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Tongue-tie support in Bexley, Bromley and Greenwich

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Tongue-tie support in Bexley, Bromley and Greenwich

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T-tie information for parents Aug 2026 PADLET V2

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South Warwickshire University NHS Foundation Trust

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If you are pregnant, call us to discuss your feeding options

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If you are pregnant, call us to discuss your feeding options

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BfN support in Greenwich

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Getting breastfeeding off to a good start

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Getting breastfeeding off to a good start

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Maximising breastmilk and re-lactation guidance

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Maximising breastmilk and re-lactation guidance

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Can I see Natural Breastfeeding positions in action?

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How compatible are medications with breastfeeding?

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How compatible are medications with breastfeeding?

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E-lactancia org українською. Чи можна приймати препарат / речовина при грудному вигодовуванні? | E-lactation

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Перевірити на сумісність препарату, іншої речовини з грудним вигодовуванням. Який ризик? Чи є альтернативи?

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Bottle Feeding Is Not The Only Way To Bond With Your Baby

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Bottle Feeding Is Not The Only Way To Bond With Your Baby

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Bottle Feeding Is Not The Only Way To Bond With Your Baby

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10 Top Tips For Introducing Your Baby To Solid Foods

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10 Top Tips For Introducing Your Baby To Solid Foods

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School of Health & Social Care, Swansea University

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10 Top Tips For Introducing Your Baby To Solid Foods

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Breast Engorgement - Video - Global Health Media Project

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This film shows a mother with engorged breasts and suggests ways she can try to resolve the condition.

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Continuous Skin-to-Skin Care - Video - Global Health Media Project

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A small baby held continuously in skin-to-skin contact, often known as kangaroo care, is kept warm, safe from infection, and will likely breastfeed sooner.

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Carrying Your Baby Skin-to-Skin - Video - Global Health Media Project

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Carrying your baby skin-to-skin, between your breasts, is the best way to care for your small baby. This continuous skin-to-skin contact, also known as

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Many mothers work outside the home and continue to breastfeed. LLLGB is here to help with information and support if you are going back to work.

I'm going back to work. Do I need to stop breastfeeding?
Why is breastfeeding so important?
But won't it be a hassle?
What are my options? Choose childcare carefully Consider expressing your milk Solid foods Making it work Somewhere to express Before you return to work Expressing
Working and breastfeeding Further reading

I'm going back to work. Do I need to stop breastfeeding?

There is no need to stop breastfeeding when you return to work. Returning to paid work doesn't prevent you from breastfeeding your baby. Depending on the nature of your job and the age of your baby, you'll probably need to adjust your nursing relationship. You'll also need to talk to your employer, but time away from your little one doesn't mean breastfeeding has to end. Continuing to nurse may be even more important to you both as you adjust to big changes in your lives. Mothers choose to continue breastfeeding for their babies' health and because breastfeeding is good for the whole family. It provides easy feeding on days at home and a warm way to reconnect at the end of a long day for mother and child. It's well worth planning how to balance breastfeeding with your work routine.

Why is breastfeeding so important?

Your milk alone is vital to your baby during the first six months of life, and continues to be an important part of his diet until 12 months and beyond. Formula just doesn't compare. As well as meeting nutritional needs, breastmilk is packed with antibodies-particularly important if your little one will be spending time in nursery or with a childminder. And when you are together, making time to reconnect through snuggling up and nursing will be even more meaningful. You'll miss each other when you're apart.

But won't it be a hassle?

Being a working mother will be challenging, but breastfeeding can make life easier. Ending the breastfeeding relationship may appear at first to be the simplest solution, but with the increased risk of illness, plus the effort involved in buying, preparing and storing formula, weaning may ultimately be the real hassle. Also consider that your baby will eventually outgrow the need to nurse. Most mothers reduce and stop pumping before their babies stop breastfeeding.

What are my options?

Your options depend on the age of your baby and the nature of your job. You can start planning before your baby is born. Gather ideas from any co-workers who breastfed their babies. Studies show that the longer you wait before returning to work, the easier the transition will be for both you and your baby.

Consider your employment flexibility and workday practicalities:

Can you extend your maternity leave, request part-time or flexible working hours, or an extended lunch hour?

Are you able to work from home for all or some of the time, or even bring your baby to work?

Can you break up your working week, perhaps working alternate days, so your baby is not away from you several days in a row?

Shorter workdays may be easier to manage, with less pumping for you and fewer missed breastfeeds for your baby.

Or you may prefer fewer but longer workdays, with more full days at home with your baby.

Choose childcare carefully

Having your baby nearby may allow you to go and nurse him during your lunch hour. Or maybe someone could bring him to you? Look for carers who are supportive of and knowledgeable about breastfeeding. It's important they respect your decision to provide only your milk for your baby.

Consider expressing your milk

You can use a good quality electric pump or learn to hand express. This is especially important if your baby is less than a year old. Expressing milk will enable you to maintain milk production as well as ensuring your baby can still receive your milk whilst you're apart. If you decide not to express your milk at work you can still continue breastfeeding when you're at home. You may need to express at first to avoid the discomfort of engorgement and the risk of mastitis.

Solid foods

Once your baby is eating more solid foods, he will need less expressed milk while you are away. But your baby will enjoy your yummy milk once you get home again!

Making it work

I don't want to wean, but I'm sure my employer will want me to!
This is one time when your employer can't tell you what to do! Daunting as it may seem, it's important to tell your employer about your need to express milk for your baby. Depending on what is available in your workplace, you may find it helpful to speak to someone from the human resources department, a health and safety representative and/or your trade union representative before speaking to your line manager. Employers are legally required to do a health and safety risk assessment for breastfeeding mothers, so you'll need to notify them in writing a few weeks before you return to work. Explain that being able to pump regularly will reduce any risk of you becoming engorged and developing mastitis.

Research shows it's a win-win situation if breastfeeding is supported and therefore continues: you'll feel positive about your company and your job satisfaction will increase-along with your willingness to work hard! Your employer will gain from your hard work and, because your baby will have breastmilk's infection protection, you're likely to take less time off.

For more information on your rights, and what employers are required to do to support you, see:
Maternity Action and their guidance on Breastfeeding at Work
ACAS: accommodating breastfeeding in the workplace
The Health & Safety Executive: Protecting pregnant workers and new mothers

Somewhere to express

You'll want to request somewhere private to express your milk, preferably with a door that can be locked. It helps to have access to electricity for your pump, a fridge and running water. A comfortable place to sit and a table for your pump and other supplies are also important. Bathrooms and toilets are not suitable. Employers are legally required to provide suitable facilities for pregnant and breastfeeding mothers to "rest". Although, they are not required by law to provide a private and safe place to express and store milk, the Health and Safety Executive recommend that they do. All employers must carry out a risk assessment so it would be very difficult for them to refuse. Be very clear about what you want to do and what you need. And do point out that expressing is something that, depending on the age of your baby, you may only need to do for a few months.

Before you return to work

Attend LLL meetings to meet other breastfeeding mothers in your area. You can offer each other vital support when breastfeeding, pumping, mothering or working becomes challenging.

Practise pumping or hand expressing to learn what works for you. You can freeze the small amounts of milk you collect to use for your first few days back at work and to give you a small back-up supply. Once you're missing feeds, the amount of milk you can pump will incre se and your baby can have fresh milk from the previous workday. Fresh milk retains more nutrients and immune factors.

Wait to introduce a bottle until just before you start back to work. Making breastfeeding a priority while you are at home will help you avoid feeding problems. An older baby may never need a bottle. Milk can be given in a cup or mixed with solid food.

Make your return to work easier by starting back on a Thursday or Friday. At the weekend, rest and prepare for any challenges you didn't anticipate. Make changes if your first strategy doesn't suit you or your baby.

Expressing

It's usually best to express milk at least every three hours while you are away from your baby. You may need to pump or express your milk more frequently at first so you don't feel uncomfortably full or start to leak. Be sure to include commuting time when deciding how often to pump. If you feel the tingling of your milk beginning to flow, pressing hard on your nipples for several seconds can prevent leaking. This can be done discreetly by crossing your arms tightly across your chest and pressing firmly on your nipples with the palms of your hands. Hold for a few seconds before releasing and all should be well. If it doesn't work first time, try again for a little longer. But bear in mind that if your breasts feel full, this is a sign you need to express some milk. With time you'll have fewer problems with leaking.

Working and breastfeeding

It can be so rewarding to continue to nurse your baby after returning to work. It's a wonderful way of reconnecting after a day apart. LLL meetings can continue to be a good source of support after you return to work. If you're unable to attend every meeting, your local LLL Leader can still listen to any concerns you have and offer support.

Written by Sue Upstone & Mothers of LLLGB.

Further reading

Working and Breastfeeding
Workday practicalities
If you leave your baby
When mum can't be there
Expressing your breastmilk
Hand expression of breastmilk
My Journey Returning To Work, a mother's story
Mothers on ... breastfeeding & work

Books
The Womanly Art of Breastfeeding LLLI. London: Pinter & Martin, 2010.
Exclusively Pumping Breastmilk Stephanie Casemore. Canada: Gray Lion Publ. 2013

LLL Articles
New Guidance For Employers on Breastfeeding Breaks in the Workplace
Supporting Women's Right To Breastfeed

You may also wish to look at the following guidance:
Maternity Action and their guidance on Breastfeeding at Work
ACAS: accommodating breastfeeding in the workplace
The Health & Safety Executive: Protecting pregnant workers and new mothers

This information is available to buy in printed form from the LLLGB Shop

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Working and Breastfeeding - La Leche League GB

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There is no need to stop breastfeeding when you return to work. Many mothers work outside the home and continue to breastfeed. LLLGB is here to help with information and support if you are going back to work.

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Breastfeeding Support for Mothers in Workplace

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Breastfeeding Support for Mothers in Workplace

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Wellbeing hub for parents in South East London

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Part of the Dadvengers New Dads Series this video video is about comforting your baby when they need it. When you become a father there are lots of new things to learn and comforting your baby is one of them. Listen to father of two Tim talk about how he's learning the different cries. We also here Tim's top tips for comforting your baby. Hopefully it will go some way to supporting you comforting your own child when they are upset.

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How you can Help Support a Breastfeeding Mum

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How you can Help Support a Breastfeeding Mum

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Creating a supportive environment where mums can breastfeed more easily is the responsibility of us all. As part of our research at Swansea University we asked over 1000 breastfeeding mums what helped them.

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School of Health & Social Care, Swansea University

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How you can Help Support a Breastfeeding Mum...

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Being Dad

Becoming a dad isn’t without its challenges. Whether it’s your first child or your third, a new baby is a major life transition, bringing different responsibilities and changing the dynamic of relationships. Our Being Dad groups are here to help you navigate fatherhood.

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"I would like to thank you for the opportunity to part take in the Being Dad group. I found the whole thing brilliant. Nev and his team had fresh and raw, hard-hitting informative sessions. Very open to talk about any subjects relating to a vast spectrum of being a dad.
The simplicity and realistic nature of how the group was formatted really worked for me, and I know that others got a lot out from it."

A dad on completing Being Dad groups

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Free 4-week wellbeing groups in London to support dads/men with parental responsibilities for children under 2 years old.

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Breastfeeding helplines and websites

Helplines

National Breastfeeding Helpline: 0300 100 0212

Association of Breastfeeding Mothers: 0300 330 5453

La Leche League: 0345 120 2918

National Childbirth Trust (NCT): 0300 330 0700

The Breastfeeding Network supporter line in Bengali and Sylheti: 0300 456 2421

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Breastfeeding Support - Bromley & Chislehurst | Bromley and Chislehurst | NCT

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Breastfeeding Support - Bromley & Chislehurst | Bromley and Chislehurst | NCT

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Our NCT Baby Cafés are run by NCT Breastfeeding Counsellors, with funding from the National Lottery. They provide trusted & personalised support, alongside evidence-based information, on a range of feeding topics to help parents feed their babies in the way they want.

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Breastfeeding Support - Bromley & Chislehurst | Bromley and Chislehurst | NCT

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On this page, we share some useful breastfeeding resources.Our breastfeeding counsellors are volunteers working from home. They will do their best to help you but cannot always be available. Please be considerate when contacting them.

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South East London Infant feeding

A one stop place for all things Infant feeding in SW London

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Welcome to Kent Baby! Find support for you and your child on the journey from pregnancy to starting school.

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The Health Visiting Service is here to support you and your baby before and after birth right up until your child starts school.

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Breastfeeding in Kent

Beside You is here to support families on their breastfeeding journey, offering trusted NHS advice, information on local support services, and real-life experiences from local families.

Local breastfeeding support today

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Breastfeeding shouldn't leave you feeling sore. In the early days, you might feel a bit of discomfort while you and your baby are learning to breastfeed but this should go away.

A latch that isn't quite right can cause a lot of pain. With the right support with positioning and attaching from a local drop-in or health professional, you should find feeding much more comfortable. Find out more at about why breastfeeding might be hurting on our why I'm finding it painful page.

You're welcome to go along to a local breastfeeding drop-in for a chat if you do have any questions.

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The #BesideYou campaign supports breastfeeding families in Kent and Medway.

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Breastfeeding Friendly Greenwich - Live Well Greenwich

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Healthy living activities around Greenwich, London

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Greenwich Breastfeeding Network Support Group at Charlton Family Centre

greenwichsupport@breastfeedingnetwork.org.uk

Opening hours

Tuesday

10:00am to 12:00pm

Charlton Family Centre
41-43 Shirley House Drive
Charlton
SE7 7EL
United Kingdom

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Do you live in Greenwich with a new baby, toddler or are you pregnant? If you would like to chat about feeding your baby join us at our support group.

Whatever stage you are at with feeding your baby/child everyone is welcome including partners and grandparents.

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Greenwich Breastfeeding Network Support Group | Greenwich Community Directory

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Do you live in Greenwich with a new baby, toddler or are you pregnant? If you would like to chat about feeding your baby join us at our support group.Whatever stage you are at with feeding your baby/child everyone is welcome including partners and grandparents.

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Breastfeeding – Quaggy Development Trust

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We regularly gather feedback from families who use our services. Here are some of the things they have been saying about us.

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BEXLEY INFANT FEEDING CLUB Danson Youth Centre Lactation Consultant Sue Burbidge, Fridays 11.45 - 13.45 - £3pw

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Under 5’s Information & Programme – Danson Youth Centre

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ADDRESS: The Danson Centre, Brampton Road, Bexleyheath DA7 4EZ

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NCT Bexley Baby café – Crayford Library wed 11-1230am- funding until Xmas- facilitated by Judianne NCT BFC Judianne also offers Tel and whats App / Zoom video support to any local family- Parents encouraged to email or message first to arrange time to speak 07958567522 judiannesherrell@gmail.com

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Infant feeding clinics :: Greenwich 0 to 4

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Our Infant Feeding drop-ins can support with:

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Infant Feeding clinics :: Bexley 0 to 19

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These clinics provide an opportunity for parents and carers to speak with a member of the Health Visiting team about infant feeding concerns and to be given information and advice. See below for a map of venues and times of clinics - click on the location pin for details.

