to happen with the new family member sets up families to continue on well for the long haul. If you're breastfeeding, this time is crucial to establishing your breastfeeding relationship and focusing on that will have a long term pay off. Pushing for too much too soon, other people interfering with the bonding, can leave moms feeling burnt out and unwell months, maybe even years later. Having true support and help to take the time to really heal leads to endurance in the parenting journey. That, and knowing we're not alone along the way.

So my gift to you is my version of this life-saving piece of paper. Ask your care provider to sign it complete with the appropriate initials behind their name then stick it on your front door when your little one arrives and leave it there for at least 6 weeks (8 if you birth via c-section). Be a good friend and print it off to give others that are expecting for them to put on their front door. Don't hesitate to point out the note, referring to it by asking if they saw how much baby weighed or how long she was and if they didn't notice, encourage them to go check out the info posted on the front door. It can be hard to ask for help yet not allowing others to help ends up creating isolation and robbing others of the joy of offering support and encouragement by helping. This little bit of guidance can help not only the new mom and family but the friends and family that want to offer quality support but just aren't sure what is needed. Take the guess work out of the picture and everyone wins.

new baby help sign for front door

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Help them help you- new baby sign with ways for visitors to help

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For my last 2 babies, my midwife had a piece of paper she taped to my front door before she left after the birth. Announcing to visitors that there was a new baby in the house, it shared birth facts such as weight, length, name, date, etc.

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Information which may help you decide if they are a good choice.

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How to keep things simple, easy and fun.

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Introducing solids to your baby can feel like yet another complicated thing that you have to do right. Just when it feels like you've finally cracked milk feeds, someone brings up the idea of starting solids.

'Have you thought about when? You must introduce / delay as much as possible'

'Are you going to spoon-feed or let your baby feed themselves?'

'Are you sure they need that much milk / don't need more milk?'

It's unsurprising that this can all start to feel a bit exasperating. Suddenly you're worrying about what, when and how much your baby needs. But need it really be this stressful?

Moving your baby onto a solid diet is an important stage, yes. But it's not the rush and precision exercise many will lead you to think it is. In the midst of all the conflicting advice you will likely get, here are 10 evidence based things to think about that will help you make the best choice for you and your baby - and stop you getting too overwhelmed in the process.

1. Try to delay solids until six months.

Research has shown that there is generally no benefit in starting any earlier, but the risk of gastroenteritis can go up if you start earlier. And besides, six-month-old babies are a lot easier to feed than 4-month-old babies as they can sit up, chew and swallow food. Far more of your carefully chosen offerings are likely to actually go in rather than around your baby.

2. The first few months of solid foods are about tastes and textures, not amounts.

Babies actually need very little solid foods until they are a year old and these foods should be the best possible choices. Estimates of how much a baby needs from food between 6 - 8 months suggests less than 200 calories. Choose wisely - choices should complement milk (hence the name complementary feeding), not replace too much of it.

3. On that note, milk should still be a major part of the diet.

You do not need follow-on formula, whatever the adverts might tell you, whether you're breast or bottle-feeding. First stage formula is more nutritious than second stage. There is no need to switch. Breast milk does not suddenly lose all its nutrients overnight at six months. Milk is one of the most energy dense and nutrient rich foods you can give your baby. Reduce it as you introduce solids but bottle fed babies will still need around 600ml a day at 6 - 8 months and breastfed babies should be fed on demand.

4. Commercial baby foods are fine occasionally and can be convenient.

However, they tend to be high in sugar and lack the range of textures home-cooked food provides; so don't give them all the time. Be careful with how much you give your baby too. Many of the jars have too much food in them for one meal for a younger baby.

5. Remember the baby food industry is there to sell products

The more you buy of their product the better for them and the worse for your pocket. Baby foods are really expensive compared to their non-jarred and 'adult' equivalents. You really don't need a load of devices and ... stuff... if you don't want it.

6. Whatever approach you take to introducing solids, remember the importance of responsive feeding.

What really matters is looking to your baby and matching their pace. Whether you're offering finger foods or puree, baby jars or home made - feed slowly, looking whether your baby wants more. Don't try to encourage them to eat or finish a meal if they don't want to. They know best how hungry they are.

7. Baby-led weaning makes a lot of sense but it might not be right for everyone

A baby-led approach promotes good choices such as delaying solids, family mealtimes and responsive feeding, but that doesn't mean spoons and purees are evil. If you don't want to baby-led wean you can still follow these steps. Let your baby sit with you at meal times and have some finger foods. Offer foods to play with - it helps them learn about textures and might help them be better eaters.

8. Foods are sadly not magical.

They will not help your baby sleep despite what your mother in law says. Weaning foods are often low in calories and end up displacing milk so your baby might even eat less. And besides, babies wake for lots of different reasons, not just hunger - just like adults do. Feeling cold, wanting a drink, or just needing to be close to someone - but babies can't sort those things out for themselves.

9. If a baby is hungry, or a big baby but not yet six months old, the best choice is to give more breast or formula milk.

Milk is energy dense. You can make enough breast milk for your bigger baby - after all the body can adapt to feeding twins or more. As above, weaning foods are lower in calories than milk and more difficult to persuade a young baby to eat.

10. Relax. It is likely your baby is getting enough.

We have survived for millennia without weaning guides and specific schedules for types of foods and nutrients. Offer your baby a wide range of foods, tastes and textures and keep giving them lots of milk. Your baby will let you know if they are hungry!

Dr Amy Brown discusses these steps and more in her new book Why Starting Solids Matters out now, published by Pinter and Martin.

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babies weaning when to feed baby solids solids baby-led complementary-foods parents parents

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Introducing solids to your baby can feel like yet another complicated thing that you have to do right. Just when it feels like you've finally cracked milk feeds, someone brings up the idea of starting solids. 'Have you thought about when?

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Practical helpful information if you need to give your baby other milk

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Babies sometimes need more milk than they can take at the breast. This may be because they were born early or small, and don't yet have enough energy to do all the work of breastfeeding. Sometimes, mothers don't have as much milk as their baby needs. It is important that babies get enough milk to be healthy and to grow normally.

La Leche League groups welcome anyone who is breastfeeding or providing their own milk for a baby, or trying to do so. Please don't feel awkward about needing to give your baby extra milk at an LLL meeting! We would love to meet you and your baby!

Get support from LLLGB here.

Why a baby might need extra milk
How to tell if your baby is getting enough milk
Normal growth
Why protecting the milk supply is urgent
Why a mother might not be able to make a full milk supply
Giving extra milk - what kind of milk
Mothers' feelings about using formula milk
Extra milk - how to give it
Extra milk - when to give it
Extra milk - how much to give
Reducing the amount of extra milk
What if you need to keep using formula milk?

Why a baby might need extra milk

The most common reason for a baby to need extra milk is a slow start with breastfeeding, when not enough milk was removed from the mother's breasts in the early days after birth. This can happen when a baby is early, small, unwell, very sleepy, or unable to breastfeed at first. It can also happen when a baby isn't taking a deep enough mouthful of breast tissue to breastfeed effectively. In this case, the mother may get sore, damaged nipples and the baby may seem unhappy and unsatisfied, never wanting to let go of the breast. When not enough milk is removed, the mother's milk supply doesn't get a strong enough signal to increase to the level the baby needs.

You can read more about this here: My baby needs more milk.

How to tell if your baby is getting enough milk

When young babies aren't getting as much milk as they need, the first sign is usually that they don't poo as much as expected. A baby over 3 days old who isn't doing at least 3 yellow poos - the size of a 2p coin or larger - every 24 hours needs to be checked by a healthcare provider. After about 6 weeks, babies find their own pooing pattern, which may be less often. As long as the baby is well and growing normally, it doesn't matter by this stage how often they poo.

Weight loss is another important way to tell whether a baby is getting enough milk. Babies usually lose up to 7% of their birth weight in the first 3-5 days after birth. If they lose more than this, or keep losing weight after day 5, they need to be checked by a healthcare provider.

You can read more about this here (is my baby getting enough milk?) and here (what's in a nappy?).

Normal growth

Babies usually get back to their birth weight by 10-14 days after birth. In the first 3-4 months of life, boys grow at an average of about 40g a day, and girls at an average of 34g a day. A baby who puts on less than 30g a day on average, or whose growth curve drops down across more than one "centile line" on their weight chart, needs to be checked by a healthcare provider.

