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Dr Jack Newman

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'Dr Jack Newman's Visual Guide to Breastfeeding' on ViewPure

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Dr Jack Newman's Visual Guide to Breastfeeding

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Back to my Breastfeeding Information Homepage

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Why your baby is only happy in your arms

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

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

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

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

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

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

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

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

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

Only swaddle your baby until he can roll over**

Always place your baby to sleep on his back

Do not swaddle tightly across your baby's chest

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

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

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

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

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

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

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

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

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Why you might want to put the baby books down

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Why you might want to put the baby books down

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School of Health & Social Care, Swansea University

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

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College of Human and Health Sciences, Swansea University

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The first week with a breastfeeding newborn

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Emma Pickett IBCLC is leading our breakout session on Breastfeeding at "Growing Families: Facts, Fiction and Other Stuff" this October. It is a one-day event for all expectant and new families - mum, dad, grandma, grandad, aunts, uncles, supporters - and the professionals who work with them. This is a not-for-profit event, created by four mothers, two of whom are also healthcare professionals. Our mission is to tackle the postnatal information that desperately needs covering for new families. To explore expectations and evidence around the early days with baby. To keep ticket prices low, with no expectation of making a profit, in order to open up the event to as many people as we can. To ensure that support for the event comes from ethical organisations and those who share our interest in evidence based information and family well-being. To give new families the confidence to face the challenges ahead.

Please click here to book your place: https://growingfamilies.co.uk/prices-booking/

Here Emma tells us about what is actually "normal" when breastfeeding a newborn baby.

I've been taking calls from new parents on the National Breastfeeding Helpline since it opened in 2008. Calls often begin with a mum in tears and she's sounding desperate. Breastfeeding really matters to her and she wants it to work. She's overwhelmed and confused. The first voice we hear might sometimes be the partner's and a mum is too upset to even come to the phone.

Hundreds of these calls end with a contented calm voice saying, "Thank you. It's such a relief to know that's normal. I feel so much better now". As it happened, breastfeeding was actually going OK but it was her understanding of everything else that was confused. What she interpreted as a breastfeeding 'problem' was actually a new baby's normal and natural response to their new environment. She just didn't know how babies were 'supposed to behave'.

If I had a magic wand, I would download into all parents the knowledge of what is normal in a newborn. Think The Matrix film - but instead of the ability to pilot helicopters or practise high level martial arts, you'd know about cluster feeding and a newborn's desire for closeness, nappies and normal fussiness.

The National Breastfeeding Helpline would be quieter overnight but we'd all feel a lot more relaxed and able to enjoy these teeny new people in our lives.

But actually... you've already had that download. You just may not have realised it. It's deep in there after millions of years of evolution, facilitated by hormones and natural instincts. It may not mean you know the exact details of the colour of baby poo on day 3 or how to correct a baby's latch without help but there's so much you do know. You probably didn't grow up surrounded by breastfeeding (as Elena Abell's recent blog highlighted) and for some aspects of breastfeeding you will need support and information, but there's a ton you do know about your baby: things that just feel right and things that don't.

And your baby had the download too. Sometimes it gets fuzzied with a birth that didn't go to plan but their instincts are in there too.

Two things that are normal:

Imagine a news story about a baby gorilla just born in London zoo:

"ZSL London are delighted to announce the birth of new baby Fumbi. Mother and baby are in good health" but days later it's reported that staff are concerned. Fumbi's mother (despite being surrounded by other older female gorillas and having observed newborn care) keeps trying to put Fumbi down. She places her in the hay and walks off repeatedly and appears to be trying to avoid holding her for long periods. Fumbi is agitated. Her heart rate and respiratory rate shows signs of distress. She's losing heat (because teeny newborn gorillas have a large surface area and need to be held to regulate their temperature). Fumbi isn't feeding as often a newborn usually does because of the periods of separation. The mother appears to be missing out on some of the oxytocin induced bonding that helps the formation of their early relationship. Fumbi is at risk.

