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A nipple shield is made of thin silicone and it can be placed over the nipple if attaching your baby is difficult or painful. They should be considered a short term solution which may not always help and should be used with support from the Infant Feeding Team.

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Please scroll right to left to see all sections, and up and down to see each column. Column headings are listed in order further down in this column. 

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Please scroll right to left to see all sections, and up and down to see each column. Column headings are listed in order further down in this column. 

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If you'd like to come along to our Infant Feeding Drop in, please see the details below: 

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If you'd like to come along to our Infant Feeding Drop in, please see the details below: 

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Expressing your milk before your baby arrives

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Expressing your milk before your baby arrives

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This padlet contains lots of evidence based information to support you with feeding your baby.

We are committed to ensuring that all parents are supported to feed their baby safely and responsively whatever their chosen feeding method and aim to give a high standard of care to all.

The evidence shows many benefits for parents and babies who breastfeed, chestfeed or give human milk. Health professionals therefore have a duty of care to promote breastfeeding for your baby’s long term health and if you choose to do so, to help you to get breastfeeding off to a good start.

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For those of you currently pregnant, please feel free to browse the whole padlet, but areas to focus on are:

The building close and loving relationships, value of human milk, colostrum harvesting, skin to skin and the best way to get your feeding journey off to the best start.

For those of you who have had your babies, congratulations! Feel free to use this padlet as a point of reference while you are in hospital or at home.

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We are aware that some parents may not self-identify as ‘’mothers’’ but still be producing milk for their infant. We strive to use inclusive language and encourage parents to let us know their preferred pronouns/terms for us to individualise their care.

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All of our SWFT team are able to help you with feeding your baby, from support workers to midwives.

Should you require more specialist help, the Infant Feeding Team extension number is visible at the top of this padlet. Collectively we can support you and your baby up to 4 weeks.

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The Trust will not share any personal or sensitive information on our patients via this padlet. To find out how the Trust collects, uses, and safeguards your personal information, please see our Privacy Notice.

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With thanks to the Infant Feeding Team at Chelsea and Westminster who inspired this padlet.

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La Leche League - Successfully breastfeeding your premature baby

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La Leche League - Successfully breastfeeding your premature baby

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

Before your baby arrives
Your premature newborn
Establishing breastfeeding
Looking after your own health and wellbeing
Taking your breastfed baby home

Before your baby arrives

If you know your baby will be arriving soon, you may wish to try antenatal expression of colostrum. This is where you hand express some of the thick, creamy first milk into a sterile container such as a syringe. This can be given to your baby immediately after birth reducing the possibility of them needing to have early formula feeds. Hypoglycaemia (low blood sugar) can cause serious long term health problems if left untreated, and preterm babies are at higher risk of low blood sugar than babies born at term. Having some colostrum ready means that this is available instead of formula (or donor milk if available).

If you are at risk of early labour and taking precautions to avoid it, then consult with your healthcare professionals about your individual case before starting antenatal expression as it may be considered to increase your risk of going into labour.
You can read more about antenatal expression here.

If there is time before your baby arrives, someone from the paediatric team on the neonatal unit where your baby will be cared for should come and talk to you about how you plan to feed your baby. You can supply them with any expressed colostrum you have in a labelled container, and discuss how you wish your baby to be fed while you are establishing your milk supply.

Some neonatal units will have access to donor breastmilk, and will be able to tell you if your baby will be eligible to receive this - as supply is limited, this is likely to be restricted to the babies who need it the most. They will discuss and get your consent if formula may need to be given while you are building your milk supply. This may also be the time to talk about how you want supplementary feeds to be given to your baby.

Smaller or weaker babies will be given a nasogastric tube, to allow milk (your own, donor or formula) to be fed down the tube. Bigger and stronger babies may be given bottles. You may wish to discuss paced bottle feeding (the art of giving bottle feeds in a way that supports breastfeeding) or cup feeding.

If you wish to express breastmilk for your baby, then your hospital should be able to provide you with a breastpump - asking for this before your baby is born means that you have it ready as early as possible. In the early days you need to be stimulating milk production in your breasts between eight and twelve times in twenty four hours, including at least once at night - this might be by your baby feeding effectively at the breast, or pumping sessions.

To read more about successfully expressing breastmilk, click here.