Why protecting milk supply is urgent

Whatever the reason, when a baby isn't taking as much milk as she needs at the breast, the mother's milk supply may not increase enough to meet all the baby's needs. Milk supply usually increases quickly in the early days after birth, reaching its peak level by the end of the first month. Most of this increase happens in the first 2 weeks, so the amount of milk that is removed at this time is really important. If too little is removed, it may limit how much milk a mother can make later.

When breastfeeding is going well, a baby nursing at the breast will remove milk much more effectively than any breast pump. However, if your baby isn't breastfeeding at all yet, or isn't taking as much milk as he needs at the breast, it is important to start expressing your milk as soon as possible. This will ensure that your body gets the signal it needs to make more milk. Babies who are not breastfeeding effectively may want to spend a lot of time at the breast, so it can be difficult to find time to express milk. Given the importance of protecting your milk supply at this stage, it may be necessary to limit the baby's time at the breast to free up enough time to express. This is an investment of time to make sure you have enough milk later. Find good breastfeeding support as soon as possible.

You can read more about expressing and storing milk here.

Why a mother might not be able to make a full milk supply

Occasionally, a mother may have a medical history or health issues which limit the amount of milk she can make. These reasons can include:

A history of infertility due to hormonal imbalances

Past breast surgery, especially breast reduction

Breast hypoplasia/Insufficient Glandular Tissue (IGT) - breasts may be unusually small, unevenly-sized, long and thin, with a wide space between them and there may be no breast changes (such as increase in size and tenderness) during pregnancy

PCOS (polycystic ovary syndrome)

Thyroid problems (over- or under-active)

Obesity (BMI over 30)

If any of these apply to you, you may still be able to make milk normally. However, if your breastfed baby isn't growing well it is important to find good breastfeeding support quickly.

Giving extra milk - what kind of milk

The first choice when extra milk is needed is your own expressed milk, which is tailor-made for your baby. The second choice is donated milk from another mother. This may be available from a Milk Bank if your baby is still in hospital.

You can read LLL's policy on informal sharing of breastmilk here.

When none of these is available in the amounts needed, infant formula milk may be necessary. If you are not sure what kind of formula milk to use, check with your midwife or health visitor. You can find independent information about infant milks in the UK here.

Mothers' feelings about using formula milk

When you were looking forward to breastfeeding your baby, it can feel disappointing to realise that he needs formula milk as well. You might even wonder whether it is worth carrying on breastfeeding, or whether your baby will come to prefer formula milk. It can help to think of formula milk as a kind of medication, to give your baby the energy he needs to breastfeed well. Babies are "hard-wired" to breastfeed and even a small amount of breastmilk can have a significant positive effect on health outcomes that no formula can provide. Even if your milk supply is very low, you and your baby can still enjoy the cuddly, calming, comforting aspects of breastfeeding, for as long as you want to. Breastfeeding is about much more than just milk!

Extra milk - how to give it

There are several options for giving extra milk to a baby.

In the first 1-2 days after birth, when the baby needs small amounts, a teaspoon can work well. You could express your own milk directly into the spoon and use it to feed the milk to your baby. On day 1 after birth, a full feed is about 7ml (1 ½ teaspoons), on average. On day 2 after birth, this doubles to about 15ml (3 teaspoons) per feed. Newborns need at least 8-12 feeds in 24 hours.

By day 3, something larger is needed. Cup-feeding can work well, with practice. You can use any clean cup - a small one, such as a shot glass, can work well. Trying to feed your partner or support person with a cup of water and having them feed you in return can help you quickly learn how far to tip the cup so that your baby can sip from it.

A nursing supplementer (also known as a lactation aid) is a tool that lets you feed extra milk (either expressed milk or formula milk) while your baby breastfeeds. It can be useful if you want to breastfeed but don't have enough milk. The extra flow of milk can encourage your baby to breastfeed. You can read more about supplementers here.

If bottles are used, it is important to know how to use them in a way that supports breastfeeding. It is easy to feed a baby too much, too fast by bottle, and this can be unhelpful for a baby who is finding breastfeeding difficult. You can find out how to do "paced" bottle feeding - at a good speed for your baby, letting him choose how much to take - here.

Extra milk - when to give it

It is often suggested that you breastfeed first, before giving the extra milk. This often means that the baby is at the breast when he is hungry and least happy, which can make breastfeeding stressful for both of you.

An alternative might be to try ending feeds with your baby at the breast. This may mean starting with some extra milk, to calm your hungry baby enough to help him breastfeed. Or you could start with one breast, give the extra milk in the middle, and finish on the second breast. It's much nicer for your baby to fall asleep at your breast than with a cup or bottle!

Even if your baby isn't breastfeeding much or even at all yet, spending happy time being at or near your breast will make it easier for him to breastfeed when he is ready. Carrying your baby in a sling, cuddling him skin-to-skin, taking a bath together and lying down together in a prepared bed ( if it is safe for you and your baby to do so) are all good ways for him to spend relaxed time at the breast. Babies who feel comfortable at the breast are more likely to try breastfeeding when they are ready. You might like to give the extra milk with your baby's cheek resting on your breast, letting him fall asleep on the breast as he finishes.

Extra milk - how much to give

Healthy, full-term babies are usually very good at knowing how much milk they need. If you are giving extra milk by cup or bottle, carefully watch your baby for signs that he wants more or has had enough. Your baby can show you how much they want.

Sometimes, though, a baby is so early, unwell or sleepy that they are not able to ask for as much as they need. A baby who has been getting less milk than he needs for a while may act as if he is not hungry, because he doesn't have much energy. He may look as if he is finished after a very short feed, but he will not be pooing or growing as expected.

When this happens, it is important to encourage the baby to take more milk. Keep your baby close, doing skin-to-skin as much as you can. This will encourage your baby's interest in feeding, and help you to notice the first signs that he is waking up and getting ready to feed. Your baby may only be able to feed for a short time, so he needs to do it very often. Feeds don't have to be equally spaced, but they need to happen at least 8-12 times in 24 hours. It can be helpful to record the number of feeds, along with the number of wet and dirty nappies he has done each day.

When your baby is growing and pooing as expected, he is taking as much milk as he needs.

It is important to keep in close touch with your healthcare provider during this time. If your baby starts doing fewer wet nappies, or it is getting more difficult to wake him to feed, please contact your midwife or doctor straight away.

Once your baby starts to take more milk, his energy will increase. He will start to catch up with his growth, and he might want a lot more milk. Don't panic! Give him as much as he wants, making sure that you feed carefully if using a cup or bottle, so that he can stop when he has had enough. Once his growth has caught up with where it needs to be, his appetite will calm down.

Reducing the amount of extra milk

If your goal is to feed your baby only with your milk, you will be wondering how to reduce the amount of donor or formula milk your baby is getting. It is important to work with your healthcare provider and your local breastfeeding supporters to come up with a plan tailor-made for you and your baby.

Read our article on Weaning from Supplements here.

What if you need to keep using formula milk?

Sometimes, however hard you try to increase your milk, your baby might need to keep having some formula milk. This might be an important part of his diet, or even most of it, but remember that breastfeeding is about much more than just milk. If you ask mothers of older breastfeeding babies or toddlers what they and their babies value about breastfeeding, they usually forget to mention milk! They talk about how much their babies enjoy it, how useful it is for calming them down and getting them to sleep, and how restful it can be for the mother to sit or lie down to feed. Breastfeeding can still work really well in all these ways, whether or not the baby is also having some formula milk.

It is sometimes possible to stop using formula milk after the baby has started eating other foods, usually from around 6 months. As your baby eats more food, he will need less milk. It is often possible to reduce the amount of formula he takes while still breastfeeding as much as you like. After a year, babies can drink unmodified animal milk (such as cow's milk or goat's milk) and no longer need formula milk. You can continue to breastfeed for as long as you and your child want to. Many mothers who have needed to use formula milk in the early months of their child's life find that the later months and years of breastfeeding are much more enjoyable, because they no longer need to think about how much milk their child is getting.
Written by Jayne Joyce, LLL Oxfordshire, June 2018

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Using donor milk and formula to support breastfeeding - La Leche League GB

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Babies sometimes need more milk than they can take at the breast. This may be because they were born early or small, and don't yet have enough energy to do all the work of breastfeeding. Sometimes, mothers don't have as much milk as their baby needs.