Oh dear. Something seems to have happened to Fumbi's mother. We'd be worried.

However this is exactly what is happening in human homes across the UK today (though not in many other countries and cultures). We are primates just as gorillas are. We're not designed to dump our babies and go off hunting and foraging for nuts. We can see that by looking at the constituents of our breastmilk. Other mammals have much higher fat milk so babies can be left while mum fishes or grabs a rabbit for lunch. Our babies are born immature because of our pelvis shape from being upright and our large brains and they are designed to have milk regularly for a relatively long time. We are supposed to hold our babies. Some people call us 'carry mammals'.

But instead we got the message somewhere that babies can be 'spoilt'. We are supposed to encourage them to be independent and sleep apart from us. We're meant to be able to put them down. If we can't put them down, if they want to sleep touching us, if we hold them when they sleep - we've apparently failed some test. Though it's not quite clear who the examiner is.

There are popular books that even use terms like 'accidental parenting' just to load on the value judgments. Parenting experts such as Truby King in the 1910s told parents to avoid cuddling and unnecessary attention and the spectrum of 'advice' has been flip-flopping backwards and forwards ever since. Today one book will tell you to wear your baby in a sling as much as possible and another will tell you to arrange a baby's sleep by the clock and leave a baby only a few weeks old to cry if necessary.

What does your baby want?

They don't want to be put down and eaten by a sabre toothed tiger (less of a problem these days). They don't want to waste energy keeping warm and crying when they don't need to. They want to keep those calories to lay down fat and develop their brain. They want to use your breathing rate to regulate their own respiratory rate. They want you to notice when they start to show early feeding cues. They want your familiar smell and taste. You are home to them.

"My baby won't go down in its Moses basket". Yes, it's frustrating when you thought that was what they were 'supposed to do'. But would it feel easier if you knew that wasn't likely to be their first choice and there are good biological and evolutionary reasons for that?

"But I'm not going to get any sleep".

From the Infant Sleep Information Source [1]:

"70-80% of breastfed babies sleep with their mother or parents some of the time in the early months, and many studies have found that mothers and babies who bed-share breastfeed for much longer than those who sleep apart."

Research shows that these mums breastfeeding through the night (and mostly bed sharing) will ALSO be getting better quality sleep and be more rested than other parents [2] Good sleep is possible if we stop battling nature.

The book "Sweet Sleep: night time and naptime strategies for the breastfeeding family" is a great place to start. It talks to you about creating a safe space where everyone gets a better night's sleep.

A lot of your baby's urges are eminently sensible. If they don't want to sleep in a separate pile of hay, trust them. They are here today because those urges have kept them safe over the generations.

Don't expect to be up and making a moussaka on day 5. The feeling that you 'shouldn't' be holding your baby is exacerbated when we live in a society which tries not to let new parenthood change our lives. Our bodies aren't supposed to change. Our commitment to work isn't supposed to change. Our ability to engage with political life and housework and social media isn't supposed to change. Actually, throughout much of human history, mum isn't going to do much of anything for a good 40 days. Someone else is making the moussaka, just as you would have once made the moussaka for them. We are supposed to be doing nothing else other than eating the food made by others (really doesn't have to be moussaka), sleeping and being with our new baby.

They come to the breast for lots of different reasons and they usually have a good reason for doing so.

Just as parents feel they've failed if their baby doesn't sleep in the separate pile of hay (aka fancy Moses basket that cost £75 and granny knitted a blanket for), they feel a failure if baby is at the breast 'too much'. I have written elsewhere on the dangerous obsession of the infant feeding interval [4]. It's dangerous for both babies and mothers. But we need to remember breastfeeding isn't just about feeding and it never has been.