Your premature newborn

When you baby arrives there is likely to be a sudden rush of activity as your baby is checked and stabilised. They may be rushed off to the neonatal unit leaving you feeling stranded in the delivery unit. Be kind to yourself. You may feel that starting to express milk is a practical way that you can be involved in their care even when you are apart from each other. There is evidence to show that if you start expressing within the first hour after birth it can have a long term positive effect on your milk supply.

Establishing breastfeeding

You may be expressing on your ward (if you are still an inpatient) or on the neonatal unit. Many mothers find that being close to their babies while they are expressing can help to increase the amount that they are able to express. If you are separated, looking at photos of your baby can help or smelling something that has been close them.

If you are expressing on the unit, you may wish to be close to your baby as you do so. Some mothers use screens for privacy. You can ask for these to be provided. You don't have to use screens if you prefer not to - using scarves or nothing at all is a completely acceptable choice. Do what you feel comfortable with and helps your milk to flow easily. Listening to music may help you to relax and increase your milk production.

You are the person most known and familiar to your baby. Being with you is the safest and most secure they can possibly feel. If your baby is very fragile they may not be able to come out of their incubator at first. Ask the staff how you can be involved in their care and to show you how to hold and comfort them through the vents in the incubator. Once your baby is able to come out of the incubator, then kangaroo care can become an important part of your time together. This is where your baby is placed skin to skin on your chest for as long as possible and a blanket put over both of you. Your baby is able to enjoy the sensations of your closeness and the deep relaxation and comfort they feel helps them to regulate their breathing, temperature and other health indicators. It also helps your breast to become a familiar environment and allows them to practise feeding directly from the breast easily.

It used to be thought that babies under a certain gestation didn't have the ability to suck and swallow, or that directly breastfeeding was tiring to them. Happily, more recent studies have disproved these concerns. Once babies are well enough to breathe unaided (off ventilation and continuous positive airway pressure - CPAP), they can be brought to the breast. Smaller and younger babies will still need to have some of their milk given to them via tube feeds, but this allows you and your baby to learn to breastfeed together without a feeling of pressure.

Smaller babies have smaller mouths and lower muscle tone. This may mean you need extra support to get breastfeeding established. Seek skilled help early and often. Keep asking until you find someone who is able to support you effectively.

Premature babies often find it easier to feed in laid back breastfeeding positions. This is where you are supported in a reclined position with your baby tummy down on top of you. This helps gravity to 'stick' your baby to you and stops them slipping off. If you need to sit in a more upright position, then supporting the whole length of your baby's body close to yours with a hand behind their shoulders means they don't have to support their weight and stops them from curling in on themselves. Read more about laid back breastfeeding here.

You may find that your baby quickly falls asleep when breastfeeding. This isn't a sign that you are exhausting them, but that they are small and being soothed. You can help them to stay awake for longer by washing their face with cool water, gently blowing on them or tickling their feet. You may find that breast compressions - gently smoothing down your breast towards the nipple - helps your baby to stay alert and interested in feeding as this makes the milk flow more quickly and easily for them.

All new babies need to feed frequently - and premature babies are no different. The volume of milk that their stomachs can take at each feed is very small, and breastmilk is easily digested. It is normal for babies to feed between 8-12 times in a 24 hour period, including at least once at night.

Neonatal unit staff need to be able to ensure that all the babies in their care are receiving the right amount of milk for them to grow. Premature or sick babies may be less able to communicate their need for milk. These two things combined mean that units often use feeding schedules, with feeds timetabled every two, three, or even four hours.

When you agree how often your baby is to be offered supplemental feeds (any milk not directly from the breast) it may be helpful to remember that four hourly is less frequently than you would expect a healthy, full term newborn to feed. You may also choose to consider these as 'backup' feeds - any time spent feeding directly from the breast doesn't reset the clock, but is bonus extra calories. Keep writing down how often you are breastfeeding in your baby's notes, as this may help you and the staff to feel confident about the transition from scheduled, measured feeds, to baby led, responsive feeding.

One of the things the unit staff will look for in a baby coming close to going home is that your baby is able to rouse themselves to feed. If your baby is waking for feeds more often than their feeding 'schedule' (and you are spotting signs of effective feeding), this may be a sign that they are becoming better able to manage their own need for milk. You will probably need to keep offering more frequently than they ask for milk - this is true for many babies. Remember, you can't feed too often, and your baby can always say no if they don't want milk right now!