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Info from the Australian Breastfeeding Association

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Yes, babies can drink from a cup! It may seem a bit awkward but they just need a little practice.

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Specific info from the Samaritans about talking to someone who may be having a tough time - in effect a revision of good listening skills

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Find a good time and place

Choose somewhere quiet, where you won't be interrupted and the other person feels comfortable. Make sure you both have enough time to talk.

If you say the wrong thing, don't panic

Don't be too hard on yourself. If you feel able to, you could try something like: "Last week I said ... and I realise that was insensitive, so I'm sorry. I'm still here for you."
Focus on the other person, make eye contact, put away your phone.
To really listen to somebody, you need to give them your full attention, maintain eye contact and be engaged.

Getting into this habit takes practice so don't be too hard on yourself and keep using these handy tips:

When starting the conversation resolve not to talk about yourself at all.

Keep a listening diary - just for a week. Record how many times you listened really well, note what challenges and distracts you and what you think went well.

Aim to learn at least one new thing about the person who is talking to you.
It may take time and several attempts before a person is ready to open up.
Effective listening is about creating trust with the other person. The person sharing shouldn't feel rushed, or they won't feel it's a safe environment.

If they've paused in their response, wait, they may not have finished speaking. It might take them some time to formulate what they are saying, or they may find it difficult to articulate what they're feeling.

Through non-judgemental listening, you are allowing the person to relax into the conversation and to use it as a place to reflect or work through difficult emotions.
Use open questions that need more than a yes/no answer, and follow up with questions like 'Tell me more'.
An open-ended question means not jumping in with your own ideas about how the other person may be feeling.

These questions don't impose a view point and require a person to pause, think and reflect, and then hopefully expand.

Avoid asking questions or saying something that closes down the conversation. Open-ended questions encourage them to talk, the conversation is a safe space that you are holding for them and nothing they say is right or wrong. Try asking, 'how are you feeling today'?
Check you've understood, but don't interrupt or offer a solution.
Repeating something back to somebody is a really good way to reassure them that they have your undivided attention. And you can check to see that you're hearing what they want you to hear, not putting your own interpretation onto the conversation.
Don't be put off by a negative response and, most importantly, don't feel you have to fill a silence.
Sometimes it can feel intrusive and counter-intuitive to ask someone how they feel. You'll soon be able to tell if someone is uncomfortable and doesn't want to engage with you at that level.

You'll be surprised at how willing people are to listen and how, sometimes, it is exactly what somebody needs to be able to share what is going on their mind.

Once a person pauses I count to three in my head. This gives them time to elaborate further if they need to. It also shows you are thinking about what they are saying which will hopefully give them confidence to keep talking.

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Choose somewhere quiet, where you won't be interrupted and the other person feels comfortable. Make sure you both have enough time to talk. Don't be too hard on yourself. If you feel able to, you could try something like: "Last week I said ... and I realise that was insensitive, so I'm sorry.

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Postnatal depression can affect women in different ways. It can start at any point in the first year after giving birth and may develop suddenly or gradually.

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Postnatal depression: the questions you really want to ask

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Postnatal depression: the questions you really want to ask

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What is postnatal depression?

Postnatal depression (PND) is the most common perinatal mental health disorder women experience in the first year after having a baby (NICE, 2014). Between 10% and 20% of women have depression and anxiety in pregnancy and after birth (Coates, 2016). PND is an illness and will get better in time.

Watch our video below where three mums talk about what it feels like to experience postnatal mental health issues.

How do I know if I have postnatal depression?

A good place to start is NHS Choices' depression screening tool. Women who are concerned should make an appointment to see their GP or call 111.

Feel proud of yourself for seeking help because recognising that you're suffering from postnatal depression is the most important step to getting better (Boots Alliance Trust, 2013). It's probably also the hardest step.

Is postnatal depression like other forms of depression?

Yes, in a lot of ways. Like depression at other times in life, it can be mild, moderate or severe. It can come on gradually or suddenly. (NICE, 2014)

The main difference though is that it can be a lot trickier to recognise. That's because your mental state is likely to change in the weeks and months after you have a baby anyway (NICE, 2014). You will also have such a lot going on around you.

When do people get postnatal depression?

It usually comes on within six weeks of giving birth although it can emerge up to a year after your baby is born (MIND, 2017). While postnatal depression should dissipate within a few months, 30% of people with PND will still be ill after the first year (NICE, 2014).

What are postnatal depression symptoms?

They can include:

feeling down and teary

an inability to concentrate

low sex drive

feeling worthless

inability to feel happiness

sleep problems

anger

finding it difficult to leave the house

overeating

problems bonding with your baby

suicidal thoughts.

(Boots Alliance Trust, 2013)

PND often goes unreported, why is that?

A terrifying 30% of new mums with perinatal mental health problems had never talked about it to a professional (Boots Alliance Trust, 2013).

First, this is because symptoms can be difficult to recognise when your life has just gone through such a large shift anyway (NICE, 2014; NHS Choices, 2017). And there's another reason: women worry that people will judge them or even that social services may take away their baby from them (NICE, 2014; Ayers and Delicate, 2016).

Try to remember that postnatal depression doesn't mean you are doing anything bad. It just means that you're suffering from an illness and deserve to get some help.

How do I know if I'm at risk of postnatal depression?

You can't really but there are a number of risk factors. You're more likely to get postnatal depression if you:

have an ongoing mental health problem

have a family or personal history of PND

have had a traumatic birth experience like a stillbirth

live in a bad or violent social or economic situation

are a refugee or asylum seeker

have a history of childhood or adulthood abuse

have poor social support.

(RCOG, 2011; NICE, 2014; Ayers and Delicate, 2016)

Speak to your GP or midwife if you think you are at risk of postnatal depression.

Is it important to get help for postnatal depression?

Yes. By speaking to your GP, midwife or health visitor and accessing the right treatment and support, you can get better (Shakespeare, 2015). If not, it can have major consequences for your mental health, your relationship, your partner's mental health and the development of your baby (Fatherhood Institute, 2010; Howard et al, 2014; Ayers and Delicate, 2016).

Treatments to try include talking therapies like cognitive behavioural therapy (CBT) or anti-depressants (talk to your GP for advice if you're breastfeeding) (NICE, 2014; NHS Choices 2017). If postnatal depression becomes severe or develops into postpartum psychosis, you might need a stay in hospital or mother and baby unit (RCOG, 2011; NHS Choices, 2017).

Is there anything else I can do to help?

Yes, here are a few self-care tips:

1. Build a support network and make time to meet friends and other mums for a much-needed cup of tea and a chat (NEF, 2008).

2. Accept offers of help. It might be your mum dusting your living room or your best friend walking your newborn around the block so you can lie down. Whatever it is, take it (Boots Alliance Trust, 2013).

3. Make time for a run or rejoin your old netball team. Exercise can work wonders for the way you feel (Cooney et al, 2013). It is also a great long-term practice for safeguarding your mental health (NEF, 2008; NHS Choices, 2017).

4. Try to eat healthily and regularly, and cut back on caffeine and alcohol (NHS Choices, 2017).

5. Get showered and dressed, even if your plan for today is to go no further than the back door to put some nappies in the bin (MIND, 2017).

6. Be mindful - apps like Headspace can help improve your mental wellbeing and help you to deal with daily challenges (NEF, 2008). You can even practice mindfulness on the sofa while your newborn is feeding.

7. Keep a mood diary. It can help you notice how people, places and activities affect your mood (MIND, 2017).

8. Sign up to a baby massage class at NCT or with your local children's centre through a referral from your health visitor (NHS Choices, 2017).

9. Contact local or national specialist organisations - they may offer the opportunity to talk to other women who are going through the same thing. Services available might include a dedicated telephone helpline, a buddy service, online support, support groups, counselling and wellbeing sessions.

This page was last reviewed in June 2018
Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

You might find attending one of our Early Days groups helpful as they give you the opportunity to explore different approaches to important parenting issues with a qualified group leader and other new parents in your area.

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby.

Contact specialist organisations like PANDAS for more help and support with postnatal depression.