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Breastfeeding Twins and Triplets UK began life as a Facebook Group. Kathryn realised that there were no UK based Facebook groups specifically for mums of twins and triplets to access breastfeeding support. So one late night she created one. It was a huge success and over the first 18 months, it gained 1400 members and now has just tipped 3000.

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Twins Trust - We support twins, triplets and more...

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Supporting you through every milestone of your journey with twins, triplets or more. From being pregnant with twins, triplets or quads through to parenting twins, triplets or quads, we are here for you.

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National Breastfeeding Helpline - Helpline

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This website uses cookies to improve your experience while you navigate through the website. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. We also use third-party cookies that help us analyze and understand how you use this website.

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The Breastfeeding Friend, a digital tool from Start for Life, offers practical information and advice on breastfeeding.

Get answers to questions asked by new mums, and tips on things like sore nipples and what to do if your baby cries during feeds.

Think of it like your health visitor but, because it's a digital tool, it's available whenever you need it - all day and all night.

The Breastfeeding Friend is available on Amazon Alexa and Facebook Messenger.

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Find out how to get NHS trusted advice from the Start for Life Breastfeeding Friend, available on Amazon Alexa and Facebook Messenger.

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Pregnancy, baby and parenting

Welcome to Better Health - Start for Life.

We may have a new name and look, but don't worry, you will still find all the trusted NHS advice and guidance you need to help you have a healthy and happy baby during pregnancy, birth and parenthood.

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Get trusted NHS advice during pregnancy, birth and parenthood. Start for Life is your essential guide for having a healthy, happy baby.

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UKAMB

Welcome to UKAMB

Donated breastmilk from the country's network of milk banks helps to save the lives of premature and sick babies.

UKAMB is a registered charity that supports human milk banking in the UK and was set up in 1997. Our motto is 'Every Drop Counts' and we believe that the provision of safe and screened donor breastmilk makes an important contribution to the care of the premature and sick infants who receive it. Our goal is to ensure access to donor milk to every child who would benefit from its use.

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UK Human Milk Bank - Breast Milk Donation, BreastMilk Storage, UKAMB

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UKAMB, a registered organization supports human milk banking to save the lives of premature and sick babies. Connect with our network today!

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Koan's Story

Koan was born with a rare genetic condition and received donor milk from the HMF. Watch Koan's parents - Shurron and Kel tell their amazing story.
WATCH VIDEO OF KOAN'S STORY

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Koan was born with a rare genetic condition and received donor milk from the HMF. Watch Koan's parents - Shurron and Kel tell their amazing story. WATCH VIDEO OF KOAN'S STORY

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We're here to support you and your unique experience of pregnancy, birth, and early parenthood.

Our vision is that everyone who becomes a parent feels confident, connected, and safe.

We share evidence-based information you can trust

We create opportunities to connect with other parents

We listen to your experiences, amplify all parents' voices and campaign for change

We are strong advocates for improving experiences of pregnancy, birth, infant feeding, and early parenthood, equitably, for all parents.

Access networks of support and build friendships through our courses and community events.

Use our resources to make informed decisions that feel right for you.

Information for parents

If you're pregnant or a new parent, we know that you will have a number of questions and concerns about coronavirus. In our sections below, we've created a range of articles about how coronavirus might affect your pregnancy, birth and early days as a parent.

Pregnancy

When it comes to your pregnancy, we've got it covered. You'll find everything you need to help you feel confident and reassured over the next nine months right here.
Find out more

Labour & birth

Thinking about how, what happens and where to give birth? We're here to help you feel more confident. We've got information and tips on everything you need to know.
Find out more

Baby & toddler

Your baby's arrived and you've probably got 101 things on your mind. Don't worry, you're not on your own. We're here with information and support as your baby develops.
Find out more

Life as a parent

You've just had a baby and everyone is focused on your little one. But how about you? We're with you on your journey with support and tips from other mums and dads.
Find out more

Courses and workshops

Interactive, engaging and social, our antenatal course is a fun and exciting way to grow your knowledge of birth and early parenthood, and make life-long friends.
View all courses & workshops

Local activities and meet-ups

Our local activities and meet-ups can help you build up a supportive social network around you.

Support NCT Charity by becoming a member

Join NCT and there's great member benefits for you - exclusive live talks, money-saving offers & competitions, digital magazine & quick-read newsletters, plus early entry to every NCT Nearly New Sale - whilst you help fund free support for others.

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The UK's leading charity for parents | NCT

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We are the charity that supports people as they become parents. We're here for you through pregnancy, birth, and early parenthood.

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Welcome! This website was developed to provide evidence-based information on breastfeeding and parenting.

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ABM are a group of trained volunteers dedicated to supporting breastfeeding mums and their families. We’ve been supporting mums and nurturing families for almost 40 years. We’d love you to join us. Become a member of the ABM and help us continue our work.

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Video Archive - Global Health Media Project

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Videos Archive - Global Health Media Project

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Breastfeeding Support - Breastfeeding tips, tricks & support

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Breastfeeding Support is an evidence-based website sharing helpful breastfeeding resources and promoting good breastfeeding practice.

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Friendly breastfeeding support from pregnancy onward.

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The Breastfeeding Network | Independent Breastfeeding Support

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The Breastfeeding Network (BfN) is an independent source of support and information for breastfeeding women and others.

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So when CAN I use my Haakaa? - Milk and Motherhood

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So when CAN you use the Haakaa*? In my last post, I wrote about some of the issues that I see from clients of mine who are repeatedly using the Haakaa in a way that causes them problems. I probably should have predicted it, but this has led to a lot of people totally [...]

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How NOT to use a Haakaa - Milk and Motherhood

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So you've probably heard about this thing called a Haakaa. You might even have one! Maybe you used it and loved it and spread the word to all of your new mama friends! And yep, indeed, it was pretty revolutionary when it was first released: A one-piece, soft flexible device that you just stick onto [...]

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We know that up to 20% of women are affected by mental illness either during pregnancy or in the 12 months after giving birth. These can include anxiety and depression, postpartum psychosis and post-traumatic stress disorder (PTSD) resulting from birth trauma or caring for an ill baby. Any of these can have a profound affect on breastfeeding and it is so important that families can access support at this difficult time.

Levels of care and support for women affected by perinatal mental illness vary across the UK - there are areas where there are great support networks in place and others where there is nothing. Find more information on how you can access NHS mental health services her e.

At the Breastfeeding Network we are in contact with, and support thousands of new mums every year. We work in a mother-centred way and are committed to supporting mothers however they feed their babies.

We know that around 15% of the contacts our Drugs in Breastmilk information servicereceives are related to mental health issues. Many mums tell us they have been told to stop breastfeeding in order to take anti-depressant medication, but the evidence shows this is unnecessary in many cases, and there should be careful consideration of the impact that stopping breastfeeding before the mum is ready might have on the mum's mental health.

There is evidence that breastfeeding can have a preventative effect on mental illness developing. A large scale research study published in 2014 showed that mothers who planned to breastfeed and who actually went on to breastfeed were around 50% less likely to become depressed that mothers who had not planned to, and who did not, breastfeed. Mothers who planned to breastfeed but who did not go on to breastfeed were over twice as likely to become depressed as mothers who had not planned to, and who did not breastfeed.

Research also shows that more than 3 in 5 women stopped breastfeeding earlier than they wanted to. This shows the importance of providing good quality breastfeeding support and evidence based information on the safety of anti-depressant medication for mums who do want to breastfeed.

We have detailed, evidence based, information sheets on anxiety and breastfeeding, feeling depressed and breastfeeding, feeling anxious and breastfeeding, OCD and breastfeeding, Bipolar disorder and breastfeeding and postnatal depression treatments and breastfeeding. These are written by our qualified and highly experienced pharmacists and can be downloaded or printed out to discuss with your midwife, health visitor or GP.

You can call the National Breastfeeding Helpline which is open 365 days a year on 0300 100 0212 to talk to a trained volunteer, who is also a mum who has breastfed. The helpline also welcomes calls from partners, family members and friends.

The 'Saving Lives Improving Mothers' Care 2023' report tells us "Deaths from mental health-related causes as a whole account for nearly 40% of deaths occurring between six weeks and a year after the end of pregnancy with maternal suicide remaining the leading cause of direct deaths in this period."

This is a scary statistic, but highlights the need to talk about it - even though it is an uncomfortable topic. It is important that we know when to ask for help, and where to get it.
Here are some sources of support if you are worried about perinatal mental illness - in yourself or someone around you: ASSOCIATION FOR POSTNATAL ILLNESS SAMARITANS Perinatal Mental Health Partnership Action on Postpartum Psychosis NHS Perinatal Mental Health NHS Accessing Mental Health Services
Northern Ireland only, Lifeline - phone 0808 808 8000 or access
Local NHS urgent mental health helpline (England only)
If you are on Twitter, search for #PNDChat, #PNDHour and #birthtraumachat to find a supportive community organised by @PNDandMe http://pndandme.co.uk/

Resources for Volunteers and Professionals

During pregnancy and the year after birth (the 'perinatal period'), women can be affected by a range of mental health problems. These can be devastating and have a significant impact on women and their families at an important life stage. It is important that any professionals and volunteers working with women during the perinatal period - whatever their primary role - understand the risks of perinatal mental health problems; how to identify symptoms or risk factors and respond appropriately. This is particularly important for professionals and volunteers who support infant feeding, who work with women - building trusting relationships and providing emotional support - at some of their most vulnerable moments.

This competency framework sets out the knowledge, skills and support that professionals and volunteers who support infant feeding should develop around perinatal and infant mental health, including:

Understanding perinatal and infant mental health and their relationship with infant feeding.

Understanding how to empower individual women to make and achieve the feeding choices that are best for them (taking account of their mental health).

The ability to support women - wherever they are in their feeding journey - in a way that protects and promotes their, and their babies' mental health.

The framework describes competencies for practitioners to work towards. It does not specify the nature of training and development opportunities required to deliver these competencies. These will vary depending on the professionals' prior experience and skills, the nature of their role and the context in which they work. We hope it will provide a useful tool to support commissioner and provider organisations, trainers, managers, professionals and volunteers themselves to consider what more might be done through infant feeding services to support the mental health of new mothers and their babies.

The Breastfeeding Network has been pleased to work with the Maternal Mental Health Alliance (Mums and Babies in Mind Project), Association of Breastfeeding Mothers, NHS Foundation Trust for Central and North West London, NCT, Lactation Consultants of Great Britain, Manorgardens and Swansea University in the development of this framework.
Perinatal Mental Health Competency Framework for Professionals and Volunteers who support Infant Feeding

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Breastfeeding and perinatal mental health - The Breastfeeding Network

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We know that up to 20% of women are affected by mental illness either during pregnancy or in the 12 months after giving birth. These can include anxiety and depression, postpartum psychosis and post-traumatic stress disorder (PTSD) resulting from birth trauma or caring for an ill baby.

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There is a lot of confusion and poor breastfeeding advice arising from the idea that there are two sorts of breast milk-namely foremilk (watery, low calorie) and hindmilk (high fat, high calorie). And, depending where you live, the confusion may go one step further, you may hear about three kinds of milk; watery soup, dinner and pudding.

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All breast milk is good

As a result of not understanding that all breast milk is good, and not really understanding how breastfeeding works, mothers are being told to stay on one breast per feed or feed from one breast for random blocks of time to "get to the hindmilk". After all, the watery soup is no more than water and without that fatty pudding a baby can't gain weight, right? Wrong. Even if that was right, why stop short of offering the "three course meal" from the second breast? Especially if a baby is having trouble gaining weight.

This article

This article looks at how babies grow, how breastfeeding works, the facts about foremilk and hindmilk, and how staying on one breast to get to the hindmilk can sabotage a breast milk supply.

How babies grow

Babies grow and gain weight from drinking lots of breast milk. All breast milk is good, it is a nutritious and complete diet and babies need plenty of it. As a rough guide babies need about 800ml or 27 fluid ounces per day in the first six months. Whether it is foremilk or hindmilk or in-the-middle-upside-down-milk, babies need lots of milk to grow.

Quantity not quality

It is the volume of breast milk that is the important factor determining a baby's weight gain not the fat content in a particular feed. Kelly Bonyata explains:

The research tells us that baby's milk intake (the volume of milk - not the amount of fat in that milk) is the only thing that has been correlated with infant growth in exclusively breastfed babies. [...] average fat content of human milk is highly variable, but has not proven to be significant when calculating baby's total energy intake or weight gain.

Whether it is foremilk or hindmilk or in-the-middle-upside-down-milk, babies need lots of milk to grow. Click To Tweet

How breastfeeding works

Your breasts make milk on demand; so that the faster your baby drinks the available milk, the faster your breasts will make more milk to replace it, indefinitely. Breasts gauge demand by their degree of fullness:

Whenever a breast is full, milk production slows down

Whenever a breast is emptied regularly, milk production increases

Storage capacity

The ideal way to make plenty of breast milk in the volumes your baby needs, is to feed your baby as often as he wants-letting him finish the first breast before offering the second side. Only your baby knows when one side is empty and whether he needs one breast or two, because breasts vary in how much milk they can hold (storage capacity). Storage capacity is explained more fully in One Breast or Two per Feed:

Breasts vary in their breast milk storage capacities. Where one mother's baby might only want one breast per feed and not be hungry for two hours, another may need both breasts per feed and be hungry again in an hour. Let your baby decide how many breasts he wants at a particular feed by looking for his feeding cues and offering him plenty of opportunities to breastfeed.

Ignoring your baby's cues and keeping to one breast to reach the hindmilk i.e. keeping your baby on one breast after he has emptied it, means the opposite breast gets little drainage, and slows down milk production. It's like trying to build a milk supply by only pumping from one breast instead of pumping from both breasts.

If you have a low storage capacity then keeping to one breast is potentially denying your baby half his milk or more. Your baby may need the "hindmilk" from both breasts.

Increasing milk supply

If your baby falls asleep after less than ten or twenty minutes into a feed, breast compressions (gently compressing and releasing the breast during a feed) can get him to start sucking again by simulating another let-down of milk. By offering the other breast when the first is finished, and repeating breast compressions if needed, your baby will get the correct balance of foremilk and hindmilk automatically. Using both breasts when needed (and sometimes three or four!) will drive up and maintain your supply.

But what about foremilk and hindmilk?

Foremilk and hindmilk are the names given to subtle differences between breast milk at the start and at the end of a breastfeed.

Foremilk describes the breast milk at the start of a breastfeed, it has a lower fat content, but has plenty of lactose the principal sugar in breast milk, not to mention all the other great ingredients in breast milk. Lactose is important for developing the brain and central nervous system, and provides 40% of a baby's energy needs. Lactose helps with calcium and iron absorption and, along with other oligosaccharides (short chain carbohydrates) promotes the growth of friendly bacteria such as Lactobacillus bifidus to fight pathogens. As the breastfeed progresses, the fat content of "foremilk" steadily increases.

