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Video on the first hour after birth and the breast crawl

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Video on the first hour after birth and the breast crawl

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Within the first few hours after birth, most healthy newborns will instinctively move to their mother's breast and attach on their own. This video shows early breastfeeding initiation through the journeys of 3 newborns and ways to ensure the success of this vital practice for any new mother and baby.

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Breastfeeding in the First Hours - Video - Global Health Media Project

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Within the first few hours after birth, most healthy newborns will instinctively move to their mother's breast and attach on their own. This video shows early

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Step by step guide to positioning your baby for a feed

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Step by step guide to positioning your baby for a feed

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Slow motion look at latching again.

As always, if anyone is willing to take some footage for me to use in videos like this please do get in touch. 
And... | By LMJ Infant Feeding Support | Facebook

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As always, if anyone is willing to take...

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Breastfeeding sleepy and reluctant babies

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Breastfeeding isn't supposed to be painful but there are a number of reasons why it can hurt sometimes. The most likely reason is when a baby is not attached to the breast deeply with a big mouthful of breast tissue in their mouth as well as the nipple. When the mother's nipple is too far forward in a baby's mouth during a breastfeed it can quickly become painfully sore.

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Once a baby can be helped to latch deeply, sore nipples caused by poor positioning or attachment (latch) usually heal quickly on their own. However, sometimes finding the causes of sore nipples is not easy and takes some time, and meanwhile sore nipples are a high risk factor for stopping breastfeeding early.

Are there any treatments to soothe sore nipples or is it all about positioning? This article discusses popular treatments for sore nipples from home remedies to prescription medication.

Treatments for sore nipples

There are many suggested treatments for sore nipples from adjusting the way a baby attaches to the breast, to using lanolin, nipple shields or prescription ointments. What works for one mother may not work for another and strategies will depend on the cause of the sore nipples. If nipples are cracked, blistered or damaged there is a higher chance of either a bacterial (e.g. Staphylococcus aureus or staph) or fungal infection (e.g. thrush) which may require medication from your doctor. Sore nipples can also be due to eczema, dermatitis or psoriasis or even caused by an allergy or side effect of a treatment you have already been using. Always check with your health professional if you have very sore nipples that are not healing.

Popular treatments

Popular treatments are discussed below but note that apart from #1 Check positioning and attachment-which is universally accepted as important-there isn't enough evidence to recommend one treatment option over another. What helps one mother may not help another and some treatments for sore nipples may even make symptoms worse.

#1 Check positioning and attachment

The number one "treatment" is to find and solve the cause of your sore nipples with the help of your IBCLC lactation consultant and health care professional. In most cases the way your baby is attaching to the breast (latching) or the way you are holding your baby to breastfeed (positioning) will be the reason why your nipples are sore. Causes of Sore Nipples and Why Does Breastfeeding Hurt? run through a selection of reasons for sore nipples and include links to articles that can help with improving positioning and attachment. If you are regularly using any pumping equipment this could also be a cause of sore nipples for example if the pump flange is not the right size for your nipple or the pump suction is too high.

#2 Pharmacy medications

In Are There Any Cures for Sore Nipples? Marsha Walker IBCLC compared various sore nipple treatments and concluded that many natural treatments (see #5 below) do not have very good evidence for their use. However since natural or household treatments do not generate big money, there is often little incentive to research them and more incentive to skew results towards a commercial product. Walker proposes the following medical based treatment plan for cracked or damaged sore nipples:

Correct positioning and latch

If there is broken skin; wash nipples daily with soap and water and apply a topical antibiotic (mupirocin) to treat any bacterial infection (eg. staph) and a topical low strength steroid for inflammation. Avoid using a dummy (pacifier), if used, wash it thoroughly with soap and water.

If there is a fluid discharge or pus or very red skin without a dry scab; systemic antibiotics are recommended. If thrush (Candida albicans) is a possibility, add an antifungal agent (topical 2% miconazole).

If the infection doesn't respond to the above; treat the baby with nasal mupirocin because he may be a carrier of the bacteria Staphylococcus aureus and may infect or reinfect the mother's nipple. Test for genetic variations (small colony variants) of staphylococci bacteria. If they are present, use the appropriate antibiotics, be vigilant for mastitis and check for anaemia (Walker, 2013).

NICE guidelines

A similar protocol for sore, damaged nipples from NICE (UK) recommends using antibiotic cream fusidic acid (or mupirocin if antimicrobial resistance is likely) for suspected bacterial infection, antifungal cream (miconazole 2%) for suspected Candida infection and hydrocortisone 1% cream if nipples are red and inflamed.

All purpose nipple ointment

Canadian paediatrician and breastfeeding specialist Jack Newman also has a similar protocol for sore nipples with his All Purpose Nipple Ointment (APNO) which contains a topical antibiotic, anti inflammatory and antifungal in one treatment. In this article Dr Newman describes the concentration of each ingredient in the cream and signposts to a website that offers compounding pharmacies in Canada and United States (US). Although APNO may not be available in your area or country, you may wish to discuss with your doctor whether a similar combination approach might be appropriate in your situation. However, not all authors are convinced about applying topical creams to nipples including APNO. One study of 151 women suggested that APNO wasn't more effective for treating painful damaged nipples than using lanolin and another did not find that APNO significantly improved mothers' pain.

#3 Wash with plain soap

Walker says washing damaged nipples with ordinary mild soap (not antibacterial) once a day keeps any wounds clean, reduces the number of bacteria present and breaks down the bacteria's protective shield. This shield (biofilm) is said to protect the bacteria from the mother's immune system and from antibiotic treatment. With the shield disrupted, topical antibiotic may reach the affected area more easily (Walker, 2013). Note; there's no need to wash healthy nipples with soap and Buchanan et al caution that washing with soap can dry the skin.

#4 Moist wound healing

Covering a wound with a dressing that excludes air and water facilitates something called "moist wound healing". Moist wound healing is said to increase the speed of healing, reduce scab formation and reduce pain. It is often recommended that moist wound healing is helpful for sore or cracked nipples and products commonly used as a dressing are purified lanolin (applied as an ointment), hydrogel dressings and petroleum based products eg vaseline.

Different opinions

Opinions differ on how effective moist wound healing products are (Buchanan et al., 2019). Douglas cautions that dry scab formation is part of normal healing of a wound, and that moist wound healing can cause overhydration and moisture associated skin damage of a lactating nipple and areola particularly when using petroleum based products (Douglas, Vol 18: 1-29 2022). Douglas reviews the research around moist wound healing of nipples in Appendix 2 of Re-thinking lactation-related nipple pain and damage 2022 and concludes that research doesn't support manufacturer's claims that lanolin or hydrogel have healing benefits for nipples.

Purified lanolin

Some mothers find purified lanolin helpful for sore nipples. Lanolin is a substance extracted from sheep's wool. Contaminants, detergent and pesticide residues are allegedly removed from ultra purified lanolin and only the smallest smear is needed on a sore nipple.

The Womanly Art of Breastfeeding explains how lanolin works:

Purified lanolin is for nipples what lip balm is for lips. It helps keep the cells' own moisture intact. A healthy nipple doesn't need ointment, but if your nipple is chapped or slightly damaged a light coating of purified (to reduce the risk of allergies) lanolin keeps newly formed cells from drying out and allows them to slide easily across the damaged area to bridge the gap more quickly. This "moist wound healing" can be very effective but only if you address what caused the damage in the first place.

Mothers using lanolin should be aware that:

Allergies to lanolin are possible. Despite the purification process, some mothers find they have a reaction to lanolin making their sore nipples worse.

Skin breakdown. Applying a topical product including lanolin to the nipple risks moisture associated skin damage (sore nipples) which may be confused with being allergic to the product (Douglas, Vol 18: 1-29 2022).

Lanolin may increase fungal infections. Frequent use of lanolin on nipples may increase the risk of nipple infections, particularly fungal infections such as thrush. Sasaki et al call for more research to establish whether lanolin is a growth medium for thrush particularly if the mother has a history of antibiotic use during childbirth.

Lanolin could make the nipple and areola slippery and mask the scent from the montgomery glands which are thought to help a baby locate the nipple. Try to use the smallest amount possible.

More studies are needed. Despite the popularity of lanolin several studies have not found it to be consistently more effective than other frequently used remedies and more good studies are needed.

Hydrogel dressings

Commercially made hydrogel dressings have a high water content which are said to cool a wound and provide a moist healing environment. Hydrogel dressings are applied to the nipple between feeds and must be washed off before a feed (Douglas, Vol 18: 1-29 2022). Marsha Walker explains:

These dressings are water based and often a combination of water and glycerin in a polymer matrix. Their value lies in their ability to maintain moisture, inhibit scab or crust formation, reduce pain, and enhance epithelial migration for wound repair.

Hydrogel dressings may be a possible option in the treatment of nipples with open sores or cracks with exudate. The dressing absorbs wound discharge and prevents the nipple skin from adhering to the mother's bra.

Wilson-Clay and Hoover state that it is not appropriate to use hydrogel dressings on infected skin and Douglas cautions against over hydration and skin breakdown (Douglas, Vol 18: 1-29 2022).

#5 Home remedies

The following are some popular remedies for sore nipples. Several authors conclude that many natural treatments do not have very good evidence for their use (Walker 2013; Douglas, Vol 18: 1-29 2022) however some mothers find them helpful. Bear in mind that any individual product may cause allergic symptoms for a particular mother or cause sore nipples due to moisture associated skin damage (Douglas, Vol 18: 1-29 2022).

Breast milk

Breast milk is a popular choice often suggested for rubbing into sore nipples to aid healing. Breast milk is full of anti infective factors that can combat bacteria. However if breast milk contains allergens that the mother is sensitive to, it may not be so calming (Minchin, 2015).

Warm water compresses

Warm water compresses were shown in one study to be more effective at soothing sore nipples than lanolin or breast milk and another study suggested warm water compresses may help with pain relief. Warm water may help blood flow to the area and help remove waste products.

Salt water (saline)

Walker states that a variation of the warm water compress above is to use a saline compress for ten minutes (Walker, 2013). A saline solution is a mixture of salt and water; "normal saline" is similar to body fluids such as tears. Walker suggests using a quarter to a half a teaspoon of salt to a litre (35oz) of warm water for the compress (Walker 2013). Kelly Bonyata discusses using half a teaspoon of salt to one cup of water (8oz or 236ml) as a soak for nipples for a minute or so but no more than 5-10 minutes as this may cause more cracking. Fernandez and Griffiths found that clean tap water may be as effective as saline for wound cleaning while Douglas states that salt water may cause pain and stinging without any benefit ( Douglas, Vol 18: 1-29 2022)

Commercial nipple creams

Used routinely, commercial nipple creams may alter the pH of the nipple and areola or block the Montgomery glands-reducing both the natural protective factors in the areola and the odours that guide baby to latch to the nipple. In addition, it is not always clear whether commercial creams with multiple ingredients are safe for mother and baby (Walker, 2013). Douglas expresses concerns that topical creams can cause epidermal over hydration and moisture associated skin damage with no evidence of benefit (Douglas, Vol 18: 1-29 2022).

Virgin coconut oil

Virgin coconut oil is credited with antibacterial, antifungal, anti-inflammatory and analgesic properties. On the safety of virgin coconut oil, Thomas Hale breastfeeding and medications author writes on a forum:

Excerpt from

Coconut Oil on Breast, Infant Risk Forum, Thomas Hale, 2012 [accessed 11 August 2022]

Coconut oil, commonly called MCT oil (medium chain triglyceride), is commonly used in our NICUs to add fat into the diet of premature infants. It consists primarily of 6-12 carbon atom free fatty acid triglycerides which are easily digested by all neonates and older children. It is an ideal triglyceride for infants.

As a pure oil, it has virtually no allergenic compounds. So, if you use a high grade Coconut oil, I would not be worried about its use at all, or worry about allergies.

That said, I don't see how it would be any better as an emollient than lanolin.

Medihoney

Medihoney is said to penetrate biofilms and be antibacterial, including against methicillin resistant Staphylococcus aureus (MRSA). Medihoney is not the usual food grade honey it is a medical grade honey product made from Leptospermum plant species. Botulism spores may be present in normal honey and honey is not recommended for babies under 12 months of age. Marsha Walker IBCLC reports that anecdotally Medihoney is thought helpful for healing sore nipples and states that it has been treated to remove botulism spores. However check with your health professional on the advisability of using this product if you have a baby younger than 12 months.

Peppermint

Peppermint is thought to help skin heal and have antibacterial and anti-inflammatory qualities (Walker, 2013). Two studies found that using topical peppermint water on the nipples resulted in less cracked nipples than using expressed breast milk. Another study found less cracked nipples when using peppermint gel compared to lanolin or a placebo while another found peppermint to be similar to using lanolin/dexpanthenol creams . A peppermint gel for breastfeeding is sold by by Dr Frank Nice. For the latest information on the safety of using peppermint containing preparations on the nipple, see the entries for peppermint at e-lactancia and LactMed who both recommend removing peppermint preparations from nipples before each breastfeed.

Silver cups?

Purpose made solid silver cups (nipple covers) are available to buy to wear over sore, cracked nipples as a healing treatment. Silver cups are thought to potentially aid nipple healing because silver is naturally antibacterial and antifungal however it may still trigger allergic reactions. Internet searches reveal mixed anecdotal opinion and little evidence around using silver nipple cups for sore nipples. Some mothers have found that using silver nipple cups kept their nipples and the skin below the cups constantly moist or soggy which prevented healing. The Breastfeeding Atlas states that more research is needed to determine if silver-impregnated caps are effective for healing sore nipples but cites one small study that found positive results. Colloidal silver treatments are not recommended for sore nipples as they could be harmful for the baby.

#6 Nipple shields

Although not a treatment or cure as such, modern silicone nipple shields can be helpful in relieving the pain of sore nipples by protecting the nipple. This may make it bearable for a mother to continue breastfeeding while she seeks specialist help with positioning or while her nipples heal. Nipple shields also have a place as a suck training tool in certain situations e.g. for babies who are retracting their tongues. For more information see Nipple Shields Good or Bad?

#7 Low level laser therapy

Low level laser therapy has been used to speed up wound healing in medicine for a long time. It is a form of light therapy that stimulates cell healing mechanisms. A number of studies suggest that this therapy can also be a helpful treatment for sore nipples. Low level laser therapy is said to speed up the healing of nipple damage and ease pain when coupled with conventional breastfeeding help such as improved positioning, or treatment for bacterial or fungal infections. One clinical trial at a hospital in Brazil found that low level laser therapy reduced the intensity of pain and helped to prolong breastfeeding and another study with a control group also found low level laser therapy provided pain relief. Some National Health Trusts or private clinics may offer low level laser therapy however it is still important to address the initial causes of nipple damage with a breastfeeding specialist.

#8 Special cases

Eczema, dermatitis and psoriasis

Other causes of sore nipples include the skin conditions; eczema, dermatitis and psoriasis. Contact your health professional for diagnosis and medication compatible with breastfeeding. In Managing Common Breastfeeding Problems in the Community, BMJ, 2014, Dr Lisa Amir explains that a mother may be predisposed to these skin conditions or they might appear following use of certain topical creams or even using a breast pump. Symptoms typically include pain and itching with reddening of the skin and may include flaking or crusting. Amir's treatment plan for eczema, dermatitis and psoriasis includes:

Treatment includes application of a moderately strong corticosteroid, such as mometasone, once daily and sparingly after a feed (no need to be washed off) for up to 10 days. When crusting is a feature, the dermatitis is likely to be colonised with S aureus, and mupirocin ointment can be added.

The article Medications and Breastfeeding lists several online resources for checking the latest compatibility of medications with breastfeeding, which can be discussed with your health professional.

Allergens

Sometimes sore nipples, eczema or dermatitis are perpetuated by an allergy to a product a mother is using. Even purified lanolin can cause a reaction for some mothers.

Paget's disease (rare)

Paget's disease of the nipple is a skin condition that looks like eczema or psoriasis with flaking skin or itching, but is due to an underlying cancer. It is usually confined to one breast and is diagnosed by nipple biopsy if a week of steroid treatment doesn't rapidly improve the condition.

It is quite uncommon in women of childbearing age but it can occur. Paget's disease is easily mistaken for eczema because of the flaking skin and itching. Most mothers with eczema get it on both breasts, though, while Paget's disease usually involves only one. If treatment with a steroid ointment does not result in rapid resolution (within a week) of the problem, the mother should see her doctor. The diagnosis is made by biopsy of the nipple. This does not mean the mother should stop breastfeeding on that side-she cannot transfer cancer to the baby by breastfeeding.

Summary

The most common cause of sore nipples while breastfeeding is when a baby is not latched correctly. Once the latch is improved, sore nipples will quickly heal on their own. However if the problem continues, nipples can soon become painfully cracked and have a higher risk of infection. There are many treatments for sore nipples available but they can vary widely in how effective they are and some remedies may even be part of the problem. There is currently not enough evidence to recommend one treatment over another. Contact your IBCLC lactation consultant and health care provider with ongoing sore nipples so that you can get the best breastfeeding help and correct treatment.

Footnotes & References

1. Wilson-Clay and Hoover, The Breastfeeding Atlas, 6e, p.60

2. Nipple nuances: From pain to peppermint and what the textbooks don't cover, Walker, Gold Conference, 2014

3. Core Curriculum for Lactation Consultant Practice, ILCA, 2013

4. Wilson-Clay & Hoover, The Breastfeeding Atlas 6e, 2017

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Breastfeeding isn't supposed to be painful but there are a number of reasons why it can hurt sometimes. The most

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Finger feeding a baby who won't yet latch is a great way to support sucking skills while giving them your expressed milk. Ask a health professional to help you the first time you do it.

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NCT explains why some babies take longer to latch, with some practical tips to help you.

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Why won't my newborn baby breastfeed?

Sometimes, newborn babies struggle to latch on to breastfeed after they're born. It can be worrying for new parents when this happens - you might think something's wrong.

There may be a simple explanation. This information could help you find your own solution, or decide if you need further support.

Some of the more common reasons for newborn babies finding it difficult to latch onto the breast could be:

a difficult labour or birth - your baby might feel sore or have a headache if the mother has had interventions in labour or if they were born very quickly

medication used during labour - anaesthesia, epidural or pethidine can make your baby sleepy or groggy

your baby being separated from you after birth - even for a few minutes

discomfort due to a birth injury or bruising

swallowing mucus at birth can make your baby feel congested, nauseous or uncomfortable

an early unpleasant experience of attempting to breastfeed, such as being forced onto the breast

the baby might have tongue-tie

Why won't my baby breastfeed anymore?

Sometimes, older babies seem to refuse to breastfeed when they'd been breastfeeding just fine until then. This is known as a 'nursing strike.' They might refuse to breastfeed for 2-4 days, but it can be up to 10 days (Mohrbacher, 2013).

Reasons that your older baby might refuse to feed at the breast could include:

something has changed that makes it difficult for baby to latch

a strong or fast flow of milk, which your baby is struggling to take

a painful mouth, due to an infection like thrush or because they're teething

being more aware of their surroundings and being easily distracted, for example by noise

a change in the taste of your milk, such as that due to your menstrual cycle

the introduction of more solid food

a small number of babies might struggle because of severe or persistent reflux, known as gastro-oesophageal reflux disease (GORD), so they may link feeding with pain.

(Mohrbacher, 2013; Gonzalez, 2014; BellyBelly, 2016; NICE, 2017; Public Health England, ND)

What can I do when my baby refuses to breastfeed?

8 top tips to help your baby who's refusing to breastfeed:

1. Try to identify what's going on for your baby. Knowing the cause can help not only with a plan but it can be reassuring to understand what is happening and know there's a solution. You could think about the following:

Do they have a cold or an infection?