Ayers S, Delicate A. (2016) Recognising and acting on perinatal mental health. Perspective; 32. Available from: https://www.nct.org.uk/sites/default/files/related_documents/Ayers%20and%20Delicate%20Recognising%20and%20acting%20on%20perinatal%20mental%20health.pdf [Accessed 1st December 2017].

Boots Family Trust Alliance. (2013) Perinatal mental health: experiences of women and health professionals. Available from: http://www.bftalliance.co.uk/the-report/ [Accessed 1st December 2017].

Coates R. (2016) Broadening the net: assessing the full range of perinatal mental health problems. Perspective; 32. Available from: https://www.nct.org.uk/sites/default/files/related_documents/Perspective-September-2016_0.pdf [Accessed 1st December 2017].

Cooney GM, Dwan K, Greig CA, Lawlor DA, Rimer J, Waugh FR, McMurdo M, Mead GE. (2013) Exercise for Depression. Cochrane Database of Systematic Reviews; (9):CD004366. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004366.pub6/full [Accessed 1st December 2017].

Fatherhood Institute. (2010) Research summary: fathers and postnatal depression. Available from:

http://www.fatherhoodinstitute.org/2010/fatherhood-institute-research-summary-fathers-and-postnatal-depression [Accessed 1st December 2017].

Howard LM, Piot P, Stein A. (2014) No health without perinatal mental health. The Lancet; 384(9956):1723-1724 Available from https://www.ncbi.nlm.nih.gov/pubmed/25455235 [Accessed 1st December 2017].

MIND. (2017) Postnatal depression and perinatal mental health pages. Available from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/postnatal-depression-and-perinatal-mental-health/postnatal-and-antenatal-depression/#.WcozHYokqRs [Accessed 1st January 2018]

NEF (National Economics Foundation). (2008) Five ways to wellbeing. A report presented to the Foresight programme on communicating the evidence base for improving people's wellbeing. Available from: http://b.3cdn.net/nefoundation/8984c5089d5c2285ee_t4m6bhqq5.pdf [Accessed 1st January 2018].

NHS Choices. (2017) Postnatal depression pages. Available from: http://www.nhs.uk/conditions/Postnataldepression/Pages/Introduction.aspx [Accessed 1st December 2017].

NICE (National Institute for Health and Care Excellence). (2014) Antenatal and postnatal mental health. CG192. Available from: https://www.nice.org.uk/guidance/cg192/evidence/full-guideline-pdf-193396861 [Accessed 1st December 2017].

RCOG. (2011) Management of women with mental health issues during pregnancy and the postnatal period. Good Practice No. 14. Available from: https://www.rcog.org.uk/globalassets/documents/guidelines/managementwomenmentalhealthgoodpractice14.pdf [Accessed 1st January 2018].

Shakespeare J. (2015) Perinatal mental health: the picture today. Perspective; 26. Available from: https://www.nct.org.uk/sites/default/files/related_documents/Perinatal%20mental%20health-%20the%20picture%20today.pdf [Accessed January 2018].

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Postnatal depression: the questions you really want to ask

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Postnatal depression (PND) is the most common perinatal mental health disorder women experience in the first year after having a baby (NICE, 2014). Between 10% and 20% of women have depression and anxiety in pregnancy and after birth (Coates, 2016). PND is an illness and will get better in time.

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Providing formula feeding guidance is outside your boundaries, but you can encourage mums to follow good practice is making up, storing and using bottlefeeds. They should be able to get a leaflet from their HV or Googling 'UNICEF formula feeds' will provide reliable links such as this one.

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Guide to bottle feeding leaflet - Baby Friendly Initiative

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This leaflet provides families and health professionals with key information about bottle feeding and how to make up feeds safely.

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The Last Drop: Grieving the end of breastfeeding

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The Last Drop: Grieving the end of breastfeeding

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Childbearing women pass a lot of milestones, from the first time we hear our baby's heartbeat to the big twenty-four-week gender-revealing ultrasound. There's that magical thirty-seventh week, when the baby can be born without being called premature. Then there's the birth itself, and the two-week-old mark at which our previously angelic sleepers turn into fussy, non-sleeping demons. There's the point at which we can have sex again, and the day we resume menstruation.

But there's one significant milestone that we don't talk about. It's an intense, emotional moment that can be both bad and good all at once. It's the day the last drop of milk we'll ever make falls from our breast.

That's it. You're done. You've had your children and you're not having any more. Whether your baby is four months, a year, or two years, you've transitioned from supporting that baby with your body.

These thoughts have been on my mind as I move toward complete weaning of my last baby. I don't mean weaning from breast to a cup. My baby is no longer much of a baby at nearly two years old. He's talking and laughing and somehow saying "butthole" in front of guests. He's also still nursing once a day. I have only a trickle, but still we hold on because bidding adieu to those sweet days forever isn't as easy as I thought it would be. He's my second and last child. I'm moving into a period that is officially classified as perimenopausal. It hardly seems fair when I could still pop out a few more kids if I wanted.

I liken the feeling about the last drop to how I have a hard time giving away the last baby outfit or baby book, even though my kids clearly aren't going to wear or read them. That little zippered sleeper with the Winnie the Pooh adventure map printed all over in size 0-3 months? Yeah, that's tucked away in a box. It's not going anywhere. When I'm eighty, I'll pull it out and hold it and remember my children's babyhood. We become sentimental hoarders as our children become kids with their own personalities and wills. And although you might keep a frozen bag of breast milk that you pumped out in the early days of nursing, when your boobs were spraying milk like Tommy guns, hidden in the bottom of the freezer under a package of short ribs, you know you really can't keep the last drop.

Emotion over the end of nursing your baby picks up speed when you see other people continue to drip. My neighbor and I were pregnant at the same time with our second children. Both of us experienced aching, stiff pregnancies that left us cranky and less than eager to go through it again. I knew my second would be my last. My neighbor wasn't so sure. Less than two years later, she's pregnant again with her third. At first this horrified me.

Three kids? The expense! The chaos! The toddler tantrums compounded by three! But of course, that's three children to love and kiss. Three people sharing the cost of your nursing home is surely better than two, right? I could have another one! I'm healthy, still in my thirties. But I'm not going to. Instead, I'm moving on to a place of physical freedom, and my toddler is moving on toward school days and interests of his own-none of which will include my breasts.

The last drop my baby drinks will be my very last connection to the world of childbirth and babyhood. In her book The Nursing Mother's Guide to Weaning, author Kathleen Huggins says that the last drop of milk is our last connection with our childbearing bodies, and it's an unmarked but incredibly poignant moment. The World Health Organization recommends breastfeeding your baby for two years. The American Academy of Pediatrics recommends breastfeeding for the first year. However long we do it-even if for a few days-the last time your last baby sucks is the last time we have a part in that special babyhood time.

There's an emphasis in Western culture on moving quickly from nursing to fast, big-kid stuff, and we don't talk about this. We don't say, "Wait a minute! The last time we nurse matters!" It's the remaining connection to those nearly ten months the baby spent inside you. It's the last link to our ability to nourish and grow another human being, and maybe even the last time the bond with our baby will be as thick. Some women aren't as affected, of course-some don't consider it a milestone. Some are glad to be done with the mess and the tied-down feeling. I can certainly understand that. But when my friend Kate could no longer squeeze a drop of milk from her breast, she cried. For women who are forced to stop nursing before they want to, it's probably devastating.

There are good things that come with the end to nursing. We'll have more freedom-fewer ties to the baby, more time for ourselves. The physical toll on our bodies will decrease. Pregnancy and nursing gingivitis, we hope, goes away. The suck, if you'll pardon the pun, on our calcium supply lessens. When we take medications, we no longer have to pause because we're not in the "if you're pregnant or nursing, ask your doctor first" category. We can have guilt-free glasses of wine. And yet, that last drop is so final. Maybe it's because after we stop having children, we're old. We might as well be grandmothers. It's like saying we're no longer able to have children, which is a terrible feeling if you want to have them. Maybe it taps into a primal desire to reproduce, to mother, to nourish.

Whatever it is, my last drop of milk will truly be my last connection to that sweet quiet that descends when your baby leans into your breast to suck and the only sound is the gentle drinking sound and your heart and your baby's heart. I'll no longer be in the childbearing game. As my mother-in-law advised, "Enjoy that baby now. You won't get to again until you have grandchildren."