Hindmilk is the name coined for the breast milk towards the end of a feed as the breast empties. There is less of it but it has a higher fat content and all the other nutritious ingredients found in milk.

All milk is good

There aren't two distinct types of breast milk with one being inferior to the other, it is a continuum of subtle changes. Hindmilk is released with every milk ejection (let-down). By the time feeding finishes on the first breast, the first milk from the second breast will contain more fat compared to the start of the feed on the first breast. The more frequently you breastfeed, and the emptier the breasts become; the higher the fat concentration in all the breast milk.

Quantity not quality

Remember, weight gain depends on the quantity of milk not just the fat content in the last few drops. Kelly Bonyata's analogy with a hot water tap is useful. When you turn on the tap (start feeding) the water starts cold (low fat milk) but as it continues to run (as the feed progresses) the water gets warmer and warmer (higher fat). If you turn the tap off and on again quite soon, the water will still be warm (high fat milk will still be present at the start of the next feed). And you don't need to run your tap for 30 minutes or an hour to get to the warmer water (if you do, call an engineer!)

What is foremilk hindmilk imbalance?

If a mother has lots of milk, more than her baby can comfortably handle, her supply will usually adjust downwards over time to meet her baby's actual needs. In the mean time some babies may get an excess of lactose rich foremilk. This is sometimes referred to as foremilk hindmilk imbalance. Babies may also get foremilk hindmilk imbalance if a mother has a robust supply and continually takes her baby off the breast before he has finished feeding i.e. switches sides too soon.

Temporary lactose intolerance

In these situations the baby can find it difficult to digest all the abundant lactose in the plentiful foremilk causing temporary lactose intolerance or lactose overload. They may be fussy and uncomfortable with copious green, frothy and foamy nappies. The sheer volume of milk and high sugar content often means babies gain weight very well with foremilk hindmilk imbalance-even though they aren't getting their "pudding". However occasionally some babies may not gain enough weight in this situation. Advice to stay on one breast per feed or for a block of time can be very helpful with true foremilk hindmilk imbalance to ensure babies get a good proportion of higher fat milk. See Lactose Intolerance in Babies for further information and consult your breastfeeding specialist.

Confusion about green nappies

Health visitors who are already hooked on the idea of staying on one breast to get to the hindmilk may think this is an absolute certainty if you mention your baby has lots of green nappies. However the frequent scant green nappy of a baby not gaining weight is NOT the same as the copious frothy green nappy of a baby with lactose overload. Staying on one breast is not the answer for a baby with green "starvation stools". See your IBCLC lactation consultant for further information if you are not sure what your baby's nappies mean or whether block feeding is a good idea for your baby.

I kept to one breast per feed and my baby gained weight just fine!

Keeping to one breast may work perfectly if your storage capacity suits this regime. But be guided by your baby and his weight chart, not by any pre-set rules or clock-watching instructions to reach that elusive hindmilk at the bottom of the barrel.

My baby isn't gaining weight

When a baby isn't gaining weight they most likely need more milk, not more time on an already empty breast which will further reduce a mother's supply. An extra 7-8 ml of high fat milk from the same breast is no substitute for the extra 70-80 ml of fore-hind-and-in-the-middle-milk they might need from the other breast. Check with your IBCLC lactation consultant for the reasons for low weight gain for your baby and see Baby Not Gaining Weight. For increasing milk supply see How to Make More Breast Milk.

Supplements are sometimes needed

If you have been following the advice to "stay on one breast to get to the hindmilk" for quite some time, your milk supply may be quite low. If your baby has not been gaining weight properly, or has been losing weight, he won't be able to wait while you build your supply. He may need supplements ( donor milk or formula) to build back his body weight so that he is strong enough to drive your milk supply all by himself.

Summary

Confusion about how breastfeeding works is causing some health professionals to unwittingly sabotage breastfeeding by recommending staying on one breast to get to the hindmilk: either as a general rule or as specific advice when a baby is not gaining weight. It is not helpful to think of breast milk as two or three different kinds of milk. All breast milk is good and babies need lots of it to grow. Breasts have different storage capacities and what works for one mother and baby may not work for another. Contact your breastfeeding specialist for tailor made recommendations for your unique situation. And forget about foremilk and hindmilk.

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There is a lot of confusion and poor breastfeeding advice arising from the idea that there are two sorts of breast milk-namely foremilk (watery, low calorie) and hindmilk (high fat, high calorie). And, depending where you live, the confusion may go one step further, you may hear about three kinds of milk; watery soup, dinner and pudding.

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A new mum is asking for help. Her 8-week-old baby is refusing the breast and every feed is turning into a battle. She can get him to feed ‘a little’ and nappies seem OK for the moment but she’s worried that her supply will soon decrease and he’s going to have weight gain problems. Breast refusal ca

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Green poop - when should you be concerned?

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Green poop - when should you be concerned?

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Baby poop is high on many new parents' worry list. How often should baby poop? Does baby's poop provide clues to how breastfeeding is going? What do color and consistency mean? When should you worry?
Normal Color and Consistency
Baby's first stools are the black and tarry meconium that was in her gut at birth. When breastfeeding is going well, by about the third day, baby's poop changes to "transitional stools," which have a dark greenish color. By the fifth day or so, the poop's color changes again to yellow. Its consistency now (and until baby begins consuming anything other than your milk) may look like split pea soup, liquid with seedy bits in it. But if your baby's poop is all liquid and no seeds, this is also normal.

Baby's yellow poop is made mostly from the fat in your milk. During the first six weeks, babies gaining weight well usually poop at least 3 to 4 times a day with stools at least the diameter of a US quarter (22 mm) or larger. There is no such thing as too many poops. (Lots of pooping just means your baby is getting lots of milk, which is great.) But too few poops mean it's time for a weight check.

If your baby is younger than 6 weeks old, is pooping fewer than 3 to 4 times per day, or her stools haven't turned yellow by the fifth day, a weight check will tell you if this is just a normal variation or a cause for concern. It's not until after 6 weeks that some healthy breastfed babies poop much less often, sometimes even once a week. Check baby's weight at a health-provider's office. A bathroom scale just won't do. A weight gain of about 1 oz. (30 g) or more per day indicates that all is well. No matter what your baby's age, as long as she is gaining weight well, don't worry if she has fewer stools than expected.
Causes of Green Poop
Despite what you may have heard (see the next section), green and brown are in the normal range of poop colors. They are not a reason to worry if baby seems well and is gaining weight.What can cause green poop?

A tummy bug.When your baby is ill, this can cause a change in poop color that may last for weeks. Keep breastfeeding! It's the best way to help baby recover.

Oversupply.If you produce so much milk that your baby receives mostly high-sugar/low-fat milk, it may overwhelm baby's gut and cause watery or green stools. (ClickHEREmore details and tips for adjusting milk production downward when needed.)

Ineffective breastfeeding.If on the fifth day, baby's stools turn green instead of yellow, as in the case of oversupply, this may be a sign that baby can't drain the breast well enough to get past the low-fat/high sugar foremilk. In this case, though, a health or anatomy issue (like tongue tie) may be the cause. Unlike oversupply, baby's weight gain may or may not be below average. Now is the time tosee an IBCLC.

Sensitivity to a food or drug.When a sensitive or allergic baby reacts to a drug you're taking, something in your diet, or something baby consumes directly, this may turn her poops green or mucusy. You may even see bits of blood in it, which is not considered serious. (ClickHEREfor info you can share with your health-care provider.)

Food sensitivity occurs most often in families with a history of allergy. When this is the cause, expect to also see other physical symptoms, such as skin problems (eczema, rashes, dry patches), tummy upsets (vomiting, diarrhea), or breathing issues (congestion, runny nose, wheezing, coughing).
What about Foremilk-Hindmilk Imbalance?
Many new parents read online that "foremilk-hindmilk imbalance" is the most likely cause of green poop. This term was coined in a 1988 journal articlethat reported the experiences of a few mothers who breastfed by the clock, switching breasts after 10 minutes even though baby hadn't finished on that side. Its results have never been duplicated, and newer findings call into question this article's conclusions. Many now wonder if foremilk-hindmilk imbalance even exists. To learn more, click HERE.
Setting Worries to Rest
In most cases, green poop is nothing to be concerned about. But it helps to know what's normal, possible causes, and some of the common myths about this experience. If your breastfeeding baby is healthy and thriving, that's the most important thing you need to know.

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Baby poop is high on many new parents' worry list. How often should baby poop? Does baby's poop provide clues to how breastfeeding is going? What do color and consistency mean? When should you worry? Normal Color and Consistency Baby's first stools are the black and tarry meconium that was in her gut at birth.

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How to support your baby to sleep without stress

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How to support your baby to sleep without stress

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How to support your baby to sleep without stress

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1. Terms of website use This page tells you the terms of use on which you may make use of our website www.all4birth.com (our site). Please read these terms of use carefully before you start to use the site. By using our site, you indicate that you accept these terms of use and that you agree to abide by them.

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When breastfed babies won't take a bottle

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When breastfed babies won't take a bottle

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Some babies need extra milk. Maybe baby is not yet able to attach to the breast well, or maybe the mother is working on building up her lactation, or is separated from her baby. Perhaps the baby is not yet feeding effectively or is struggling to gain weight.

Bottle feeding is ubiquitous in our society and when a baby needs extra milk, a bottle is often suggested by health professionals involved in their care. However, using bottles can make breastfeeding more challenging.

Research suggests that early introduction of bottles and teats leads to premature cessation of breastfeeding. Reasons for this may be that the feeding technique and experience is quite different. The teat can be a firm stimulus to the baby's suck reflex and the baby may become progressively less responsive to the softer stimulus of mother's nipple - baby may exhibit behaviour such as increased 'fussiness' at the breast or breast refusal once accustomed to fast flowing milk from a bottle and teat.

In addition, the impact on the mother's confidence and feelings of self-efficacy when her baby needs to be given additional milk is often overlooked. A mother may be aware that using bottles and teats can significantly undermine breastfeeding and be anxious to avoid their use.

A mother may be unaware that bottles and teats may undermine breastfeeding and enter into their use with little safeguards in place to protect her breastfeeding and find herself with subsequent feeding issues that could have been avoided.

For an assisted feeding method to work well and avoid undermining breastfeeding:

It needs to be suitable for the baby and the individual feeding situation

The mother needs to view it positively as supportive of her breastfeeding goals and not 'supplantive'.

There are actually many ways of delivering extra milk to a baby which can be effective at supporting breastfeeding. This is a brief overview of some assisted methods of feeding that Breastfeeding Supporters may wish to become more familiar with:
Breastfeeding aide tube
If a baby can attach to the breast effectively, they could have extra milk via a tube at the breast.

The other end of the tube is placed in a container of milk. As the baby suckles at the breast extra milk is delivered via the tube. The flow can be adjusted by raising or lowering the milk container.

This encourages the baby to stay at the breast, so alongside delivering the required extra milk, it also helps stimulate the mother's lactation.

There are commercially available kits for breastfeeding aide devices, and 'Nursing Support tubes' are also available to purchase to make up a breastfeeding aide tube device.
Spoon Feeding
If a young baby needs small quantities of colostrum or milk, a spoon can work well.

Baby needs to be awake and alert in order to take milk from a spoon. Baby should be well supported in a semi upright position. Milk is placed on a clean, shallow plastic spoon and brought to the baby's lips. Baby sucks and laps the milk from the spoon. Milk should not be poured into the baby's mouth as this risks the baby aspirating the milk.
Syringe Feeding
Another great option particularly for small quantities of colostrum is via a syringe (no needle).

Colostrum in small 'doses' is introduced via the syringe into the corner of the baby's mouth, aimed into the cheek and the baby observed closely for acceptance of milk and safe swallowing.
Cup Feeding
For larger volumes of milk a small baby feeding cup can be used. In the home any clean suitable receptacle can be used - a clean 'shot glass' or egg cup can be used successfully. Again, baby should be positioned so s/he is well supported in a semi-upright position, bring the cup to the baby's mouth. Tip the milk slightly so the milk reaches the edge of the cup and the baby will lap the milk.

Milk should not be poured into the baby's mouth as this risks the baby aspirating the milk.

Cup feeding is often preferred as an adjunct to breastfeeding in resource-poor settings as they are usually easier to keep clean and avoid the potential for contamination and illness associated with unhygienic bottle use.
Finger Feeding
For slightly larger volumes of colostrum or milk, finger feeding using a syringe is an effective, accessible, and popular option with many families. Baby is supported in a semi-upright position facing the parent so there is good eye contact and baby can be closely monitored. Baby is encouraged gently to accept a clean finger orally. Once the finger is accepted and resting lightly at the hard palate/soft palate junction the baby's suck reflex is triggered. Baby starts sucking and swallowing rhythmically, the tip of the syringe is placed gently into the corner of the baby's mouth and pressed very gently to introduce milk in small volumes (e.g 0.1-0.2mls). The parent monitors the baby closely so that milk is introduced in a slow and paced manner that baby is clearly coping well with and enjoying.

Finger feeding can also be done using a feeding tube taped onto a clean finger. Baby is supported in a semi-upright position facing the parent so there is good eye contact and baby can be closely monitored. Place or tape a feeding tube to a clean finger. The other end of the tube is placed into a container of milk. Baby is encouraged gently to accept the clean finger (nail side down) with tube attached orally. Once the finger is accepted and resting lightly at the hard palate/soft palate junction the baby's suck reflex is triggered. Baby starts sucking & swallowing rhythmically and milk is drawn up through the feeding tube. Baby's sucking controls the flow, although the flow rate can be varied by raising or lowering the height of the container of milk.

The sucking mechanism of finger feeding is considered to be more similar to suckling at the breast. Finger feeding using a syringe or feeding tube can work really well with babies who can't yet attach well and feed effectively and who require additional milk 'top ups'. Supporting not supplanting the dyad's breastfeeding journey.

When helping parents to draw up and implement a feeding plan, all methods of assisted feeding should be considered and discussed - it is often helpful if more than one assisted feeding method is employed as part of a feeding plan, e.g. a common approach when weight gain needs a boost is for the mother to breastfeed using a breastfeeding aide tube for some breastfeeds and her partner to finger feed additional milk after other breastfeeds.

Bottle and teat use has overwhelming cultural connotations in our society and once introduced appear to often negatively affect maternal confidence and self-efficacy and lead to early breastfeeding cessation.

Offering information on and supporting the use of a 'toolkit' of assisted feeding methods that do not appear to undermine breastfeeding in the same way may empower the mother to continue her breastfeeding journey despite her baby requiring additional milk from another source for a period of time.

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Beyond bottles: when a breastfed baby requires additional milk - ABM

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Some babies need extra milk. A bottle is often suggested however, using bottles can make breastfeeding more challenging.

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How do you stop an older child breastfeeding? 

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How do you stop an older child breastfeeding? 

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Often a challenge most parents face, Emma speaks about how this can be done stress free

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Bob is 18 months. He is breastfeeding on demand. This usually means breastfeeding at least 6 times in 24 hours.

Billie is 3 years old. She breastfeeds in the morning, at bedtime and usually once during the night.