Was there something that might have caused them to not want to feed?

Talk to one of our Breastfeeding Counsellors or contact our Infant Feeding Line on 0300 330 0700 (option 1) for further support. It can be a great way to get some help to find out what's happening.

You could also contact a health professional to investigate any medical reasons why your baby might not be feeding.

2. Try to stay calm and not force a feed. Instead, allow your baby to take the lead.

3. Especially for young babies, many mums find skin-to-skin contact in a laid-back position helps to take the pressure out of the situation. It allows your baby to use their own natural instincts to feed (Burbridge, 2017).

4. Don't worry if your baby bobs their head or moves it from side to side, they're not rejecting the breast as it might appear. These are your baby's natural ways of finding your breast (Coulson, 2012).

5. Try a different feeding position to see if you can get your baby more comfortable. Some babies find a laid-back breastfeeding (also called biological nurturing) position helpful if they are struggling to get a deep latch or if you have a strong let-down of milk (Coulson, 2012).

6. Sometimes, feeding your baby while they're sleepy or even asleep can be helpful. Many mums say that these 'dream feeds' can be very effective for a baby who is uninterested when awake (Pitman and Bennett, 2008).

7. You could try feeding your baby while rocking them or walking around, singing or playing with them or playing white noise or background music to them (Australian Breastfeeding Association, 2017).

8. You might want to try feeding in a quiet room, away from distractions, as some babies are so keen to be involved that they limit their feeds (Gonzalez, 2014).

What can I do if I've tried everything but my baby still won't breastfeed?

One of the key things to consider is maintaining your milk supply. You might need to consider expressing, either by hand or with a pump. You can find more information about expressing and storing your milk here.

Another consideration is making sure your baby is getting enough milk. How might you know how much milk your baby is getting, you might ask. The answer lies in their dirty and wet nappies. You can expect six wet nappies in 24 hours if your baby is over a week old (UNICEF, 2016). If you're unsure, it's best to ask for support from your health visitor, GP or NCT breastfeeding counsellor.

In the short term, you might need to look at alternative ways to feed your baby if you think they're not getting enough milk. A newborn baby needs to be fed regularly and parents can use syringe or cup feeding as an alternative to a bottle in the early days (Flint et al, 2016; NHS, 2016).

If you decide to use a bottle, it might be helpful to feed with plenty of skin-to-skin contact (UNICEF, 2018). Gently offering the bottle to your baby by tickling their top lip, waiting for the wide-open gape might also help mimic a breastfeed (UNICEF, 2019). That can support the transition back to the breast.

Taking frequent breaks during the bottle feed, and perhaps swapping sides, can be helpful (UNICEF 2018). Continuing to have skin-to-skin time with your baby and allowing them access to the breast will help this. It'll also be a bonding and calming experience for you both.

How can I deal with the stress of my baby refusing to breastfeed?

When a newborn refuses the breast, or an older baby goes through a nursing strike, it can be very upsetting for both you and your baby. You're definitely not alone in struggling with the emotions of breastfeeding problems. So here are some tips that might help:

1. Try to take time to enjoy plenty of extra cuddles and quiet time together.

2. Many mums find a 'babymoon' helpful for allowing their baby access to the breast in a non-pressurised way. A babymoon means spending some hours together in a relaxed setting, such as lying down snuggling in bed. This can allow you to enjoy your baby without worrying about feeding.

3. For older babies, some mums find that having a bath with their baby or bringing their baby into bed with them helps their baby to latch.

4. Try to find some support from other mums and trained breastfeeding supporters. Chatting with other people about this can help to unburden the stresses and worries you might be feeling. Breast refusal is not uncommon and you might find that chatting to someone who understands is invaluable while you're struggling.

5. For many mums, time and patience can help the situation. Your baby's instincts and behaviour can change and develop, especially in the early days.

6. If you're struggling, do contact the NCT Infant Feeding Line and speak to a breastfeeding counsellor. They'll listen, offer you information and will support you to find your own path.

This page was last reviewed in August 2019.
Further information

NCT supports all parents, however they feed their baby. If you have questions, concerns or need support, you can speak to a breastfeeding counsellor by calling our helpline on 0300 330 0700, whether you are exclusively breastfeeding or using formula milk. Breastfeeding counsellors have had extensive training, will listen without judging or criticising and will offer relevant information and suggestions. You can also find more useful articles here.

National Breastfeeding Line (government funded): 0300 100 021.

NHS information on mastitis.

Best Beginnings - Bump to Breastfeeding DVD Chapter 7 'Overcoming Challenges'.

Healthtalkonline.org: Managing Breastfeeding - dealing with difficult times.

Australian for Breastfeeding Association (2017) Breast refusal. https://www.breastfeeding.asn.au/bf-info/breast-refusal [Accessed 22nd February 2019]

BellyBelly. (2016) Breast refusal - 13 tips for a baby that refuses the breast.
https://www.bellybelly.com.au/breastfeeding/breast-refusal/ [Accessed 22nd February 2019]

Burbridge A. (2017) Nursing strikes. La Leche League GB. Available at: https://www.laleche.org.uk/nursing-strikes/ [Accessed 1st August 2019]

Coulson S. (2012) Biological nurturing: the laid-back breastfeeding revolution. Midwifery Today, 101 Available at: https://midwiferytoday.com/mt-articles/biological-nurturing/ [Accessed 1st August 2019]

Flint A, New K, Davies MW. (2016) Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed. Cochrane Database Syst Rev. (8):CD005092. Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005092.pub3... [Accessed 1st August 2019]

Gonzalez C. (2014) Breastfeeding Made Easy. London: Pinter &Martin

LLLGB. (2016) My baby won't breastfeed. Available at https://www.laleche.org.uk/my-baby-wont-breastfeed/ [Accessed 1st August 2019]

Mohrbacher N. (2013) Is your formerly nursing baby refusing to breastfeed? Breastfeeding Reporter Blog. Available at http://www.nancymohrbacher.com/articles/2013/1/26/is-your-formerly-nursing-baby-refusing-to-breastfeed.html?rq=refusing [Accessed 1st August 2019]

NICE. (2017) Breastfeeding problems. National Institute for health and Care Excellence, Clinical Knowledge Summaries. Available at: https://cks.nice.org.uk/breastfeeding-problems#!scenario [Accessed 1st August 2019]

Pitman T, Bennett H. (2008) 0-1 year: nursing strikes; breastfeeding while baby's falling asleep may help end a nursing strike. Today's Parent. 7:137.

Public Health England. (ND) Breastfeeding challenges. NHS, Start 4 life. Available at: https://www.nhs.uk/start4life/baby/breastfeeding/breastfeeding-challenges/reflux/ [Accessed 1st August 2019]

UNICEF. (2016) Breastfeeding checklist for mothers - How can I tell that breastfeeding is going well? UNICEF UK Baby Friendly Initiative. Available at https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2016/10/mothers_breastfeeding_checklist.pdf [Accessed 1st August 2019]

UNICEF. (2018) Skin-to-skin contact. Available from: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/guidance-for-health-professionals/implementing-the-baby-friendly-standards/further-guidance-on-implementing-the-standards/skin-to-skin-contact/ [Accessed 1st August 2019]

UNICEF. (2019) Responsive bottle feeding. Available from: https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2019/04/Infant-formula-and-responsive-bottle-feeding.pdf [Accessed 1st August 2019]

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Why is my baby refusing the breast? 8 tips that help | Baby & toddler, Feeding articles & support | NCT

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Sometimes, newborn babies struggle to latch on to breastfeed after they're born. It can be worrying for new parents when this happens - you might think something's wrong. There may be a simple explanation. This information could help you find your own solution, or decide if you need further support.

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Breasts that are over full or engorged with milk can feel uncomfortably full, swollen, hot, lumpy and painful. If the milk is not removed by your baby or by hand expression or a breast pump, engorged breasts can lead to mastitis (painful breast inflammation). It's normal to have some engorgement when your milk first comes in but it can also happen unexpectedly at other times. This article describes ways to help with engorgement.

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Reasons for engorgement

When milk first comes in

Many mothers will have some engorgement in the early days or weeks after birth. As the milk "comes in", extra blood and tissue fluids will also be present in the breasts to help with milk production which may add to the feeling of fullness and congestion, especially if your baby is not feeding well. Engorgement in the breasts may be worsened if you had an intravenous (IV) drip during the birth and could take some time to clear. Since breast tissue can extend into the armpit, some mothers may notice they have some engorgement/a lump in their armpit as their milk comes in (see below).

Engorged breasts after the first few weeks

Although engorgement is very common in the first few weeks of your baby's life, it can happen at any time, even during weaning. Possible causes include;

your baby sleeping longer than expected (a missed feed)

feeding a baby on a schedule instead of on demand

poor position and attachment affecting how baby breastfeeds

using a poorly fitted nipple shield

weaning too quickly

tight clothing or a tight bra or bag strap or even a finger pressing on the breast during a breastfeed

having too much breast milk (oversupply)

pumping more milk than your baby needs

breast trauma including vigorous massage or previous breast surgery

Anything that interferes with breastfeeding on demand can increase a mother's risk of engorgement. If painfully engorged breasts are neglected, this puts a mother at risk of breast inflammation which includes blocked ducts or mastitis. If you regularly have a lot more milk than your baby needs it may be helpful to discuss breastfeeding management with an IBCLC lactation consultant and see our article on oversupply of breast milk.

Relieving engorgement

Whatever the reason for your overly full breasts, and you may not always be sure why, softening engorged breasts with our tips below can help you feel comfortable again.

#1 Breastfeed often

Frequent breastfeeds will help relieve engorgement. Breastfeeding every couple of hours or at least 12 times in 24 hours gives your baby lots of opportunity to remove the milk that is building up. Conversely, going long periods without removing any milk can increase the discomfort. If your baby can breastfeed well, this will usually be more effective than using a breast pump. Other helpful strategies include holding your baby in as much skin-to-skin contact in the early weeks as possible, and letting baby suckle for comfort as well as nutrition.

#2 Check positioning and attachment

The way a baby attaches to the breast (latch) and the way they are held to breastfeed (positioning) can help or hinder milk removal. When a baby has a big mouthful of breast tissue as well as the nipple in their mouth (a deep latch) it helps them remove milk efficiently and comfortably from all areas of the breast. Pamela Douglas, lactation consultant and doctor writes that certain pressures on the breast can cause inflammation, these might include pressing a finger into the breast through a feed, a deep vigorous breast massage or a poor latch. If breastfeeding is not comfortable ask a breastfeeding specialist to check your positioning and attachment and see Latching Tips, Breastfeeding Positions for Newborns and Why Does Breastfeeding Hurt?

Some mothers find trying different breastfeeding positions to usual can help to relieve areas of the breast that are unexpectedly engorged.
If the engorgement has changed the shape of the breast and nipple making it difficult for your baby to latch, see #3 below.

#3 Help baby to latch

If your breasts are extremely full and engorged they may feel very tight and sometimes your nipples may seem to flatten out and almost disappear. If this happens it can be difficult for a baby to latch on. When engorgement is preventing a baby from latching on, it can help to move some of the milk away from directly behind the nipple either by hand expressing or a technique known as reverse pressure softening.

Hand expression

Gently hand expressing a little milk before feeding can help soften the breast around the nipple so that baby can latch. See Hand Expressing Breast Milk for videos and further information

Reverse pressure softening

If your breasts are so full and engorged that your baby can't latch on, a technique called reverse pressure softening can help. Reverse pressure softening can bring out a nipple flattened by severe engorgement by temporarily redistributing the extra fluid away from the nipple area back into the breast. Jean Cotterman explains more about the technique in the article below:

#4 Hand express or pump to comfort if needed

If your baby can't breastfeed, isn't feeding well yet, or can't keep up with the volume of milk, you will need to remove enough milk to stay comfortable by other means than breastfeeding.

Hand expression. Frequent hand expressing is a good way to remove excess breast milk in the early days after birth, see Hand Expressing Breast Milk for videos and further information. A pump may attract more swelling to the area before your milk is in properly by pulling more blood or tissue fluid towards the nipple. If you do use a pump at this time, keep the suction at its lowest setting and make sure the pump flange is the correct size.

Pumping. Pumping with a good quality breast pump can help to keep the breasts comfortable if they are engorged after your milk has "come-in". If you still feel painfully engorged after a breastfeed, a breast pump can remove enough milk until you feel comfortable again. Do not over pump as this could make the engorgement worse and check the pump flange is a good fit and the pump is working correctly.

When milk won't flow. See Engorgement Relief When Milk Won't Flow for more ideas if you are unable to get milk flowing.

Keep baby well fed. If your baby is not latching, any expressed milk can be given to your baby to keep him well fed until you can find some good breastfeeding help.

Expressing just enough milk to stay comfortable won't make the engorgement worse. It is important to remove enough milk to soften the breasts, this will protect your milk supply in the days to follow and will help avoid blocked ducts or mastitis. Expressing a little milk may also make it easier for your baby to latch deeply (see #3 above).

#5 Breast movement

Natural breast movement may help to prevent breast inflammation but bra wearing and inactive lifestyles can restrict this normal movement (Douglas, Vol 18: 1-20 2022). Solutions to this could include:

Go without a bra as much as possible (Douglas, Vol 18: 1-29 2022). For a more in depth discussion about the pros and cons of bra wearing during lactation see Nursing Bras FAQ.

Breast gymnastics. Doctor and lactation consultant Pamela Douglas says that gentle upper limb stretches or moving the breasts in gentle circular movements with the hand or palm laid over the breast may help to prevent breast inflammation. Lactation consultant Maya Bolman calls this type of movement breast gymnastics for engorgement and she demonstrates her method in a Facebook video.

Breast massage. Breast massage is sometimes mentioned as a way to prepare the breasts for breastfeeding or hand expressing to release milk from all areas of the breast. One study found that a light breast massage combined with hand expression helped to drain engorged breasts. However several authors are concerned that any kind of massage, unless professionally done, could worsen or cause breast inflammation (Douglas, Vol 18: 1-20 2022; Mitchell et al, 2022) since the ducts in the breast can be easily damaged.

If a mother is considering trying massage, it is important to do so gently so as not to bruise the breast tissue or increase inflammation (Morgensen et al, 2020). Massage techniques and therapies favoured by some lactation consultants include:

Lymphatic massage

The lymphatic system is a network of little tubes in the body that drains waste products from the cells in lymphatic fluid. Lymphatic massage is thought to help engorgement by helping to drain lymphatic fluid from the breast towards the lymph nodes in the armpits (axilla). Lactation consultant and breast surgeon Katrina Mitchell has developed a handout showing how to do this type of massage using very light touch circular movements similar to that used to stroke a cat. Douglas cautions that even gentle pressure could contribute to breast inflammation (Douglas, Vol 18: 1-20 2022).

Therapeutic Breast Massage

A technique popularised by Maya Bolman of Breastfeeding Medicine of Northeast Ohio called Therapeutic Breast Massage in Lactation (TBML) involves alternating breast massage with hand expression (see video). As above, this type of gentle massage is also said to help drain lymph/tissue fluid from the breast via the lymphatic system in the armpits.

Circular massage

Global health Media summarises six steps to take to relieve engorgement in the following video and describes a massage involving making circular hand movements at 01:40.

Other physical therapies

Mogensen et al discuss a number of other physical therapies that may help relieve engorgement including therapeutic ultrasound and cupping therapy.

Ultrasound is used by medical professionals to reduce pain and increase circulation and some mothers have found it helped improve the symptoms of engorgement. However Douglas states that there is no evidence supporting the use of therapeutic ultrasound in lactation (Douglas, Vol 18: 1-20 2022) and cites a systematic review that found no positive effect.

Cupping therapy is a traditional Chinese medicine technique performed by a physical therapist that uses suction cups to create a vacuum to improve lymphatic fluid drainage (Mogensen et al, 2019).

#6 Cold therapy and cabbage

Cold compresses (e.g. frozen peas or crushed ice in a damp cloth) placed against any sore areas of the breast for up to 20 minutes at a time, or chilled cabbage leaves in your bra can provide pain relief between feeds (Mitchell et al, 2022). The Womanly Art of Breastfeeding, a popular breastfeeding book, explains more about cabbage and cold therapy:

Use green cabbage (red can stain), which may help reduce swelling [Stop use if a skin rash or other signs of allergy appear]. Remove the outer leaves in case there are any pesticides on them. Tear off some inner leaves, tear out the hard central stem, crumple the leaves gently in your hand, and apply them to your breast (not over your nipple, so the taste isn't left behind to bother your baby). Doesn't that feel wonderful? You can wear them inside a bra or under a tight shirt to keep them in place. replace the leaves with fresh ones whenever you want to.

Inflammation responds best to cold. Wrap a bag of frozen peas (or carrots) in a small towel and use it as a cold compress, alternating about twenty minutes on and twenty minutes off, as much as you like. Refreeze as needed. If you feel like a hot shower, let the water play over your back, not your chest. Same for a heating pad.

#7 Pain relief

If engorgement is very painful, appropriate pain relief or anti-inflammatory medication can help with the pain and accompanying inflammation (Mitchell et al, 2022). Pain relief may also help the let-down reflex however Pamela Douglas cautions that over reliance on medication could interfere with the body's own systems to calm the inflammatory response (Douglas, Vol 18: 1-20 2022).

Warmth before a feed

Some authors recommend placing a warm compress or warm towels on the breast just before pumping (or breastfeeding) as a little warmth can help with the let-down reflex and also provide some pain relief (Lawrence, 2016). It's important not to go too warm as too much heat could bring more blood to the area and make the engorgement worse.

#8 Gravity

The Womanly Art of Breastfeeding suggests lying flat on your back to rest allows gravity to help drain fluids away from the breasts. Trying reverse pressure softening while lying down can be helpful to release engorgement behind the nipple.

Lumps in the armpit

Breast tissue extends into the armpit (called the Tail of Spence) and this breast tissue could become engorged in the form of a lump in the armpit. Engorgement here will respond to the same measures used for engorgement in other areas of the breast such as frequent breastfeeds and cold therapy. Occasionally the lump in the armpit will be swollen glandular tissue that does not drain into the rest of the breast; cold compresses for pain relief and a little time will help this to resolve naturally. Note: extra milk making glandular tissue can also be found in other parts of the body on the 'milk line'. Persistent lumps should always be checked with a health professional.

Summary

Breasts that are over full with milk are known as engorged. Engorgement in the early weeks may also include blood and tissue fluid in the breast as well as breast milk. If engorgement is left unchecked it could develop into painful mastitis (inflammation of the breast). Breastfeeding frequently, hand expressing or pumping to stay comfortable, and gentle breast movement can all help to reduce breast engorgement and avoid mastitis. If you are having trouble expressing any milk see Engorgement Relief When Milk Won't Flow. If you do develop symptoms of mastitis and are not starting to feel better after 12-24 hours of treatment, contact your health professional for advice. See Mastitis Symptoms and Treatment for further information.

* Extract reproduced by permission from Pinter & Martin

Footnotes & References

1. The Womanly Art of Breastfeeding*, LLLI, Pinter and Martin 2010, p387

2. Breastfeeding A Guide for the Medical Profession, Lawrence and Lawrence, 2016

3. The Womanly Art of Breastfeeding, LLLI, Pinter and Martin 2010, p387

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Breasts that are over full or engorged with milk can feel uncomfortably full, swollen, hot, lumpy and painful. If the milk is not removed by your baby or by hand expression or a breast pump, engorged breasts can lead to mastitis (painful breast inflammation).