Breastmilk is an incredibly responsive food, made specially for each baby. The milk that you are making for your premature baby will be even more densely nutritious than the milk of a full term mother. Every drop of milk that you can supply for your baby is like medicine - strengthening and building their immune system and providing the calories they need to grow. Some mothers feel that providing milk for their babies is a unique way that they can care for their babies. It can be an important part of bonding with a new and fragile baby. While your baby will continue to benefit from your milk for as long as you provide it, you aren't tied to expressing for longer than you want to do so. If you decide it's time to stop, then gradually reducing your pumping sessions will slow and stop your milk production without causing problems for you.

Looking after your own heath and wellbeing

You will be recovering from pregnancy and birth, and may be experiencing additional health problems. It is important to remember to look after yourself - the more smoothly your recovery goes, the more strength and energy you will have to become more and more involved in your baby's care. If you have older children at home, you may be struggling to balance meeting their needs with being present with your newborn. Many mothers have to leave hospital long before their baby is ready to come home and have to travel back and forwards to be with their baby. This is a time to say yes to as many offers of help as you possibly can. If someone can provide a lift, deliver a meal, entertain an older child or do a load of washing - or just sit with you to talk things over in the hospital cafe - these may make life a little easier for you and help you to keep going at a difficult time.

You may be taking medications yourself and be concerned about them passing through your milk. Discuss your concerns with your and your baby's medical teams. They may be able to reassure you or find suitable alternatives. For specialist information about whether a drug is compatible with breastfeeding, you can contact your local LLL Leader who has access to resources and professional support.

It may feel impossibly painful to keep leaving your baby. Remember that by looking after yourself - eating, sleeping and taking the medication you need to get well - you are making sure that you carry on being able to be there to look after your baby.

Taking your breastfed baby home

Separately to any health issues your baby may be facing, your neonatal unit will want to know that you are able to make sure your baby is getting enough milk to continue growing. Being aware of your baby's early hunger cues is important so that you can feed responsively and before baby gets too upset. You may have a very sleepy baby who still needs your help to wake themselves up to feed beyond their due date. Setting an alarm for the middle of the night can help you to make sure they don't go for longer than a four hour stretch without feeding at night.

Read more about recognising early hunger cues and about waking a sleepy baby here.

Read more about how to tell if your baby is getting enough milk here.

Many breastfeeding mothers and babies enjoy safe cosleeping. Premature babies are at greater risk of Sudden Infant Death Syndrome or Sudden Unexplained Death in Infancy (SIDS/SUDI). While they will benefit from sleeping close to their mother, premature babies should sleep on a separate, firm surface such as a sidecar cot.

It can be scary to make the transition from caring for your baby in hospital with a team of staff around you, to being at home. Your healthcare professionals are likely to make extra visits to support you and to keep an eye on your baby's weight gain. You may find that being home together, able to stay together all the time, and in a comfortable environment, you rapidly get to know and understand your baby more easily and become more confident in your mothering skills.
Photo credits: Olivia Brown and other mothers
Other resources

You can read a mother's story about mothering her premature baby through special care

This video looks at breastfeeding in the first hour after birth

The drugs in breastmilk service, while not an LLL resource, gives quick access to information from a qualified pharmacist

The Small Wonders films follow families through their experiences of having a baby on a neonatal unit

Global Health Media have a series of videos about various aspects of life with a small baby

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Successfully breastfeeding your premature baby - La Leche League GB

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

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Warwickshire 0-5 Services :: South Warwickshire University NHS Foundation Trust

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The Warwickshire 0-5 service includes Health Visiting, Infant Feeding, Family Nurse Partnership, and Stop Smoking in Pregnancy, provided by the South Warwickshire University NHS Foundation Trust.

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Breastfeeding is intended to be comfortable and enjoyable-so experiencing painful or sore nipples is a clear sign that something isn't quite right. The information should help you identify the most likely cause of your discomfort and take steps to resolve it.