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.

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.

You get to choose when you stop.

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.

If you are 100% confident with your decision, feel free to skip to the row of asterisks.

Are you ending breastfeeding because you want to conceive again and you believe weaning will be necessary?

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.

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 you need to take medication and the doctor says you have to?

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.

Are you ending breastfeeding because someone else is putting pressure on 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?

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.

Are you ending breastfeeding because you aren't getting enough sleep?

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.

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.

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.

First steps:

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.

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.

Night weaning

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.

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.

What about weaning breastfeeds in the daytime?

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.

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.

Pre-schooler Billie

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.
Remember
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.

Bob is 18 months. He is breastfeeding on demand. This usually means breastfeeding at least 6 times in 24 hours.

Billie is 3 years old. She breastfeeds in the morning, at bedtime and usually once during the night.

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.

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.

You get to choose when you stop.

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.

If you are 100% confident with your decision, feel free to skip to the row of asterisks.

Are you ending breastfeeding because you want to conceive again and you believe weaning will be necessary?

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.

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 you need to take medication and the doctor says you have to?

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.

Are you ending breastfeeding because someone else is putting pressure on 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?

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.

Are you ending breastfeeding because you aren't getting enough sleep?

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.

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.

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.

First steps:

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.

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.

Night weaning

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.

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.

What about weaning breastfeeds in the daytime?

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.

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.

Pre-schooler Billie

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.
Remember
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? - Emma Pickett IBCLC

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Bob is 18 months. He is breastfeeding on demand. This usually means breastfeeding at least 6 times in 24 hours. Billie is 3 years old. She breastfeeds in the morning, at bedtime and usually once during the night. Let's imagine you are Bob or Billie's mum and you want to end breastfeeding.

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A companion to your infant feeding journey, this podcast explores how to get breastfeeding off to a good start (and how to end it) in a way that meets everyone's needs.

Breastfeeding / chest feeding may be natural, but it isn't always easy for everyone. Hearing about other parent's experiences and getting information from lactation-obsessed experts can help.

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A companion to your infant feeding journey, this podcast explores how to get breastfeeding off to a good start (and how to end it) in a way that meets everyone's needs. Breastfeeding / chest feeding may be natural, but it isn't always easy for everyone.

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Questions mums ask about stopping breastfeeding - ABM

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It’s up to you to decide when you want to stop breastfeeding. An article about common questions mums ask about stopping breastfeeding.

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By Kelly Bonyata, BS, IBCLC

PDF version (great for printing) | Bulgarian

Breastfeeding benefits toddlers and young children...
nutritionally, immunologically and psychologically.

Breastfeeding contributes to your child's NUTRITION

Although there has been little research done on children who breastfeed beyond the age of two, the available information indicates that breastfeeding continues to be a valuable source of nutrition and disease protection for as long as breastfeeding continues.

"Human milk in the second year postpartum contained significantly higher concentrations of total protein, lactoferrin, lysozyme and Immunoglobulin A, than milk bank samples, and significantly lower concentrations of zinc, calcium, iron and oligosaccharides."
- Perrin 2016

"Human milk expressed by mothers who have been lactating for >1 year has significantly increased fat and energy contents, compared with milk expressed by women who have been lactating for shorter periods. During prolonged lactation, the fat energy contribution of breast milk to the infant diet might be significant."
- Mandel 2005

In a study of 250 toddlers in western Kenya, breastmilk provided, on average, 32% of the child's total energy intake. "Breast milk made an important contribution to the fat and vitamin A intakes of toddlers in this community."
- Onyango 2002

"Breast milk continues to provide substantial amounts of key nutrients well beyond the first year of life, especially protein, fat, and most vitamins."
- Dewey 2001

In the second year (12-23 months), 448 mL of breastmilk provides:

29% of energy requirements

43% of protein requirements

36% of calcium requirements

75% of vitamin A requirements

76% of folate requirements

94% of vitamin B12 requirements

60% of vitamin C requirements

- Dewey 2001

Studies done in rural Bangladesh have shown that breastmilk continues to be an important source of vitamin A in the second and third year of life.
- Persson 1998

It's not uncommon for weaning to be recommended for toddlers who are eating few solids. However, this recommendation is not supported by research. Research does indicate that in situations where breastfed toddlers have an increased risk of malnutrition, this appears to be due to inadequate complementary feeding or reverse causality (the mother is more likely to continue breastfeeding a child who is ill or growing poorly). In one study of 250 toddlers in Kenya, solid food intake increased after weaning, but not enough to replace all the fat, vitamin A, and niacin that the child had been getting via breastfeeding (Onyango 2002). According to Sally Kneidel in "Nursing Beyond One Year" (New Beginnings, Vol. 6 No. 4, July-August 1990, pp. 99-103.): Some doctors may feel that nursing will interfere with a child's appetite for other foods. Yet there has been no documentation that nursing children are more likely than weaned children to refuse supplementary foods. In fact, most researchers in Third World countries, where a malnourished toddler's appetite may be of critical importance, recommend continued nursing for even the severely malnourished (Briend et al, 1988; Rhode, 1988; Shattock and Stephens, 1975; Whitehead, 1985). Most suggest helping the malnourished older nursing child not by weaning but by supplementing the mother's diet to improve the nutritional quality of her milk (Ahn and MacLean. 1980; Jelliffe and Jelliffe, 1978) and by offering the child more varied and more palatable foods to improve his or her appetite (Rohde, 1988; Tangermann, 1988; Underwood, 1985).
References
Breastfeeding contributes to your child's HEALTH

The American Academy of Family Physicians notes that children weaned before two years of age are at increased risk of illness (AAFP 2008).

Breastfeeding toddlers between the ages of one and three have been found to have fewer illnesses, illnesses of shorter duration, and lower mortality rates (Mølbak 1994, van den Bogaard 1991, Gulick 1986).

"Antibodies are abundant in human milk throughout lactation" (Nutrition During Lactation 1991; p. 134). In fact, some of the immune factors in breastmilk increase in concentration during the second year and also during the weaning process. (Lawrence & Lawrence 2011, Goldman 1983, Goldman & Goldblum 1983, Institute of Medicine 1991)

"Human milk in the second year postpartum contained significantly higher concentrations of lactoferrin, lysozyme and Immunoglobulin A, than milk bank samples" collected from donors less than 12 months postpartum. (Perrin 2016)

Per the World Health Organization, "a modest increase in breastfeeding rates could prevent up to 10% of all deaths of children under five: Breastfeeding plays an essential and sometimes underestimated role in the treatment and prevention of childhood illness." [emphasis added]
References
Breastfeeding contributes to your child's INTELLECTUAL DEVELOPMENT

Extensive research on the relationship between cognitive achievement (IQ scores, grades in school) and breastfeeding has shown the greatest gains for those children breastfed the longest.
References
Breastfeeding contributes to your child's MENTAL and SOCIAL DEVELOPMENT

A couple of studies have shown a positive relationship between longer breastfeeding duration and social development.
- Duazo 2010, Baumgartner 1984

"A shorter duration of breastfeeding may be a predictor of adverse mental health outcomes throughout the developmental trajectory of childhood and early adolescence."
- Oddy 2010

According to Elizabeth N. Baldwin, Esq. in "Extended Breastfeeding and the Law":
"Breastfeeding is a warm and loving way to meet the needs of toddlers and young children. It not only perks them up and energizes them; it also soothes the frustrations, bumps and bruises, and daily stresses of early childhood. In addition, nursing past infancy helps little ones make a gradual transition to childhood."

Baldwin continues: "Meeting a child's dependency needs is the key to helping that child achieve independence. And children outgrow these needs according to their own unique timetable." Children who achieve independence at their own pace are more secure in that independence then children forced into independence prematurely.
References
Breastfeeding your child past infancy is NORMAL

The American Academy of Pediatrics recommends that "Breastfeeding should be continued for at least the first year of life and beyond for as long as mutually desired by mother and child... Increased duration of breastfeeding confers significant health and developmental benefits for the child and the mother... There is no upper limit to the duration of breastfeeding and no evidence of psychologic or developmental harm from breastfeeding into the third year of life or longer." (AAP 2012, AAP 2005)

The American Academy of Family Physicians recommends that breastfeeding continue throughout the first year of life and that "As recommended by the WHO, breastfeeding should ideally continue beyond infancy, but this is not the cultural norm in the United States and requires ongoing support and encouragement. It has been estimated that a natural weaning age for humans is between two and seven years. Family physicians should be knowledgeable regarding the ongoing benefits to the child of extended breastfeeding, including continued immune protection, better social adjustment, and having a sustainable food source in times of emergency. The longer women breastfeed, the greater the decrease in their risk of breast cancer." They also note that "If the child is younger than two years of age, the child is at increased risk of illness if weaned." (AAFP 2008)

The Academy of Breastfeeding Medicine affirms breastfeeding beyond infancy as the biological norm. "The average age at weaning ranges anywhere from six months to five years... Claims that breastfeeding beyond infancy is harmful to mother or infant have absolutely no medical or scientific basis," says Arthur Eidelman, MD, president of the Academy of Breastfeeding Medicine. "Indeed, the more salient issue is the damage caused by modern practices of premature weaning." The global organization of physicians further notes that "Human milk contains nutrients, antibodies, and immune-modulating substances that are not present in infant formula or cow's milk. Longer breastfeeding duration is further associated with reduced maternal risks of breast cancer, ovarian cancer, diabetes, hypertension, obesity, and heart attack." (ABM 2012)

A US Surgeon General has stated that it is a lucky baby who continues to nurse until age two. (Novello 1990)

The World Health Organization emphasizes the importance of nursing up to two years of age or beyond (WHO 1993, WHO 2002).

Scientific research by Katherine A. Dettwyler, PhD shows that 2.5 to 7.0 years of nursing is what our children have been designed to expect (Dettwyler 1995).

References [see also position statements supporting breastfeeding]

MOTHERS also benefit from breastfeeding for a longer duration

Breastfeeding has been shown to decrease insulin requirements in diabetic women. There is also a decreased risk of Type 2 diabetes mellitus in mothers who do not have a history of gestational diabetes (References).

Additional Resources

Extended Breastfeeding Links @

Extended Breastfeeding References @

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Breastfeeding Past Infancy: Fact Sheet * KellyMom.com

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Breastfeeding children benefit NUTRITIONALLY Although there has been little research done on children who breastfeed beyond the age of two, the available information indicates that breastfeeding continues to be a valuable source of nutrition and disease protection for as long as breastfeeding continues.

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First Steps Nutrition Trust is an independent public health nutrition charity. We endeavour to fill practical and policy-relevant information gaps and provide resources for health workers supporting eating well from pre-conception to five years.

Our Mission

To influence policies which enable the safe, appropriate and optimal feeding of infants and young children in the UK, and to protect them from commercial interest.

To ensure that the importance of good nutrition from pre-conception to age five remains on everyone's agenda.

To provide conflict of interest-free information on infant milks marketed in the UK, and to promote better regulation and marketing of breastmilk substitutes.

To provide resources for health workers to support them in their work with pregnant women and young families.

Our Resources:

Are put together by nutrition experts and are regularly updated.

Can be used in Unicef UK Baby Friendly Initiative accredited settings.

Are available as free pdf downloads for use by anyone promoting better public health on a not-for profit basis.

Everyone who works at First Steps Nutrition Trust feels passionately about the need for better information and support for good nutrition - and good food - from pre-conception to five years.

First Steps Nutrition Trust is supported by generous individual donations and conflict of interest free grants. First Steps Nutrition Trust does not work with organisations or individuals that work with, or take funding from, the breastmilk substitute industry and we reserve the right not to sell them our subsidised resources.

First Steps works with and supports a number of organisations including Unicef UK Baby Friendly Initiative, the Baby Feeding Law Group, the Obesity Health Alliance, the Children's Food Campaign and the APPG on Infant Feeding and Inequalities.

First Steps Nutrition Trust host and regularly update their partner site infantmilkinfo.org which contains comprehensive information about infant milks (for 0-12 month olds) available on the UK market.

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First Steps Nutrition Trust is a charity which provides clear, evidence-based and independent information and support for good nutrition from pre-conception to five years of age.

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The decision about how long to breastfeed is very personal and can depend on a number of factors. We provide information and support to help you make the decision that is right for you and your baby.

Both the World Health Organisation (WHO) and UNICEF recommend that you exclusively breastfeed your baby for the first six months (around 26 weeks), and that you continue breastfeeding alongside introducing solid food for two years or more. The reality is that although most babies are breastfed at the beginning, very few babies in the UK continue to be breastfed beyond the first few months as we have one of the lowest breastfeeding rates for any developed country.

This means that our society is not used always to seeing breastfeeding and schools, colleges, employers, families and communities can lack awareness of breastfeeding. This can make the decision to breastfeed and to keep breastfeeding more difficult for you, particularly during times of change like returning to study or going back to work.

Support and understanding of breastfeeding is growing. We know that every drop of breastmilk that a baby receives is valuable and the longer breastfeeding continues, the greater the benefits to both your baby and you.

Each month of breastfeeding lowers the risk of illnesses that can put babies into hospital. It also helps protect babies against becoming overweight or obese, which means they are less likely to develop diseases like diabetes in the future. Every breastfeed is beneficial for your baby and breastfeeding for even a short time, or in combination with feeding infant formula, will still benefit your baby.

There is no need to decide how long you will breastfeed for at the beginning of your breastfeeding journey. You can take it day-by-day, week-by-week, month-by-month and even year-by-year. You can continue for as long as it feels right for you and your child. We can provide information on and support with stopping breastfeeding at any point, if you need it. The natural duration of breastfeeding is thought to be anywhere between two and seven years.

We are here to help you make breastfeeding work for you.

You may find these NHS links useful:

Why breastfeed, Start4Life, Building Blocks leaflet

You can read more about breastfeeding toddlers and older children here:
How long should a mother breastfeed? (La Leche League International) What are the benefits of breastfeeding my toddler? (La Leche League International) Toddler Breastfeeding - Why on Earth? (Jack Newman's Site)

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How long should I breastfeed for? - The Breastfeeding Network

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The decision about how long to breastfeed is very personal and can depend on a number of factors. We provide information and support to help you make the decision that is right for you and your baby. Both the World Health Organisation (WHO) and UNICEF recommend that you exclusively breastfeed your baby for the first [...]

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Your rights as a breastfeeding mother returning to work

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Your rights as a breastfeeding mother returning to work

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Breastfeeding exclusively (giving your baby no other food or drink) is recommended for around the first 6 months. After this time, breastfeeding is recommended alongside solid food.

Therefore, it's likely that you'll be breastfeeding when you return to work, training or education.

There are several options. You can:

arrange for childcare close to work or college so that you can breastfeed during breaks, or before and after work - the evening feed can be a wonderful way for you to relax with your baby

express breast milk (taking milk from the breast by hand or using a pump) so that someone else can feed your baby while you're at work

ask your employer or college for flexible working hours arranged around your breastfeeding needs

combine breastfeeding and bottle feeding to fit around your hours

Think about it early. Before you go back to work or college, tell your employer or tutor you're breastfeeding.