A phrase most breastfeeding supporters would like to evaporate from the planet is, 'he is using me like a dummy'. No, dummies were invented partly because we forgot what breastfeeding was about. There's not enough evidence to say for certain how dummies impact on breastfeeding [5] but those of us who work with breastfeeding families can see how the sucking action and latching can sometimes shift when babies use dummies a lot and there can be issues when mums feed less and milk supply doesn't get the messages it needs.

Babies have jobs to do. They are helping you to form new breast tissue in the first few weeks. They are elevating your prolactin levels (the hormone that governs milk supply). They are stimulating oxytocin hormone (which is the hormone key in relationship-building and creating a sense of calm and well-being). They are increasing milk volume and altering fat content. They are reducing cortisol stress levels. They are facilitating digestion and the passing of stools. They are hydrating, regulating their temperature, feeling emotional secure, growing brain connections, trying to get to sleep (which YES is one of the purposes of breastfeeding.)

If you just think breastfeeding is about food and calories (and "quick, measure the gap between breastfeeds!") you are doing a nature a huge disservice.

And you want to use an app on your phone to measure all those different reasons why a baby comes to the breast? You're measuring fairy dust. Do you count all the times your partner cuddles you, strokes your arm, kisses you, smiles at you affectionately, communicates with you, has a drink of water, eats a snack, has a meal? You wouldn't find an app for that and if you did, it would probably flag you up as someone needing some urgent assistance.

Stop thinking about minutes. No one can tell you a baby should feed for X number of minutes because we all have different physiology and our babies do too. Create your world around you so you can meet your baby's needs in the way they are asking you to. Don't try and mould your baby to fit into a world that has become obsessed with counting and measuring. If you know you are routine person and you are struggling with a feeling of 'losing control', give yourself a few weeks and see how it feels to trust your baby. Once your milk supply has maximised, you'll have some options. Try and 'control' too early and you'll find things go out of your influence in ways you can't come back from easily.

Get help if things feel wrong- if breastfeeding hurts, if you're not sure about weight gain or nappies, if you can't work out how to meet your own needs for food and sleep. There are lots of people who will help out and we're at the end of a phone or a Twitter account or Facebook page. But don't confuse your baby behaving unexpectedly for something going 'wrong'. Maybe no one told you what normal would be.

If we let normal happen it WILL make all of your lives easier in the long term.

You're creating a little person who enters this world with their needs being met - we call it love.

Emma Pickett IBCLC
ABM Breastfeeding Counsellor

is kindly sponsoring Emma's session at Growing Families - http://abm.me.uk/

References:

1. https://www.isisonline.org.uk/where_babies_sleep/parents_bed/

2. http://www.ncbi.nlm.nih.gov/pubmed/17700096

3. http://www.llli.org/sweetsleepbook

4. http://www.emmapickettbreastfeedingsupport.com/twitter-and-blog/the-dangerous-game-of-the-feeding-interval-obsession

5. http://www.unicef.org.uk/BabyFriendly/News-and-Research/Research/Miscellaneous-illnesses/Review-of-dummy-use-and-its-potential-impact-on-breastfeeding/

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Is THIS normal? The first week with a breastfeeding newborn

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Emma Pickett IBCLC is leading our breakout session on Breastfeeding at "Growing Families: Facts, Fiction and Other Stuff" this October. It is a one-day event for all expectant and new families - mum, dad, grandma, grandad, aunts, uncles, supporters - and the professionals who work with them.

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Feeling anxious? Fretting about feeding? It might be more about your brain rather than your breasts....

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From joy and attachment to anxiety and protectiveness, mothering behavior begins with biochemical reactions.

The artist Sarah Walker once told me that becoming a mother is like discovering the existence of a strange new room in the house where you already live. I always liked Walker's description because it's more precise than the shorthand most people use for life with a newborn: Everything changes.