Whilst there are a number of causes of nipple pain, by far the most common is poor attachment at the breast. Almost always the first step is to try to improve your baby's latch-on. Experiment with different ways of holding your baby and also try letting your baby take the lead: sitting in a semi-reclined position and placing your baby on your front triggers his instinctive feeding reflexes ( laid-back breastfeeding). If improving attachment brings no relief then you may need to consider other causes.

An LLL Leader can tell you more about specific causes and treatments, and further information can be found in our other pages linked below.

You can get skilled help from an LLL Leader online, by calling your local Leader or our national helpline, or through one of our breastfeeding support groups. Getting support and encouragement from other breastfeeding mothers in your local LLL Group may be a real help. The sooner you seek help, the easier it usually is to resolve the problem.

Pain on latch-on that improves as milk starts flowing, caused by:

Holding your breast between your index and middle fingers while latching on, too close to the nipple - Try supporting your breast between your thumb and fingers, keeping your fingers well back from the areola. Sometimes shaping your breast slightly to match the oval of your baby's mouth can help. Or try laid-back breastfeeding, which reduces the need to hold your baby, leaving you with both hands free to shape your breast and help him latch.

Slow let-down of milk - At the start of a feed use gentle massage, relaxation, hand expression and breast compression to get milk flowing before or as your baby latches on.

Pain throughout feed, stops when baby comes off, caused by:

Baby is using tongue incorrectly having become used to bottle teat or dummy -Avoid using teats or dummies. See Nipple Confusion? and Dummies and Breastfeeding

Baby is using his tongue incorrectly possibly due to a tongue-tie (ankyloglossia) - Seek skilled breastfeeding help to assess your baby for tongue-tie. Ask for a referral for assessment and treatment if necessary.

Pain as baby comes off, caused by:

Suction not broken when taking baby off - put a clean finger between your baby's gums to break the suction if you need to remove him from the breast.

OK at first, painful as feed progresses.

Attachment has slipped during feed perhaps because either your breast or your baby has dropped into a lower position - Sit or lie comfortably with your body and arms supported. Keep your baby's whole body against yours. If you recline, some or all of his weight can be supported by your body so your arms aren't holding his entire weight throughout the feed. Let your breast rest at its natural level and bring your baby to breast, not breast to baby. Experiment with different breastfeeding positions and seek further help from an LLL Leader.

Stabbing pains in the breast throughout feed and afterwards.

Raynaud's phenomenon. This is where blood vessels narrow, associated with cold - Eliminate other causes first, especially if breastfeeding has always been painful or your nipples are flattened or wedge-shaped after feeds. Seek medical assessment. Keep warm and avoid nicotine and caffeine, which can be triggers.

When baby is around 3 months or older.

Shallow latch because baby has grown and positioning has not been adjusted - Adjust how you hold your baby so he can latch more deeply onto the breast. Seek further help if needed.

- Offer your baby something cold to chew on before breastfeeds.

Baby bites to get your full attention or clamps down as he releases the breast at the end of a feed - Give your baby your full attention while nursing and have a finger ready to break suction at end of feed if needed.

Skin of nipple reacting to food particles present in baby's mouth - Rinse baby's mouth with water before nursing; avoid offering that particular food for a while.

Hormonal changes associated with pregnancy or your period can increase nipple sensitivity - Hand express to get milk flowing and vary nursing positions. A toddler may be willing to nurse for shorter times until the discomfort decreases.

Nipple shaped normally but pain experienced, commonly at the tip of the nipple.

Breastpump suction too high or pump flange poor fit - Reduce suction or vacuum to a comfortable level. Moisten the flange of the breastpump. Centre your nipple in the flange and/or try a different sized flange. Use breast massage and hand expression to encourage milk to flow. Lubricate your nipples and areolae with purified lanolin suitable for breastfeeding mothers.

Nipple not so prominent-baby having difficulty latching on.

Nipple looks white and misshapen or wedge shaped when baby comes off; pain during and after feeds.

Nipple turns white, possibly bluish, then red.

Raynaud's phenomenon. May experience similar symptoms in fingers and toes, associated with cold - Seek medical assessment. Keep warm and avoid
nicotine and caffeine, which can be triggers.

Soreness or crack in line with the position of your baby's lower lip.

Shallow attachment and/or your baby's lower lip is sucked in - Use your fingers to ease your baby's lower lip out. Take steps to help your baby latch more deeply. Avoid pressure on the back of your baby's head.