You may have an HR department that can help. It can make preparations, such as finding you a private room where you can breastfeed or express your milk.

Organising breastfeeding and work

Before returning to work you can:

label and date expressed breast milk before putting it in the fridge or freezer so your childminder knows which one to use first

have a trial run with childcare before returning to work

store breast milk in a sterilised container or in special breast milk storage bags in the fridge for up to 5 days at 4C or lower (you can buy fridge thermometers online) - if you're not sure of the temperature of your fridge, or it's higher than 4C, use it within 3 days

Information for employers about breastfeeding mothers

Employers have certain legal obligations to breastfeeding mothers. Supporting breastfeeding has business benefits too. These include:

reduced absence due to child sickness (breastfed babies are generally healthier)

increased staff morale and loyalty, and a subsequently higher rate of return to work

lower recruitment and training costs

an extra incentive to offer potential employees

How employers can help breastfeeding mothers

Employers can have a policy to support breastfeeding. This includes:

a break allowance for mothers to express milk

provision of a clean, warm, private room (not the toilet) for expressing

a secure, clean fridge to store expressed milk

flexible working hours for breastfeeding mothers

Let your employees know about your policy before they start their maternity leave.

What the law says about breastfeeding mothers at work

It's up to you to decide how long you want to breastfeed. Returning to work doesn't mean you have to stop. Before returning, you should give your employer written notification that you're breastfeeding. Your employer must then conduct a specific risk assessment.

Workplace regulations require employers to provide suitable facilities where pregnant and breastfeeding mothers can rest.

The Health and Safety Executive (HSE) recommends that it's good practice for employers to provide a private, healthy and safe environment for breastfeeding mothers to express and store milk. The toilets are not a suitable place to express breast milk.
The HSE has more advice for employers about protecting pregnant workers and new mothers

Talk to other breastfeeding mums

If you know any breastfeeding mothers who have already gone back to work, ask them for advice.

Got a breastfeeding question?

Sign into Facebook and message the Start for Life Breastfeeding Friend chatbot for fast, friendly, trusted NHS advice anytime, day or night.

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Information for employees and employers on returning to work and breastfeeding, including tips on expressing and storing breast milk.

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Commissioned by The Office for Health Improvement and Disparities (OHID), the new Better Health Start for Life campaign promotes information from the NHS on introducing babies to solid food from around six months.

The campaign comes after 1,000 parents across England with children aged three to 18 months completed an online survey about their attitudes and experiences of weaning. Findings indicate that 40% of first-time mums introduced solid food by the time their baby was five months old (earlier than the NHS recommendation of around six months) and almost two-thirds (64%) said they had received conflicting information on what age to start weaning.

The campaign includes a new online Start for Life Weaning Hub featuring information and guidelines from the NHS, including 120 healthy and easy-to-prepare recipes and meal ideas for every step of the weaning journey.

With more than 1 in 4 (27.7%) children being overweight when they reach school age, the campaign says it will also play a crucial role in supporting parents to get their child's diet right at the earliest stage, encouraging healthy food variety and developing good food habits.

To learn more about this campaign, visit the website of The Office for Health Improvement & Disparities.

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New Better Health Start for Life weaning campaign - Baby Friendly Initiative

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The campaign comes after 1,000 parents across England with children aged three to 18 months completed an online survey about their attitudes and experiences of weaning. Findings indicate that 40% of first-time mums introduced solid food by the time their baby was five months old (earlier than the NHS recommendation of around six months) and almost two-thirds (64%) said they had received conflicting information on what age to start weaning.

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Breastfeeding and the late preterm infant.

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Breastfeeding and the late preterm infant.

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Safe sleep for premature babies and low birth weight babies

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Safe sleep for premature babies and low birth weight babies

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Safer Sleep for Premature & Low Birth Weight Babies | The Lullaby Trust

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Essential safer sleep advice tailored for premature and low birth weight babies, offering guidance to reduce SIDS risks.

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Do you often find yourself wondering how long your baby should sleep? We explain baby sleep patterns, baby sleep cycles and what to expect…

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There's been a bit of conversation about tongue tie on social media after the Loose Women episode that highlighted the challenges experienced by Stacey Solomon

We've heard from a lot of women that the feedback that Stacey received on air didn't match their understanding of tongue tie. So we wanted to help clear up any confusion and point mums in the right direction if they need support.

A tongue tie can restrict normal tongue movement in babies and can lead to breastfeeding difficulties. This can include being unable to attach to the breast, or staying attached, pain while feeding and slow weight gain. Some babies can feed without difficulties, others may find feeding easier after a frenotomy.

The key to identifying and dealing with tongue tie is accessing support from somebody appropriately skilled and well informed as soon as possible - such as your local infant feeding team.

Another good place to start is National Breastfeeding Helpline on 0300 100 0212, which is open 9.30am - 9.30pm every single day of the year. Your call will be answered by highly trained volunteers, who are also mums with personal breastfeeding experience.

For more information on tongue tie:
https://www.nhs.uk/conditions/tongue-tie/ https://www.laleche.org.uk/tongue-tie/ https://www.breastfeedingnetwork.org.uk/sams-story-and-ton.../ https://www.tongue-tie.org.uk/ https://www.unicef.org.uk/babyfriend.../support-for-parents/.../ https://gpifn.org.uk/tongue-tie/

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Help and Support on Tongue Tie - The Breastfeeding Network

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There's been a bit of conversation about tongue tie on social media after the Loose Women episode that highlighted the challenges experienced by Stacey Solomon We've heard from a lot of women that the feedback that Stacey received on air didn't match their understanding of tongue tie.

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Tongue-tie can range from mild to severe. In severe cases, the tongue may be completely fused to the floor of the mouth.

You may be able to see if your newborn or baby has tongue-tie by looking into their mouth when they're yawning or crying, although it's not always easy to spot.

Signs of tongue-tie in your baby might include:

your baby's tongue not lifting or moving from side-to-side

their tongue looking heart-shaped when they stick it out

difficulty breastfeeding or bottle feeding (and weight gain may be slow)

frequent, long periods of feeding but seeming unsettled and unsatisfied

refusing to feed

clicking noises when feeding

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Find out about the symptoms and how to treat tongue-tie - a common breastfeeding problem that can make it difficult for your baby to latch on properly.

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Read more for support for parents on tongue-tie

Many babies have a piece of membrane under their tongue (the frenulum) which does not usually cause problems. Tongue-tie (ankyloglossia) occurs when the frenulum is abnormally short, stopping the tip of the tongue from protruding beyond the lower gum. This may cause problems with feeding as a result of the inability to move the tongue in a normal way and therefore attach and suck effectively. The frenulum may reach the tip of the tongue and be easily seen, and may be either thin and stretchy or thicker/tighter. A posterior frenulum, which is at the back of the tongue, can be less easy to see and in some cases may only be felt. If you and/or your baby are experiencing feeding difficulties, an assessment of your baby's tongue function and a feeding assessment by a specially trained professional will determine whether a division of the membrane ( frenulotomy) could help.

Many tongue-ties are asymptomatic and do not require treatment, and some may resolve spontaneously over time. In some instances, support to improve attachment is all that is needed. However, if the condition is causing problems with feeding, surgical division of the lingual frenulum can be recommended and carried out as early as possible. This may enable the mother to continue breastfeeding rather than having to switch to artificial feeding.
NICE has approved the division of tongue-tie.

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Many babies have a piece of membrane under their tongue (the frenulum) which does not usually cause problems. Tongue-tie (ankyloglossia) occurs when the frenulum is abnormally short, stopping the tip of the tongue from protruding beyond the lower gum.

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Colic is a very common condition affecting 1 in 5 babies. See our NHS-approved advice on how to soothe a colicky baby.

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This information can also be viewed as a PDF by clicking here.
The information provided is taken from various reference sources. It is provided as a guideline. No responsibility can be taken by the author or the Breastfeeding Network for the way in which the information is used. Clinical decisions remain the responsibility of medical and breastfeeding practitioners. The data presented here is intended to provide some immediate information but cannot replace input from professionals.

Feeding with artificial formula in the first 4-6 months of life increases the risk to cow's milk protein allergy (CMPA) compared to exclusive breastfeeding (Vandenplas et al 2007)

0.5% of exclusively breastfed infants show reactions to cow's milk protein compared to 2%-7.5% of formula fed infants. (Vandenplas et al 2007)

If a breastfed baby is thought to have CMPA the mother should eliminate all sources of cow's milk from her own diet as well as that of her baby for a minimum of 3 weeks. Although improvement may be seen after 3 days it may not resolve for 4 weeks (Ludman et al 2013)

A breastfeeding mother who is on a diet free of cow's milk protein she should be prescribed a supplement of 1000 mg of calcium and 10 microgramme of vitamin D every day. (Ludman et al 2013)

Cows' milk allergy can often be recognised and managed in primary care. Patients warranting a referral to specialist care include those with severe reactions, faltering growth, atopic comorbidities, multiple food allergies, complex symptoms, diagnostic uncertainty, and incomplete resolution after cows' milk protein has been excluded (Ludman 2013).

Cow's milk protein allergy (CMPA) can affect people of all ages but is most prevalent in infants, affecting between 2 and 7.5% of formula fed and 0.5% of exclusively breastfed babies. Exclusively breastfed babies develop CMPA as a result of milk proteins from products the mother has eaten transferring through breast milk. The level of cow's milk protein present in breast milk is 100,000 times lower than that in cow's milk. Most reactions to cow's milk protein in exclusively breast fed babies are mild or moderate and severe forms of CMPA very rare. It is thought that immunomodulators present in breast milk and differences in the gut flora of breastfed and formula fed infants may contribute to this. (Ludman 2013).

Secretory immunoglobulin A (sIgA) in breastmilk "paints" a protective coating on the inside of a baby's intestines to prevent penetration by potential allergens such as foreign proteins. SIgA cannot be replicated in formula.

The reaction may be mediated by IgE (anaphylaxis, urticaria) if they occur immediately following consumption of cow's milk protein or non IgE (GI reactions, eczema, GOR) which may occur several hours or even days after consumption. The immune system responds to the protein casein or the whey found in cow's milk.

Although these symptoms may be related to other conditions, they are likely to be due to CMPA if the severity is related to a change in the amount of cow's milk consumed by the mother and/or baby, or if cow's milk based formula or other similar foods are introduced into the baby's diet. CMPA is also a likely cause if the symptoms appear in more than one system, for example diarrhoea and atopic dermatitis, and also if these symptoms are resistant to treatment. It is important to consider all outcomes and to take a full medical history to ensure that the symptoms are not due a cause other than CMPA. (Ludman 2013). Attention should also be paid to optimising attachment and frequent feeding if the baby is breastfed.

Where CMPA is suspected in a breastfed baby, the recommended treatment is for the mother to remove all sources of products containing cow's milk from her diet, ideally under medical supervision. Mothers should be prescribed a supplement of 1000mg of calcium and
10 microgrammes of vitamin D every day.

Algorithm for the diagnosis and management of cow's milk protein allergy (CMPA) in exclusively breast-fed infants. (eHF= extensively hydrolysed formula.)

Vandenplas et al (2007) state that 10-35% of infants with CMPA have adverse reactions to soya. While Ludman et al (2013) report that up to 60% of patients with non-IgE mediated cow's milk allergy and up to 14% with IgE mediated allergy also react to soya.

Where solid foods have been introduced, all sources of products containing cow's milk should also be removed from the baby's diet. It will usually take between 2 and 4 weeks for symptoms to disappear. It is suggested that milk is then reintroduced to ensure that this has been the cause of the symptoms. (Ludman 2013, NICE 2011).

Where a diagnosis of CMPA is confirmed the mother should avoid cow's milk products in her diet for as long as she is breastfeeding. She will continue to require support to manage her nutrition, particularly where the elimination diet is over an extended period of time. A dietician or other healthcare professional managing the case will recommend at which point reintroduction of cow's milk should be trialled and how this should be managed. Care should also be taken with the weaning diet and appropriate alternative sources of calcium included under dietetic supervision.

There is generally no need to add special prescription formula or soya formula. The baby can continue to receive breastmilk even whilst his/her mother is beginning to eliminate cow's milk protein from her diet.

A diagnosis of cow's milk protein allergy has many ramifications for mother and baby. A mother should not be asked to remove products containing cow's milk protein lightly e.g. to resolve colic symptoms, without first considering referral to a breastfeeding expert to address issues around optimal attachment.

Update 2019

In a BMJ article in 2018 Dr C Van Tullekan suggested that the diagnosis of CMPA is a trojan horse for formula milk manufacturers to forge relationships with healthcare professionals under the guise of education. He noted that "Between 2006 and 2016, prescriptions of specialist formula milks for infants with cow's milk protein allergy (CMPA) increased by nearly 500% from 105 029 to over 600 000 a year while NHS spending on these products increased by nearly 700% from £8.1m to over £60m annually. Epidemiological data give no indication of such a large increase in true prevalence-and the extensive links between the formula industry and the research, guidelines, medical education, and public awareness efforts around CMPA have raised the question of industry driven overdiagnosis. Nigel Rollins from the World Health Organization's department of maternal, newborn, child, and adolescent health agreed that "It's reasonable to question whether these [prescription and spending] increases reflect a true increase in prevalence."

It would be easy to identify virtually every child with symptoms in the table above. This does not imply that every day has CMPA although an exclusion diet is recommended to many mother "just to see if it helps". The repercussions from diagnosis cannot be underestimated for the mother, the baby and the health economy. A diagnosis can be made only by excluding cows' milk protein from the maternal diet, observing symptoms, and then reintroducing. Many mothers are willing to go to any lengths to maintain breastfeeding although others may perceive their milk as toxic to their baby and stop breastfeeding. Many support organisations and guidelines are written by industry sponsored sources and therefore seen as likely to influence perception of symptoms. Conflict of interest with organisations such as Nutricia should be taken into consideration when interpreting information.

Dr Helen Crawley First Steps Nutrition booklet Specialised Infant Formula (2018) notes that:

Amino-acid based infant milks contain protein in the form of individual amino acids and are marketed to be used in the dietary management of moderate to severe cows' milk protein allergy or multiple allergies. Amino-acid based infant milks are unlike other hypoallergenic infant milks in that they contain amino acids which are synthetically derived, as opposed to peptides originating from cows' milk, meat or soya as found in extensively hydrolysed formula.

These milks are about three times more expensive than extensively hydrolysed formula milks, and are an area in which cost savings to the NHS can be made with use of appropriate prescribing.

Breastfeeding is the optimal way to feed a baby with cows' milk protein allergy, with individualised maternal elimination of cows' milk protein foods and fluids, and with adequate calcium and vitamin D supplementation to meet the mother's nutritional requirements during breastfeeding.

Amino-acid based infant milks are low in lactose or are lactose-free and contain maltodextrin or dried glucose syrup as the main carbohydrate source, meaning that oral care is particularly important for individuals being given these products.