Because a lot of things do change, of course, but for new mothers, some of the starkest differences are also the most intimate ones-the emotional changes. Which, it turns out, are also largely neurological. Even before a woman gives birth, pregnancy tinkers with the very structure of her brain, several neurologists told me. After centuries of observing behavioral changes in new mothers, scientists are only recently beginning to definitively link the way a woman acts with what's happening in her prefrontal cortex, midbrain, parietal lobes, and elsewhere. Gray matter becomes more concentrated. Activity increases in regions that control empathy, anxiety, and social interaction. On the most basic level, these changes, prompted by a flood of hormones during pregnancy and in the postpartum period, help attract a new mother to her baby. In other words, those maternal feelings of overwhelming love, fierce protectiveness, and constant worry begin with reactions in the brain.

Mapping the maternal brain is also, many scientists believe, the key to understanding why so many new mothers experience serious anxiety and depression. An estimated one in six women suffers from postpartum depression, and many more develop behaviors like compulsively washing hands and obsessively checking whether the baby is breathing.

"This is what we call an aspect of almost the obsessive-compulsive behaviors during the very first few months after the baby's arrival," the maternal-brain researcher Pilyoung Kim told me. "Mothers actually report very high levels of patterns of thinking about things that they cannot control. They're constantly thinking about baby. Is baby healthy? Sick? Full?"

"In new moms, there are changes in many of the brain areas," Kim continued. "Growth in brain regions involved in emotion regulation, empathy-related regions, but also what we call maternal motivation-and I think this region could be largely related to obsessive-compulsive behaviors. In animals and humans during the postpartum period, there's an enormous desire to take care of their own child."

There are several interconnected brain regions that help drive mothering behaviors and mood.

Of particular interest to researchers is the almond-shaped set of neurons known as the amygdala, which helps process memory and drives emotional reactions like fear, anxiety, and aggression. In a normal brain, activity in the amygdala grows in the weeks and months after giving birth. This growth, researchers believe, is correlated with how a new mother behaves-an enhanced amygdala makes her hypersensitive to her baby's needs-while a cocktail of hormones, which find more receptors in a larger amygdala, help create a positive feedback loop to motivate mothering behaviors. Just by staring at her baby, the reward centers of a mother's brain will light up, scientists have found in several studies. This maternal brain circuitry influences the syrupy way a mother speaks to her baby, how attentive she is, even the affection she feels for her baby. It's not surprising, then, that damage to the amygdala is associated with higher levels of depression in mothers.

Amygdala damage in babies could affect the mother-child bond as well. In a 2004 Journal of Neuroscience study, infant monkeys who had amygdala lesions were less likely to vocalize their distress, or pick their own mothers over other adults. A newborn's ability to distinguish between his mother and anybody else is linked to the amygdala.

Activity in the amygdala is also associated with a mother's strong feelings about her own baby versus babies in general. In a 2011 study of amygdala response in new mothers, women reported feeling more positive about photos depicting their own smiling babies compared with photos of unfamiliar smiling babies, and their brain activity reflected that discrepancy. Scientists recorded bolder brain response-in the amygdala, thalamus, and elsewhere-among mothers as they looked at photos of their own babies.

Greater amygdala response when viewing their own children was tied to lower maternal anxiety and fewer symptoms of depression, researchers found. In other words, a new mother's brain changes help motivate her to care for her baby, but they may also help buffer her own emotional state. From the study:

Thus, the greater amygdala response to one's own infant face observed in our study likely reflects more positive and pro-social aspects of maternal responsiveness, feelings, and experience. Mothers experiencing higher levels of anxiety and lower mood demonstrated less amygdala response to their own infant and reported more stressful and more negatively valenced parenting attitudes and experiences.

Much of what happens in a new mother's amygdala has to do with the hormones flowing to it. The region has a high concentration of receptors for hormones like oxytocin, which surge during pregnancy.