Crack across or beside nipple that may or may not bleed.

Crack that weeps or crusts.

Possible infection -Visit your GP who may prescribe an antibiotic. Change breastpads frequently and wash affected area daily with a mild, unperfumed soap.

Nipple area red and/or itchy. Burning sensation and/or flaky skin.

Irritation due to contact with detergent or toiletries, or from clothing rubbing - Identify the cause of the irritation Wash nipples with plain water, avoiding soaps and other toiletries, including proprietary nipple sprays, creams and lotions.

Eczema, dermatitis, psoriasis or impetigo - Seek treatment from your GP.

A blister or white spot on your nipple which may/may not be painful.

Milk blister or 'bleb'. Thickened milk may block milk flow near the opening of the nipple or a thin layer of skin may block the milk duct opening - Apply moist heat using warm compresses or soak the nipple in warm water. Then compress the nipple behind the blockage to try and express the blockage. If this does not bring quick relief seek medical help.

Written by Karen Butler and Sue Upstone and mothers of LLLGB

Further Reading

Positioning & attachment
Comfortable Breastfeeding
Engorged Breasts - avoiding and treating
Hand Expression of Breastmilk
Inverted Nipples?
Nipple Confusion?
Nipple Shields?
Positioning and Attachment (link to a Kindle publication)
Too Much Milk
Tongue-tie
Treating Thrush

The Womanly Art of Breastfeeding. LLLI. London: Pinter & Martin, 2010.
Breastfeeding Answers Made Simple. Mohrbacher, N. Amarillo, TX: Hale Publishing, 2010.

LLLI Resources
Breastfeeding with Sore Nipples
Other websites
Biological Nurturing™
This information is available to buy in a printed form from the LLLGB Shop

Copyright LLLGB 2016

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Breastfeeding is intended to be comfortable and enjoyable-so experiencing painful or sore nipples is a clear sign that something isn't quite right. The information should help you identify the most likely cause of your discomfort and take steps to resolve it. Whilst there are a number of causes of nipple pain, by far the most [...]

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This information was updated in December 2022. A PDF version is available here.

"I was surprised by how suddenly I felt ill. We went to a wedding and I only missed one feed.
Within a couple of hours I felt fluey and achey. My GP was reluctant to prescribe antibiotics,
saying they were often not needed if I kept feeding. I also took ibuprofen tablets which helped
me cope. I was surprised how well the self-help worked and that I never needed a prescription.
I felt very miserable and depressed when I had the symptoms, wondering whether
breastfeeding was worth all this - but once I felt better I remembered how good it feels."

Mastitis means inflammation of the breast.

The first sign of mastitis is a swollen usually painful area on the breast. On darker skin tones
there might be a darkening of the skin and on lighter skin tones this might be visible as a red
area on the breast. However, it is important to note that there could be no visible change in
skin colour at all. The inflammation and swelling is not always a sign of infection (WHO, 2000).
Harmful bacteria are not always present: antibiotics may not be needed if self-help measures
are started promptly. Very rarely mastitis can develop into a more serious condition which
needs urgent hospital admission and IV antibiotics (RCOG, 2012).

You may get mastitis when milk leaks into breast tissue from a blocked duct. The body reacts
in the same way as it does to an infection - by increasing blood supply. This produces the
inflammation.
NB You may not have all of the above signs during mastitis.
Prevention of Mastitis

A localised area in the breast which is painful to the touch, often in the outer upper
area. Some mums might notice a change of colour or a red area on their breast.

A lumpy breast which feels hot to touch.

The whole breast aches and may appear swollen and skin may be reddened or darker,
depending on skin tone.

Flu like symptoms - aching, increased temperature, shivering, feeling tearful and tired
(Jahanfar et al., 2013). This feeling can sometimes start very suddenly and get worse very quickly.

Signs that the Baby is Well Attached

Try to avoid suddenly going longer between feeds. If you are intending to reduce breastfeeding, cutting down gradually reduces the risk of mastitis.