References

Crawley H Specialised Infant Milks in the UK 0-6 months. First Steps Nutrition 2018 https://www.firststepsnutrition.org/composition-claims-and-costs

LIFIB Cows' Milk Protein Allergy Briefing Paper Oct 15 http://lifib.org.uk/cows-milk-protein-allergybriefing-paper-oct-15/

Ludman, S., Shah, N., Fox, A.T. Managing Cow's Milk Allergy in Children BMJ 2013; 347:f5424

National Institute for Health and Clinical Excellence (2011) Food allergy in children and young people Diagnosis and assessment of food allergy in children and young people in primary care and community settings

Van Tulleken C Overdiagnosis and industry influence: how cow's milk protein allergy is extending the reach of infant formula manufacturers. BMJ 2018;363:k5056

Vandenplas, Y., Brueton, M., Dupont, C., Hill, D., Isolauri, E., Koletzko, S., Oranje, A.P., Staiano, A. Guidelines for the diagnosis and management of cow's milk protein allergy in infants Arch Dis Child 2007; 92:902-908

Competing interests of referenced papers

Vandenplas et al declared funding "Funding: The consensus panel, the literature search and the drafting of the manuscript were funded by a grant from SHS/Nutricia. The paper was drafted by Mark Greener, a medical writer. SHS International Ltd and Nutricia did not have any editorial control over the final manuscript, which remains entirely the responsibility of the authors. Competing interests: DH, CD, MB, SK and YV declare they have received support for clinical research projects from SHS/Nutricia and the same authors and MB declare they have presented lectures at SHS/Nutricia-sponsored meetings. Also, SK has presented lectures at sponsored meetings and received support for scientific work from Mead Johnson and Nestle. YV has received support from Janssen Pharmaceuticals, Astra, Wyeth, Biocodex and Nestle. None of the other authors made any declarations relevant to the preparation of this manuscript. The authors declare the absence of competing interests and confirm their independence regarding the content of this manuscript.

Ludman et al We declare the following interests: ATF has done consultancy work for Mead Johnson Nutrition Danone, Nestle Nutrition,and Abbot. He has received fees for lectures or producing educational material from Mead Johnson Nutrition and Danone. He is site principal investigator for a Danone sponsored study funded through Guy's and St Thomas' NHS Hospitals NHS Foundation Trust and King's College London.
©Dr Wendy Jones MBE, MRPharmS and the Breastfeeding Network Sept 2019

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Cows' Milk Protein Allergy (CMPA) and Breastfeeding - The Breastfeeding Network

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This information can also be viewed as a PDF by clicking here. The information provided is taken from various reference sources. It is provided as a guideline. No responsibility can be taken by the author or the Breastfeeding Network for the way in which the information is used.

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Some breastfeeding women feel negative emotions such as sadness, depressed mood, anxiety, irritability or anger just before their milk lets down and starts to flow. These emotions might continue for a few minutes. The feelings are usually described as either Dysphoric Milk Ejection Reflex (D-MER) or breastfeeding aversion and agitation (Aversion). The two phenomenons are similar but slightly different. Some women may feel nauseous during breastfeeding. This article looks at both D-MER and Aversion and answers frequently asked questions.

What is Dysphoric Milk Ejection Reflex (D-MER)?

D-MER is described as an abrupt drop in emotions just before milk is released from the breast by the milk ejection reflex or let-down reflex. The drop in emotions only lasts for a few minutes and is always associated with the let-down reflex. The negative feelings involved might range from feeling sad to feelings of hating oneself. Three distinct emotions are often described namely depression, anxiety and anger. The strength of these feelings varies between sufferers. D-MER is not connected to postnatal depression.

What causes D-MER?

Physiological not psychological

D-MER is thought to have a physiological cause (a physical and chemical process occurring in the body) over which there is little control. Heise and Wiessinger liken it to a reflex action that you cannot stop:

Imagine tapping your knee to cause a reflexive jerk. Now tell yourself that you are going to resist the reflex with all your will, and tap again. Does your willpower make any difference? This is precisely the problem for the mother with D-MER. The emotions are unavoidable. She can feel them coming, but cannot stop them.

Theories to explain the phenomenon include:

Drop in dopamine

One theory for the cause of the negative feelings of D-MER is a drop in dopamine (a chemical messenger released by the brain) that occurs whenever milk is released. During the let-down, dopamine may fall more than usual in some women causing a temporary deficit or they may be more sensitive to the drop in level (Heise and Wiessinger, 2011).

Oxytocin surge

Another theory suggests the sudden oxytocin surge during the let-down reflex may be the trigger.

Is there any treatment for D-MER?

Avoid stress, dehydration, caffeine

It can be useful for mothers to try and track their own symptoms against life style factors such as stress, dehydration or caffeine as these may exacerbate symptoms of D-MER. Details such as getting more rest, drinking more and having more exercise can be helpful for some mothers. Uvnas-Moberg and Kendall-Tackett explain how lowering stress levels to make the mother feel comfortable and safe might be helpful:

A clean and orderly environment can be helpful in downregulating a mother's stress response-have music the mother enjoys, with a comfortable place to sit, and nice things to look at. Warmth also triggers the oxytocin response. Give the mother a hot pack around her shoulders, or suggest that she soak her feet in warm water. The goal is to use the mother's environment to help her feel comfortable and safe.

Dopamine

Dopamine is an important hormone and messenger (neurotransmitter) in the body. An information sheet on Alia Macrina Heise's Dysphoric Milk Ejection Reflex website discusses prescription treatment for severe cases of D-MER in the form of dopamine supporting medications.

Skin to skin contact

Skin-to-skin contact between mother and baby is another way to increase oxytocin and reduce stress in mother and baby. The power of skin to skin contact may help override the negative feelings of D-MER (Uvnas-Moberg and Kendall-Tackett. 2018).

Mindfulness

Being aware of negative thoughts and focussing on one's breathing is part of mindfulness and may be helpful to cope with the emotions of D-MER. Uvnas-Moberg and Kendall-Tackett explain:

With mindfulness, mothers focus on their breathing, are in the present moment, and treat themselves with compassion. They remind themselves that the negative thoughts they are experiencing are thoughts, not facts. Patient education about the symptoms can also be helpful, so mothers know what these symptoms are and that they will go away soon.

Nutrition and self care

One case study showed that increasing protein in the mother's diet and not pumping beyond her baby's immediate needs helped alleviate symptoms (Uvnas-Moberg and Kendall-Tackett. 2018)

Where can I get help and support?

Most women with D-MER usually find that their symptoms gradually reduce, sometimes disappearing as time goes on but for others symptoms do not completely disappear until their baby is weaned and they are no longer breastfeeding. Finding out as much as possible about D-MER and seeking help and support can make D-MER more manageable. Many mothers find knowing that the phenomenon has a name and has a physiological cause is helpful (Heise, 2011). Three good places for assistance include the D-MER.org website, the book Before The Letdown: Dysphoric Milk Ejection Reflex and a Facebook support group run by Alia Macrina Heise.

Excerpt From

Breastfeeding and Human Lactation, 6e, Wambach and Spencer, 2021

Clinicians can support women with D-MER in several ways; often, simply knowing that it is a recognised phenomenon makes the condition tolerable.

Breastfeeding aversion and agitation

Breastfeeding aversion involves the nursing mother feeling negative emotions. The reasons why are not known and more research is needed. A website dedicated to breastfeeding aversion collated by Zainab Yate explains:

Breastfeeding / Nursing Aversion & Agitation (BAA) is a phenomenon whereby breastfeeding / pumping mothers experience negative emotions triggered whilst breastfeeding, these include anger, rage, agitation and irritability. Women also struggle with an 'overwhelming urge to de-latch', and often a skin itching sensation. BAA or 'aversion' can be experienced by any breastfeeding (or even pumping) person, at any stage of their feeding journey, and it varies in onset, severity and duration.

Anecdotal ideas to help with breastfeeding aversion are listed on Zainab's website. These include making sure baby's attachment at the breast is as good as possible, distracting oneself with other activities during breastfeeding, getting enough sleep, making sure you have enough time for yourself away from breastfeeding and ensuring you have drunk enough and are eating well. For some mothers a hormonal imbalance can trigger the aversion. Finding peer to peer support from others who experience BAA can also be helpful.

Nausea

Feeling nauseous (as if one might be sick) during breastfeeding is not common but may be due to high levels of oxytocin and other hormones active during the let-down reflex. .

Allergic to breastfeeding?

There are occasional case reports in the literature of mothers noticing physical symptoms with breastfeeding similar to those experienced with allergy for example rashes, itching or shortness of breath. The severe form of this occurrence is known as breastfeeding induced anaphylaxis or lactation anaphylaxis and can be managed with antihistamines.

Lawrence and Lawrence also discuss less dramatic rashes/hives (urticaria) associated with the let-down reflex which can be managed with antihistamines or low dose corticosteroids. The reactions are thought to be associated with the let-down (when milk is ejected from the breast), a time when the hormones oxytocin and prolactin are released. However the direct cause of the symptoms is not known and more research is needed.

Summary

Dysphoric Milk Ejection Reflex or D-MER, is a collection of negative emotions-anxiety, depression, anger-experienced by some breastfeeding mothers just before they have a milk let-down (milk ejection reflex). These feelings last for a few minutes. The cause is thought to be due to a sudden drop in dopamine during let down which can affect susceptible women. There are a number of treatments available that can help. Other negative states experienced by some nursing mothers include breastfeeding aversion and agitation or nausea. Very rarely, a mother can experience an allergic reaction to breastfeeding.

Footnotes & References

1. Is D-MER Real: Does Breast Milk Letdown Really Cause Depression? Heather Turgeon, 2011

2. Wambach and Spencer. Breastfeeding and Human Lactation. 2021 p. 262

3. Lawrence and Lawrence. Breastfeeding A Guide for the Medical Profession. 8e. 2016 p 619

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Some breastfeeding women feel negative emotions when they breastfeed. This article looks at both D-MER and Aversion and answers frequently asked questions.

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Supporting babies with cleft lip/palate to breastfeed

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Supporting babies with cleft lip/palate to breastfeed

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The NHS recommends exclusive breastfeeding for the first six months of a baby's life, but feeding issues caused by a cleft lip and/or palate can make breastfeeding very difficult.
At this time, it is important to remember three key things:

1. It is very unlikely that your child's cleft was caused by something you did or didn't do.

2. Many mothers and babies have difficulties with breastfeeding, regardless of whether or not there are issues like a cleft to deal with.

3. Any amount of breast milk is beneficial. If you are unable to breastfeed, you may still be able to express milk and bottle-feed your baby.

Babies with a cleft lip

Babies with a cleft lip (without a cleft palate) may be able to breastfeed. There can be difficulties with forming a seal between the breast and lip but, depending on the type and size of the cleft, the breast may be able to mould to the gap.

A hissing sound usually means air is entering the mouth, so try to re-position the baby on the breast to help them to form a vacuum. The nipple needs to stay on the back of the tongue, so it may be useful to help the baby by holding the breast in the mouth. Small changes in the vacuum will result in the nipple slowly moving towards the front of the baby's mouth which will make feeding less effective.

You may need to try several different positions over time before you find one which works, and it will help to seek support from medical professionals experienced in feeding babies with clefts, such as your Cleft Nurse Specialist.

A good flow of milk helps and this can be encouraged by massaging the breast or using a breast pump. Your midwife or a feeding specialist will be able to help you with this.

Babies with a cleft palate

Breastfeeding a baby with a cleft palate may work when the cleft is very small or narrow. The breast needs to be held well into the area where there is palate so that the baby can get a good grip and work at the breast with the tongue. A baby born with a cleft palate will need help in achieving a good 'latch on'. A nurse specialist will be able to help you with this.

If your baby is unable to suckle at the breast before they have their palate repaired at 6-12 months, it is possible, with commitment, for them to taste and lick milk expressed onto the nipple and be fed with expressed breast milk by another feeding method. Any amount of breast milk is beneficial.

For babies with a cleft palate, breast milk can be especially helpful as it does not irritate the delicate tissue in the nose and throat as much as formula milk and can help to reduce the risk of ear problems developing later on.

There are a number of alternative methods, including cup and spoon feeding, and a supplemental nursing system. Many Cleft Teams have breast pumps available for hire which will allow you to express feed your baby. Talk to your midwife or Cleft Team about this, or get in touch with a CLAPA Parent Supporter to discuss your experiences.

It is generally advised to take things a week at a time and review the situation regularly.

General breastfeeding tips

Your baby may not have a strong enough suck to stimulate the flow of milk, so you will need to help them. You can encourage the flow of milk by massaging the breast or using a breast pump. Your midwife or a feeding specialist will be able to show you how to massage your breast and hand express the milk when a breast pump is not available.

If your baby isn't able to take much milk during the feed, you may need to express more milk after feeding to ensure the breasts receive enough stimulation to keep producing milk.

Your baby will satisfy their thirst on the first suckling and their hunger on the hind milk which contains more calories. Even if you are able to breastfeed, your baby may need to be supplemented using expressed breast milk with an alternative feeding method, as breastfeeding alone may not give them enough milk.

Source(s): Range of feeding literature from Cleft Units, with assistance from Cleft Nurse Specialists in Manchester, Nottingham and South London. Stories and suggestions from parents of children born with a cleft were also used.

If you have a comment or question about the information in this page, or would like to know more about the sources of this information, please contact Communications & Information Manager Anna Martindale at [email protected] or 020 7833 4883.

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The NHS recommends exclusive breastfeeding for the first six months of a baby's life, but feeding issues caused by a cleft lip and/or palate can make breastfeeding very difficult. At this time, it is important to remember three key things: It is very unlikely that your child's cleft was caused by something you did or didn't do.

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How to Use Nipple Shields | Infant Feeding Team

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A nipple shield is a flexible silicone nipple that is worn over the mother's own nipple during breastfeeding.
When are they used?
Nipple shields can help establish breastfeeding with some babies who seem to have difficulty achieving and/or maintaining attachment to the breast. However, very few benefit from using a nipple shield. Please consult a breastfeeding counsellor or health professional for one-to-one support before you use a nipple shield. A nipple shield can be a temporary solution but not a permanent fix to an underlying problem. They may affect transfer of milk to the baby which may contribute to poor weight gain and health problems for both mother and baby.
What might cause my baby to have difficulty with attachment?

Events around labour and delivery.

Use of artificial nipples.

Baby's physiology.

Other reasons a shield could be used:

Flat or inverted i.e. non protractile nipples.

Breast refusal.

Sore, cracked, bleeding nipples.

Weaning a baby from bottle to breast.

Re-lactation or induced lactation (adoptive breastfeeding).

Before using a nipple shield, consider:

Accessing skilled breastfeeding support, ideally face-to-face.

Prolonged skin contact, and 'biological nurturing' i.e. laid-back breastfeeding techniques.

Hand expressing drops of milk onto the nipple to tempt the baby to attach.

Regular (2-3 hourly) hand expressing of colostrum to protect milk supply.

Regular (2-3 hourly) feeding of expressed breast milk (EBM) via syringe/cup.