So while I look forward to that older stage of childhood, the interaction and conversations, the running and jumping and all-day adventures, and their ability to wipe their own butts, I'm going to have a moment of silence for that last drop.

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The Last Drop: Grieving the End of Breastfeeding

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Childbearing women pass a lot of milestones, from the first time we hear our baby's heartbeat to the big twenty-four-week gender-revealing ultrasound. There's that magical thirty-seventh week, when the baby can be born without being called premature. Then there's the birth itself, and the two-week-old mark at which our previously angelic sleepers turn into fussy, non-sleeping demons.

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Weaning Depression

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KellyMom.com - Breastfeeding and Parenting

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Sadness and depression during (and after) weaning - KellyMom.com

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It’s not unusual to feel tearful, sad or mildly depressed after weaning; some mothers also experience irritability or mood swings. These feelings are usually short-term and should go away in a few weeks, but some mothers experience more severe depression that requires treatment. What causes these moods swings, and are some mothers at greater risk?

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Paced and responsive feeding can help parents make the most of a close and connected bottle-feeding experience.

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Emma Pickett
IBCLC, Lactation Consultant and Breastfeeding Counsellor

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Responsive Bottle-Feeding - Attachment Parenting UK

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We know bottle feeding isn’t just about the milk. It’s also about holding the baby in a particular way & responding to cues.

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How to gently night-wean a breastfed baby or toddler

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How to gently night-wean a breastfed baby or toddler

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Breastfeeding is an amazing tool to help settle children at night. As a mother of four I have found that by far the easiest way to get my children to sleep at night was by breastfeeding them (well into the toddler years). Similarly when my children woke at night breastfeeding was by far the quickest and easiest way to get them back to sleep and resulted in more sleep for us all.

Science has found a link between an increased number of night wakings and breastfeeding. There is however also evidence to suggest that overall the length of wakings is less for breastfed infants which may actually lead to breastfeeding mothers getting *more* sleep than their formula feeding counterparts. For any parent who has both bottle and breastfed the ease of being able to breastfeed instantly compared with the time taken to make up and cool a bottle of milk is obvious. For this reason a night waking breastfed infant tends to require less overall parental input at night than a child who is formula fed.

Despite the widespread belief that formula fed babies sleep for longer than breastfed babies, research has found that any initial difference disappears by toddlerhood.

Many sleep experts claim that infants no longer require night feeds after six months of age. This is an incredibly naive belief. Nobody knows when a child is capable for sleeping long stretches of time without milk apart from the child itself. In addition this belief assumes that the night feed is providing nothing more than nutrition. The reality however is that night feeding allows a complex mix of emotional and physical needs to be met. The actual reality of night weaning readiness, in my opinion, occurs at some point between six months and four years of age.

While there is no guarantee that night weaning will result in improved sleep, for many families this is the case. I feel I should however point out that for many night weaning makes no (positive) difference. For some families it can even make the whole situation much worse, with night wakings increasing and parents left unable to settle the child as quickly and easily as they would have done if they were still breastfeeding at night.

For these reasons I would urge you to really think about night weaning and the potential impact on your family before you begin it. You should ask yourself these questions:
1. Why am I considering night weaning?
The only correct answer here is "because it feels right for me". If a seed of doubt has been planted by a doctor, health visitor, friend, family member or baby sleep expert don't proceed any further. Your child is normal. It is normal to feed at night well into the toddler years. Your child won't need to feed at night forever. Ignore the ill informed comments and carry on doing what works for your family.
2. Am I considering night weaning because I am exhausted?
This isn't a great reason to night wean in my experience. Sometimes night weaning can cause a child to wake more. Sometimes you are left with a child you can no longer settle at night without the ease of breastfeeding. Night weaning takes a lot of work - emotionally and physically with no guarantee of success. You may be better to look elsewhere to help with your exhaustion first. Is there anything you can downsize in your life? Are there any ways of taking more 'me time' and nurturing yourself? Are there any voluntary organisations near you who can help?
3. Am I considering night weaning because I am going back to work soon?
This is by far the most common reason people approach me for help with night weaning. I refer you to point number 2 above. In addition if you are returning to work, particularly full time, night times are an important time for your child to reconnect with you. Allowing them to stay close to you and feed at night can help to soothe any disconnect they may have felt by being away from you during the day. It can also help breastfeeding to continue while you are at work.
4. Am I considering night weaning because I am pregnant or want another baby?
Fertility/return of periods aside it is perfectly possible to continue night time feeding an older baby or toddler whilst pregnant or with a newborn. As with point number 3 this can help the older child to still feel connected, reducing any emotional effects (and resulting difficult behaviour - which often includes sleep regression) once a new family member arrives. See also point number 2.

If you still feel ready to progress with night weaning you need to put a plan into place. My personal opinion is that night weaning should never be considered before six months of age, and ideally not until a child is over one year.
Things to think about are:
1. Slowly conditioning your child to take comfort from objects that are not your breasts. More on this in a minute.

2. Finding time in your diary when nothing else is happening (no holidays/starting childcare etc.). If you are bedsharing/cosleeping do not be tempted to move your child our of your bed/room either before, or at the same time as, night weaning. The move to their own bed/room should happen after night weaning is established.

3. Helping older children to understand what is about to happen. I like this book.
Step by Step Night Weaning Plan.
If you would like to learn more about infant sleep, including many more sleep tips c heck out my latest book, available HERE:

p.s: Did you like this post? Want to read more similar content and receive weekly top tips, reader Q&As, hear my take on current parenting research and enter the odd competition? Then why not sign up to my new FREE WEEKLY NEWSLETTER and get the latest in gentle parenting delivered straight to your inbox. I promise I will never share your email with anybody else and if you don't like what I send you can unsubcribe straight away!

About SarahOckwell-Smith

Sarah Ockwell-Smith, Parenting author and mother to four.

This entry was posted in Babies, Toddlers and tagged baby sleep, baby won't sleep, gentle sleep coach, gentle sleep training, night weaning, nightweaning, sleeping through the night, stop night feeds, stopping night feeds, toddler sleep, toddler won't sleep, weaning baby from the breast, weaning toddler from the breast. Bookmark the permalink.

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How to gently night wean a breastfed baby or toddler

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Breastfeeding is an amazing tool to help settle children at night. As a mother of four I have found that by far the easiest way to get my children to sleep at night was by breastfeeding them (well into the toddler years). Similarly when my children woke at night breastfeeding was by far the quickest and easiest...

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Weaning Toddler Bob and Pre-schooler Billie

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Weaning Toddler Bob and Pre-schooler Billie

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Useful ideas for parents weaning or night-weaning older breastfeeders

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Billie is 3 years old. She breastfeeds in the morning, at bedtime and usually once during the night. Bob is 18 months. He is breastfeeding on demand. This usually means breastfeeding at least 6 times in 24 hours.
Let's imagine you are Bob or Billie's mum and you want to end breastfeeding.

First, let's take a moment to check this is a decision you are happy about. Am I going to try to talk you out of it? Nope.

I breastfed both my children until they self-weaned and I speak to mothers breastfeeding toddlers every day. I know it isn't for everyone.
You get to choose when you stop.
If you are in the tiny minority of mothers breastfeeding well into the second year and beyond, that is something to be celebrated and praised and baton-twirled.

The job of the breastfeeding support community is to enable each mother to reach her own breastfeeding goals. When it comes to breastfeeding an older child, we are allowed to listen to our own maternal instincts. Not everyone's maternal instincts tell them the same thing.

However this is an important decision so let's do a few checks.
Are you ending breastfeeding because you want to conceive again and you believe weaning will be necessary?
If you are 100% confident with your decision, feel free to skip to the row of asterisks.

Every woman's fertility responds differently to breastfeeding. To conceive, we need oestrogen levels to rise again and ovulation to occur and then we need the womb to receive a fertilised egg and give it enough chance to hang around and implant properly. Most women do not need breastfeeding to end completely for this to happen. However most of us do need at least one gap of 5-6 hours without any breastfeeding in 24 hours.