"We see changes at both the hormonal and brain levels," the brain researcher Ruth Feldman told me in an email. "Maternal oxytocin levels-the system responsible for maternal-infant bonding across all mammalian species-dramatically increase during pregnancy and the postpartum [period,] and the more mother is involved in child care, the greater the increase in oxytocin."

Oxytocin also increases as women look at their babies, or hear their babies' coos and cries, or snuggle with their babies. An increase in oxytocin during breastfeeding may help explain why researchers have found that breastfeeding mothers are more sensitive to the sound of their babies' cries than non-breastfeeding mothers. "Breastfeeding mothers show a greater level of [brain] responses to baby's cry compared with formula-feeding mothers in the first month postpartum," Kim said. "It's just really interesting. We don't know if it's the act of breastfeeding or the oxytocin or any other factor."

What scientists do know, Feldman says, is that becoming a parent looks-at least in the brain-a lot like falling in love. Which helps explain how many new parents describe feeling when they meet their newborns. At the brain level, the networks that become especially sensitized are those that involve vigilance and social salience-the amygdala-as well as dopamine networks that incentivize prioritizing the infant. "In our research, we find that periods of social bonding involve change in the same 'affiliative' circuits," Feldman said. "We showed that during the first months of 'falling in love' some similar changes occur between romantic partners." Incidentally, that same circuitry is what makes babies smell so good to their mothers, researchers found in a 2013 study.

The greatest brain changes occur with a mother's first child, though it's not clear whether a mother's brain ever goes back to what it was like before childbirth, several neurologists told me. And yet brain changes aren't limited to new moms.

Men show similar brain changes when they're deeply involved in caregiving. Oxytocin does not seem to drive nurturing behavior in men the way it does in women, Feldman and other researchers found in a study last year. Instead, a man's parental brain is supported by a socio-cognitive network that develops in the brain of both sexes later in life, whereas women appear to have evolved to have a "brain-hormone-behavior constellation" that's automatically primed for mothering. Another way to look at it: The blueprint for mothering behavior exists in the brain even before a woman has children.

Perhaps, then, motherhood really is like secret space in a woman's brain, waiting to be discovered. "Although only mothers experience pregnancy, birth, and lactation, and these provide powerful primers for the expression of maternal care via amygdala sensitization," researchers wrote, "evolution created other pathways for adaptation to the parental role in human fathers, and these alternative pathways come with practice, attunement, and day-by-day caregiving."

In other words, the act of simply caring for one's baby forges new neural pathways-undiscovered rooms in the parental brain.

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What Happens to a Woman's Brain When She Becomes a Mother

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From joy and attachment to anxiety and protectiveness, mothering behavior begins with biochemical reactions. The artist Sarah Walker once told me that becoming a mother is like discovering the existence of a strange new room in the house where you already live.

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One parents practical and humorous take on finding what works for you.

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A doctor told a very good friend of mine that the first three months of a newborn's life is like a fourth trimester. He said that some major development is far from done but we wouldn't be able to give birth to their giant heads if they stayed in the womb any longer (I wouldn't say that they fit really well at 40 weeks either but I'm not going to argue with nature.)

My friend told me this when my first son was about a month old and I was trying to implement all the "well intended" (code for "shit") advice that is often bestowed on a new mother. It was like an Oprah A-Ha moment and it made perfect sense. If I just let him live his life like he's still in the womb my life will become way less complicated.

I stopped trying to give him a bath every night.

Someone told me a bath was essential to establishing a bedtime schedule. She also told me that this should be followed by a massage (sadly for him, not me) and a story. He hated bath time because he was naked and freezing (for the record, he loves being both now), the massage confused him just long enough to get through it and I don't know why I thought reading "Go Dog Go" to a two-week old was logical, but then "sane" wasn't an adjective I'd use for me in the first three months of my child's life. I accepted that he was a newborn and not a member of the Deadliest Catch fishing crew so he wasn't dirty and he didn't need a bath.

I stopped dressing him in anything other than jammies.