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Lactation Consultant Carol Smyth explains reflux

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Lactation Consultant Carol Smyth explains reflux

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Reflux - it's a biggie. There's a good chance that in the early weeks of your baby's life you will wonder if he has reflux (perhaps starting around 3-4 weeks), or have it suggested to you. You likely know other babies who are on medication for reflux. It almost seems that reflux is queried now for any fussy feeding or unsettled behaviour, but is anyone actually looking at why that baby is unsettled? Reflux exists of course, but is it a medical problem, and do all these babies need medicated? Are large numbers of babies really producing excess acid making their reflux painful? I believe that many cases of reflux are actually indicating a feeding issue, and have non medical solutions.

Reflux is common and physiologically normal. The NICE guidance describes it as follows:

Gastro-oesophageal reflux (GOR) is the passage of gastric contents into the oesophagus. It is a common physiological event that can happen at all ages from infancy to old age and is often asymptomatic. It occurs more frequently after feeds / meals....

The passage of gastric contents - that can sometimes be air. Reflux is normal. Each time we burp, we are having reflux. Reflux is something that happens to us all frequently and is not problematic. What the word has come to mean however is something different. It has come to mean unsettled behaviour in babies. It is come to be associated not just with vomiting, or posseting, but also frequent waking, or a baby wanting to be held, or a baby who is having feeding issues. In practice Western society has started to confuse reflux with other issues and behaviours.

NICE guidance suggests that 40% of babies spit up/vomit, and for the vast majority of these babies it is a laundry issue, not a medical one. Another group of babies are often labelled as having 'silent reflux' or 'occult reflux' where the reflux doesn't make it as far as the mouth, or perhaps is re-swallowed once it gets there. Sometimes we hear swallowing or see other symptoms, but sometimes there are no signs of reflux at all, but it is diagnosed simply from behaviours like crying, back arching, pulling on and off the breast ( which is sometimes misdiagnosed as breast refusal).

A common picture is that a mum with a concern visits her GP. After a discussion around symptoms baby is often started on a milk thickener (carobel) or an Alginate (gaviscon), and so starts a medication cycle. These medications make many babies constipated and the now constipated baby has tummy pain and is more unsettled and fussy. This often becomes confused with more reflux symptoms and so the baby is moved on to the next level of medication - proton pump inhibitors which reduce stomach acid.

Can we all just take a step back? Imagine your washing machine is leaking. Each time you wash a load of clothes you see a puddle of water gathering on the floor. You call a plumber and explain about the puddle of water. Your plumber diagnoses a leak and suggests you change a valve to reduce the amount of water which fills the machine. Now when you use the machine the puddle is smaller but your clothes don't seem to be washed properly either. Is that a good solution?

You call a second plumber. This time the plumber comes to your home and observes a wash. He pulls the machine away from the wall so that he can observe the entire water cycle and notices that one of the pipes is loose. He fixes it. No more puddle. Your clothes get washed, the floor stays dry and everything works as it should because he understood what was causing the problem and removed it, rather than working on the symptoms.

Why are we not looking for the root cause of a baby's reflux? Why are we managing symptoms? Deal with the root cause and maybe we can eliminate the problem with reflux.

So what are the root causes?

1. Babies have little core strength and many spend a lot of time either semi horizontal or horizontal. They have a liquid diet and can have an immature valve closing the top of the stomach, so that makes it leaky. It's a bit like half screwing on the top of a bottle of water and then laying it down. The water is going to leak back out of the top. This normal physiological reflux generally resolves in time as the baby begins to sit up and moves to solid food. In the mean time it may actually be beneficial. The Canadian paediatrician Jack Newman believes that spit up may be a good thing in an otherwise healthy, content baby as it coats the oesophagus twice with antibodies - once on the way down and once on the way up again. The NICE guidance is very clear that either spitting up or silent reflux in and of itself is not a problem and should not be medicated without other symptoms being present.It's a baby - The spitting up may be entirely normal.

2. Too Much Milk Too Quickly - Babies are designed to drink small amounts frequently - much more frequently than we expect. A normal physiological frequency for a baby may be to have small amounts every 90 mins - however we often expect them to feed 3 hourly. A baby feeding 3 hourly needs to drink twice as much at each feed as a baby drinking every 1.5 hours. Overfilling the stomach causes it to stretch and that loosens the valve at the top of the stomach - allowing the overflow to escape. Think of this as a safety valve in this case allowing excess to escape and for the baby to feel more comfortable. Adjusting feeding so that there are appropriate amounts at a normal frequency can reduce reflux episodes.

3. Aerophagia - This is a medial term which just means swallowing air. A baby who is clicking, gulping, spluttering may be taking in more air than they should. A baby who has a sub optimal latch may be taking in air. Scheduling feeds and feeding on a very full breast or expressing for a freezer stash can create issues with swallowing air due to the flow being so fast which may interfere with a baby's suck-swallow-breathe rhythm. A tongue tie or muscle tightness from birth can also impact that nice relaxed suck-swallow-breathe rhythm potentially causing swallowing of air. In my previous blog I talked in detail about why a baby may swallow air during a feed so if you missed it click here. If a lot of air is swallowed, the stomach valve opens to allow it to escape again - for the baby to burp. As the air comes back up, milk may come with it. The resolution for this is to correct feeding issue, or resolve the tongue / muscle issues so that air isn't swallowed. Without the air being swallowed the reflux can be eliminated or reduced to a manageable level. Having a good feeding assessment will help to optimise feeding and identify any issues with air intake.

4. Low Milk Intake - This is more usually applicable to silent reflux where the diagnosis has come from symptoms of back arching, pulling on and off the Breast (which may have been misdiagnosed as breast refusal), and poor weight gain. The poor weight gain is sometimes considered to be due to "silent reflux" causing pain, however the most common cause of poor weight gain is lack of calories so this should be investigated first. Where milk supply is low the flow of milk is slow. It is a very common behaviour for a baby to arch, pull on and off the breast and cry in frustration when flow is slow. Milk volume is a complex interaction of both mum and baby so low supply could be due to ineffective transfer from mum to baby due to birth interventions, something anatomical, poor latch, or baby not being at the breast enough. Resolution would be to increase supply in mum and ensure baby is transferring effectively. A good breastfeeding assessment and support can help to get things back on track.

5. Allergies/intolerances - This is a more complex picture. When reflux occurs in healthy babies it is generally painless. Babies are on a milk diet (which neutralises acid), and the oesophagus has a number of defence mechanisms against acidity, so generally babies who are spitting up are pretty comfortable, or only mildly upset by refluxing. A minority of babies however, do become very distressed when refluxing. Where pain is involved there is often another underlying. Allergies can cause inflammation within the body, and where reflux is touching already inflamed tissue, there may be pain where a non-allergic baby would experience none. For these babies, identifying and removing the allergen allows the inflammation to resolve and for the reflux to become normal physiologic, pain-free reflux again.
It's important to say that allergy has multiple symptoms - reflux alone is not diagnostic of allergy. Allergy affects multiple systems in the body - the GI system, the skin, the respiratory system, so there are usually multiple indicators of an allergy present. My blog on allergy and symptoms is here. Again, a good feeding assessment should pick these up and hep you to figure out if an allergy may be an issue for your baby.

6. Gut microbiome - Our gut bacteria is a huge topic of research at the minute. We have as many bacterial cells in our bodies than human cells and a healthy microbiome is necessary for digestion and for immune function, among other things. A healthy microbiome should allow for easy digestion, and the production of gas that is reasonably comfortable and easy to pass. A microbiome which has more pathogenic species however may cause issues with digestion. It may produce more of the methane and sulphur gases causing bloating and pain. It may cause constipation and straining. That constipation and straining in return can cause reflux due to the abdominal pressure. A feeding assessment should look at gut function and any undiagnosed constipation as well.

7. Baby's habitat - A baby is extremely immature at birth, with a nervous system reliant on mum's body. If a baby is not in contact with mum, digestion does not work optimally. We have been primed to believe that we need to set a baby down after feeding, not to spoil our babies, or create rods for our backs. When a baby is separated from mum however the baby can become distressed, and emotional stress can lead to vomiting. This may explain why baby wearing / carrying baby also seems to help with reflux.

Usually babies are not bothered by reflux, but they do receive emotional regulation from their mum. If a parent is worried, and stressed about their baby, then a worried and stressed nervous system is regulating the baby. This leads to a more anxious baby and that can lead to more fussy behaviour and even more reflux. A good breastfeeding assessment should involve counselling about what is normal, and concentrating on the parent's worries and fears just as much as the baby's feeding.

NICE guidance is very clear on where normal reflux becomes something which needs investigation.

in well infants, effortless regurgitation of feeds... does not usually need further investigation or treatment

For silent reflux it states the following:

Do not routinely investigate or treat for GOR if an infant or child
without overt regurgitation presents with only 1 of the following:
unexplaied feeding difficulties (for example, refusing to feed, gagging or choking)
distressed behaviour
faltering growth
chronic cough
hoarseness
a single episode of pneumonia

If a baby meets the criteria for further investigated, the guidelines are also clear about what should happen next:

In breast-fed infants with frequent regurgitation associated with marked distress, ensure that a person with appropriate expertise and training carries out a breastfeeding assessment.

Is this happening? If your baby was diagnosed with reflux were you first referred to a person with appropriate training to carry out a breastfeeding assessment?

What's wrong with the medications?

Most mums don't feel comfortable with the idea of medicating their tiny baby, and side effects of the drugs are often not discussed in depth. Thickeners often have a side effect of thickening stools or causing constipation. Proton Pump Inhibitors (such as Losec) or H2 blockers (such as ranitidine) reduce stomach acid. These do not stop the reflux (in fact vomiting is listed as a side effect). Reducing acid may initially seem like a good idea, but we have stomach acid for a very good reason. Our bodies need an acid environment in order to digest proteins, and it also acts as an immune defence against pathogenic bacteria which are destroyed in an acidic stomach environment. Without adequate stomach acid babies are more at risk of infection, of developing allergies, even of bone fractures. In some cases treatment can even suppress appetite In cases where the issue is low milk intake the drug may seem to help for a while, but the supressed appetite can mean that baby drinks even less milk, and weight gain falters. Acid levels also affects absorption of vitamins and minerals in the gut. With these side effects, and the clear guidelines from NICE, doesn't it make sense to investigate fully before considering drugs?

There is no doubt that some babies do have GORD. These are very unhappy babies, and they need our help. They may indeed need medication, but they also need help with breastfeeding. Those babies are in the minority though. Most babies probably don't need medication, but they absolutely do need good breastfeeding support. A thorough feeding assessment should involve observing a feed, optimising latch, and looking at a complete history of feeding so far. It should consider baby's ability to transfer milk, weight gain and pattern of feeding through the day, any extra expression that happens regularly, how birth went and if there could be subtle effects, mum's feelings around feeding, any pain or discomfort, concerns or fears etc. It should consider parent and baby as a unit and is much more than treating a stomach. A feeding counsellor or lactation consultant should also know when reflux is more than a feeding issue and does need medical help.

Reflux is distressing - for the whole family, and our babies deserve to have someone take the time to investigate and treat the cause, not just symptoms.

For every effect there is a root cause. Find and address the root cause rather than try to fix the effect, as there is no end to the latter. - Celestine Chua

See Part 2 on the Importance of Stomach Acid

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Important Information

All material on this website is provided for educational purposes only. Online information cannot replace an in-person consultation with a qualified, independent International Board Certified Lactation Consultant (IBCLC) or your health care provider. If you are concerned about your health, or that of your child, consult with your health care provider regarding the advisability of any opinions or recommendations with respect to your individual situation.

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Reflux and breastfeeding | Carol Smyth IBCLC & CBT

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Reflux - it's a biggie. There's a good chance that in the early weeks of your baby's life you will wonder if he has reflux (perhaps starting around 3-4 weeks), or have it suggested to you. You likely know other babies who are on medication for reflux.

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Short video on how babies attach at the breast

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Short video on how babies attach at the breast

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Unicef UK Baby Friendly Initiative | Positioning and attachment

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UNICEF's breastfeeding assessment tool (used by midwives)

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UNICEF's breastfeeding assessment tool (used by midwives)

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Maternity Action on mothers' legal rights

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Maternity Action on mothers' legal rights

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LAM (lactational amenorrhoea) as a form of birth control

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LAM (lactational amenorrhoea) as a form of birth control

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Lactational amenorrhea is a period of temporary infertility that accompanies breastfeeding and is marked by the absence of monthly periods. Postpartum fertility is an important topic and many mothers who seek breastfeeding support have questions about using lactation as a means of birth control.

The physiology of lactational amenorrhea involves a highly sensitive hormonal feedback loop between the brain and ovaries (or hypothalamus-pituitary-ovarian axis). When the infant is at the breast, the suckling action triggers nerve signals that travel from the breast to the brain. This causes the hypothalamus to alter the hormones released from the pituitary gland. This state of altered hormones disrupts normal activity in the ovaries, triggering a temporary period of infertility because ovulation is suppressed. This period of infertility is often referred to as LAM, or the Lactational Amenorrhea Method and can provide very effective birth control.

In 1988, scientists and fertility specialists gathered in Italy at the Bellagio Consensus Conference to define the conditions for using lactation amenorrhea as birth control. They established that in order for LAM to be effective three important conditions must be met:

1. The infant is less than six months old,

2. The menstrual cycle is absent, and

3. The baby is exclusively breastfeeding.

Once any of these conditions are not met, the effectiveness of LAM begins to wane (Kennedy et al., 1996). The Bellagio Consensus established the risk of pregnancy to be less than 2% in the first six months postpartum while using LAM (Lancet, 1988). According to the World Health Organization, the risk of pregnancy while using this method correctly is less than 1% (WHO, 2020).

There are many benefits to using LAM as birth control in the first six months postpartum. LAM requires no special equipment, no pills, prescriptions or supplements, and is universally available. Unlike hormonal birth control such as the contraceptive pill, some intra uterine devices (IUDs) and implants, the LAM method does not involve synthetic hormones, which for many nursing parents can interfere with milk supply. In addition, using the LAM method is highly cost effective as it is free.

LAM provides excellent birth control for six months but also enhances positive maternal and infant health outcomes. For example, one of the LAM requirements is full or exclusive breastfeeding. Exclusive breastfeeding for six months, aside from promoting LAM, is known to optimize infant gut health, support normal infant weight gain, and protect against certain respiratory illnesses and diarrhea. Exclusive breastfeeding also promotes positive outcomes for maternal health as well. Breastfeeding decreases the risk of developing certain cancers and conditions. For example, breastfeeding decreases the risks for breast and ovarian cancers as well as the risk of developing type 2 diabetes (Chowdhury et al., 2015).

There are some ways to enhance the use of LAM. LAM appears to be associated with the intensity and duration of feeding, not just in terms of duration of months, but also duration of minutes throughout the day. The period of ovulation suppression and infertility can therefore be enhanced by:

Offering the breast whenever baby displays feeding cues (nursing on demand)

Nursing frequently throughout the day

Nursing baby on demand at night as long stretches without nursing can impact LAM (Gross & Eastman, 1985.)

Allowing baby to determine the end of the feeding instead of using arbitrary time limits

Allowing babies to meet all their sucking needs at the breast (no dummies or pacifiers)

Waiting until mid-way through the first year to introduce solid foods

Research shows that the physical stimulus of suckling at the breast directs suppression of ovulation (McNeilly, 2002). Therefore, it is important to maximize the infant's time at the breast for suckling, even for comfort. The Bellagio Consensus did not expressly state that dummies or pacifiers be prohibited, and it is very likely that some people have success with LAM even while occasionally using a pacifier (dummy or soother). However, it may be best to minimize the use of pacifiers in order to protect the action of LAM. Minimizing the use of pacifiers also enhances milk production.

Lactational amenorrhea as birth control might not be the best option for everyone. For some, it can be hard to practice exclusive breastfeeding. In addition, there is some evidence that the risk of pregnancy is slightly higher for working mothers who practice LAM (Valdés et al., 2000). Another consideration for this method is that it is less reliable after six months, making it necessary to use alternative birth control after that time.

Some mothers or nursing parents who have purposefully used LAM or others who are meeting the LAM criteria for other reasons (promoting good milk supply, using responsive feeding techniques, or when cultural norms promote exclusive breastfeeding) have noticed that they experience a longer period of sub-fertility than they would prefer. Sometimes, for those with intense duration of breastfeeding, fertility has not yet returned when they are ready to conceive another child. There is evidence that the pattern of breastfeeding is a factor when it comes to fostering the return of fertility. For those who take months to gradually wean, the return of fertility could be stalled. On the other hand, abrupt changes to the nursing pattern can bring on ovulation more quickly (Andersen, & Schiøler, 1982) but stopping breastfeeding completely is not usually necessary. There are anecdotal stories about ovulation returning for women who experience temporary separation from their toddler, for example, after a weekend away. Reducing feed frequency, longer stretches between certain feeds or night weaning have triggered ovulation for some mothers.
Further reading
Taking Charge of Your Fertility by Toni Weschler.
References

Andersen, A. N., & Schiøler, V. (1982). Influence of breast-feeding pattern on pituitary-ovarian axis of women in an industrialized community. American Journal of Obstetrics and Gynecology, 143(6), 673-677.

Breastfeeding as a family planning method. (1988). Lancet (London, England), 2(8621), 1204-1205.

Chowdhury, R., Sinha, B., Sankar, M. J., Taneja, S., Bhandari, N., Rollins, N., ... & Martines, J. (2015). Breastfeeding and maternal health outcomes: a systematic review and meta‐analysis. Acta paediatrica, 104, 96-113.

Gross, B. A., & Eastman, C. J. (1985). Prolactin and the return of ovulation in breast-feeding women. Journal of Biosocial Science, 17(S9), 25-42.

Kennedy, K. I., Labbok, M. H., & Van Look, P. F. A. (1996). Lactational amenorrhea method for family planning. International Journal of Gynecology & Obstetrics, 54(1), 55-57.

McNeilly, A. S. (2001). Lactational control of reproduction. Reproduction, Fertility and Development, 13(8), 583-590.

Valdés, V., Labbok, M. H., Pugin, E., & Perez, A. (2000). The efficacy of the lactational amenorrhea method (LAM) among working women. Contraception, 62(5), 217-219.

Family planning/contraception methods. (2020, June 22). WHO | World Health Organization. https://www.who.int/news-room/fact-sheets/detail/family-planning-contraception

Kelly Durbin has been a Leader for about ten years in the United States with experience leading meetings in five different states across the country. She, her husband and their two daughters now live in Austin, Texas, USA.

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Lactational amenorrhea: fertility, birth control and breastfeeding - La Leche League International

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Kelly Durbin, Austin, Texas, USA Lactational amenorrhea is a period of temporary infertility that accompanies breastfeeding and is marked by the absence of monthly periods. Postpartum fertility is an important topic and many mothers who seek breastfeeding support have questions about using lactation as a means of birth control.

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Eating well: the first year
A guide to introducing solids and eating well up to baby's first birthday

This guide provides information and practical advice on introducing solid foods to babies (also called weaning, complementary feeding), with recipes and photos to show the sorts of foods, and amounts of foods, that will give them a good start to their eating journey.

The information is in line with current policy in the UK and provides a pictorial guide which can be used to support families in the first year of their baby's lives. This guide includes information and example recipes for vegan, vegetarian, gluten-free, egg-free and dairy-free diets. Information on cultural diets and fussy eating are also included in this guide.

Downloading options for this resource
This guide is 130 pages long and in full colour. Please be aware that printing it out in full will use a lot of ink - especially yellow ink (!) and when we have done it on a home printer it has used more than one cartridge, so you might find it cheaper to buy a hard copy if you are doing this yourself.