It might be worth experimenting with night weaning or extending intervals in order to trigger your period before ending breastfeeding entirely if you'd rather not. Get familiar with your cervical fluid (or as my friend Sarah Panzetta, a fertility expert, calls it, 'your lady liquid') and get a sense of what it's likely to look like when you ovulating (stretchy and egg-whitey). Some people are told they need to wean from breastfeeding in order to start another round of IVF. That is a very difficult and personal decision.
Are you ending breastfeeding because you need to take medication and the doctor says you have to?
We can probably say that is likely that you would be maximising your chances of conceiving by ending breastfeeding. You may still decide you'd rather continue breastfeeding.
Are you ending breastfeeding because someone else is putting pressure on you?
Check. Many many women are told this inaccurately. In the UK, the Breastfeeding Network is a great source of information - both their medication factsheets and the 'drugs in breastmilk' helpline. You can also check with LactMed or the resources (book and website) of Dr. Thomas Hale. There are many lactation consultants available through Twitter who would be happy to check for you.

Is this someone who you feel has a right to comment on your body and what you choose to do with it? Is it someone who you feel has as much right to make decisions about your child's health and happiness as you do? If you answer yes to both of those questions, then you may feel you want to listen.

However, you should also feel you have the right to explain very clearly why this matters to you and carry on. You have the right to continue even though other adults in your life are uncomfortable. Just because we live in a society which squirms at the idea of breastfeeding older children, it doesn't mean a push into unhappy weaning is the 'right' opinion. You have science on your side.

This is a decision you will live with for a very long time. You have invested a huge amount in making breastfeeding work up until now. For many women, it has taken literal blood, sweat and tears. You have spent hours and hours and hours breastfeeding. One day, decades from now, you may be a grandmother and breastfeeding will be part in your world again. Wouldn't it be great to look back with no regrets and know that you stopped breastfeeding at a time that was absolutely right for you?
Are you ending breastfeeding because you aren't getting enough sleep?
Your nursling can't speak up. If you are being pressured to wean when you don't want to, you may need to be brave and speak up for them.

One possibility is to night wean and see how that feels. It may enable you to continue breastfeeding for longer than you imagined you would. You can follow the suggestions below and pause at any point in the process.

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So we're going to try and wean Bob. He's breastfeeding a lot. He breastfeeds in the morning and at naptime. He falls asleep breastfeeding at the beginning of the night and breastfeeds during the night several times. He uses the breast for comfort when he feels sad or shy. It's the first thing he wants when he falls over. When you sit together on the sofa, he wiggles over and lifts your shirt with a big smile on his face. He loves it all.

Have you done anything wrong by parenting this way up until now? No, you have not. You have followed your instincts and met his needs and what a lucky little bloke Bob is.

This is clearly going to be tough and Bob may be sad but YOU ARE STILL ALLOWED TO WEAN. This is your choice and you will be able to make it happen with the minimum amount of upset if you are sensitive and careful.

Some things to bear in mind before we start:

This is not about milk - completely. This is about YOU. Bob is connecting with you and being as close to you as he possibly can. He is feeling safe and loved and cosy and warm. Your milk still contains immunological properties and Vitamin A and protein and all the other useful things. However Bob's breastfeeding behaviour is about security and love and not much about Vitamin A.

So don't offer milk in a bottle or sippy cup instead and not in response to a request to breastfeed. Don't offer milk in a cup at bedtime instead of that connection with you. That's like you asking a loved one for a hug and he gives you a sausage roll. You may be a big fan of sausage rolls but right then, in that context, that's a rejection.

We need to talk about ways of trying to avoid the 'rejections'. It may not be entirely possible but we want to minimise them as much as possible.

Don't offer another person instead. Does it seem entirely logical that at the moment we are pulling bits of ourselves away from our nursling, we pull our entire self away?

Does it seem logical to leave your toddler for a night or longer just to wean from breastfeeding when breastfeeding was about connecting with you as much as the milk?

We need to show that you are still there and you are still very much there for connecting - just not at the nipply bits.

You will still be there at bedtime when he feels scared and vulnerable. You will still be there for comfort. You will be there for him when he's going through this really tough transition of losing breastfeeding. Does it seem sensible to pull yourself away when he's potentially going to be losing something that really matters? You are the person he really needs to help him through this.

Of course partners and dads are a key part of this process but in addition to mum - not instead of. I hope daddy/partner is part of the bedtime process and able to comfort your child. I'm just not sure it's brilliantly sensible for you to be stepping away and leaving them entirely to it.

Together - all 3 of you (mum, partner and nursling) - you will be making new routines and patterns and developing a new parenting language.
First steps:
That doesn't take a night and it probably doesn't take a week. It might take a week for the 18 month old who is only breastfeeding a couple of times in 24 hours and falls asleep without the breast in his mouth - but that isn't Bob.

While it's true that this isn't simply about milk, Bob has been having quite a lot of milk which have met a lot of his nutritional demands and provided a portion of his hydration through the day. We need to look at his diet. Is Bob confidently using a cup? Would he be able to indicate if he was thirsty? Can he help himself?

What will be Bob's sources of calcium, protein, vitamins and minerals and good quality fats? It might be that Bob enjoys drinking cow's milk but he also might really not. Does he eat dairy? He would ideally get around 300ml of full-fat cow's milk a day. If he won't drink milk, he can eat cheese and yoghurt and you can use cream and butter in cooking. He might like a yoghurt-based fruit smoothie or a milkshake. There are other sources of calcium and other minerals like green leafy vegetables, nuts and tofu. Bob doesn't need to drink a commercial formula. Full-fat cow's milk is the recommendation.

Take a moment to reflect on what his nutritional sources will be. Do some research. He's been taking a significant portion of his calories overnight so you will need to look at extra snacks and opportunities to offer food once that's gone.

Now it's time to look at sleep skills. This may be the most difficult aspect of the process so we need to address it from the beginning because it could take the longest.
Night weaning
Bob right now has a prop dependency - a loving and comforting prop dependency. He's using the breast to aid his drop-off to sleep and he's using it to transition between sleep cycles at night. As he moves between sleep cycles, he fully rouses and seeks the breast to help him move on to the next sleep cycle. Some babies need dummies replugged or a pat. Bob has a breast as his sleep prop. For lots of mums, this is not really something that bothers them and it can continue until it naturally fades. But if you want to wean from breastfeeding, it's a problem for you.

You can't end breastfeeding until you have helped Bob find a new way to sleep. If we just take breastfeeding away suddenly, it's really not very fair. This has been the way Bob has fallen asleep for a very long time. Sleep time is often when we feel the most vulnerable and when we can really get into habits.

Imagine you'd always fallen asleep by putting your head on a pillow and turning out the light and thinking peaceful thoughts and someone suddenly announces sleep isn't allowed to happen this way anymore and you have to touch your nose with your thumb while whistling the star-spangled banner. You'd quickly become distressed and angry and think the whole thing was entirely unreasonable. You literally wouldn't know how to do it.

You would probably prefer to make any transition gradually and with the support of someone you love.

A really good resource for this stage is 'The No-cry Sleep Solution for Toddlers and Pre-schoolers' by Elizabeth Pantley. You may already have read about her 'pull-off' method in her book aimed at babies. You would start a feed as normal but then resist the temptation to feed right to the end when your toddler is in a deep sleep and absolutely out for the count. You would use your little finger and break the latch just before they completely fall asleep. The first time, it really would only be seconds before. You want them to do the final drop-off from drowsy to deep sleep without the breast actually being in their mouth. You are right there but the breast has been removed. If your nursling fully rouses at this point and searches for the breast, you may gently place your hand on their chin to see if they might still settle. If not, and they wake further, you latch them back on again and try a few moments later. Then, over several nights, you would gradually detach them earlier and earlier in the process. After a while, you may feed them and after the feed they may still pretty much be awake. It has been a gentle and slow process. They learn how to fall asleep without actually sucking. What then often starts to happen is the nursling who can do the final drop-off without the breast being in their mouth is less likely to rouse between sleep cycles during the night. They semi-wake (as we all do between sleep cycles at night) but feel safe about moving onto the next sleep cycle without needing their prop.