He ate, he pooed, he slept and he cried in a one-hour, round-the-clock cycle. When you have a newborn there is no day and night. I quickly found out that newborns don't have schedules and they are like those creepy rave kids strung out on E, they want to party at 4am AND 4pm. It was a perpetual Groundhog Day so why dress for that? Plus, you just have to undress them if they happen to fall into a blissful sleep around 8pm because IT'S BEDTIME!! (said in a high-pitched control freak shrill) and they don't help with the undressing for a while so it's like stripping a surly, drugged monkey. Not pretty.

I fed him when he wanted to eat.

I remember crying, "he can't be hungry, I just fed him!" so I would try everything to get him to stop only to find out he did want to eat. He would promptly spit it all up but he was happy and therefore I was happy. My motto was "Pick him up. Fill his mouth. Change his bum." If that didn't work, I'd hand him to his father, say "I can't take it anymore" then cry in the bathroom. It worked for us.

I always let him sleep.

Another "helpful" person told me I should never let a child sleep past 4pm because you'll never get them to bed. This is, in fact, true FOR A TWO YEAR OLD. If your newborn is sleeping, don't wake them. Even though it may not seem like it, they sleep about 16 hours out of 24 in a day and if you think you can roll that into 8 consecutive hours you think wrong. That's like you sleeping one month so you can stay up for two - you'd starve and/or go bonkers. If your baby is sleeping, sleep yourself or hit the Southern Comfort - don't poke the bear.

I didn't do any classes for newborns.

You know these classes that they have to "stimulate" your newborn. Let me tell you something, being awake stimulates your newborn. Jingling keys is like an effing air show to them so don't bother with the damn classes. If you want to feel normal and a part of humanity go do something that stimulates you (in a non-porn way) and just sit the baby in the corner or have it strapped to you in a baby carrier. They don't know where the hell they are anyway so there's no point in you having to sit through "If You're Happy and You Know It" clapping your baby's hands like a newborn/E.T. puppet show because I can guarantee you that your newborn is thinking "I'm not happy and I know it. If I had a dry bum, a full tummy and was asleep on your chest while you lay on the couch binge watching your favourite show, now that would be pretty damn sweet".

I stopped changing his bum constantly.

When I was sent home from the hospital they gave me a chart to record his peeing and pooing to make sure he was eating enough and everything was in "working order". I was so happy. I love charts and I loved the small sliver of control I had over the situation. The problem was I got into the habit of changing him every 20 minutes or so. This included the night so if he woke up to eat, I changed him after which meant he woke up that much more which meant it was harder for him to go back to sleep which was not pretty because by the time I got him back to sleep he was hungry again. Once I figured out that if you grease up their little bums and slap a diaper on them they can pretty much make it through the night without a change unless they poo.

I picked him up if he cried.

Some people warned me that this would "spoil him" and he would manipulate me and cry every time he wanted me. Er, okay, look at me and my sneaky baby! My thinking was I would rather pick him up to find out nothing was wrong rather than leave him to cry and find out something was.

I let him sleep on me.

This was considered a big no-no by many because I was "creating a bad habit". Even I wondered if I would have to rock him to sleep and have him sleep on my chest in his dorm room at college (which would make for some awkward roommate moments) because I didn't establish a sleep schedule early on. Here's the thing, even if you get something established in the beginning, they change so damn quickly that it will be out the window the next week and you're back to square one. A wise friend once told me "whatever gets you though the day" and him sleeping on my chest while I watched a movie got me through the day. So there.

My overall theory about newborns

Personally, I think you have plenty of time to get all these schedules into place so just do "whatever gets you through the day" for the first little while and cut yourself a break. I like the idea of the fourth trimester. All you need for those first few months is to provide them with warmth, food and love - the nightly baths, ferberizing and Mommy and Me classes can wait a bit. I'm just grateful nature decided that it made more sense for them to be on this side of the fish tank rather than making us give birth to 18lb babies, but I'm weird like that.