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Eating well in the first year - First Steps Nutrition Trust

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A guide to eating well and starting solids up to baby's first birthday. This guide introduces weaning/complementary feeding and gives practical tips on introducing food to your baby.

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Blog from lactation consultant Emma Pickett on weaning

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Blog from lactation consultant Emma Pickett on weaning

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The Department of Health and the Department of Health of every other industrialised country in the world recommends the introduction of solid food at around six months.

You may hear 'rumours' that this will change.

You may hear people tell you that there's something wrong with this recommendation and earlier is best.

Not true. The recommendation to wait until six months was the result of some careful deliberation and an examination of a wide range of evidence that looked at issues like disease and allergy prevention.

There are a few bits of infant physiology that are hard to argue with. Babies need the amylase enzyme to digest starch and it isn't properly released until around six months. In the days when people would spoon rice cereal into their small babies like filling cracks in the wall with polyfilla, some of those nutrients weren't going anywhere useful. Babies are born with what we call an 'open gut'. This means the gut wall which separates the baby's intestines from the blood stream is extremely permeable. Larger molecules that might cause disease and allergic reaction can pass through easily. Breastmilk does a clever thing as it forms a protective mesh over the gut wall that prevents various nasties passing into the baby's bloodstream. However to get that mesh functional we need the baby's gut flora to be the good stuff. Just as if we were going to end exclusive breastfeeding, adding in solids will change the gut Ph. and gut flora and some of that protection could be lost. However by around six months, gut closure has occurred in babies and introducing other food then appears to have less of an effect.

A baby who is six months can also participate much more in the feeding process. They can sit up and hold and bite and select and get that food is colourful and textured and wonderful. They can control the process, rather than simply be vehicles for beige mush. You'll often hear people say, 'But my four month old looks so longingly at us when we eat our bacon sandwiches. He looks so fascinated and he wants to reach out and grab my food. I don't want to make him wait until six months'. Sure, but the same baby is probably going to look equally fascinated when you apply mascara and lipstick. Probably not the best argument for starting solids ahead of the recommendations.

"My baby is big. He'll need solids sooner". Nope. It's really not the way it works. Our bodies are designed to make enough milk for twins. It can cope with your bigger-than-average baby.

"My baby is smaller. She'll need solids sooner". Nope. If you're concerned about weight gain, there are more effective things we can do to increase calorie content.

"My baby doesn't sleep well. He needs solids sooner". This may well be the classic sleep phase we often see at around four months. Babies can wake more frequently for a variety of reasons including gross motor development ("I'm getting to a lighter phase of my sleep cycle and I CAN MOVE MY LEG. I HAVE LEGS. I'M MOVING THEM. And while I'm at it, where's that nice big mummy person gone? I'm fully awake now"). Or it could be teething. This waking phase is rarely connected to insufficient nutrition. We may even find that introducing solids causes more restless nights initially, not improved ones. Babies are experiencing new digestive sensations, pooing at different times and are more likely to be constipated.

This is one area where we may get a lot of pressure from friends and family. Many of them weaned at a time when the recommendations were different. If you've been breastfeeding, they are probably super keen to get the spoons out and literally get stuck in. You may hear this from your mother-in-law: "Well, Bob had baby cereal from six weeks and he's just fine." Bob now plays rugby, runs marathons, splits atoms - delete as appropriate. The anecdotal evidence argument is never a worthwhile one. Bob is probably a member of a generation with shocking levels of obesity, heart disease and diabetes. Perhaps if Bob hadn't have been weaned at six weeks, he'd play better rugby and split more atoms.

The recommendations didn't change because someone in government had a long lunch and was feeling cross with Heinz baby foods that day. Evidence looking at the health of babies breastfed for 3-4 months vs six months was reviewed. This evidence was relevant to babies living in all countries and in all conditions.

The recommendations may change again. More evidence is always needed. But right now 'around six months' seems right.

There are different ways to feed a baby solid food. Broccoli can be held by its convenient little handle and baby gums can mash down and take mouthfuls of stuff directly from the source. Or it can be steamed and pureed and spoon fed. Baby-led weaning is a method where spoon feeding doesn't happen. Baby is in charge. Food is offered in pieces and chunks that can be held in a little baby fist and they just go for it. They sit and feed themselves while you sit and eat your own dinner.

Imagine two families with babies in a restaurant. On one table there is a baby sitting up and in front of him is a selection of finger foods: a bit of pitta bread, some vegetables from mum's plate, some chicken. While his parents eat and talk themselves, he picks up pieces of food and self-feeds. At the other table there is a baby being fed pureed foods. While his parents eat, he sits and watches and perhaps is shown books or toys. When his parents are finished, they ask the restaurant to heat up some puree and then a parent sits and feeds him with a spoon.

Both babies are being fed and getting the nutrition they need. One baby is part of the social experience of the meal and is moving towards feeding independence and one baby isn't quite.

The advantages of baby-led weaning are that baby is experiencing food as a full sensory world. They touch it, smell it and see its natural colours. They are part of the family meal. Food starts out 'real' and never changes. Some babies may gag when self-feeding finger food but the chances of choking are no more than if a baby was being puree fed. Plus you don't have to worry about eventually transitioning to more solid food. If you are really nervous about choking, this can be a good time to do a course in baby first aid. They are often available cheaply in places like local children's centres or even take some time to look at some videos online: http://www.redcross.org.uk/What-we-do/First-aid/Baby-and-Child-First-Aid/Choking-baby.

You can tell from my obviously biased description that I'm a fan of baby-led weaning. It's been recently promoted by the work of Gill Rapley, a health visitor who has written some useful books on the process. I heard her speak at a food festival once and she got us to do an exercise. We got into pairs. Someone spoon fed me a puree. I couldn't communicate when I was ready for the next mouthful or easily communicate when I was done. I couldn't smell the food or easily see the colour. The spoons of beige mush kept on coming. It tasted fine but I couldn't even put a hand up to slow the process down or ask for a smell or ask to take a breath. It felt overwhelming and the spoons kept coming. After a few minutes, I started to feel like a torture victim. Clearly I am being melodramatic here but imagine you are breastfed baby who up until now has been fairly in control of their own feeding. Wouldn't it be nice if solid food was an extension of that experience?

Of course, you may feel purees are right for you and be particularly attached to your steamer. Like with most things in parenting, you must do what is right for you. Lots of people combine pureed foods and finger foods in a baby-led weaning style. However I would recommend you at least find out about 'baby-led weaning' as it can be enormous fun.

Food before twelve months is 'just for fun' people sometimes say. Not quite true because in many cases, we will need to give baby additional sources of iron and other micronutrients before twelve months. When babies are born they get stores of iron from you and then as they breastfeed, they receive easily absorbable iron from the breastmilk. There was a time when scientists looked at the iron in breastmilk and thought it looked a bit low but we now know that was misleading as it is absorbed incredibly efficiently and is very bioavailable. Studies have shown that when babies are exclusively breastfed for as long as eight or nine months, they still have sufficient levels of iron in their system. However the recommendation to start solids at around six months gives them plenty of time to get up and running before we need to worry about there being a problem. It simply isn't true that because we are now starting a little later, we're in a huge rush to get huge bowlfuls of food into our baby or the world will end. We have time. It's really important to remember that milk remains the primary source of nutrition up until twelve months. It's only at twelve months that solids starts to take equal status and then gradually becomes to primary source of nutrition. Some eighteen month olds are still happily breastfeeding several times a day (and at night) alongside solids and it's a valuable part of their nutrition. These statistics are helpful: 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). That's not me saying everyone should breastfeed for 23 months. That's me saying breastmilk continues to have good stuff in it, the best stuff. It's not going to turn into some useless white fluid when your baby reaches six months and now it's all about the mashed banana.

What should we feed them? Well, what do you like eating? There's very little a baby over six months can't have (something else that's easier after six months). We don't give a baby under 12 months honey because of the risk of botulism poisoning. We want to be careful about whole nuts which could be a choking risk but nut butters are fine. If you are worried about a history of family allergies, you should talk to your doctor but automatically avoiding certain foods may not be the most sensible approach - certainly not for everyone. You don't have to wait a few days before introducing another new food. You need to be sensible with sugar (and that includes dried fruit) and salt can be dangerous so if you are cooking meals for the family, season your own food separately after cooking. Babies can enjoy herbs and spices and strong flavours. They can eat eggs and seafood and meat and fish. Though you need to pay attention to the quantities of oily fish as they contain pollutants. Did you know that boys can eat more oily fish than girls? There's some more information here:
http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/understanding-food-groups.aspx#close

Babies can eat dairy products and they can also be vegan or vegetarians. They can drink water. They don't need juice. The suggestion is to minimise the amount of wholegrain foods a child eats under two years old.

Some people are concerned about how they are going to time their solid food meals. They are also worried about how to go about 'dropping' a breastfeed and reduce breastmilk appropriately. This is one of the great things about breastfeeding and introducing solids - you don't have to stress about any of that. It happens naturally and organically and your baby is in charge with very little assistance from us. You just continue to breastfeed to your baby's cues. That's it. Bottle feeding mums do have to plan things out more carefully. Breastfeeding mums just continue to response to their baby's cues and just ensure that the solids intake doesn't increase too quickly.

When you introduce their first solids, think 'milk first'. That means we don't feed a solid meal when a breastfeed is due and then find they aren't that hungry for breastmilk. Better to offer solid food in between breastfeeds or not long after a breastfeed. Food is like a new activity. You've introduced this wonderful new toy that tastes a lot better than the plastic giraffe they've been chewing on for a while. When two meals start to happen, milk is still 'first'. It doesn't have to be first in the sense that you breastfeed and then run from the sofa and plunge them into their high chair - just not long after or a few hours after. We don't want the quantities of breastmilk they receive to really change much for a while. As they start to take more solids, gradually over a 24 hour period, they will take less breastmilk. You may not even notice it happening. Feeds may become a little shorter and intervals between breastfeeds a little longer. It will happen very naturally.

Eat with your baby. Enjoy meals together.

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The Department of Health and the Department of Health of every other industrialised country in the world recommends the introduction of solid food at around six months. You may hear 'rumours' that this will change. You may hear people tell you that there's something wrong with this recommendation and earlier is best.

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Lactation consultant Emma Pickett discusses weaning babies and older children from breastfeeding

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Lactation consultant Emma Pickett discusses weaning babies and older children from breastfeeding

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A post shared by Emma Pickett (@emmapickettibclc)

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UNICEF's guide to feeding responsively with a bottle - whether expressed breastmilk or formula

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UNICEF's guide to feeding responsively with a bottle - whether expressed breastmilk or formula

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A quick overview of how breasts make milk

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A quick overview of how breasts make milk

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In-depth look at milk production from La Leche League

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In-depth look at milk production from La Leche League

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Mothers have successfully fed their children for thousands of years of human history without understanding how it works. It's a bit like driving a car - as long as it's working well, you don't need to know what is going on under the bonnet!

If you are having breastfeeding problems, such as low milk supply or too much milk, or are wondering why your baby's feeding pattern is different from what you expected, it can help to understand more about the science of lactation (producing milk).

Most of the research that has ever been done on breastfeeding and human milk has been done in the last few years. It is a very exciting time for lactation science. Lots of things that experienced mothers have always known turn out to have a clear basis in the anatomy of the breast and the science of milk production, for example:

Each baby and mother pair is different

Healthy babies are the best judges of when and how to feed

The way to make more milk is to remove more milk

Getting ready - the developing breast

Breast development starts around the age of 10-12 years. From puberty, the breast grows a little with each menstrual cycle. Inside the breast, the branches and buds that will become milk ducts and alveoli (milk storage sacs) start to develop. Radiation or trauma to the chest at this stage can have an impact on later breast development.

Lactation begins - pregnancy

For many women, tender breasts are an early sign of pregnancy. The breast completes its development during pregnancy, and milk production begins in the middle trimester. If a pregnancy ends after 15-16 weeks, colostrum (early milk) will be present. Some women choose to express colostrum in the last few weeks of pregnancy. This is recommended for women with diabetes, whose milk may be a bit slower to increase and whose babies may have low blood sugar after birth. Colostrum expressed before birth can be stored, to be given to the baby if they need extra milk. Mothers with high-risk pregnancies, or who are concerned about having enough milk, may also choose to express colostrum in the last weeks of pregnancy. It is usually recommended not to start before 36 weeks, unless premature birth is imminent. The amount of colostrum you can express before birth does not predict your ability to make enough milk afterwards.

After birth (day 1-3)- lactation takes off!

During pregnancy, milk production is held in check by the hormone progesterone, produced by the placenta. Once the baby is born and the placenta is delivered, levels of progesterone drop rapidly; this, coupled with high levels of prolactin, allows lactation to begin fully.

Retained placental fragments can reduce or even stop milk production. If you have unexplained low milk production and are still bleeding heavily or irregularly after you would expect to have stopped, check with your midwifery team or doctor. Removal of the last fragments of placenta will usually allow milk production to resume normally.

Mothers typically start to notice the signs of " onset of copious milk production " (also known as milk "coming in") two or three days after birth. For a day or two you might experience:

The discomfort you feel is primarily due to tissue swelling, in response to the sudden increase in milk volumes. Don't panic - your breasts won't feel like this for long! As your breasts adjust to making the amount of milk your baby needs, the swelling will settle down. If feeding your baby or expressing milk doesn't quickly help you feel more comfortable, there are other steps you can take to deal with engorgement.

Onset of copious milk production can happen a bit more slowly:

For first-time mothers

After a more difficult birth

You may have read that being overweight or obese (having a higher BMI, especially over 30) can lead to breastfeeding problems. It is not clear whether having a higher BMI, by itself, is a problem for breastfeeding and many women with high BMI breastfeed easily. We do know that some conditions associated with higher BMI, such as diabetes and metabolic syndrome, may delay your milk "coming in" (increasing in volume) in the early days after birth. This can make breastfeeding more challenging.

To make milk, remove milk (day 3-4 onwards)

Until day 3-4, milk production is controlled entirely by hormones and will happen automatically, whether or not you go on to breastfeed. After day 3-4, another mechanism comes into play. Milk will only continue to be made if milk is removed from the breasts. The more milk that is removed, the more milk will be made. This enables your body to adapt to the number of babies you have. With enough milk removal, it is possible to exclusively breastfeed twins or triplets! If you do not breastfeed or express milk at all, your milk production will shut down within about two weeks after birth.

Remove milk early

The amount of milk that is removed in the period immediately after birth is important for later milk production. Research on lactation after premature birth has shown that starting to express milk within an hour of birth, compared with starting at six hours, is associated with more milk six weeks later.

If your baby has any risk factors for not being able to feed effectively at first, such as being:

then early, frequent milk expression will help to ensure plenty of milk to meet their needs, now and later. You can see a useful video about this here:

Parents who have risk factors for low milk supply can give their milk production the best possible start by removing milk early and frequently after birth.

Risk factors include:

Previous history of low milk production

Previous breast radiation or surgery

Polycystic ovary syndrome (PCOS)

Thyroid problems (hypo- or hyper-)

A history of infertility with hormonal cause

Unevenly sized, widely spaced breasts, with little or no changes during or after pregnancy

Obesity (BMI over 30)

People with these risk factors may be able to make a full or partial milk supply - you never know what you can do until you try! If you are not producing all the milk your baby needs, you can still enjoy a close, happy feeding relationship with your baby. You can read more about how to use donor breastmilk or formula milk to support breastfeeding here.

Some mothers who need to supplement their own supply with donor milk or formula milk in the early months are able to reduce or eliminate the supplementary milk after their baby starts complementary foods, at around six months, going on to happily breastfeed alongside solids.

Remove milk often

After their first feed and a few hours of sleep, full-term, healthy newborn babies feed frequently, around the clock. Most babies need to feed at least 8-12 times in 24 hours in the early weeks, suckling and swallowing actively at each feed, to get enough milk and stimulate their mother's milk production. If your baby is not feeding as often or energetically as this yet, it is important to express your milk, if your goal is a full milk supply.

As milk builds up in the breast, a protein in the milk, known as the "Feedback Inhibitor of Lactation" (FIL), begins to slow down milk production. Breasts that are full make milk slowly, and eventually not at all. Breasts that are well drained make milk quickly. This is why, if you are trying to maximise milk production, it is important not to wait until your breasts feel full before feeding or expressing. Over time, this will reduce milk production.

Different breasts, different feeding patterns

Storage capacity is quite a new concept in breastfeeding, and it explains a lot of things that mothers instinctively knew, but were not in the textbooks!

A mother's storage capacity is the amount of milk that her breasts can hold between feeds. It is not related to breast size and it is not related to the total amount of milk that a mother can make each day.

To understand storage capacity, let's assume that:
Alisha and Beth both have 3 month old babies and well established milk supplies. Alisha's breasts can hold 75ml of milk and Beth's breasts can hold 150ml of milk.
Both their babies need about 750ml of milk per day (this is an average amount. Some babies might take as much as 1200ml per day).
Alisha's baby needs to feed at least 10 times in 24 hours to get this amount of milk, while Beth's baby could get the same amount of milk in only five or six feeds. [Feeding this infrequently is not common - it is at one end of a wide spectrum of feeding patterns!]
Both babies are getting as much milk as they need and growing well, but they have very different feeding patterns. What happens if Alisha and Beth are told that their babies "should" both be feeding eight times in 24 hours?
Alisha's baby is hungry and miserable. She is no longer getting enough milk and if this continues, Alisha's milk production will slow down due to the action of FIL in the full breast. It might be hard to increase milk production again, after the early weeks, when milk supply settles at a stable level. Beth's baby is irritable because his mother keeps trying to feed him again when he doesn't want any more milk!
Both Alisha and Beth can successfully breastfeed their babies as long as their feeding pattern works for their milk storage capacity.
Beth, with her larger storage capacity, has more flexibility in her feeding patterns. Her baby is likely to have fewer feeds per day than Alisha's, is more likely only to take one breast per feed and may start sleeping for longer stretches earlier. She could choose to feed more often, if her baby wanted to. Alisha has less flexibility in her feeding patterns because if she doesn't feed often enough, her breasts fill up and she doesn't have room to make more milk. Her baby is likely to feed frequently day and night during the exclusive breastfeeding period and may need to feed on both breasts at most feeds.
Most babies need to feed at least 8-12 times in 24 hours and it is important to ensure frequent feeding during the early weeks, when milk production is becoming established. After the early weeks, most babies spend less total time feeding, as efficiency improves. Some babies will also significantly reduce the frequency of feeds.

Most mothers never need to worry or even think about their breast storage capacity, because their babies are brilliant at working it out for them! Full-term, healthy, thriving babies are able to choose their own feeding pattern that works with their mother's breasts and their own needs as they grow. . If your baby is growing well and seems contented, their feeding pattern is working well for them.

Fat in milk

This is a topic that often worries parents, because of poorly understood information circulating among families about the differences between "foremilk" and "hindmilk".

We know from research that:

The breast makes milk fat at a stable level. The types of fat in milk are somewhat related to the types of fat in the mother's diet, but the amount of fat is not related to her diet.

The milk available at the start of a feed (often referred to as foremilk) has a lower level of fat than the milk at the end of the feed (often referred to as hindmilk). As the breast is drained, fat levels in milk increase as more fat droplets are "squeezed" to the front of the breast and out through the nipple.

The level of the fat at the start of one feed depends on how long it has been since the last feed. The longer the interval between feeds, the lower the level of fat at the start of the next feed.