At the same time as working on the pull-off technique, you can work on introducing a different structure for bedtime. Before you even start, you could introduce a lovey - a comfort object that could become associated with sleep and bedtime. It could be cuddled between you during night time breastfeeds. Then as the feeds start to change, the lovey is still there. You could also think about singing a little song that is your 'bedtime song'. This is a song that you initially sing during the breastfeed and as the breastfeed fades, it's a new part of your routine. It might happen during the final cuddle or if they appear to rouse and be looking for comfort. It's calm and soothing and - this is the important bit - you don't mind singing it every night for a while. If you are feeling very creative, choose a tune you know well and write your own lyrics about your day and your loved ones. Or choose a little poem and phrase that says, 'this is sleep time now'.

As the breastfeeds end, the song or the poem is still there. It remains consistent. It's the sign that it's sleep time now. You are still there and we're just removing the prop of the breast.

As your nursling finishes a breastfeed more and more awake, you've got the chance to insert other things as your new 'final stage'. You could read a story. It is sometimes said that sharing a book with your toddler is more similar to breastfeeding than offering a cup or bottle of milk. You are devoting yourself to your child. You are sharing a connection. They have your attention and a cuddle.

There are even some books on the process of weaning and night weaning that you might find useful. I don't mean books for you about technique but picture books for both of you that will usually have illustrations of jolly toddlers and rested mothers greeting the sunrise. 'Nursies when the sun shines' is a classic example.

You could also make your own book. Make a photo book using one of the online photo companies about your night weaning journey. Toddlers at this age love seeing photos of themselves and their friends and family. It could just be something as simple as saying 'goodnight' to all the things he loves. And I dare you to have 'good night mummy's boobs' on the last page. 'See you in the morning!'

So the breastfeeding moves back further. After it comes the story and the song (bored of it yet?). Then one day, breastfeeding happens in a different room and then before bath and one day, it gets dropped. Perhaps that night something exciting happens instead - a new toy in the bath, some ice cubes to play with. The breastfeed is something that he will want to get out of the way to get onto the fun stuff.

Some people prefer to leave the bedtime breastfeed as the very last one that gets dropped when full weaning happens. You may have been working on daytime feeding while this whole process was going on. The point is though that we may need to start AND finish with the weaning the bedtime feed because the process of setting up a new routine could take a while.

When a nursling wakes up in the middle of the night, we can hopefully develop new techniques that help them transition without using breastfeeding. Ideally now that we've done the pull-off, we are getting fewer night wakings but we may still see some. What else will make your toddler feel calm and safe? You may be able to use some of those techniques from bedtime. The lovey is there. You can sing your special song and use your special phrases. You may stroke and pat. You may put on a gentle piece of music or white noise. You're going to be finding your own strategies.

There may be tears. It may be tempting to offer the breast because this is too difficult to manage. You have to follow your instincts. You may discover you are not ready to wean and you can cope with just one feed at night. You may decide that some tears of frustration are going to have to happen because you are absolutely ready to end this stage of motherhood. Try and be consistent.

Daddy/partner can be a great help but you also need to develop your boob alternatives now - the way you will show physical love and give your mothering comfort.
What about weaning breastfeeds in the daytime?
Some 18 month olds are verbal enough that they can understand that milkies are sleeping now and they will be awake in the morning - cuddles instead.

Once you have broken the sleep prop, the process will get easier. You will need to ensure of course that naps can happen without breastfeeding. Now the rest of the weaning is about distraction.

We are trying to avoid the need for refusal. This is a key aspect of weaning all older nurslings. You sometimes hear the phrase ' Don't offer, Don't refuse' used as a weaning technique. It will work for everyone in the end but sometimes we need to jiggle our day around so we don't actually get to the point of being asked if we want weaning to happen more quickly.

Once we get to the point of being asked, refusal means rejection. Not just a missing out on milk but a rejection from mummy. The request and breastfeed was a way that toddler communicated with you. He asked and it happened and it was magic. It was a dialogue between you that made him feel empowered and special. Really not just about the milk.

What other things can be ask for? Make a special box of books he can request. Make a snuggly book nest with pillows and beanbags. Instead of asking for a breastfeed, he could lead you by the hand and ask for a 'book cuddle'. Or a dance? Or a big squeezy cuddle with a raspberry on his neck?

You may need to restructure your day for a while - more time outside or at activities. Perhaps meals as a picnic if he normally asks for feed at the dinner table and climbs onto your lap. Perhaps moving the special chair where he normally asks for a feed. In the morning, it's a big hug and a scoop out of bed and a race downstairs to find the little ice cube tray full of fun snacks to avoid the morning feed. Or Thomas The tank Engine says good morning in a silly voice before mummy says a word. Distraction.

You may need to get up a little earlier for a while so you've got the energy to think ahead before he wakes and starts asking.

When you see the glint in his eye that indicates an 'ask' is on its way, think imaginatively. It's really not about offering a cup of cow's milk instead.
Pre-schooler Billie
Some toddlers will do really well with limits. Some are starting to become fascinated by counting. If you've not managed to avoid 'the ask', how about? "We'll have milkies for as long as it takes mummy to count to ten". Count as fast or as slow as you like. You are in control. Talk about what you will be doing next. If there's a big protest at the end of a feed? "OK, one more. Do you want 'count to ten' or 'count to eleven'?" He is control too.

A lot of the techniques will be the same for three-year-old Billie. She'll also need to learn how to drop to sleep without the breast and transition between sleep cycles in another way. It's likely she'll have a much greater understanding of what's going on and you can talk about your plans together.

You may decide to use a token system. Each morning you could give her 2 or 3 (or however many) tokens and she can swap them for breastfeeds at any time but she won't get new tokens until tomorrow. The tokens may be plastic gold coins (that one seems a bit too 'Wolf of Wall Street' for some) or perhaps little stretchy bracelets that she wears in the day and takes off each time she wants to 'buy' a breastfeed.

Again - you are both in control. She gets to decide whether to hold on to her tokens. When she requests a feed you might talk through her decision: "Are you sure? Because that means you only have one left for tonight? It's up to you but maybe check you're really sure." You may well find she gains comfort from keeping that last one 'just in case' and it never gets used. Gradually there are fewer tokens given.

She would also be old enough to talk about a weaning party or special treat. We don't want too much emphasis on the 'you're a big girl now' stuff because that sounds pretty scary. Big girls want cuddles and mummy too - but she might be ready for something new that celebrates her moving on.

It's OK to talk about what's happening. This is her first intimate relationship and you are teaching important lessons about empathy and understanding. Mummy's milkies are getting ready to stop breastfeeding soon. We will find new ways to give cuddles and be close. A three year old may also have ideas about a cosy reading corner and a new bedtime routine.

This might not be easy but you are allowed to stop. You have given such a magical gift to your child but that doesn't mean you have to continue breastfeeding beyond a point that feels right for you. I once heard a mother of a toddler say she simply couldn't 'bear' breastfeeding anymore. She counted the seconds in her head until each feed finished and felt physically uncomfortable. Is it in that toddler's interest for his mother to carry on?

If we say mothers of older nurslings are not allowed to wean, we will be frightening people of younger children who will feel stuck on a path. We do not want a world where mothers of nine month olds are ending breastfeeding because 'it's easier when they're younger'.

Breastfeeding can continue when it's right for toddler AND mother. It can also end when it feels right.

There are forums and Facebook pages with other mums in your situation who you may be able to share your decision and your journey with. You can make up your own rules. You may decide to pause along the way. Perhaps when you have finished night-weaning, it will suddenly seem more manageable for a while. Just see how you feel.

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Weaning toddler Bob and pre-schooler Billie: how do you stop breastfeeding an older child?

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Billie is 3 years old. She breastfeeds in the morning, at bedtime and usually once during the night. Bob is 18 months. He is breastfeeding on demand. This usually means breastfeeding at least 6 times in 24 hours. Let's imagine you are Bob or Billie's mum and you want to end breastfeeding.

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A sensitive leaflet from the USA

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Supportive info for the toughest of situations

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A woman's breasts start making colostrum during pregnancy. The timing of this varies from woman to woman. This article provides information on 'lactation after loss' and assists women to understand how they can manage and respond to the experience of making milk following a miscarriage, stillbirth, neonatal or older infant death. Not all women will experience lactation after miscarriage or stillbirth. Some women may experience a sensation of fullness of the breasts, while others will produce and leak milk. However your body responds, it is helpful if you, and those around you, understand how to manage the physical and emotional challenges that this can bring.