Related: Breastfeeding in the First Week: 4 Things You Will Be Glad You Knew

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What you Need to Know About Newborns | Pregnant Chicken

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A doctor told a very good friend of mine that the first three months of a newborn's life is like a fourth trimester. He said that some major development is far from done but we wouldn't be able to give birth to their giant heads if they stayed in the womb any longer (I wouldn't say that they fit really well at 40 weeks either but I'm not going to argue with nature.)

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Nappies contents in the first weeks are a great way to know how feeding is going

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As new parents, we suddenly find ourselves examining our babies' poo more closely than we could ever have imagined. We pay attention to the colour, quantity, texture and smell, and notice the slightest changes. We then go to the internet looking for answers and fear the worst. There are many versions of normal, and we will share some of these below.

When your baby is born, your colostrum (first milk) has laxative and diuretic compounds in it to make your baby wee and poo. In the first few days your midwife and health visitor will ask how many wet and dirty nappies your baby has had, so you may find it helpful to take note of how many nappies you change.

Your baby may not poo much at first but this will increase as your milk comes in. For an idea of how many poos to expect, see https://www.laleche.org.uk/is-my-baby-getting-enough-milk/#dirtynappies

It can be tricky to tell if disposable nappies are wet - after five full days, when copious milk comes in, they should be heavy.
Many disposable nappies have a faint line down the middle of the nappy which changes colour when wet.
You can feel what a properly wet nappy should feel like by putting three tablespoons (45ml) of water onto a clean, dry one. Urine should be pale and mild smelling.
This post on signs of effective feeding has more information.

Pictures 1-9 below show the contents of one baby's nappy in the first few days of his life, to give you an idea of what to expect from a healthy, full-term baby. If you have any concerns about your baby's poo, or if you see blood in the nappy (beyond the first few days, when baby girls can have a mini period caused by birth hormones), don't hesitate to contact your midwife, health visitor or GP.

Picture 1
Baby's first bowel movement, called meconium, is tar-like, sticky and hard to remove.

Picture 2
Baby's second bowel movement.

Picture 3
Poo from the first day of baby's life. Reddish pink urate crystals are visible in this nappy; see picture 10 for more about urates.

Picture 4
Bowel movement on day two. Your baby's poo will gradually change colour, from black to green to brown. It becomes a lot easier to wipe off as your baby begins to drink more milk.

Picture 5
Day three bowel movement. Looking a lot paler, heading towards a yellowish colour, and much less sticky.

Picture 6
Day four bowel movement.

Picture 7
Day five bowel movement.

Picture 8
Day six bowel movement.

Picture 9
Day ten bowel movement. By this age most fully breastfed babies' poo will be this pale yellow colour. It is common for babies to have what are described as "explosive" poos, which may take you by surprise if your baby poos while you are changing her nappy!
The following pictures show some ways in which your baby's poo may look different from the typical pattern shown above.
Picture 10
In the first few days, you may see reddish pink crystals called urates in your baby's nappy. They are often described as looking like brick dust. As your baby begins to take more milk, the urates should stop appearing in her nappy.

Picture 11
Sometimes your baby's poo may be light green rather than yellow, and have small lumps in it like cottage cheese. This is common and not significant by itself, unless your baby has other symptoms that you are worried about.

Picture 12
This poo came from a three-week-old baby who was given Gaviscon because of reflux. When the medication was stopped, the baby went back to having runny yellow stools.

Picture 13
After the 12-week injections this baby had green poo, which went back to being yellow after a few days.

Picture 14
This dark green poo came from a baby who was later diagnosed with cow's milk protein intolerance.

Picture 15
This poo, containing mucus, came from a baby diagnosed with allergies. Mucus in the poo is also common when a baby has a heavy cold, but this should be temporary and should stop when the baby is well again. If your baby's nappy has persistent or unexplained mucus in it, seek medical advice.