Parents often worry, or are told, that their baby might not get enough fat (this is often described as "getting too much foremilk")

Research shows that full-term, healthy, thriving babies are brilliant at balancing their own diets. They will stop feeding when they have had enough calories. When fat levels in milk are higher, they will take less milk. When fat levels are lower, they will take more. The varying amount of fat in milk is not a problem - all the milk is good! It enables babies to quench their thirst at the start of a feed and finish with a creamy "dessert", if they want to.

The balance of fat in milk can be a problem for a small number of babies, if:

The baby is taken off the breast before they have had as much milk as they wanted; or

There is an overwhelming amount of milk. In this case, the baby may be growing very fast (their growth curve crosses centiles upwards on the growth chart) and may struggle with the speed of milk flow, coming off the breast gagging, spluttering and upset. You can find practical tips to help your baby manage fast milk flow here.

In either of these two situations, the baby may not get enough fat to slow down the transit of milk through their gut. Milk may rush through the gut faster than the baby can digest the milk sugar (lactose). The sugar ferments in the gut, producing green, frothy, explosive poo, flatulence (farting) and severe discomfort.

A baby who does yellow poo and is comfortable does not have any problem with the balance of fat in their diet. A baby who is growing more slowly than expected needs more milk overall, not just more fat. These babies should be seen by a doctor to rule out an underlying health problem.

You can read more about fat levels in milk here.

How much milk?

In the first 24 hours after birth, volumes of colostrum are small, but enough for your baby. The average amount per feed is about 7ml (1 ½ teaspoons). This is because full-term babies are not hungry - they are born with food stores in their body. They don't need fluid - they shed extra fluid in the first few days (this is why most babies lose a little weight). Colostrum is primarily immune protection, rather than food. It coats the inside of the baby's gut to keep pathogens out, stimulates the baby's immune system, and provides the baby with a powerful, tailor-made dose of growth factors, hormones, live immune cells and other components that no manufactured milk can begin to match.

The small quantity and thick texture of colostrum give the baby a chance to practice feeding before they have to manage larger volumes. The amount of colostrum increases quickly, more or less doubling every day in the first few days. If you need to express on the first day after birth, you might use a syringe to catch drops. A syringe quickly becomes too small for the increasing volumes. By the 5 th day after birth a baby might be taking 60ml (2oz) or more per feed.

If you are expressing your milk, for example because your baby was born early, it can help to know how much to aim for:

500ml in 24 hours by the end of the first week after birth

750ml in 24 hours by the end of the second or third week after birth

Your baby might not need this much milk yet, but aiming for a full supply now means you will have enough to satisfy them for the rest of their breastfeeding time.

Milk production remains stable, within a range of about 600ml - 1200ml per 24 hours, from about one month after birth to six months. After the baby starts eating complementary foods, milk production starts to decrease, as milk is gradually replaced by other foods in the baby's diet. If you are making as much milk as your baby needs at one month, you are likely to keep on doing so, as long as your baby keeps on removing enough milk and you don't get pregnant or use one of a small number of medications that can affect milk production. Birth control methods that contain progesterone may reduce milk production in some women.

How milk changes

If you are expressing your milk, you will be able to see the change from sticky, transparent, yellow or orange colostrum to thinner, white or blue-ish "transitional milk" by about the fourth day after birth. The composition of your milk is changing to adapt to your baby's need for more energy. Your milk changes from day to day for as long as you breastfeed or express, responding to your baby's stage of development, any illnesses you or your baby are in contact with, and even the time of day or night it was made. The milk of mothers who give birth prematurely is initially different from the milk of mothers who give birth at full term, to meet the extra needs of their babies.

Getting back on track after a difficult start

Milk production peaks by about a month after birth, with most of the increase happening in the first two weeks. Many mothers find it becomes more difficult - in some cases impossible - to increase the amount of milk they are making, after the early weeks. This is why it is important to get good feeding support early, if there are any signs that there might be a problem with your baby getting enough milk, for example, if your baby:

Does not poo every day (in the first 4-6 weeks)

Has pink crystals (urates) in their nappy after the third day

Is not doing yellow poo by the end of the fourth day

Loses more than 7% of their birth weight by the fifth day

Loses weight after the fifth day

Does not regain their birth weight by 10-14 days

An LLL Leader or infant feeding specialist can help you work out whether there is likely to be a problem with milk production or whether (more commonly) your baby is not yet feeding effectively. If not enough milk is being removed, the risk is that your milk production will not increase to the level your baby needs. Expressing your milk gives you time to work on any feeding issues.

If the problem is with milk production, your breastfeeding supporter can help you make a plan to keep your baby safely fed while you work to maximise your milk supply. You will need to work closely with your baby's healthcare providers to monitor their growth and wellbeing.

Lactation beyond the early months

Parents are sometimes told that their milk has no value to their baby after 6 months, or 12 months. This is not the case. Milk is the baby's main source of protein and calories until about a year of age, and continues to contribute to the child's health and nutrition through the second year and beyond.

Your milk adapts to meet your baby's needs as they grow. For example:

From about six months, the digestive enzyme amylase starts to be present in milk, helping your baby digest starchy foods.

From about six months, levels of the antibacterial enzyme lysozyme increase in milk, protecting your baby as they put foods and other objects in their mouth.

As the total amount of milk begins to decrease gradually, from about six months, levels of key immune factors such as immunoglobulins increase, so that the child receives about the same amount per day, even though they take less milk.

Levels of fat, protein and energy in milk are higher in the second year than in the first year of lactation.

Lactation ends - involution

Milk will continue to be made in the breast for as long as milk is removed from the breast. In the early days of lactation, milk supply is relatively fragile - the mother's body quickly shuts down production if milk removal stops. In later lactation, milk production is much more robust. Mothers returning to work after six months, for example, can be confident that their milk supply will withstand variations in their schedule from day to day and week to week. In later lactation it is possible to breastfeed part-time, even if you work shifts or need to travel away overnight. Many breastfeeding toddlers and older children spend time away overnight with a non-resident parent, grandparents, etc. and continue breastfeeding when they are with their mother.

It takes at least 40 days for the breast to reach complete "involution" (a non-lactating state) after the end of breastfeeding or milk expression. Some mothers find that they leak or can express drops of milk months or even years after their last feed. If the amount of milk is large, or you start making milk again after a gap even though you are not pregnant, check with your doctor. Spontaneous milk secretion (galactorrhoea) can be a side effect of some medications, or a sign of hormonal dysfunction.

When children are able to wean from the breast at their own pace, weaning often takes place over a period of months and years. The most common time for children to choose to stop breastfeeding is between their second and third birthdays. Milk production reduces gradually and, by the time the child has their final feed, may have dwindled to almost nothing. Some of the immune components of milk become more concentrated as milk volumes decrease, so the child continues to benefit to the last drop of breastmilk.

Written by Jayne Joyce, LLL Oxfordshire and Karla Napier, LLL Edinburgh - February 2021
Endnotes:

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How milk production works - La Leche League GB

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Mothers have successfully fed their children for thousands of years of human history without understanding how it works. It's a bit like driving a car - as long as it's working well, you don't need to know what is going on under the bonnet! If you are having breastfeeding problems, such as low milk supply [...]

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Paced Bottle Feeding - Guide for Postnatal Professionals

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In this article the author refers to the 'magical hour' however babies can still do the breast crawl in the first few days and weeks after birth.

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Healthy Children Project 159 Long Pond Drive Harwich, MA 02645 Ph: 508.888.8044 Fax: 508.888.8050 The First Hour After Birth: A Baby's 9 Instinctive Stages The first hours after birth are a developmentally distinct time for a baby and there are well documented short and long term physical and psychological advantages when a baby is held skin to skin during this time.

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This video takes you through the first feed after birth.

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All our mums have different birth experiences. Find out why skin-to-skin contact is so important and about breastfeeding for the first time. "It's a great feeling to be able to provide for him without anything else, just me myself," Angela says. Melissa's partner Andy says breastfeeding is healthy, cheaper and much less effort than making up bottles.

The rest of the DVD can be viewed by clicking through the links below. While they work very well as stand-alone films, From Bump to Breastfeeding is best viewed as a whole:

From Bump to Breastfeeding

From Bump to Breastfeeding extra films

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3. Birth, skin-to-skin and the first feed

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All our mums have different birth experiences. Find out why skin-to-skin contact is so important and about breastfeeding for the first time. "It's a great feeling to be able to provide for him without anything else, just me myself," Angela says. Melissa’s partner Andy says breastfeeding is healthy, cheaper and much less effort than making up bottles.

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Some mums like to practise expressing before birth - also known as 'antenatal expressing/colostrum harvesting'. You can do this from 37 weeks of pregnancy. This video shows how to hand express.

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UNICEF explores the benefits of skin to skin

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UNICEF explores the benefits of skin to skin

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Whether mums have a vaginal or caesarean birth, are breastfeeding or feeding with formula, skin to skin should be offered straight after birth to support early breastfeeding and bonding with the baby.

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Skin-to-skin contact - Baby Friendly Initiative

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Skin-to-skin contact is important for babies and mothers to develop close, loving parent-infant relationships and to initiate breastfeeding.

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This podcast discusses the first 48 hours of breastfeeding

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This podcast discusses the first 48 hours of breastfeeding

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Breastfeeding: The First 48 Hours with Sally Wright, IBCLC

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Listen to this episode from Pregnancy & Birth Made Easy on Spotify. One of the first things on our minds as soon as we have our babies is feeding them. Those first few days can feel like a blur and if you're choosing to breastfeed you may be feeling overwhelmed by ALL of the things you need to learn seemingly overnight.

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A video overview of signs your baby is getting enough

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A video overview of signs your baby is getting enough

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This video from the lactation consultant Lucy Webber, takes you through all the signs a baby is getting enough.

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How do I know my baby is getting enough milk?

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There is a vast selection of bottles and teats available online or in the High Street. Many of them claim to be closer

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This support group for parents of twins and multiples was set up by the lactation consultant Kathryn Stagg.

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Breastfeeding when you have a disability

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Breastfeeding when you have a disability

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The Breastfeeding Network offers information on breastfeeding when you have a disability

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Information from La Leche League on breastfeeding a child who has a disability

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This guide from the Breastfeeding Network talks through expressing and storing breastmilk.

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This page gives you some tips on how to hand express and store your breastmilk. It also answers some frequently asked questions on this topic.

You might be thinking of returning to work, or study, or planning a night out. It can also help relieve pressure from a blocked duct or mastitis. Expressing small amounts of colostrum before your baby is born can help give your baby extra milk in the first few days.

Please also refer to our downloadable leaflet on Expressing and Storing Breastmilk.

If you will be exclusively expressing (feeding only expressed breastmilk), whether for just a few days or longer, you might like to read our blog post on this.

Note: If your baby has been ill or was born prematurely please discuss this information with your health professional to check that the storage times apply. This is especially important if you are bringing your colostrum or milk into hospital for your baby.

Your breastmilk

Can be expressed by hand, by hand pump or by electric pump. Once you know how, hand expressing is easy and needs little equipment.

Contains anti-infective ingredients that limit the growth of unwanted bacteria.

Should still be handled and stored carefully to stop unwanted bacteria from getting into your milk and growing.

Stays at the highest quality when stored in a fridge, particularly when running at 4°C or below. Note: some fridges run higher at 5-10°C - if you don't know the temperature of your fridge assume it is running at this higher temperature.

Can be frozen, which affects some (but by no means all) of the nutrients and anti-infective ingredients of breastmilk.

Expressing breastmilk

When you first start to express it is common to get only a few drops of milk. As with breastfeeding, the more you practice, the easier it gets. Expressing at a different time of day may work better for you.

When might I need to express?

Before your baby is born - you may be advised that your baby might need extra milk when they are born. You can express and store your first milk (colostrum) from 36 to 37 weeks gestation. You can read more about this here.

In the first few days - if your baby is sleepy, or to help them attach and feed.

For both these stages your midwife will give you small oral syringes to collect your milk. These are usually 1ml to begin with.

Use the ideas in this leaflet to discover what works for you. Colostrum usually starts in tiny droplets and is often sticky - having help to collect these drops in the syringe can be useful.

Aim to express twice a day from 36-37 weeks for no more than 10 minutes, freezing the same day.

Once your baby is born, express as needed aiming to stimulate your breasts at least 8 times a day including once overnight through direct breastfeeding or expressing as this will increase your milk supply to meet your baby's needs and can help you feel more comfortable.

Hand Expressing

Once your milk is flowing, you will need a wide mouthed container like a sterile plastic pot or container that is well-cleaned and scalded with boiling water - a jug is ideal - so get this ready before you start.

Remember to wash your hands first.

Find somewhere comfortable to relax, then to help your milk to flow (let down) you might:

Relax with a warm drink, music or TV.

Have your baby close, or look at a photograph, clothing or toy to remind you of your baby.

Warm your breasts in a bath, shower or using warm flannels and practice expressing.

Try some ways to gently massage your whole breast, working from the outside toward your nipple.

Take care not to drag your skin:

Stroke with your fingertips

Roll using your knuckles.

Try using circular movements.

Make a 'C' shape by placing your thumb above and your fingers below your breast 2-3 centimetres back from your nipple

Gently press your thumb and fingers together, release your fingers and repeat in a rhythmic movement.

Sometimes pressing inwards back towards your chest wall as you squeeze helps. You may need to experiment with how far back from your nipple to squeeze - everyone is slightly different.

When the milk flow slows, re-position your fingers and thumb (as if moving them around a clock face), then express another area of your breast.

Try to express all areas of your breast and alternate between breasts.

See this video on hand expressing from UNICEF for more ideas.

Good hygiene is very important:

Always wash your hands before expressing and handling breastmilk and ask others giving expressed milk to do the same.

Always use a sterile container with a lid, not the collection jug, to store your breastmilk. You can buy disposable containers. Take care with plastic bags that can puncture easily.

Try to use a different storage container each time you collect milk. If necessary, newly collected milk may be cooled and added to previously stored milk on the same day only.

Label the storage containers or syringes with your name, breastmilk, time and date and put inside a clean sealed bag or box before storing. Name and date the bag too.

Store your breastmilk in the fridge or freezer as soon as possible.

Store away from meat products, eggs or any uncooked foods. Store at the back of the fridge and not in the door.

Storing expressed breastmilk

How long can I keep my breastmilk at room temperature if a fridge is not available?

If your breastmilk is freshly expressed it will keep for 6 hours without refrigeration, either at home or away from home. See 'travelling with breastmilk' section below for more details.
If your baby has been ill or was born prematurely please discuss this with your health professional to check that the same storage times apply.
How long can I store breastmilk in the fridge?

You can store your breastmilk for up to 3 days where you don't know the temperature, or it runs between 5-10°C.

Breastmilk can be stored for 5 days in a fridge running at 4°C or lower.*
*One study has shown fresh breastmilk can be used for up to 8 days when the fridge temperature is kept stable at 4°C or below.

If the fridge temperature goes above 4°C during this time, use your milk within 6 hours or throw away.

If you can't use a fridge at 4°C, try using a cool bag or box with deep frozen ice packs (changed every 24 hours). Protect your milk from direct contact with the ice packs or it may freeze - try wrapping the ice packs in kitchen towel. The bag can also be used to carry milk.

The lower the storage temperature, the longer expressed breastmilk can be stored. The storage temperatures given here include a degree of caution so that your milk remains safe for your baby.

If you wish to store your breastmilk for longer than 5 days, freeze as soon as you can after expressing.
If taking colostrum or milk into hospital follow their storage and transport times. REMEMBER: The more often the fridge door is opened, the more likely the temperature will rise. Try to check the temperature of every fridge (or cool bag) used for storing your milk each time you use it. If the fridge has no built in thermometer, use a fridge thermometer which can be bought cheaply from kitchenware stores.
How long can I store breastmilk in the freezer?

Breastmilk can be stored in a freezer at -18°C for up to six months.

You can store breastmilk in the ice compartment of a fridge for two weeks.

Safe Storage of breastmilk in the home

This table aims to provide a guide to how long you can store breastmilk for a full term baby with no additional health concerns.

Why are there variations in recommendations for storing expressed breastmilk?

More information about this can be found at the bottom of this page.

Please note that previous versions of our leaflet are still available in our shop and the information is still correct, noting the above.

Feeding baby expressed breastmilk

What happens if my baby doesn't take all of one bottle? Can I put it back in the fridge or on the side use it again?

Once the baby has drunk from a bottle of expressed milk it should be used up within an hour or thrown away. To avoid wasting your expressed breastmilk it is best to offer the baby only a little (e.g. 30ml) at a time until you know your baby's pattern. You can do this by keeping most of it in one container, in the fridge, and using it to top up the baby's bottle a little at a time.

Defrosting frozen breastmilk

How do I defrost my milk?

Ideally, defrost frozen breastmilk in the fridge. This milk should be used once fully defrosted which usually takes about 12 hours. If your breastmilk is still frozen after this time or you need to use it quickly, try defrosting under cool, then warm, running water. Dry the outside of the container with kitchen paper before use and use immediately. If you frequently find your milk is frozen after 12 hours in the fridge, try to freeze in smaller quantities.

How long can I keep defrosted breastmilk?

Defrosted breastmilk should be used straight away once it has fully defrosted. Throw away any unused milk.

Why can't I defrost breastmilk in a microwave?

Breastmilk should not be defrosted in the microwave because it heats unevenly, destroying antibodies and nutrients. There is also a risk of scalds and the milk would need to be left at room temperature before use.

Travelling with expressed breastmilk

How do I bring my milk home, which I have expressed at work or elsewhere?

Try to use a cool bag for transportation and put the milk in the fridge once you are home.

Fresh breastmilk can be transported within 24 hours provided storage temperatures are maintained using an insulated box or bag and deep frozen ice-packs, and total storage and transportation times do not exceed the recommended storage times.

Previously refrigerated breastmilk can be kept cool (10°C or below) for up to 24 hours when in a well-insulated bag with deep-frozen ice-packs. Take care not to freeze your milk by wrapping the ice-packs in kitchen paper first. Ensure this milk is used within the recommended refrigeration storage times as mentioned above.

Re-heating expressed breastmilk

How do I re-heat expressed breastmilk?

Expressed breastmilk can be used straight from the fridge. It does not need to be warmed. If you would like it warmed place the container (such as a bottle or sealed cup) in warm water to take the chill off. Take care not to over warm.

If the milk smells sour DO NOT USE.

When stored, the cream and milk may separate out. This is normal. Shake gently to mix before use.

Some babies are reluctant to take milk from a bottle, particularly at first. Try offering milk from a cup or spoon. They may be less reluctant when someone else gives it. If expressed milk is refused try not to worry - your baby will make up any missed feeds by breastfeeding more often or for longer on your return. See also info on this page about introducing a bottle.

Finding a breast pump

The two UK breast pump hire companies are:
Ardo breast pumps Medela breast pumps
Your midwife, health visitor or a local breastfeeding supporter may also be able to give you details of pump hire services near you.

Useful links
Human Milk Foundation
UKAMB (UK Milk Banks - find out about donating or receiving milk)
Milk Bank Scotland
Antenatal Expressing - more detailed information about this

References

(links checked May 2023)

Cook, P. Food Standards Agency. MCN10. 2006 Handling and storage of expressed breastmilk pp1-12 https://www.nice.org.uk/guidance/ph11/documents/mcn-consultation-expert-report-handling-and-storage-of-expressed-breast-milk2

Eglash, A, Simon, L, and The Academy of Breastfeeding Medicine, ABM Clinical Protocol #8: Human Milk Storage Information for Home Use for Full-Term Infants, BREASTFEEDING MEDICINE Volume 12, Number 7, 2017 (c) Mary Ann Liebert, Inc. pp390-395 https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/8-human-milk-storage-protocol-english.pdf See correction to freezer temp here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6065517/

Forster, Della A et al. (2017) Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]): a multicentre, unblinded, randomised controlled trial. The Lancet, Volume 389, Issue 10085, 2204 - 2213 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31373-9/ppt

Hands A. (2003) Safe storage of expressed breastmilk in the home. MIDIRS Midwifery Digest, vol 13, no 3.