Trying different positions/techniques e.g. cross cradle hold and exaggerated attachment, lying down feeding, underarm hold.

Applying cold to a soft nipple to firm it.

Use of nipple massage, gentle use of breast pump or other suction device to draw nipple out.

If milk is in, deal with any engorgement to soften areola to facilitate attachment.

When breastfeeding is uncomfortable, using a nipple shield can feel like a quick fix, but shields are not a substitute for finding qualified breastfeeding support. If there is an underlying latching problem, adding a shield on top can risk blocked ducts and mastitis, supply reduction, and a baby not getting enough milk. Feeds can end up being long and unsettled and baby may take in more air. When the shield is removed, the underlying problems remain, and may even be worse as the baby has become accustomed to using the shield. Always try and find qualified help if breastfeeding is uncomfortable or challenging.
Care
Wash the shield with hot soapy water, rinse with clean water, dry carefully and store in a clean container.
Choosing a shield
Nipple shields are sized according to the diameter of the base of the mother's nipple. A poorly fitting shield can cause problems including reduced milk transfer and pain.

In the U.K., the standard sizes are 16mm (small), 20mm (medium) and 24mm (large). A larger 28mm size is available online but can be difficult to find.

The size of shield you use is not the same size as the pump funnel you use. Shields are a closer fit. Many shops will only sell one size and you may have to shop online to get a wider selection.

A 'contact' nipple shield has a cut away piece that allows baby's nose or chin to remain close to the breast. This is preferable to a shield where the baby's nose is pressed against plastic.
How to use a nipple shield
It's often helpful to place your baby in skin to skin contact well before you attempt a feed. This will stimulate baby's instinctive feeding behaviours and make attachment to the breast more likely to be successful.

First, try latching the baby without the shield if you feel you can. How long you spend trying to latch effectively without the shield is a very personal decision and will depend on how long ago the baby fed, the support you have, and how breastfeeding has been going in the past.

A warm wet shield sticks to the breast better - run the shield under warm water prior to use.

Roll the wet, warm shield back about halfway down the shank of the shield.

It may adhere to the breast better if you apply a little water or breastmilk around the edge.

Roll the shield back onto the breast so the nipple is drawn into the teat of the shield.

There are some videos online that show you how to apply a shield with this 'slightly inside out' method.

Attachment
Attachment technique is still important with a shield. Don't just poke the shield teat centrally into baby's mouth. Baby should be held close, mouth wide open and chin in contact with the breast. Once attached, you should notice their chin moving deeply to show active swallowing and you will often hear some swallowing at the beginning of a feed.

Towards the end of the feed (when baby's swallowing slows) it is a good idea to use breast compression while baby suckles to increase the milk and fat transfer to the baby. Offering baby both breasts at each feed will mean baby gets more milk.

The nipple shield is a projection of the nipple so, when the baby unlatches, it should look well rounded, just as though baby had a good latch directly at the breast. You should see milk in the shield when baby comes off. As using a shield is often associated with reduced milk transfer, it can be recommended to express in addition, to help protect your supply. Your breastfeeding counsellor or health professional can support you to consider how often this is needed, depending on how things are going.

It's a good idea to keep an especially close eye on baby's bowel movements and urine output while you're using a nipple shield, as these give an indication of milk intake. Baby should have about three tablespoon-sized yellow, grainy stools in 24 hours (after the fifth day) and have at least six wet nappies.

If baby is discharged from hospital using nipple shields, their progress should be closely monitored by the community midwife or health visitor.
Weaning from a shield
Be sure not to make this a battle with your baby, or they will resist more. Don't obsess with weaning off the shield to the point that you are unhappy with breastfeeding. As long as your baby is gaining weight well, there is no need to rush into trying to wean them from the shield. Don't cut down a shield to wean a baby off it - this practice is no longer recommended.

You may be able to remove the shield part way through a feed and continue without. You may only use a shield on one breast, or for the first few minutes. Some babies need only one or two sessions with the nipple shields, while others may need more.

Keep trying as often as you can and give it some time. Your baby might be more receptive to feeding without the shield when they are less hungry or sleepy. Some continue to use a shield for the duration of their breastfeeding experience, but most are able to stop using the shield after only a short time if they wish to.

Be patient while you work through this time of transition. Breastfeeding with a shield is still breastfeeding.

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Using a nipple shield with a breastfed baby - ABM

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Nipple shields can help establish breast-feeding with some babies who seem to have difficulty achieving and/or maintaining attachment to the breast.

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Breast and nipple pain in breastfeeding women can be caused by a thrush infection in the breast. You can still breastfeed while being treated for thrush.

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Gastro oesophageal reflux and the breastfed baby - ABM

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Many babies bring milk back up through their food pipe at different times of the day or night. This is called reflux (short for Gastro-Oesophageal Reflux, or GOR). Simply put, the valve between the stomach and the food pipe (oesophagus) is not keeping the baby's milk down and it comes back up the pipe the wrong way.

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A vasospasm is a sudden narrowing (or constriction) of blood vessels. If the blood vessels in the nipple have a vasospasm this can cause nipple pain and sometimes deeper breast pain. A breastfeeding baby can trigger a nipple vasospasm if they are not attached (latched) to the breast comfortably ie with a big mouthful of breast tissue as well as the nipple. A nipple vasospasm can also be connected with Raynaud's phenomenon (a condition affecting blood supply). This article looks at the symptoms, causes and possible treatments for easing nipple vasospasm.

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Nipple vasospasm and breastfeeding

If a nipple is flattened or compressed because a baby is pinching the nipple during a breastfeed, this may trigger a nipple vasospasm. The nipple may look pointed or slanted like the top of a new lipstick straight after a feed and, since the blood vessels in the nipple are narrowed, less blood can flow and the nipple can temporarily turn white. When the blood flows back to the nipple after each breastfeed, mothers may feel a painful burning or throbbing sensation.

What are the symptoms of nipple vasospasm?

Symptoms of nipple vasospasm include:

Painful nipples-the pain is often described as burning, stabbing or itching and may be felt a short time after breastfeeding and/or in between feeds.

Sore nipples-nipple vasospasm is associated with misshapen nipples and sore nipples or previously damaged nipples that are healing.

White nipples-nipple tips may look white (blanched) after a feed or mothers may notice other colour changes in their nipples e.g. blue or dark red (also associated with Raynaud's Phenomenon-see below)

Deep breast pain-some mothers may feel deep breast pain or shooting pains deep in the breast sometimes referred to as Mammary Constriction Syndrome.

Cold temperatures and stress may worsen the pain or trigger it.

Not vasospasm? Other causes of pain

There are many causes of sore nipples or pain during breastfeeding and for a complete overview see Causes of Sore Nipples and Why Does Breastfeeding Hurt? Vasospasm symptoms such as burning pain and soreness can be very similar to those of a bacterial infection (e.g. a Staph infection) or a fungal infection (e.g. thrush). Note that a misdiagnosis of thrush and resulting unnecessary prescription medication, may make vasospasm symptoms worse.

What causes nipple vasospasm?

There are a number of risk factors that seem to make nipple vasospasm more likely:

A shallow latch. In breastfeeding mothers, the main trigger for nipple vasospasm is likely to be a poor latch (the way a baby attaches to the breast). If a baby breastfeeds with mostly only the nipple in their mouth and not a good deep mouthful of breast tissue as well, this is often called a shallow latch. In a shallow latch the nipple is more likely to get pinched between baby's tongue and the roof of their mouth and trigger the vasospasm. Some babies also learn that pinching the nipples is a good way to slow the milk flow in a fast let-down.

Sore nipples. Sore nipples, damaged or cracked nipples, and nipples that are healing are associated with poor positioning at the breast and are risk factors for vasospasm (Thomas, 2013).

Cold temperatures. Exposure to cold temperatures and climates, or the sudden drop in temperature when a baby lets go of the nipple is a risk factor for a nipple vasospasm.

Severe stress. Severe emotional stress is a risk factor for nipple vasospasm and a history of migraines may be a risk factor (Goldfarb, 2019).

Medical conditions. An existing history of autoimmune disease eg lupus, rheumatoid arthritis, thyroid dysfunction, scleroderma, or previous diagnosis of Raynaud's syndrome increases the likelihood of nipple vasospasm.

Cigarette smoking. Exposure to cigarette smoke, second-hand smoke or nicotine can be triggers for nipple vasospasm (Goldfarb, 2013).

Medications. Certain medications including fluconazole (prescribed for thrush), some decongestants, or birth control medication are risk factors for nipple vasospasm (Goldfarb, 2019; Breastfeeding Network, 2019) also beta-blockers, or vasoconstrictor medications which narrow blood vessels (Douglas, Vol 18: 1-29 2022).

Caffeine may be a trigger for vasospasm (Goldfarb, 2019; Breastfeeding Network, 2019) however Douglas says there is no clear evidence linking caffeine intake to secondary Raynaud's syndrome (vasospasm without existing Raynaud's) (Douglas, Vol 18: 1-29 2022).

How can I avoid vasospasm symptoms?

Minimising the risk factors can work very well to help prevent symptoms of nipple vasospasm, namely:

Get help with positioning from an International Board Certified Lactation Consultant so that your baby's latch is not triggering vasospasm. A poorly latched baby, an ineffective suck or the baby clamping on the nipple can all cause nipple blanching. Babies with high muscle tone or those with tummy ache (e.g. from a food allergy) may seem to "bite" at the breast and can cause a nipple vasospasm. A baby needs to attach to the breast deeply with a big mouthful of breast as well as the nipple. See Breastfeeding Positioning for Newborns, Latching Tips and Why Does Breastfeeding Hurt? for more information and see your breastfeeding specialist for one to one help.

Check pumping equipment. A poorly fitted pump flange could cause nipple damage and vasospasm symptoms, conversely pumping with a well fitted pump may offer relief to symptoms compared to breastfeeding for some women until they can get help with positioning.

Keep warm; breastfeed in a warm room and cover the nipple as soon as a breastfeed ends. Don't leave nipples to air dry as they will get colder that way. Keep breastpads dry, some mothers use woollen or fleecy breastpads for warmth. Try to avoid sudden temperature changes.

Avoid latching a baby while the nipple is having a vasospasm, as this may cause damage to the nipple, try warming the breast and repeatedly squeezing the nipple to help blood flow back into this area before latching (Hills, accessed Oct 2022).

Gentle massage. Try massaging the nipples with warm olive oil after a breastfeed to stop a nipple vasospasm. Repeatedly squeezing the nipple during a vasospasm helps blood flow return to the nipple and can improve recovery time.

Rule out a bacterial infection or thrush-check with your health professional that you don't have any other causes of burning pain and sore nipples.

Avoid potential triggers: cigarette smoke and smoking, nicotine, caffeine, or any medications that promote vasoconstriction e.g. some decongestants and avoid stress where possible.

Keep active with aerobic exercise.

Raynaud's phenomenon

Raynaud's is a disorder of the tiny blood vessels of the extremities which reduces blood flow. Cold temperatures or strong emotions cause the blood vessels in the extremities to go into spasms, which may cause pain, numbness, throbbing and tingling. Some women who have Raynaud's in the fingers and toes may find they get Raynaud's of the nipple when they breastfeed. This might be because breastfeeding affords lots of opportunities for nipples to get cold e.g. just before and after latching. Painful breastfeeding can also be stressful. Raynaud's is often misdiagnosed as thrush or a poor latch .

Diagnosis of Raynaud's

Raynaud's symptoms affecting the nipple may be difficult to distinguish from nipple vasospasm caused by a poor latch:

Symptoms can be triggered by cold and may still occur in spite of a good latch.

Colour changes of the nipples e.g. from white to blue to red/purple may be seen with lighter skin tones.

Raynaud's may be linked with a history of migraines or a history of poor circulation .

Treatments for nipple vasospasm

In addition to using the above ideas to avoid getting vasospasm symptoms, there are a number of treatment options for nipple vasospasm that still persists after a poor latch has been corrected and other infections ruled out. Treatments options are discussed in the following patient information handout from the Goldfarb Breastfeeding Clinic and include pain relief, dietary supplements (calcium, magnesium and vitamin B6), omega fatty acids and prescription medication:

Excerpt from

Nipple Vasospasm Patient Handout, Herzl Family Practice Centre, Goldfarb Breastfeeding Clinic, 2019

The use of Advil™ or Motrin™ (ibuprofen) and/or Tylenol™ (acetaminophen) may be very useful to treat the pain of nipple vasospasm. These medications are safe during breastfeeding.

Your health professional may suggest high doses of calcium and magnesium, and vitamin B6. Please consult your health professionals for doses specific to your case.

Omega fatty acids may also help. Evening primrose oil (up to 12 capsules a day) and fish oil capsules are rich sources of omega fatty acids.

Nifedipine (Adalat™) [...] normally used for high blood pressure, can also be used for nipple vasospasm, and is safe for breastfeeding mothers and infants.

Nifedipine

Refer to the full Goldfarb article online for precautions regarding nifedipine and share this with your health care professional. The Breastfeeding Network discusses doses and side effects of nifedipine in their fact sheet Raynaud's Phenomenon in Breastfeeding Mothers and for more places to find information about the safety of nifedipine online see Medications and Breastfeeding. Always discuss medications or medicinal doses of supplements with your health care provider.

Treatment tips from Dr Jack Newman

Jack Newman, a Canadian paediatrician and breastfeeding expert, has a protocol for treating vasospasm; see Vasospasm on his website. In addition to a discussion of certain vitamin and mineral supplements (also referred to in the patient handout quoted above), Dr Newman advocates:

Complementary medicine

Scleroderma and Raynaud's UK (SRUD) discuss natural and over the counter complementary medicine for scleroderma and Raynaud's in Natural Therapies. They discuss how vitamin C, vitamin E, gamolenic acid (GLA), ginkgo bilboa and ginger may help symptoms in the general population but note this article is not specific to breastfeeding mothers. For the latest recommendations on the compatibility of individual supplements with breastfeeding check online at e-Lactancia or LactMed. Always discuss taking therapeutic doses of supplements with your qualified health professional to make sure they are compatible with your medical history and existing medication.

The Breastfeeding Network fact sheet for Raynaud's adds that it may be helpful to include ginger in the mother's diet e.g. drink ginger tea, or even add a spoonful of ground ginger to bath water.

Summary

Nipple vasospasm is a narrowing of blood vessels in the nipple. It can be triggered by a baby breastfeeding in a shallow latch and can cause burning, stabbing or itching pain in the nipples after a breastfeed. Nipple vasospasm can also be associated with Raynaud's phenomenon and can also cause Mammary Constriction Syndrome or deep breast pain. Treatment involves improving a baby's latch and positioning at the breast, and avoiding the triggers of nipple vasospasm. Some medications and natural remedies may help symptoms.

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A vasospasm is a sudden narrowing (or constriction) of blood vessels. If the blood vessels in the nipple have a

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Moist wound healing to aid faster healing

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Read our top tips on breastfeeding in public, including your legal rights and real mums’ stories.