Make sure your breasts don't become overfull

Avoid pressure on your breast from clothing and fingers

Start self-help measures at the first sign of any lumpy or swollen areas on your breast

Factors which make mastitis more likely:

Difficulty with attaching your baby to the breast - this may mean that the milk is not

being removed effectively and milk may leak into the breast tissue

Pressure from tight fitting clothing, particularly your bra, or a finger pressing into the

breast during feeds

Engorgement or a blocked duct

Sudden changes in how often the baby is feeding, leaving the breasts feeling full

Injuries, such as bumps or knocks from toddlers

Self-Help Measures
Mastitis starts with poor milk drainage. If your baby is not effectively attached to your breast,
or has difficulty feeding, it may be hard for the baby to remove the milk and some parts of
your breast may not be drained during a feed. Improving the way your baby is attached at
the breast will reduce the chance of you getting mastitis again. If in doubt, contact your
midwife, health visitor or breastfeeding peer supporter for help with attaching your baby for
feeding. You can also contact the National Breastfeeding Helpline.

Your baby's chin is firmly touching your breast.

Your baby's mouth is wide open

Your baby has a large mouthful of breast.

If you can see the darker skin around your nipple, you should see more dark skin above your baby's top lip than below your baby's bottom lip.

It doesn't hurt you when your baby feeds (although the first few sucks may feel strong).

No change in shape or colour of the nipple after feeds e.g. it should not be lipstick shaped or have a pressure line across the nipple

Your baby's cheeks stay rounded during sucking.

Your baby rhythmically takes sucks and swallows (it is normal for your baby to pause from time to time).

Your baby finishes the feed and comes off the breast on his or her own.

Your baby produces 6 or more heavy wet nappies every 24 hours (from 7 days old)

Your baby produces at least two yellow poos at least the size of a £2 coin every 24 hours (from 7-28 days old). See UNICEF's breastfeeding checklist for more details.

If your mastitis comes back after you have taken a full course of antibiotics, or is unusually severe, it is good practice to send a sample of milk for bacteria tests. This will help the GP chose the correct antibiotic for your symptoms (Jahanfar et al., 2013). For public health reasons doctors try to avoid antibiotics that are not essential or are unlikely to be effective. It is important that you finish the whole course of antibiotics to make sure that you recover fully and to help prevent the mastitis coming back with resistant bacteria (NICE NG15).
When should I contact my GP or health visitor? If you do not begin to feel better after 24 hours despite using self-help measures, or especially if you start to feel worse, you should speak to your GP or health visitor. You may need to take antibiotics.
These will also help to clear blocked ducts and engorgement. Most cases of mastitis can be improved or resolved with self-help measures.
When should I seek help urgently?

Keep on breastfeeding - you may feel ill, in pain, tearful or discouraged but continuing to breastfeed will help you to get better, and your breastmilk is still the best food for your baby

Feed your baby frequently and responsively (whenever your baby seems like they want to feed), and/or pump to your normal routine (Mitchell et al., 2022; Douglas 2022)

Don't attempt to "empty the breast" by prolonging feeds or expressing extra milk between feeds. You may see this suggested in some places, but the current research suggests you should aim to meet your baby's needs, but avoid increasing your supply beyond that as it could make the inflammation worse. (Mitchell et al., 2022; Douglas 2022)

Try to rest as much as you can, as this will help you recover

Check that your baby is effectively positioned and attached to your breast - if in doubt seek help from your midwife, health visitor or breastfeeding supporter, as even a minor tweak can make a difference.

Try feeding with your baby in different positions.

If necessary, soften your breast, by expressing a little milk or running warm water over it, so that the baby finds it easier to feed well.

Some mothers find warm compresses are soothing, and warmth on the nipple can aid let-down. However, take care using these as compresses that are too hot or used frequently could increase swelling and inflammation. Cool compresses may ease symptoms in between feeds. (Mitchell et al., 2022; Douglas 2022)

Avoid any firm pressure or massage to the breast, or use of items such as an electric toothbrush to massage lumps or sore areas. This could cause tissue damage and increase inflammation (Mitchell et al., 2022; Douglas 2022). Any pressure you apply to your breast should be no firmer than stroking a cat.

Check for clothing or anything else which is pressing into your breast. This includes a bra - some women find it helpful to go without.

Medical Treatment for Mastitis
If you feel these symptoms beginning again, start self-help measures right away.