Royle, J. Weaver, G. (2016) Guidelines for the Preparation and Handling of Expressed and Donor Breast Milk and Special Feeds for Infants and Children in Neonatal and Paediatric Health Care Settings. 2nd Ed. Section 6, p18-32
BDA Guidelines for the Preparation and Handling of Expressed and Donor Breast Milk and Specialist Feeds for Infants and Children in Neonatal and Paediatric Health Care Settings
IMPORTANT: If you have any further questions on expressing or breastfeeding, do contact your midwife, health visitor or breastfeeding supporter for help and support. You can also call the National Breastfeeding Helpline on 0300 100 0212, open 9.30am-9.30pm every day of the year.

Page reviewed and updated November 2019

Variations in Recommendations for Storing Expressed Breast Milk

Written by Anabel Hands

In 2003, aware of the confusion for mothers resulting from the significant variations in recommendations for storing expressed breast milk, the BfN decided to collate all available information from primary research papers, and national and local guidance documents. These findings were published in the MIDIRS Midwifery Digest 1. The study found that storage temperature clearly determines storage time. Recommended storage times given in our Expressing and Storing Breast Milk leaflet were based on the primary research papers discussed in the study. You can find the link to this leaflet below for more information 2.

Our publication was sent to other breastfeeding organisations, including the Department of Health (DH), to facilitate agreement on storage recommendations using the results of primary research. The DH asked the National Institute of Clinical Excellence (NICE) to review breast milk storage guidelines, and official storage recommendations were changed from 24 hours in the fridge to up to 5 days at 4°C or lower, two weeks in the ice compartment of a fridge and up to six months in a freezer (March 2008) 3.NICE also recognised that refrigeration preserves the unique properties of breast milk more effectively than freezing. The National Health Service (NHS) adopted these guidelines, which appear in their leaflet Off to the best start (updated November 2009) which you can find a link to below 4.

Although a little different to BfN guidelines, the NICE and NHS recommendations took into account that fridge temperatures can vary and that a 5-day storage time covered most situations, including the need for milk expressed at the end of one working week to be used at the beginning of the following week. Some busy hospital neonatal units restrict the time milk is refrigerated as an added precaution; this is because their fridges are opened very frequently, which may affect the storage temperatures 5.

Other breastfeeding organisations, such as La Leche League, updated their published recommendations to distinguish between acceptable storage (8 days in the fridge) from ideal storage (72 hours in the fridge), and also recognised that refrigerated expressed breast milk was preferable to frozen breast milk (March 2012) see link below for more information. These recommendations are in line with the BfN leaflet 6.

It is important for mothers and breastfeeding supporters to note that leaflets and recommendations inconsistent with the published research are still in circulation, particularly on the Internet, and that countries outside of the UK may recommend different guidelines.

Please note that previous versions of our leaflet are still available in our shop and the information is still correct, noting the above.

References

1. HANDS A. Safe storage of expressed breast milk in the home. MIDIRS Midwifery Digest, vol 13, no 3, Sep 2003, pp 378 & 385.

2. BfN (Breastfeeding Network) leaflet. Expressing and storing breast milk. September 2004.

3. National Institute for Health and Clinical Excellence (NICE) Public health guidance 11: Maternal and child nutrition. March 2008.

4. Department of Health. Off to the best start. Crown Copyright 2007 278957 5p 200k Nov 09 (BEL) 299223.

5. MCN consultation: Expert report & Handling and storage of expressed breast milk. 05 April 2007.

6. La Leche League International. "The Breastfeeding Answer Book" Updated March 2012.

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Expressing and storing breastmilk - The Breastfeeding Network

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This page gives you some tips on how to hand express and store your breastmilk. It also answers some frequently asked questions on this topic. You might be thinking of returning to work, or study, or planning a night out. It can also help relieve pressure from a blocked duct or mastitis.

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An expressing bra hack using a nursing bra

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An expressing bra hack using a nursing bra

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Did you know every nursing bra and tank top converts into a hands free pumping bra?!

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LGBTQ breast and chest feeding/body feeding parents

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LGBTQ breast and chest feeding/body feeding parents

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La Leche League is an international, nonprofit, nonsectarian organisation. 1 LLLGB supports everyone who wants to breastfeed or chestfeed in reaching their goals. We do not discriminate based on sex, gender or gender identity.

Trans men, trans women and non-binary individuals may choose to breastfeed or chestfeed their babies. You do not need to have given birth to breastfeed or chestfeed, as we can also see in the experiences of those nursing adopted babies.

Transgender dad Trevor MacDonald writes that, "It is equally important to note that some trans people experience severe gender dysphoria when breast or chestfeeding, and that they may decide not to nurse their babies for mental health reasons. Trans parents choosing to breast or chestfeed and those choosing to suppress lactation and bottlefeed may require the support of breastfeeding counsellors or lactation professionals." ²

Amazing milk

One of the concepts La Leche League is founded on is that: human milk is the natural food for babies, uniquely meeting their changing needs. Human milk is amazing. It has everything a growing baby needs in exactly the right amounts and babies can easily digest it all. Research shows that a baby who is not fed on human milk is more likely to suffer from illnesses and diseases, both as a child and later in life. By meeting your baby's needs for warmth, food and security at your chest you give them a secure attachment so they can develop into a conﬁdent child.

Skin-to-skin

Skin-to-skin contact is beneficial for babies and parents; it simply means holding your naked baby on your bare chest. You can drape a blanket over you both for warmth. Within minutes, you will see the benefits of skin-to-skin as you and your baby relax. Your baby's body temperature, breathing, and heart rate will stabilise. Babies often latch on and nurse more efficiently during and after skin-to-skin contact.
It is a lovely way to nurture your baby even if you are not nursing.

Your milk supply

Some transgender and non-binary parents have a full milk supply. If you have had chest (top) surgery you may be able to produce some milk. Many factors will affect the amount of milk you can make.

Two reasons that a trans man might have a reduced milk supply are:
1. Milk-making tissue has been surgically removed, and/or ducts have been damaged in surgery.
2. Testosterone interferes with the hormone necessary for lactation (prolactin) and can cause a significant decrease in milk supply. However, taking testosterone would not prevent someone from using an at-chest supplementer and having a nursing relationship.

Trans women can use a protocol similar to adoptive and other non-gestational mothers and stimulate their milk supply: it is called the Newman-Goldfarb protocol. You can read more here https://www.laleche.org.uk/relactation-induced-lactation/ and here http://www.asklenore.info/breastfeeding/induced_lactation/protocols4print.shtml.

You can also give human milk or formula supplements using an at-breast supplementer. Your healthcare provider can help you look at your options, and your local LLL Leader can offer support with your breast or chestfeeding goals and journey.

You may find the following websites have useful information:
Breastfeeding After Breast and Nipple Surgery http://bfar.org/index.shtml?fref=gc
Low Milk Supply http://www.lowmilksupply.org/

Many parents worry about whether their baby is 'getting enough'. LLL meetings are a good place to get support from others. These LLL posts are great for checking signs your baby is feeding effectively:
https://www.laleche.org.uk/is-my-baby-getting-enough-milk/
https://www.laleche.org.uk/signs-effective-feeding-early-days-2/

Using a nursing supplementer

If your baby needs a supplement of expressed milk or formula you might want to consider using a nursing supplementer. Doing this can give your baby that extra milk while they are nursing.
Supplementers can help parents have an at-breast or at-chest relationship with their baby whether or not they are able to produce milk.

This post has lots of useful information about nursing supplementers: https://www.laleche.org.uk/nursing-supplementers/.

Milk sharing

Some transgender and non-binary parents use milk banks to acquire human milk for their babies. La Leche League fully supports the use of human milk for babies; we cannot facilitate or set up milk sharing networks, though your local LLL Leader can help you with contact information for non-profit human milk banks, other regulated collection centres, and formal/medically supervised or informal milk sharing networks. 3 Human milk banks provide pasteurised, screened donor milk.

There are documented benefits and risks to informal milk sharing. Benefits of human milk include, but are not limited to:

optimal nutrition

easy digestibility

immunological protection

Risks of sharing milk can include, but are not limited to:

transmission of certain infectious agents, like bacteria or viruses, some of which may be found in milk expressed by asymptomatic people

medicines and other drugs

environmental contaminants as a result of unhygienic storage and handling of unprocessed donated milk

Human Milk for Human Babies (HM4HB) is an "informed milk sharing network", and is an international organisation that many parents use to source human milk: https://www.facebook.com/HM4HBUK/

LLL Support

All parents need support and La Leche League is a great place to find it. There are over 70 LLL groups across Great Britain, most offer meetings open to all - contact your local group to find out how they can support you. Many groups also have closed Facebook groups where you can ask questions and connect with other nursing parents.

LLL meetings are held in a wide range of venues - LLLGB is not affiliated to, and does not endorse or support, any business, organisation or religion whose premises we use. https://www.laleche.org.uk/find-lll-support-group/?fref=gc

LLLGB also offers these services:
National Helpline: 0345 120 2918 https://www.laleche.org.uk/telephone-helpline/
Online Helpform support: https://www.laleche.org.uk/submit-help-request/
Contact us for non judgmental information and support.

Find more LLLGB support listed here:
https://www.laleche.org.uk/get-support/?fref=gc<

Other support

International Facebook group for 'birthing and breast or chestfeeding trans people and allies': https://www.facebook.com/groups/TransReproductiveSupport/?fref=gc&hc_location=ufi

La Leche League - Inducing lactation and relactation Facebook group

Resources

Where's the Mother? Stories from a Transgender Dad. Trevor MacDonald: Trans Canada Press, 2016

LLL article: Support for Transgender and Non-binary parents

Defining Your Own Success: Breastfeeding After Breast Reduction Surgery. Diana West: LLLI, 2001:
https://www.bfar.org/book.shtml

My Journey: Non-binary Nursing - from LLLUS
https://lllusa.org/my-journey-non-binary-nursing/

Trans breastfeeding FAQ:
http://dianawest.com/trans-breastfeeding-faq/?fref=gc

US based website Kellymom's post:
http://kellymom.com/bf/got-milk/transgender-parents-chestbreastfeeding/?fref=gc

Transmasculine individuals' experiences with lactation, chestfeeding, and gender identity: a qualitative study:
https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-016-0907-y?fref=gc

Transgender/transsexual/genderfluid Tip Sheet - General Information, LLL Canada
https://www.lllc.ca/sites/default/files/REVISED-Trans-Nursing_Tip-Sheet.pdf

Breastfeeding without giving birth, LLLI article by Aylssa Schnell
https://www.llli.org/breastfeeding-without-giving-birth-2

Language

We are aware that transgender and non-binary individuals use a variety of different terms to describe their anatomy and the acts of feeding and nurturing their babies. We have used the terms "chestfeeding" and "nursing", with the second of these capturing the nurturing relationship associated with this way of feeding a baby.

Elsewhere on the site we use 'breastfeeding', 'breastmilk' and 'mother': they reflect the founding and unchanged mission of LLLI to provide mother-to-mother support for breastfeeding. They also reflect the stated identity and valued role of the majority of people whom we support and provide information to - those who identify as breastfeeding mothers.

Whatever language you use we hope that much of the information we share is still helpful and relevant.

References
1 La Leche League International Bylaws, Section 1: General Purpose
2 http://kellymom.com/bf/got-milk/transgender-parents-chestbreastfeeding/?fref=gc
3 http://leadertoday.breastfeedingtoday-llli.org/milk-donation-policy/

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Support for Transgender & Non-binary Parents - La Leche League GB

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La Leche League is an international, nonprofit, nonsectarian organisation.1 LLLGB supports everyone who wants to breastfeed or chestfeed in reaching their goals. We do not discriminate based on sex, gender or gender identity. Trans men, trans women and non-binary individuals may choose to breastfeed or chestfeed their babies.

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An overview of why babies feed frequently and when to feed them, including the cues to look for.

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When should I feed my baby?

As a rough guide, babies need to feed at least eight to 12 times (sometimes more) over 24 hours during the first few weeks (NHS, 2019a; UNICEF, 2010). That means they'll probably need to feed every two to three hours.

Watch our video for tips on how often and how long to breastfeed your baby for.

It's best to feed babies responsively or in a baby-led way rather than sticking to a feeding schedule (WHO, 2009; Entwistle, 2013; Fallon et al, 2016). Letting your baby feed when they want will help them get the milk they need. It will also stimulate your milk supply (Infant and Young Child Feeding, 2009).

What if I'm struggling or worried about the number of feeds?

We know from the experiences of new mums that breastfeeding responsively can feel emotionally and physically challenging (Fallon et al, 2016).

A baby that breastfeeds frequently can give parents a sense of reassurance but it can also cause worry. Some people may think frequent feeding is a sign of insufficient milk, or that baby isn't getting enough breastmilk during feeds. This sometimes leads to women supplementing feeds with formula milk or deciding to stop breastfeeding (Leurer, 2015).

Try and keep in mind that a newborn baby's stomach is really small. They need to feed little and often (NHS, 2020). It's really common for babies to have a good feed and then appear to be hungry again quite quickly. This doesn't mean something is wrong or that they're not getting enough milk. It's just the way newborn babies feed (Kent et al, 2012).

All of this also means that newborn feeding is frequent. In fact, much of the time, it's not really a question of clearly-defined 'feeds' with clear beginnings and endings (WHO 1998).

Your baby knows your voice, your smell and your taste but they are much less familiar with the 'world' outside your womb. Staying close to you gives them a vital sense of safety and reassurance. This builds their confidence that they are loved and cared for (Crenshaw, 2007).

If you're worried, it can really help to talk through your concerns with a breastfeeding counsellor. So call our Infant Feeding Support line on 0300 330 0700.

Will I produce enough milk?

The more you breastfeed your baby, the more milk you will produce (Daly & Hartmann, 1995). If your baby is attached properly, and you're both comfortable and feeding them when they ask for it, you will make enough milk for them (Kent et al, 2012; WHO 2019).

How do I know when to feed my baby?

When your baby is hungry they may give you little signals, known as early feeding cues (NHS, 2019a,b). They might:

* get restless

* suck their fist or fingers

* make murmuring sounds

* turn their head and open their mouth (rooting).

Looking out for and responding to these cues is important. It can help prevent your baby from becoming upset and frustrated, which will make it more difficult to feed them (WHO, 2009). Here's what you might see...

How long should each feed last?

Every baby is different and they will go through different patterns of feeding as they grow (Kent et al, 2012). How much milk a baby needs per breastfeeding session will vary. It's best to be guided by your child (Kent et al, 2012).

Some feeds will seem to last a long time, with your baby dozing for short periods before wanting more. And more. And still more! It's normal for a young baby to be on the breast many times a day and night. 12-15 'visits' to the breast is well within a normal range (Entwistle, 2013).

As a general rule, babies who are feeding well will feed for between five and 40 minutes at each feed (UNICEF, 2010). Your baby will let you know when they've had enough milk. They will usually come off the breast themselves, look sleepy or calm, and look around (UNICEF, 2010).

During each breastfeed, your milk changes slightly. So the milk at the end of the feed is more creamy and filling than the milk at the beginning of the feed (Ballard and Morrow, 2013). Offer one breast and let your baby feed until they stop drinking. If they still appear hungry, offer the second breast - allowing them to drink as much as they want (NICE, 2015).

Should I wake my baby up to feed?

In most cases, healthy, thriving newborns will wake up for feeds and, provided they are well latched on, get all the milk they need (Australian Breastfeeding Association, 2017). But there might be reasons why a newborn might be more sleepy and therefore need to be woken up for feeds.

This includes medical reasons, such as jaundice, infection or a heart problem, or perhaps because the pain relief used during birth is still affecting them (Australian Breastfeeding Association, 2017). If you're worried your baby might be sleeping too much and this is affecting their feeding, talk to your health visitor or call our Infant Feeding Support line on 0300 330 0700.
This page was last reviewed in March 2021
Further information

We support all parents, however they feed their child. If you have questions, concerns or need support, you can speak to a breastfeeding counsellor by calling our helpline on 0300 330 0700, whether you are exclusively breastfeeding or using formula milk. Breastfeeding counsellors have had extensive training, will listen without judging or criticising and will offer relevant information and suggestions. You can also find more useful articles here.

National Breastfeeding Line (government funded): 0300 100 0212.

Australian Breastfeeding Association. (2017) Do I need to wake my baby for feeds? Available at: https://www.breastfeeding.asn.au/bfinfo/do-i-need-wake-my-baby-feeds [Accessed 20 March 2021].

Ballard O, Morrow AL. (2013) Human milk composition: nutrients and bioactive factors. Pediatric Clinics of North America. 60(1):49-74. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3586783/ [Accessed 20 March 2021].

Crenshaw J. Care practice #6: No separation of mother and baby, with unlimited opportunities for breastfeeding. Journal of Perinatal Education2007;16(3):39-43. Available at: doi:  10.1624/105812407X217147 (Accessed 26 Apr 21)

Daly SEJ, Hartmann PE (1995). Infant Demand and Milk Supply. Part 1: Infant Demand and Milk Production in Lactating Women. Journal of Human Lactation. 11(1):21-26. doi:10.1177/089033449501100119 Available at https://journals.sagepub.com/doi/10.1177/089033449501100119 [Accessed 13 April 2021]

Entwistle FM. (2013) The evidence and rationale for the UNICEF UK Baby Friendly Initiative standards. UNICEF UK. Available at: https://www.unicef.org.uk/babyfriendly/about/evidence-and-rationale-for-the-baby-friendly-standards/ [Accessed 20 March 2021].

Fallon A, Van der Putten D, Dring C, Moylett EH, Fealy G, Devane D. (2016) Baby-led compared with scheduled (or mixed) breastfeeding for successful breastfeeding. Cochrane Database of Systematic Reviews. (9):CD009067. Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009067.pub3/full [Accessed 20 March 2021].

Kent JC, Prime DK, Garbin CP. (2012) Principles for maintaining or increasing breast milk production. Journal of Obstetric, Gynecologic, and Neonatal Nursing. 41(1):114-121. Available at: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1552-6909.2011.01313.x [Accessed 20 March 2021].

Leurer MD, Misskey E. (2015) "Be positive as well as realistic": a qualitative description analysis of information gaps experienced by breastfeeding mothers. International Breastfeeding Journal. 10(10):2-11. Available at: https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-015-0036-7 [Accessed 20th March 2021].

NHS. (2019a) Breastfeeding: the first few days. Available at: http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/breastfeeding-first-days.aspx#building [Accessed 20 March 2021].

NHS. (2019b) Breastfeeding: is my baby getting enough milk? Available at: http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/breastfeeding-is-baby-getting-enough-milk.aspx [Accessed 20 March 2021].

NHS. (2020) Your breastfeeding questions answered. Available at: http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/your-breastfeeding-questions.aspx [Accessed 20 March 2021].

NICE (2015) Postnatal care up to 8 weeks after birth. CG37. Available at: https://www.nice.org.uk/guidance/cg37 [Accessed 20 March 2021].

UNICEF. (2010) Baby Friendly Initiative. Breastfeeding checklist for mothers - How can I tell that breastfeeding is going well? Available at: https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2016/10/mothers_breastfeeding_checklist.pdf [Accessed 20 March 2021].

World Health Organization. (1998) Evidence for the Ten Steps to Successful Breastfeeding. Geneva: World Health Organization.