Picture 16
As your baby starts to eat solid foods, you will see the results in his nappy. It is common for your baby's very first foods to come out looking almost exactly as they did when they went in, as his digestive system is not used to dealing with these other foods yet. This is much easier to spot if your baby is eating finger foods rather than mashed food; the mashed foods are passing through semi-digested in the same way, but are less obvious in the nappy.

With time, your baby's poo will gradually change from yellow liquid to soft brown lumps, and you won't generally see pieces of food. However, some foods are hard to digest and tend to pass through the body unchanged (even for older children or adults). This picture shows an 11-month-old's nappy with partially digested grapes visible in it. Strongly coloured foods (like blackberries or beetroot) can also affect the appearance of your baby's wee and poo.

Written by Amanda Dunbar and Emma Taylor for LLLGB, 2017

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As new parents, we suddenly find ourselves examining our babies' poo more closely than we could ever have imagined. We pay attention to the colour, quantity, texture and smell, and notice the slightest changes. We then go to the internet looking for answers and fear the worst.

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...feeding your baby at times that suit you too.

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The mother above is practising responsive feeding but... brace yourself...her baby showed absolutely NO feeding cues before the breastfeed started. Wasn't remotely interested. No cues. No 'demand'.

And...put on a second brace...the mother looked at her watch before starting a feed. The feed started because of the clock.

How can that be?
Isn't responsive feeding all about being 'baby-led'?
Shouldn't the mother be feeding in response to the baby's cues and messages?
Isn't responsive feeding simply another way of saying 'feeding on demand' but we don't use the word 'demand' anymore because it sounds a bit bossy and rude?

Nope.

Responsive feeding is not just a polite way of saying 'feeding on demand'.

Let's imagine this mum was looking at her watch because she has to go and pick her toddler up in an hour. She wanted to get a feed in before she had to leave.
Still responsive feeding.

Let's imagine she has to leave for work. She has a Zumba class. She wants to go and have a bath and leave the baby with her partner.
Still responsive feeding.

She's feeling engorged. She is feeling anxious. She just had a horrible phonecall and really wants a cuddle.
Still responsive feeding.

Because mums can have 'demands' too. They are allowed to have needs and urges and instincts and wishes. Responsive feeding is a two-way street. It's a relationship between two people with back and forth and compromise. Sometimes one takes the lead. Sometimes the other.

It's not a mother under the control of a teeny babygro-wearing master (or mistress).

Mothers can make decisions too. They can take the lead. They can be demanding. Sometimes their feelings might take priority for a while. Responsive feeding isn't all about a mother sacrificing her own needs. Or always putting herself second (or third or fourth).

Responsive feeding is two people meeting each other's needs. The mother won't get milk out of the arrangement but then the baby often isn't looking for milk alone either. Responsive feeding meets the emotional needs of both mother and baby.

Here are some extracts from the UNICEF Baby Friendly infosheet which can be found in full here:
https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2017/12/Responsive-Feeding-Infosheet-Unicef-UK-Baby-Friendly-Initiative.pdf

"Responsive breastfeeding involves a mother responding to her baby's cues, as well as her own desire to feed her baby. Crucially, feeding responsively recognises that feeds are not just for nutrition, but also for love, comfort and reassurance between baby and mother."

"She can also offer her breast to meet her own needs, for example before she goes out, before bedtime or because she wants to sit down, rest and have a cuddle with her baby."

So, yes, sometimes a new mother might feed 'by the clock' and that can be OK. She might want to breastfeed for her own reasons - and that's how it's supposed to work.

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Sometimes responsive feeding looks like this...

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The mother above is practising responsive feeding but... brace yourself...her baby showed absolutely NO feeding cues before the breastfeed started. Wasn't remotely interested. No cues. No 'demand'. And...put on a second brace...the mother looked at her watch before starting a feed. The feed started because of the clock.