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Successfully breastfeeding your premature baby - La Leche League GB

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You may be reading this because you have a preterm baby, or because you are expecting to deliver your baby before full term and you want to be prepared. Perhaps you’re supporting someone who has recently had a preterm baby. Whatever your situation then we hope this information will help to get breastfeeding off to […]

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Recommendation

Complete a full assessment to understand the underlying cause of the low milk supply and correct any known problems before considering domperidone.

Domperidone is the medicine of choice if medical treatment is required for low milk supply.

Use 10mg three times daily, initially for 7 days then review.

Limited evidence shows negligible amounts of domperidone pass into breast milk.

How lactation works

Lactation is complex, involving hormonal, physical, and emotional factors.

Several hormones (including prolactin, insulin and hydrocortisone) are needed for colostrum production, and for the onset of copious milk supply. For breasts to continue producing milk, the following are needed:

a rise in prolactin levels, usually caused by nipple stimulation

oxytocin release to allow milk ejection, caused by nipple stimulation

regular removal of milk

Milk production is based on supply and demand. If milk isn't removed, supply will reduce and eventually stop.

Signs of normal milk supply

Colostrum, in small volumes, is produced during the first 24 to 48 hours after birth. Larger volumes of breast milk are produced by the fifth day.

After the first two weeks of life, the best indicator of adequate milk supply is the baby gaining weight, and wetting nappies and passing stools as expected.

Diagnosing low milk supply

Up to half of breastfeeding women worry their milk supply is low. A true low milk supply is uncommon, affecting only about 15% of mothers.

There is often an underlying cause which can be resolved. A proper assessment of breastfeeding technique and other maternal and infant factors to identify any potential cause, will lead to the most successful outcome, potentially without the need for medication.

Assessment tools are available and should be used by a suitable qualified person with skills in lactation support.

Some medicines may affect milk production. If you are concerned, check the Safety in Breastfeeding information, or contact the UK Drugs in Lactation Advisory Service (UKDILAS).

Medicines used to increase milk supply

Substances to increase milk supply are known as galactagogues.

No medicines are licensed in the UK for the treatment of low milk supply, and are therefore used off-licence. Follow the GMC's guidance on unlicensed and off-licence prescribing.

Most galactagogues work by increasing prolactin levels. However, a higher prolactin level does not mean more milk. It is unknown if all women with a low milk supply also have low prolactin levels, and therefore if increasing prolactin levels further would help. A sudden increase in prolactin levels (usually triggered by nipple stimulation) seems to be important, not the maximum level produced. The frequent removal of milk via feeding also increases prolactin levels.

Evidence for the efficacy of galactagogues is limited, but they probably do increase milk volume initially. Prolactin levels also increase. We do not know if they help maintain breastfeeding long-term or increase infant weight gain.

Choice

If a galactagogue is required, domperidone is first choice due to most evidence for use and efficacy, better side-effect profile, and negligible passage into breast milk.

Other galactagogues include metoclopramide, sulpiride, and some herbal products. However, there is less evidence of efficacy, and these have other safety considerations.

Domperidone

Most evidence is in pre-term infants, which shows a moderate short-term effect on expressed breast milk volume, increasing by around 86 to 245mL per day. There is less evidence evaluating domperidone in mothers feeding term infants.

When to start

In studies, domperidone was started between days 1 and 33 post-delivery. It may be effective after this point, but there is no good evidence to support this.

Dose

Domperidone should be prescribed at a dose of 10mg three times daily. Doses higher than this should not be used.

Most studies used domperidone 10mg three times daily. Some small studies used higher doses. Only two small studies compared domperidone 10mg and 20mg three times daily. The 20mg groups produced on average slightly more milk, but it is uncertain whether this was a real difference or due to chance.

Domperidone does not always work. One study used domperidone 10mg and 20mg three times daily found a third of mothers did not have an increased milk supply at either dose. The study suggested that if there was no response to 10mg, increasing to 20mg was unlikely to work.

Duration of treatment

Domperidone should be prescribed for 7 days and then reviewed.

This is in line with the maximum treatment duration for the licensed indication (nausea and vomiting), due to the increased risk of cardiac events (particularly in certain populations), and potential for psychiatric withdrawal effects.

There is limited evidence regarding how long to use domperidone to increase milk supply. Some evidence shows the maximum effect is usually achieved within 7 to 14 days. Therefore, continuing treatment is unlikely to make a difference.

Whether to continue domperidone for longer than 7 days is a clinical decision after considering the evidence and potential increased risks.

Stopping treatment

Maintaining milk supply

It is not known whether stopping treatment with a galactagogue suddenly or gradually is better for maintaining milk supply. The American Academy of Breastfeeding Medicine recommends considering gradual discontinuation.

If milk supply reduces after stopping domperidone and improves on restarting again, gradually decrease to the lowest effective dose, and attempt discontinuation again.

Gradual withdrawal may also help reduce concerns about discontinuation.

Withdrawal symptoms

A small number of case reports suggest withdrawal symptoms occur when domperidone is discontinued either suddenly or gradually. In all cases, either prolonged use (up to 10 months) or higher than recommended doses (up to 160mg daily) were used.

Symptoms of withdrawal include insomnia, anxiety, headaches, palpitations, gastro-intestinal disturbances and depression. Re-emergence of previous mental health conditions has been reported.

If suspected withdrawal symptoms occur, increase the dose of domperidone back to a level that does not produce symptoms, and restart withdrawal more slowly.

A Canadian Safety Review on this issue is available.

Risk of cardiac events

Domperidone can cause a small increased risk of serious cardiac events, including certain types of arrhythmias, especially when used in high doses, for longer periods, or when additional risk factors are present. Patients at higher risk include those with cardiac disease, severe liver problems, electrolyte imbalances, or taking medicines affecting the QT interval or which interact with domperidone.

Maternal risk

Most breastfeeding women are relatively young and healthy and their baseline risk of cardiac events is very low.

A large cohort study involving over 1 million post-partum patients found domperidone increased the baseline ventricular tachycardia rate from 0.20 to 0.74 per 10,000 person years. It is not possible to prove whether the increase was due to chance or not. No sudden cardiac deaths in the domperidone group were reported, and the rate of all-cause mortality was decreased.

An increased incidence of arrhythmia in women with no arrhythmia history, taking domperidone to increase milk supply, has generally not been seen in studies.

Domperidone can be considered if a woman has no additional cardiac or medical risk factors, and is not taking medication that interacts with domperidone or affect the QT interval. Further information on drug-induced QT interval prolongation is available.

However, if risk factors are present, then ECG monitoring may be required, or an alternative considered. Contact UKDILAS for alternative galactagogue use.

Infant risk

Cardiac events in the infant have not been reported after domperidone exposure via breast milk.

In one study in premature infants, five babies had a prolonged QT interval, although none had symptoms or needed intervention. This was more likely due to infant prematurity than domperidone exposure.

If the infant has cardiac disease, severe liver disease or is receiving medicines which may be a problem, then domperidone use in the mother is best avoided. Contact UKDILAS for alternative galactagogue use.

Domperidone levels in breast milk

Very limited information shows domperidone passes into breast milk in negligible amounts (less than 0.5% of the maternal weight-adjusted dose), even with high dose, long term therapy.

In addition, there is a very low risk of accumulation in the infant and its low oral bioavailability will limit the amount absorbed from the breast milk.

Monitoring the infant
No serious side-effects have been reported in infants exposed to domperidone via breast milk.
As a precaution, monitor for gastro-intestinal disturbances, or signs of dry mouth, such as difficulty feeding.

Since there is no evidence that domperidone via breast milk can cause significant ECG changes in the infant, infant ECG monitoring is not routinely required. If there are additional risk factors, contact UKDILAS.

Ongoing support

Ongoing lactation support will be necessary during treatment with domperidone. Regular review is needed if domperidone is used beyond 7 days.

Induced or restarting lactation

Inducing lactation in a person who has not given birth, or restarting after a period of non-lactation, is beyond the scope of this article.

Get in touch with the UK Drugs In Lactation Advisory Service if:

you need further advice

you are considering a different medicine for low milk supply

multiple medicines are being taken

Acknowledgement

Thanks to Dr Louise Santhanam, General Practitioner, and Leicester Mammas CIC for their expert review.

Bibliography

A referenced version is available on request.

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Domperidone can be used to treat low milk supply. However, this is only after thorough assessment and once non-medical interventions have been tried.

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Another place to read factsheets on whether drugs are safe whilst breastfeeding

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Another place to read factsheets on whether drugs are safe whilst breastfeeding

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The LactMed® database contains information on drugs and other chemicals to which breastfeeding mothers may be exposed. It includes information on the levels of such substances in breast milk and infant blood, and the possible adverse effects in the nursing infant. Suggested therapeutic alternatives to those drugs are provided, where appropriate.

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A list of all the factsheets available on Breastfeeding-and-Medication.co.uk. But happy to answer any other questions if you email me wendy@breastfeeding-and-medication.co.uk

If you search for any word on the title the factsheet page should appear
List of factsheets Breastfeeding and Medication
If you use them a lot maybe you need the books

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A list of all the factsheets available on Breastfeeding-and-Medication.co.uk.

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You can search whether certain drugs are safe to take whilst breastfeeding

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You can search whether certain drugs are safe to take whilst breastfeeding

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An increasing number of mothers and health professionals have sought to find more information on the levels of medicines passing through milk to the baby. Standard reference books such as the British National Formulary (BNF) provide little information for professionals and parents to make decisions on individual situations. BfN endeavours to provide information to enable mothers to breastfeed their babies for as long as they wish and to provide information on the safety of medicines for each mother and baby pair.

Please use the below links for more information

We are constantly reviewing the information available on drugs and breastfeeding as new research is conducted. Therefore, from time-to-time the information on this website may be updated - please be sure to check regularly for any new information and changes to the drug information fact sheets and leaflets.

What is the Drugs in Breastmilk Information Service?

The original Drugs in Breastmilk Helpline was set up by BfN in response to the number of calls we were receiving that concerned medication.

In 2017 we noticed that majority of enquiries from parents and professionals to the Drugs in Breastmilk Helpline were coming via email or social media. As a charity operating on reducing funds we need to run the service in the most efficient and effective way possible without compromising the needs of parents. As a result we decided to run the Drugs in Breastmilk service via email and social media enquiry only.

You can still access information on taking prescription drugs while breastfeeding by sending a private message via our Facebook page or via . Please provide as much information as possible (age of baby, dose, frequency and name of medication or drug). All enquiries are answered as soon as possible by one of our small, volunteer team of qualified pharmacists or breastfeeding supporters. As we can't guarantee a response time, in an emergency situation, please do not wait for our reply, but access help from a trained healthcare professional.

If you call the old Drugs in Breastmilk helpline 0844 number, you will hear a recorded message with information about where to access alternative support. Calls won't be answered live and there is no voicemail service available.

If you still have the Drugs in Breastmilk helpline number on any materials or web pages please could you remove it and replace it with the following information:
'If you have specific questions about medications or treatments, please message the Drugs in Breastmilk information service Facebook page or email druginformation@breastfeedingnetwork.org.uk. If you require breastfeeding support, please call the National Breastfeeding Helpline on 0300 100 0212."

The service is open to mothers and professionals. As the time available to deal with breastfeeding support of mothers is limited, professionals are encouraged to find out the information to enable them to support the mothers themselves.

Evaluation of the Drugs in Breastmilk Information Service

In 2019, BfN commissioned Swansea University to undertake an evaluation of the DIBM service we offer. The executive summary of this report can be found and the full report can be found .

Become a Friend of Drugs in Breastmilk

Please click here for more information on how you can help support this vital service.

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Drugs In Breastmilk - Is It Safe? - The Breastfeeding Network

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An increasing number of mothers and health professionals have sought to find more information on the levels of medicines passing through milk to the baby. Standard reference books such as the British National Formulary (BNF) provide little information for professionals and parents to make decisions on individual situations.

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Search if certain medications are compatible with breastfeeding 

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Search if certain medications are compatible with breastfeeding 

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The picture shows the writing in Spanish but when you click on the link it is in English

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Por La Paz en Ucrania. NO a la guerra.

La guerra se asocia a disminución de la prevalencia y duración de la lactancia materna y aumento de uso de fórmula infantil, lo que implica graves riesgos para la salud infantil.

Las consecuencias de una guerra son especialmente graves para los niños y las mujeres...

OMS 2004, principio 3: Se debe controlar estrictamente la cantidad, distribución y uso de sucedáneos de la leche materna en los entornos de emergencia.
La guerra y la lactancia en e-lactancia.org

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Por La Paz en Ucrania. NO a la guerra. La guerra se asocia a disminución de la prevalencia y duración de la lactancia materna y aumento de uso de fórmula infantil, lo que implica graves riesgos para la salud infantil. Las consecuencias de una guerra son especialmente graves para los niños y las mujeres...

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The clinician can find evidence-based information specifically on the safety of drugs in breastmilk via the links and support services listed on this page.

This slideshow requires JavaScript.

The Breastfeeding Network Drugs in Breastmilk Information Service (UK Site) Run by the charity The Breastfeeding Network (BfN). Dr Wendy Jones, Specialist Pharmacist and BfN Breastfeeding Supporter provides evidence-based information for patients on the safety of drugs in lactation via factsheets, email and a dedicated Facebook page. The service is open to mothers and professionals. As the time available to deal with breastfeeding support of mothers is limited professionals are encouraged to find out the information to enable them to support the mothers themselves.

The Breastfeeding Network Drugs in Breastmilk Factsheets A range of factsheets with detailed information on prescription drugs, over the counter treatments, cosmetic treatments and medical conditions.
The Breastfeeding Network Drugs in Breastmilk Facebook Page http://www.facebook.com/BfNDrugsInBreastmilkinformation
UK Drugs in Lactation Advisory Service (UKDILAS) (UK Site) The UK Medicines Information Service (UKMi) NHS Pharmacist-led service providing evidence based information on the safety of drugs in breastfeeding. They have risk assessed every drug available in the UK, and this information can be accessed via the SPS website (Search for the drug you are interested in using the search bar, and select the 'lactation safety information' link).

Summaries for various commonly prescribed medications, aimed at prescribers, are also available. These are accessible here.

The service can also advise on specific, individual clinical cases including complex cases such as mothers who are taking multiple medicines, premature and unwell infants. They will usually provide a response the same working day.

UKDILAS Telephone: 0116 258 6491 or 0121 4247298

UKDILAS Email: ukdilas.enquiries@nhs.net

UKDILAS Website https://www.sps.nhs.uk/ukdilas/

Lactmed The US National Library of Medicine Toxicology Data Network (Toxnet) Drugs and Lactation Database. A smart phone app is also available.

Published April 2017, Updated September 10th 2019

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The clinician can find evidence-based information specifically on the safety of drugs in breastmilk via the links and support services listed on this page. The Breastfeeding Network Drugs in Breastmilk Information Service (UK Site) Run by the charity The Breastfeeding Network (BfN). Dr Wendy Jones, Specialist Pharmacist and BfN Breastfeeding Supporter provides evidence-based information for patients...