World Health Organization. (2009) Session 2 The physiological basis of breastfeeding. In: Infant and Young Child Feeding. Model Chapter for Textbooks for Medical Students and Allied Health Professionals. Available at: https://www.ncbi.nlm.nih.gov/books/NBK148970/ [Accessed 20th March 2021].
Further reading
Hoddinott P, Craig, LCA, Britten J, McInnes RJ. (2012) A serial qualitative interview study of infant feeding experiences: idealism meets realism. BMJ Open 2:1-14. Available at: https://bmjopen.bmj.com/content/2/2/e000504 [Accessed 20 March 2021].

Martin CR, Ling PR, Blackburn GL. (2016) Review of infant feeding: key features of breast milk and infant formula. Nutrients, 8(5):279. Available at:   https://www.mdpi.com/2072-6643/8/5/279 [Accessed 20th March 2021].

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How often should I breastfeed my baby? | Baby & toddler, Feeding articles & support | NCT

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Read our tips on when to breastfeed your baby and how much milk they need.

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NCT explains what it means to combination feed 

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NCT explains what it means to combination feed 

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When it comes to feeding their baby, some parents decide to exclusively breastfeed and some to exclusively formula feed. Many families decide to combine breastfeeding and formula feeding; this often called combination feeding or mixed feeding (NHS, 2019).

What is mixed feeding?

Mixed feeding usually means mixing breast and bottle feeding. The content of the bottle can be either breastmilk or formula milk.

Watch our video to find out more about mixed/combination feeding.

Why do some families combination feed?

You might start mixed feeding for a variety of reasons.

If you and your baby have some difficulties getting breastfeeding established or if there are concerns about your baby's weight, you might be advised to give some formula feeds alongside breastfeeding.

You might need to leave your baby for periods of time (for example, if you are returning to work).

Your partner might want to be involved with feeding.

You might be bottle feeding and want to start or resume breastfeeding.

It can be helpful to talk to a breastfeeding counsellor, a midwife or health visitor about your options and the potential impact on breastfeeding of mixed feeding (see below). You could also call our infant feeding line on 0300 330 0700.

How do I combine bottle feeding and breastfeeding?

Some families choose to express milk and feed it to their babies through a bottle. They might do this if someone else would like to feed the baby or if the mum has to be away from their baby for a while.

Others choose to substitute some breastfeeds for formula. If you want to do this, you and your baby will adjust more easily if you reduce the number of feeds gradually (NHS, 2019).

You can offer formula feeds before, during, after or instead of a breastfeed. Talk to your midwife, health visitor or a breastfeeding counsellor about this, as different options will suit different circumstances. And will also depend on what you wish to achieve ultimately.

There are some cases when formula might be given before a breastfeed (for example, with babies who are not breastfeeding well). In other cases, the formula feed might be given instead of a breastfeed. This might happen if you're not with your baby and can't breastfeed or if someone else is sharing the feeding.

Gradually cutting down breastfeeding reduces the chance of your breasts becoming uncomfortably engorged. It will also reduce your risk of developing mastitis (NHS, 2019). It helps to reduce the number of breastfeeds slowly, starting with the one which is convenient for you (NHS, 2020). If you substitute a breastfeed with a formula feed, it may take around five to seven days for the amount of milk your breasts are producing to adjust to missing that one feed (NHS, 2017).

If you 'top up' with formula during one or more feeds, rather than replacing an entire feed, this is likely to extend the gap between breastfeeds. It will also signal to your breasts to make less milk (NHS, 2020).

On the other hand, if you've been advised to 'top up' as a temporary measure and want to return to exclusive breastfeeding, it is important to express milk between feeds to prevent a decrease in the amount of milk you make (NICE, 2017). Try and feed your baby any available breastmilk before each formula feed.

What effect will combining breastfeeding and formula feeding have?

Your baby will enjoy the benefits of breastmilk, even if you're not exclusively breastfeeding. For instance, they will still gain some of the antibodies that will protect them against infection (NHS, 2019).

If you want to feed your baby with both breastmilk and formula milk, it is recommended to wait until feeding is firmly established before introducing a bottle (NHS, 2019). This can take up to a month (La Leche League, 2019).

It's best to wait until breastfeeding is established because breastmilk supply is generally driven by frequent, effective removal of milk from the breasts. Giving your baby formula reduces your milk supply, which is particularly important when you are both getting used to breastfeeding. If your baby breastfeeds less often, your breasts produce less milk (Daly and Hartmann, 1995).

You might have heard that babies can get 'nipple confusion' but there is no evidence that this exists (Kotowski et al, 2020).

How many breastfeeds does an older combination-fed baby need?

Older babies, beyond the newborn stage, can maintain your breastmilk supply alongside formula feeding as long as you breastfeed several times a day. Much older babies - from eight or nine months - can breastfeed just a handful of times a day, and there is still a supply.

Very well-established breastfeeding, with a baby who is one year or older, can continue with as few as one or two feeds in 24 hours.

If your baby is over six months they can use a beaker or cup rather than a bottle (NHS, 2020).

Tips to introduce a bottle to a breastfed baby

You might find your baby does not want to take a bottle at first. The different sensations may confuse them and they don't know the bottle contains food. But there are lots of different things you can try to help your baby:

Offer a bottle when your baby is relaxed and happy, rather than very hungry.

Maybe ask someone else to offer a bottle so they can't smell their mother's milk.

Try softening the teat with warm, boiled water.

Hold your baby in a different position from their usual breastfeeding one. It might help your baby get used to the new way of feeding.

Try a different bottle or teat, this might make a difference.

(La Leche League, 2019)

Unicef (2016) recommend feeding responsively, which means following your baby's cues, whether breastfeeding or bottle feeding. They also recommend using paced bottle feeding. The way a baby is fed with the bottle can affect their comfort, their control of the amount of milk they drink, and the transition between breast and bottle (Kotowski et al, 2020).

Tips for paced bottle feeding

Hold your baby upright, close to your body. (If your baby is lying back, they are less able to control how much milk they swallow, so they can overfeed.)

Touch the teat against the baby's top lip to encourage them to pull it into their mouth.

Hold the bottle horizontal, so that when the baby is actively sucking, they get milk and when the baby is pausing, they don't get milk.

Give the baby several breaks by removing the bottle from their mouth.

Watch what the baby is doing, rather than how much milk they have drunk. End the feed when the baby is no longer drinking.

(UNICEF, 2016; La Leche League, 2019)

This all helps to build a close, loving relationship, a responsive feeding relationship, and avoids overfeeding your baby.

Where can I go for breastfeeding support?

If you have questions, concerns or need support, you can speak to one of our breastfeeding counsellors by calling our infant feeding line on 0300 330 0700, whether you are exclusively breastfeeding or using formula milk. Breastfeeding counsellors have had extensive training, will listen without judging or criticising and will offer relevant information and suggestions.

Further information

Healthtalkonline.org has a comprehensive library of face-to-face interviews where parents share their experiences about breastfeeding, birth, parenting and many other issues.

Best Beginnings has video clips from the 'Bump to Breastfeeding' DVD.

UNICEF have produced a summary guide for parents on how to responsively bottle feed babies.

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Mixed feeding: combining breastfeeding and bottle feeding | Baby & toddler, Feeding articles & support | NCT

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Here we look at mixed feeding your baby, which is combining breastfeeding and bottle feeding

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Partners can make a huge difference to breastfeeding. The NCT explains how.

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When it comes to breastfeeding, you might wonder what you can do to support your partner and baby. The truth is you can make a huge difference.

Did you know that a mum is more likely to choose to breastfeed if she's sure her partner is positive about it? And if she does decide to breastfeed, she's much more likely to have a good experience and manage any difficulties if her partner supports her decision (Tohotoa, 2009; Rempel, 2011). A partner's emotional support is so important for helping mums to breastfeed for longer too (Tohatoa et al, 2009; Su, 2016).

Why is breastfeeding important?

If your partner is breastfeeding your baby - or planning to - that's fantastic because breastmilk has so many benefits for babies. For instance, breastmilk can help to reduce the risk of your baby getting infections and diseases (NHS, 2017). It also contains hormones that help your baby's development (Victora et al, 2016).

Overall, breastfeeding will have a positive impact on your baby's health. What's more, it can influence their health as an adult too (Victora et al, 2016).

Is breastfeeding hard or will my partner just know what to do?

Many parents see breastfeeding as a natural process but it can take time for mum and baby to learn this new skill together. It might take around six weeks to get the hang of it fully (NHS, 2016).

The good news is that with the right support, your partner can overcome any challenges and continue breastfeeding if she wants to. If you think your partner needs more information, support or just someone to talk to, why not give one of our trained breastfeeding counsellors a call on our support line: 0300 330 0700. The line is open every day from 8am to midnight, including bank holidays.

You might find it helpful to read up about breastfeeding and attend a breastfeeding session before your baby is born. This can help you know what to expect and perhaps give you a little more confidence. It can also help you both talk about feeding your baby and raise any questions or worries you might have.

What do I need to know about breastfeeding?

You might find it helpful to know how breastfeeding works and what normal behaviour is for breastfed babies. Here are a few quick and handy facts:

Babies are happier if they're fed as soon as they show signs of being hungry.

Babies usually feed frequently (anything from eight to 12 times or more in 24 hours) in the early weeks, especially during the evenings.

Some babies are slow feeders at first, but they get quicker as they get older.

The more a baby feeds, the more milk their mum makes because it's the removal of milk that drives the production of it.

The Department of Health recommends exclusive breastfeeding for at least your baby's first six months. Breastfeeding is also beneficial for toddlers because it gives them a health boost every time they feed. So your partner can breastfeed your baby for as long as they both want to.

Nipple soreness or pain during feeding might be a sign that a baby needs some adjustment to their attachment at the breast. If there is soreness or pain when breastfeeding, talking to a healthcare professional or breastfeeding counsellor can help.

Women enjoy feeding more when they are comfortable and relaxed.

(Department of Health, 2011; La Leche League, 2016; NHS, 2016)

What can I do to help support my partner with breastfeeding?

There are lots of things you can do to support and encourage breastfeeding.

Here are 10 tips:

1. Boost your partner's confidence by encouraging her and being positive about her progress. As with learning any new skill, reassurance and praise are a massive help.

2. Listen and talk honestly about how you each feel about finding your way with your new baby.

3. Be involved with your baby in other ways so that the caring is shared (see below).

4. Help to reduce the household chores so your partner can feed your baby for as long and as often as they need.

5. Try to help your partner to relax by giving them a massage.

6. Women don't need to eat anything special while breastfeeding, but it's a good idea to encourage your partner to eat and drink regularly.

7. Help her get specialist support if she's struggling with breastfeeding. As mentioned above, you can both talk to one of our breastfeeding counsellors on 0300 330 0700.

8. Help out by bottle feeding your baby expressed milk once your partner and baby have got the hang of breastfeeding (see below).

9. Accept your partner's decision on when to stop breastfeeding.

10. Try to remember that with your support, breastfeeding can quickly become just another part of your family life.

(Rempel et al, 2010)

What practical support can I give to my baby if my partner is breastfeeding?

You might expect to feel like a bit of a spare part with feeding but it's good to remember that each parent plays a different and vital role. The decision on how you feed your baby is certainly a joint one (deMontigny et al, 2018). It might take a while to get used to the different parts you play though.

Whatever you decide to do, you might actually find feeding is less important to you than you expected anyway. Especially if you're hands-on with your baby in different and rewarding ways.

Tips for being a hands-on partner with your baby

Changing nappies and generally caring for your baby - it's great if you can spend time with your baby and interact (see below) with them while you're looking after them.

Bathing your baby - you could bath your baby or even have a bath with your baby. You'll both enjoy the bonding benefits of skin-to-skin contact and one-to-one time together (NHS, 2018).

Talking and playing - babies enjoy hearing gentle sounds. They even recognise the muffled tones of people talking from their time in the womb and they'll be aware of familiar voices like yours (Lee and Kisilevsky, 2013). So a chat with your baby might be a little one-sided but rest assured, they know it's you. Socially interacting with your baby through their senses helps to stimulate their brain development; for example, you could pull some different expressions (Boucenna et al, 2010).

Baby carrying - this means taking your baby out and about in a sling. It can be a rewarding and comforting experience for both you and your baby (Miller, 2019).

For more ideas on being a hands-on parent, see our article about bonding with and getting to know your baby.

How can I share feeding our baby?

If you're keen to feed your baby, you could give them expressed breastmilk from a spoon, syringe, cup or a bottle. But only introduce your baby to a bottle once breastfeeding is going well. For more on expressing, see our 10 bottle feeding tips for breastfed babies article.

And once your baby's moved on to solid food, there are so many ways you can get involved with that...chopping, mashing, cleaning up all the food that ends up on the floor...

I want to support breastfeeding but will it affect our sex life?

Possibly, but tiredness - and your partner's birth experience and recovery - is more likely to affect their sex drive rather than breastfeeding (Rowland et al, 2005). See our article about breastfeeding and sex for more details.

What if I feel uncomfortable about my partner breastfeeding in public?

If you're feeling uncomfortable or nervous about your partner breastfeeding in public, have a chat with her so you can talk it through. Maybe you're worried about your partner showing her breasts in public? Yet in reality, very little breast actually shows when a baby is feeding. You might have even seen a mum breastfeeding before without realising it.

It might also help to talk to other families where the mum is breastfeeding and find out about both partners' experiences of it. The chances are, you'll change your mind as you get used to seeing breastfeeding.

It's good to know that breastfeeding in public is protected by the law under the Equality Act 2010. That means providers of any services or facilities open for the public are not allowed to discriminate against women who are breastfeeding (Maternity Action, 2019).

Many places now welcome breastfeeding and have special facilities for mums if they'd prefer to feed in private.

Some mums might feel uncertain themselves about feeding in public at first and may appreciate the reassurance of having their partner with them.

At the end of the day...

Don't underestimate the huge difference you can make if your partner is breastfeeding. With you both on board, breastfeeding can quickly become an everyday part of your lives (Rempel, 2011).
This page was last reviewed in October 2017.
Further information

NCT supports all parents, however they feed their baby. If you have questions, concerns or need support, you can speak to a breastfeeding counsellor by calling our helpline on 0300 330 0700, whether you are exclusively breastfeeding or using formula milk. Breastfeeding counsellors have had extensive training, will listen without judging or criticising and will offer relevant information and suggestions. You can also find more useful articles here.

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

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

Visit our breastfeeding support contacts page.

NHS Choices breastfeeding information.

National Breastfeeding Line (government funded): 0300 100 021.

Health Talk has some interesting videos about different people's experiences of breastfeeding, click here to view them.

Boucenna S, Gaussier P, Andry P, Hafemeister L. (2010) Imitation as a communication tool for online facial expression learning and recognition. 2010 IEEE/RSJ International Conference on Intelligent Robots and Systems, Taipei: 5323-5328. Available at: https://ieeexplore.ieee.org/abstract/document/5650357 (Accessed 1st July 2018)

deMontigny F, Gervais C, Larivière-Bastien D, St-Arneault K. (2018) The role of fathers during breastfeeding. Midwifery. 58:6-12. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29272696 (Accessed 1st July 2018)

Department of Health. (2011) Breastfeeding. Available at: http://webarchive.nationalarchives.gov.uk/+/http://www.dh.gov.uk/en/Publichealth/Nutrition/Nutritionpregnancyearlyyears/DH_127625 (Accessed 1st July 2018)

La Leche League. (2016) Still nursing? Available at: https://www.laleche.org.uk/still-nursing/ (Accessed 1st July 2018)

Lee GY, Kisilevsky BS. (2013) Fetuses respond to father's voice but prefer mother's voice after birth. Dev Psychobiol. 2014 Jan;56(1):1-11. Available at: https://www.ncbi.nlm.nih.gov/pubmed/23817883 (Accessed 1st July 2018)

Miller R. (2019). Babywearing education in the neonatal intensive care unit. The International journal of childbirth education: the official publication of the International Childbirth Education Association. 34. 43-47. Available at: https://www.researchgate.net/publication/334151320_Babywearing_Education_in_the_Neonatal_Intensive_Care_Unit (Accessed 1st July 2018)

NHS. (2016) How to combine breast and bottle feeding. Available at: https://www.nhs.uk/conditions/pregnancy-and-baby/combining-breast-and-bottle/ (Accessed 1st July 2018)

NHS. (2017) Benefits of breastfeeding. Available at: http://www.nhs.uk/Conditions/pregnancy-and-baby/Pages/benefits-breastfeeding.aspx (Accessed 1st July 2018)

NHS. (2018) Washing and bathing your baby. Available at: https://www.nhs.uk/conditions/pregnancy-and-baby/washing-your-baby/ (Accessed 1st July 2018)

Rempel LA, Rempel JK. (2010) The breastfeeding team: the role of involved fathers in the breastfeeding family. J Hum Lact. (2):115-21. Available at: http://journals.sagepub.com/doi/abs/10.1177/0890334410390045 (Accessed 1st July 2018)

Rowland M, Foxcroft L, Hopman WM, Patel R. (2005) Breastfeeding and sexuality immediately post partum. Can Fam Physician. 2005 Oct;51:1366-7. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1479788/ (Accessed 1st July 2018)

Su M, Ouyang YQ. (2016) Father's role in breastfeeding promotion: lessons from a quasi-experimental trial in China. Breastfeed Med. 11:144-9. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26836960 (Accessed 1st July 2018)

Tohotoa J, Maycock B, Hauck Y, Howat P, Burns S, Binns C. (2009) Dads make a difference: an exploratory study of paternal support for breastfeeding in Perth, Western Australia. Int Breastfeed J. 4:15. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2788531/ (Accessed 1st July 2018)

Victora CG, Bahl R, Barros AJ, França GV, Horton S, Krasevec J, Murch S, Sankar MJ, Walker N, Rollins NC; Lancet Breastfeeding Series Group. (2016) Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. Lancet. 387(10017):475-90. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26869575 (Accessed 1st July 2018)

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How can dads and partners support breastfeeding? | Baby & toddler, Feeding articles & support | NCT

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This article looks at how dads and partners can help support a new mum who is breastfeeding in the early days.

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The Breastfeeding Network answers FAQs about medications.

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UNICEF guide to feeding your baby at night

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UNICEF guide to feeding your baby at night

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However your baby is fed, they will need milk throughout the day and overnight. Here are some tips on feeding at night.

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All babies need small, frequent feeds because they have tiny tummies.

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While breasts will never be fully drained, all breasts store different amounts of milk and this also affects how often your baby feeds.

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I decided to try my hand at one of the new innovations in communication, infographics. You have my permission to copy and use the infographic on breast storage capacity below, if you think it might be helpful. --Nancy

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Infographic on Breast Storage Capacity - Nancy Mohrbacher

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I decided to try my hand at one of the new innovations in communication, infographics. You have my permission to copy and use the infographic on breast storage capacity below, if you think it might be helpful. --Nancy

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This document from 1st Steps Nutrition outlines how to eat and drink well as a new mum, including how much alcohol is safe to consume. The guide is for all new mums, with pages 43 onwards looking specifically at the guidelines for breastfeeding parents.

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Local support groups, national feeding lines, useful books and podcasts

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Local support groups, national feeding lines, useful books and podcasts

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NCT's Infant Feeding Helpline 0300 330 0700 - This national line is available from 8am to midnight every day of the year.

The helpline supports parents with exclusive breastfeeding, combination feeding and feeding exclusively with formula.

National Breastfeeding Helpline 0300 100 0212 - open every day of the year from 09:30-21:30 - for support with breastfeeding

Do also call me on 07795 113721 if you need support and/or email rosie.heptonstall@nct.org.uk

Breastfeeding support groups with NCT Breastfeeding Counsellors

My support group is on Wednesdays from 11:30 - 13:30 at Pollokshaws library. Please come along during your pregnancy too. No need to book!