Women can experience a variety of emotions in response to their lactation after loss. Each woman and her family may want to manage their lactation differently. There are a variety of ways to manage this including:

i) Lactation suppression (stopping your milk supply)

ii) Sustained expressing

iii) Donation of your breastmilk (where available).

iv) Memory making using breastmilk.

This article will provide you with an overview of these options. The booklet linked to at the end of this article will go into these options in greater detail.

Although this article and the booklet focus on lactation after infant death, there may be other situations where a mother lactates after a loss, such as giving a baby up for adoption, being a surrogate mother or in the case of a child being removed by child protection authorities. In addition to these losses, there are many other reasons why you may want or need to suppress lactation such as:

You want or need to wean quickly for personal, work or medical reasons. Helpful resources about breastfeeding and medications can be found here.

You thought you had finished breastfeeding, but woke a few days later with very full breasts

i) Lactation suppression

Wear a firm bra both day and night to support your breasts and keep you comfortable.

Use breast pads to soak up any leaking milk. Change them as they become wet.

Relieve pain and swelling by putting cold/gel packs in your bra, or use cold compresses after a shower or bath.

Cold cabbage leaves worn inside the bra can also be soothing. Wash and dry the leaves before use and cut out any large, bumpy veins. Keep them in the fridge as they need to be cold. Change the leaves every 2 hours or when they become limp. Continue using the leaves until the breasts stop feeling overfull.

Handle your breasts very gently as they can bruise easily.

Whenever your breasts feel too full, express a little milk. Express only enough to make you comfortable.

Mild painkiller medications may help relieve pain. Your doctor will be able to advise you about this.

Drink when you are thirsty. Cutting down fluids will not help reduce your milk supply.

For the first few days you may be uncomfortable lying in bed because your breasts are so full. Try lying on your back or on one side with an extra pillow supporting your breasts. If you like to lie on your front, place a pillow under your hips and stomach to ease the pressure on your breasts. Place a soft towel or cloth nappy across your breasts to soak up any leaking milk.

There are some prescribed drugs that have been used to suppress lactation. Talk over the pros and cons of using lactation suppression drugs with your doctor before making a decision about whether they are necessary in your case.

If your breasts are firmly supported and you don't express milk more than needed for comfort, your milk supply will gradually decrease. Some mothers want to stop their milk from coming in or dry up their milk as quickly as possible.
Things to watch for and what to do Milk leakage
Most mothers will be able to suppress their lactation by limiting the volume of milk removed, wearing a firm bra, using cold packs or cabbage leaves and medication for pain and inflammation if required.

Use breast pads. Avoid any breast pads that hold moisture against the skin. Make sure your bra is roomy enough to hold whatever sort of pad you choose without putting pressure on your breasts. If you wear your bra to bed, take care that it doesn't dig in when you are lying down as this may lead to blocked milk ducts.

Stop the flow when necessary.If your milk starts to leak out strongly (ie your milk 'lets down') you can stop the overflow by pressing firmly on your nipple with your hand or forearm for several seconds.

Engorgement (painful, overfull breasts)
At times, you may experience milk leaking from your breasts during the lactation suppression process. Here are some tips to help with leaking breasts:

If your breasts become engorged and the ideas given above do not ease your discomfort, it may help to express all the milk in the breasts, just once, with an electric breast pump. This can relieve the pressure and from then on, you may be able to prevent it building up to that point again.
Blocked ducts and mastitis
Wear a firm bra and express only for comfort.
To treat blocked ducts and mastitis:

Apply warmth to the breast for up to a few minutes. Then express your milk.

Express every few hours to keep the breast as empty as possible. When the mastitis has passed, you can go back to reducing your milk supply.

While expressing, massage your breast gently.

If you can hand express, a good place is under the shower or in a deep warm bath with your breast supported by the water.

Between expressing sessions, use well-wrapped cold packs (a face washer cooled in the freezer, a frozen nappy wet with water or a first-aid cold pack) to reduce swelling and relieve pain. Cold cabbage leaves can also help in this situation.

Consult your doctor straight away if you have a fever, feel unwell, or if you cannot clear a blocked duct within a few days.

Anti-inflammatory medication may also help (speak with your doctor of pharmacist about this or call one of the numbers on our Breastfeeding and prescription medications article).

How long before the milk goes away?
When breasts are left very full, there is a risk that one or more of the ducts that carry milk to the nipple will become blocked. A lump forms and the breast begins to feel sore. Sometimes there is a red patch on the skin or the breast may feel hot. If the blockage remains, milk can be forced out of the duct and into the breast tissue, which becomes inflamed. You may get the shivers and aches and feel like you are getting the 'flu'. This is called mastitis and can come on very quickly. See your doctor if you get the flu-like symptoms or if you cannot clear a blockage within a few days. If this happens, you will need to express more milk than usual to clear the blockage. If mastitis is not treated, a breast abscess may develop. Fortunately, these are now quite rare.

How old your baby was and how much milk you were making, or your stage of pregnancy if you had not yet given birth.

How much milk is taken from the breast through expressing, let-downs and leaking.

How much your nipples are touched, such as in lovemaking.

Another pregnancy.

Some mothers find it takes weeks for their milk to go away completely. Others find that it takes days. You may notice milk stains on your bra or that you leak during or after a shower. You may even feel the let-down months or even years after losing your baby. Every mother will have a slightly different experience.

ii) Sustained expressing
This depends on a few things. These include:
iii) Donation of breastmilk after loss
Some mothers may not want to suppress their milk production after the loss of their baby. These mothers may appreciate the time expressing gives them to connect with and grieve for their baby. Mothers may want to continue to express their milk for days, weeks or even months. You can express as often each day as you like for as long as it suits you. The lactational amenorrhea method is an accepted and effective method of family planning and is a factor which may be relevant for some mothers to consider when expressing. Avoiding significant and sudden changes to your expressing regime can help reduce the risk of your breasts becoming engorged and blocked ducts.
iv) Memory-making using breastmilk
When you decide to wean from expressing, doing so gradually (eg by dropping one expressing session every few days or so) can help your breasts adjust more comfortably. For tips of expressing and storing breastmilk, see Expressing and storing breastmilk.
One step at a time
The milk produced by mothers can be kept, or used as a memento. Some mothers may wonder if the breastmilk they express can be used to help another baby. Many mothers have found that this is beneficial as the ability to help other babies has assisted with their grieving.

This option may not be available to all mothers. There are only a few human milk banks in Australia. Milk donors need to be screened by having blood tests before they can donate their milk. If you would like to know more about this, contact the milk bank in your state or territory, or ask your doctor or the hospital staff if there is one in your state which might accept your milk.
Helpful resources
There may be stores of your frozen milk at home or in the hospital. If you have frozen breastmilk stored in the hospital, you can approach the hospital staff to make decisions about what to do with these frozen stores of milk such as to discard it, keep it as a memento or donate it (if possible).

Some women have used their breastmilk in an activity or item to help create a memory. For example defrosting it and pouring it on a special plant in the garden, using it to make breastmilk jewellery, burying some milk with the baby, using breastmilk as a symbol in the funeral service, donating it. You do not have to make these decisions quickly. You can keep your milk in a freezer and take it with you if you move house.

It can take a long time to recover from the death of a baby. There will be times when you feel you have made some headway, only to fall back into the deep sadness of it all. You may find it hard to get to sleep or you may wake often. This is quite normal.

This is the time to be kind to yourself. Talking with others who have also have lost a baby may give you support and some comfort. Details of support groups are listed below.

Further information can be found in the ABA booklet Breastfeeding: lactation suppression.
Miracle Babies
There are also a number of organisations that may be of some help to you at this difficult time. These vary from state to state. Look in your local telephone book or on the internet for the following:

SANDS (Stillbirth and Neonatal Death Support) (phone 1300 072 637)

Red Nose (phone 1300 308 307)
© Australian Breastfeeding Association January 2020
Angel Baby Foundation (phone 1300 283 238)

The Compassionate Friends (NSW)

Cradle Inc NT)

These organisations may have comprehensive libraries with a wide variety of useful books and other literature for further reading.

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A woman's breasts start making colostrum during pregnancy. The timing of this varies from woman to woman. This article provides information on 'lactation after loss' and assists women to understand how they can manage and respond to the experience of making milk following a miscarriage, stillbirth, neonatal or older infant death.

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