Bumps and Babies is run by NCT Breastfeeding Counsellors every Wednesday from 2-4 pm at the Merry-go-round on Nithsdale Road. Here is their Facebook page.

NCT Breastfeeding Counsellor Nicola Smith holds a group at the Moon Rooms in Newton Mearns on a Tuesday. Attendance is free, but please do click on the link and fill out the form, if you are planning on going.

NCT Breastfeeding Counsellor, Laura Hansom, also supports mums at the Kirk Rooms in Strathblane, every Wednesday. It is £3 a session to attend.

NCT's Glasgow Breastfeeding Buddies

Glasgow Breastfeeding Buddies offers face to face and online group support, one to one videos and phone support. All support is provided by breastfeeding peer supporters who have trained with the NCT.

https://linktr.ee/glasgowbreastfeedingbuddies

Breastfeeding Support Scotland holds groups in Milngavie and Cambuslang

Interactive map for Breastfeeding Friendly locations in Scotland

Glasgow Sling Library

General help with mental health for both mums and dads

This Link Tree is for organisations that support both parents with their mental health and is for all parents, however you are feeding your babies.

Podcasts

Breastfeeding survival guide, with lactation consultant, Olivia Hinge

Preparing for chest and breastfeeding with birth doula, Claire Smith

Birth and Breastfeeding with midwife and lactation consultant, Katie James

Books

The links here are to Amazon but most titles are also available on eBay and from other retailers.

Breastfeeding and the 4th Trimester - Lucy Webber, IBCLC

The Positive Breastfeeding Book - Professor Amy Brown

You've got it in you - Emma Pickett, IBCLC

Dr. Jack Newman's Guide to Breastfeeding - Dr. Jack Newman and Teresa Pitman

The Womanly Art of Breastfeeding - La Leche League International (A great book if you ignore the strange title...)

Making More Milk - Lisa Marasco and Diana West

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This document can be very useful for parents who are worried about reflux, colic and allergies. There is also information for vegan and vegetarian parents on which milks to use.

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The Unicef UK Baby Friendly Initiative supports breastfeeding and parent infant relationships by working with public services to improve standards of care.

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Which expressing method is right for me?

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Which expressing method is right for me?

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My quick guide to the various different forms of expressing, including hand expressing and electric pumps.

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Which expressing method is right for me (1)

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Photos and videos from La Leche League on positioning your baby so they attach well

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Photos and videos from La Leche League on positioning your baby so they attach well

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Getting your baby positioned and attached comfortably at the breast is an art-mothers often say it takes a little while for breastfeeding to feel entirely comfortable and natural, even if they've breastfed before. In the past girls grew up learning about breastfeeding by watching mothers in their families and communities. These days many of us become mothers having never seen a baby breastfeed.
But breastfeeding has worked for mothers and babies for thousands of years and it can work for you too.
Many babies can find their way to the breast by themselves, especially if they haven't been too affected by birth interventions. Other mums and babies need a little longer to work it out with maybe some help from a skilled breastfeeding supporter such as an LLL Leader.

When all is going well, specific holds and positions don't really matter because you and your baby will work out what suits you best. However if you are finding it awkward, uncomfortable or downright painful then the following information is designed to help you think about where you can make adjustments and get breastfeeding working comfortably for you.

Good positioning and attachment is important for maintaining milk production. A baby who attaches deeply at the breast is able to remove milk effectively. This is important for maintaining milk production. Well-drained breasts make milk quickly. If there is any concern about how much milk you are making, working on improving positioning and attachment is an important first step.

There's no 'right' or 'wrong'. If you are comfortable, your baby is producing plenty of dirty nappies and is gaining weight after the first few days, then breastfeeding is going well for you. There are no rules-but there are a few principles that can help you work out what to do if things aren't going well: see Latching on - getting a good attachment.

Positioning describes how you sit or lie and how you support your baby as he takes the breast. How you hold your baby can make a big difference to how well he can breastfeed. Even small adjustments can be significant. Attachment describes the way he latches onto the breast.

Tips for getting started
The laid-back approach
Latching on - getting a good attachment
Different breastfeeding positions
As time goes by

Tips for getting started

If it hurts then make changes

If it doesn't feel right to you, then it isn't fine, whatever anyone says. Pain is your body's way of letting you know something is wrong. Start by trying to improve positioning and attachment. A few quick adjustments to how you are sitting or lying or how your baby comes towards the breast may be all that are needed.

Sometimes it can take a little longer. You may need to work with one or more skilled breastfeeding supporters over a period of time to get to the point where everything falls into place and breastfeeding starts feeling natural.

Each mother and baby pair is different and what works well for one mother and baby may not work for you. This is one reason why you may hear different suggestions from different helpers. You are the best judge of what is helpful so don't be afraid to use what feels right for you and discard the rest.

Your baby needs to be calm

You can offer the breast at any time when you are both calm. You may even find it easier if your baby isn't obviously hungry. Feed your baby before he needs to cry. Early cues for wanting to eat include suckingtheir hand, smacking their lips, turning their head towards you, or fussing. They won't latch well if they are distressed. If your baby is upset take time to soothe them. Hold them upright against you, stroke them and talk to them. A little expressed colostrum or breastmilk given on a spoon can help to calm them if they are desperately hungry.

Your baby needs full body contact

When your baby is held in full body contact against you, they will feel stable and be better able to coordinate their movements. Laid back positions ensure full body contact. If you're sitting up, you'll need to hug your baby in as tightly as if you were standing up holding them against you. Babies who don't feel stable tend to wave their arms around, which can make latching more difficult. Pillows can get in the way and aren't always necessary. So wait until after your baby's latched on, and then tuck them in only if you need them for support.

Some babies need time

Some babies find it difficult to latch on, or simply nurse ineffectively at the breast. Often a difficult birth or interventions during labour or birth are the cause. Giving a baby time to recover, and using laid-back breastfeeding positions with skin-to-skin contact can maximise your baby's natural instinct to breastfeed. If your baby isn't latching or feeding well seek help from an LLL Leader and read our page My Baby Won't Breastfeed. With time and patience, most babies will breastfeed. In the meantime express your milk for your baby to maintain milk production and give you both the time to work it out.

Laid-back breastfeeding

Many people assume you have to sit up to breastfeed. Not so. In fact evidence suggests humans evolved to breastfeed in laid-back positions with our babies upright against our chests. You may have experienced this type of position when you had your first feed, soon after your baby's birth. There is more and more evidence that laid-back breastfeeding positions (also called Biological Nurturing) help babies breastfeed more effectively and are more comfortable for mothers, especially in the early days and weeks.

Laid back breastfeeding is really useful for those first few days and weeks when you want to rest and recover and your baby needs to be in close contact with you to get breastfeeding established. It can be done skin-to-skin or with you both lightly dressed. You don't have to be in bed; the sofa or a reclining chair is a comfortable alternative.

You can also use laid-back breastfeeding principles when sitting in an upright chair by shifting your weight back onto your tail bone and reclining your body back a little, to open up a space for your baby. This allows more of their weight to be supported by your body and less by your arms. It isn't safe to sleep with your baby on a chair or sofa.

Sleepy babies

If your baby is sleepy, perhaps because of birth interventions, then using laid-back positions with skin-to-skin contact can encourage your baby's interest in feeding. In laid-back positions babies often attach and feed when in light sleep so it helps to spend substantial periods of time with your sleepy baby against you. When you notice the little movements that indicate your baby is moving into a light period of sleep you can encourage them to latch.

How laid back breastfeeding works

You lay back in a comfortable, supported semi-reclining position (not flat) that opens up your body, creating space for your baby.

Your baby lies against you, their whole front against your body, vertically or at any comfortable angle.

Your baby feels stable and secure and their instinctive feeding reflexes are triggered, prompting them to bob their head and seek out the breast.

Gravity helps them latch deeply and stay latched, rather than hindering the process.

Your hands are free to support and caress your baby and help them attach.

Your body releases the hormones that stimulate milk production and make you experience loving feelings towards your baby.

There are no rules-you and your baby are free to work it out between yourselves.

Latching on - getting a good attachment

Your baby needs to tip their head back and reach forward with their lower jaw. As your baby tips their head back their jaw drops and their mouth opens wide, so they can anchor their chin and lower lip firmly against your breast. If they have to tuck their chin in to reach the nipple they won't be able to open their mouth so wide. Tipping their head back also makes a deep latch possible, swallowing easier, and frees up their nose for comfortable breathing. In laid-back positions lay your baby with their head between your breasts. If you are sitting up, keep your supporting hand away from the back of their head. Babies tend to creep forward, so try shifting them so that their eyes and nose are opposite the nipple to encourage them to reach forward and anchor their chin first. In sitting or side lying positions a little push between the shoulder blades with your supporting hand or arm as they latch brings their chest in closer and helps their head tip back.

Their lower jaw needs a clear space to anchor. Think about how you might take a mouthful from a big sandwich by placing your lower jaw first then opening your mouth to accommodate the top of the sandwich-the principle is the same. Your baby's lower jaw needs to be deeply placed on your breast well away from the nipple. Keep the fingers of your supporting hand away from the place where their chin and lower jaw need to be so their lower lip and chin can sink into your breast. Your baby's chin needs to stay firmly in contact with your breast.

Your baby needs a big mouthful. When a baby chews on a nipple, this compresses the milk ducts, prevents milk flowing and hurts. When a baby has a good big mouthful of breast beyond the nipple, breastfeeding is comfortable and milk can flow. Some women like (or need) to hold their breast when nursing. They flatten their breast as they would a big sandwich they were offering to the baby, matching it to the oval of his mouth. This can help their baby grasp more breast tissue. It doesn't matter if fingers are closer to the upper jaw but try to keep the "lower jaw fingers" out of your baby's way. Biological Nurturing™ positions make use of gravity to help a baby get a bigger mouthful.

The exaggerated latch. To get an even deeper latch you could try this optional extra. Place your thumb or finger near the base of the nipple where the middle of your baby's upper lip will be, lined up with their nose. If you press, your nipple will tilt away from your baby, presenting them with your breast rather than your nipple. Avoid pressing your nipple into their mouth. As they open wide, snuggle them in close and use your thumb or finger to tuck the breast into their mouth. Your nipple will be taken in last and unroll in their mouth. You can then slip your finger out.

Our own video below demonstrates flipple technique (aka exaggerated latch), it can be very helpful for getting an effective pain free latch:

Let your breast rest at its natural level. It can be tempting to lift your breast and move it towards your baby's mouth. If you do this, your baby probably won't get a full mouthful, and after a while your hand will get tired and the breast will drop and slip out of their mouth. Breastfeeding pillows can get in the way too because they lift a baby up too high and prevent you tucking them in against your tummy. See where your breasts naturally rest and hold your baby accordingly. If you need them, tuck pillows in after they are well attached.

Bring baby to breast, not breast to baby. Since breasts are attached to you and you baby is moveable it makes much more sense to bring your baby to the breast, not the other way round! And it works better too. With their body tucked firmly against you (or laid on top of your body), your baby will feel more stable and have better head control, and you'll feel a lot more comfortable too.

It's easier to latch onto a softer breast. It's much easier to get a deep mouthful if the breast is soft so breastfeed frequently to avoid engorgement. When your baby bobs their head and licks the nipple, it naturally makes it easier to latch on. If your breast is full and hard, you can use reverse pressure softening to move fluids away from the nipple area so your baby can latch on well. Apply gentle steady pressure with your fingertips on the areola around your nipple for about a minute. You can also press with the sides of your thumbs or fingers. Denting the breast at the edge of the areola with a finger and placing your baby's chin in the dent may also help. Gently hand express a little milk too if needed.

Your baby needs to choose his own timing. Your baby will probably do best if they pick the moment to latch on. You can help by supporting them in a position that lets them do this when they are ready. To encourage your baby to gape hold them close against you, close enough to the breast so they know the nipple is there, but where they can't quite reach it. Be prepared for your baby to lick and nuzzle for several minutes before they are ready to open wide.

The natural or laid-back breastfeeding positions shown in the following videos can be a great help in encouraging your baby to latch on well, as well as being comfortable for you. You can recline comfortably with your baby on top of you with their whole front against you and their body completely supported by yours.

Best Beginnings' video demonstrates clearly how to make sure your baby is attaching well to the breast, you can view it here.

This video demonstrates how to enable your baby to latch deeply on to your breast so that breastfeeding is comfortable for you and means your baby get enough milk:

This video shows how to attach your baby well, and shows a variety of comfortable breastfeeding positions:
http://m.raisingchildren.net.au/articles/breastfeeding_attachment_video.html

Using different breastfeeding positions

The cradle hold

Although the cradle hold is one of the most common nursing positions it can be a challenge for new mothers to learn. You need to hold your baby's body firmly against you to give them stability because their weight is supported mainly by your arms. Shifting so you are sitting on your tailbone, rather than upright can help stability and reduce the strain on your arms (see picture right). It can be difficult to control a baby's head and to keep them high enough and close enough to your breast. A small baby may tend to curl up in a ball in this position if not pulled in closely enough against your body. It may not be the best choice at first if you're experiencing any problems with latch-on, milk transfer or if you have sore nipples. Once you're more confident with breastfeeding, you may find you use a version of the cradle hold much of the time, especially when out and about.

Your baby's whole front is against your tummy, their hip resting on or near your thigh, tucked around you like a comma. Their chest will be snuggled into the breast and your nipple near their nose.

Their head is resting on your forearm and/ or wrist (not the crook of the elbow).

As your baby opens their mouth to take the breast, pull their body in firmly against you.

Once your baby is attached, settle back a little for your own comfort and so that more of their weight is taken by your body.

Laid back breastfeeding

Remember that Biological Nurturing™ positions aren't just for the first week or two. They can be really useful later on when you want to relax, and especially if you are breastfeeding more than one baby or if your baby is fussy or unwell.

The cross-cradle hold

The cross-cradle position can be useful in the early days because it gives you more control in guiding your baby to the breast. It can be uncomfortable to maintain without good support under your arms, especially with larger babies, so once your baby is attached, switch arms as shown in the picture below. After the first few weeks and as your baby grows longer and heavier, you may prefer to use other comfortable holds. Avoid touching the top or back of your baby's head because it often causes a baby to pull back from the breast. Forcing a baby onto the breast by firmly holding the back of the head usually has the opposite effect and can put a baby off breastfeeding.

Cross cradle

Tuck their whole front against your tummy, their hip near or resting on your thigh.

Your hand supports their neck (not the back of the head) with your palm between their shoulder blades.

Your other hand is free to shape or stabilise your breast if needed.

Make sure your baby isn't too far round the front-line them up so their eyes and nose are near the nipple.

As your baby opens their mouth, give a little push with the palm of your hand to bring their chest in close against you.

This will help their head tip back and let them plant their chin deeply against your breast.

Once your baby is attached you can bring your other arm round to support your baby's body and settle back a little for your own comfort and so that more of his weight is taken by your body. Hold your baby with the arm opposite to the breast he's going to latch onto.

The underarm (clutch or rugby) hold

The underarm hold is useful if you have had a caesarean birth. It helps keep the weight of your baby off your incision. It is also a good position for mothers with flat or inverted nipples and for babies with latch-on or sucking problems because it offers you a good view of baby and breast and control of your baby's head. You can also feed two babies at once in this position. For larger, longer babies you may need extra cushions behind your back to bring you further forward and allow space for your baby's length.

Your baby's front is close against your side, with your hand under their shoulders and neck.

Your elbow keeps them tucked closely against your body.

Your baby approaches your breast from below. This can work well if you have large breasts. If you have smaller breasts you may need to bring your baby into a semi-sitting position.

Make sure your baby isn't too far round the front. You may need a cushion between your back and the chair back to allow room for your baby's length and prevent them pushing themselves forward with his feet.

Side lying

This side-lying position is helpful if you are recovering from a caesarean birth or an episiotomy and invaluable for nursing in bed during the night.
It can take a while to get the knack but it's well worth persisting because it can make night feeds so much easier.
Some mothers decide to sleep with their baby alongside them. Others choose to move their baby back onto a separate sleep surface.
Safe Sleep and the Breastfed Baby will help you decide on the safest sleep arrangements for your family, based on your own individual circumstances.

* Lie on your side, with your knees bent up and a pillow under your head.
* Place your baby on their side facing you so that their body and your body form a V-shape, meeting at your hips, with your nipple level with their nose or eyes.
* You can put your arm under your baby's head as shown, or up by the pillow with your baby lying on the bed.
* As your baby latches, give a little push between their shoulder blades to bring their chest in closer and help their head to tip back and their mouth to
open wide.
* You may find it helpful to tuck a small pillow or rolled blanket behind the small of your back and/or between your knees.

Standing up

At some feeds babies just do better if you stand up. You can sway or bounce gently to help calm your baby, and the lack of a lap can be helpful. As always keep your baby nice and stable and let them lead the way. Try angling their legs down instead of holding them horizontal, and see what happens. Or try starting with them against your shoulder, supporting them as he moves down to the breast. Even when using other positions, sometimes just standing up and sitting down again straight away helps everything settle into a comfortable position.

As time goes by

Whether you choose to breastfeed sitting up, reclining or lying on your side, you will need to adjust how you support your baby as he grows in length and weight. Use the principles shown here as you experiment with different positions. Sometimes there are physical or medical causes for pain or discomfort such as tongue tie or a thrush infection. If you are still finding it difficult to get comfortable, do persist with seeking further and continued support. There is almost always a breastfeeding solution to breastfeeding problems. You can contact an LLL Leader by calling our Helpline. You can also find support and encouragement from breastfeeding mothers in your local LLL group.

Written by Sue Upstone, Karen Butler and mothers of LLLGB

Further Reading

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

Mastitis
Beginning Breastfeeding
Breastfeeding Your Baby - easy read
Caesarean Birth & Breastfeeding
Comfortable Breastfeeding - easy read
Skin-to-Skin
Engorged Breasts - Avoiding & Treating
Hand Expression of Breastmilk
Inverted Nipples
My Baby Needs More Milk
My Baby Won't Breastfeed
Nipple Confusion?
Nipple Pain
Nipple Shields
Nursing Supplementers
Safe Sleep & the Breastfed Baby
Sleepy Baby - Why & What To Do
Tongue Tie
Too Much Milk & Oversupply

LLLI Resources
Position to breastfeed

Other resources
How to do Biological Nurturing: www.biologicalnurturing.com/video/bn3clip.html
Best Beginnings videos to watch online: www.bestbeginnings.org.uk/watch-fbtb

References
Breastfeeding Answers Made Simple. Mohrbacher, N. Amarillo, TX: Hale Publishing, 2010.
Biological Nurturing: Laid-back breastfeeding for mothers (DVD). Colson, S. et al. 2012.
An Introduction to Biological Nurturing; New angles on breastfeeding, Colson S. Amarillo, TX: Hale Publishing, 2010.
Supporting Sucking Skills, Watson Genna, C. Burlington, MA: Jones & Bartlett, 2012.

This information is available to buy in printed form form the LLLGB Shop.
It is also available in kindle edition.

Information, references and links on this page are taken from La Leche League resources, unless stated otherwise. Please note that LLLGB does not endorse information from outside sources, extra information is provided for you to consider. Information supplied is not intended as advice, and you are in the best position to make a decision as to how the information offered will affect you and your baby.

Copyright LLLGB 2016

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Positioning & Attachment - La Leche League GB

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Good positioning and attachment is important for maintaining milk production. A baby who attaches deeply at the breast is able to remove milk effectively.