You should contact your GP if the area becomes round and swollen or, if you can see redness or a change of colour on your skin and the pattern of the colour change/redness changes. Redness may be less visible on darker skin tones. Mastitis can develop into an abscess (a painful collection of pus). There is more information about this here: https://www.nhs.uk/conditions/breast-abscess/.
The World Health Organisation (WHO) recommend Flucloxacillin 500 milligrams four times a day as first line treatment with erythromycin 250-500 milligrams four times a day or cefalexin 250-500 milligrams four times a day if the mother is penicillin allergic. Other options have been suggested by Jahanfar et al., (2013).
If you feel seriously unwell, dizzy, confused, develop nausea, vomiting or diarrhoea or slurred speech along with the symptoms of mastitis you need to seek urgent medical attention. These can be signs that mastitis is developing into sepsis. If severe, this is a medical emergency which needs urgent hospital admission and IV antibiotics. (NHS Choices: Sepsis, RCOG, 2012:6.1)

This information comes from the Drugs in Breastmilk Service.
References

Ibuprofen reduces the inflammation, relieves pain and reduces temperature. Take 400mg three times a day after food. Ibuprofen should not be taken by women who have asthma, stomach ulcers or are allergic to aspirin. The levels of ibuprofen which pass to the baby are small. Ibuprofen is safe to take whilst breastfeeding. See https://www.breastfeedingnetwork.org.uk/analgesics/ for more information.

Paracetamol relieves pain and reduces temperature but has no anti-inflammatory action. Take two 500mg tablets four times a day.

Aspirin should not be taken by breastfeeding mothers.

Antibiotics may be needed if no improvement is seen with self-help measures. Mostantibiotics can be safely taken whilst breastfeeding.

It is essential that breastfeeding is not interrupted during mastitis.

Note: Antibiotics can make the baby produce loose, runny motions and become irritable, colicky and restless. This lasts for a short time and will get better when you finish the antibiotics.

Jahanfar S, Ng CJ, Teng CL. Antibiotics for mastitis in breastfeeding women. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD005458. DOI:10.1002/14651858.CD005458.pub3 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005458.pub3/abstract (accessed 19 November 2020)

Crepinsek MA, Crowe L, Michener K, Smart NA. Interventions for preventing mastitis after childbirth. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD007239. DOI:10.1002/14651858.CD007239.pub3. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007239.pub3/full (December 2022)

Hale T., Medications and Mothers' Milk 2014 (16th Ed),

NICE guideline [NG194] Published: 20 April 2021 https://www.nice.org.uk/guidance/ng194/chapter/Recommendations (accessed December 2022)

World Health Organization. 2000, Mastitis: causes and management, WHO: Geneva http://apps.who.int/iris/bitstream/10665/66230/1/WHO_FCH_CAH_00.13_eng.pdf?ua=1.(accessed December 2022)

NICE guidelines [NG15] Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use www.nice.org.uk/guidance/ng15 (accessed December 2022)

NHS Choices: Sepsis www.nhs.uk/conditions/Bloodpoisoning/Pages/Introduction.aspx (accessed December 2022)

Royal College of Obstetricians and Gynaecologists (RCOG) (2012) Green-top Guideline No. 64b. Bacterial Sepsis following Pregnancy: 6.1. www.rcog.org.uk/globalassets/documents/guidelines/gtg_64b.pdf (accessed December 2022)

Unicef: https://www.unicef.org.uk/babyfriendly/wpcontent/uploads/sites/2/2016/10/mothers_breastfeeding_checklist.pdf (Accessed December 2022)

Mitchell, K. B., Johnson, H. M., Rodríguez, J. M., Eglash, A., Scherzinger, C., Zakarija-Grkovic, I., Cash, K. W., Berens, P., Miller, B., & Academy of Breastfeeding Medicine (2022). Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022 Breastfeeding medicine : the official journal of the Academy of Breastfeeding
Medicine, 17(5), 360-376. https://doi.org/10.1089/bfm.2022.29207.kbm
Please note this information is not yet available in print. The previous print version has now been withdrawn and should no longer be used. A new print version is planned for 2023.
Douglas P. (2022). Re-thinking benign inflammation of the lactating breast: Classification,
prevention, and management. Women's health (London, England), 18, 17455057221091349.
https://doi.org/10.1177/17455057221091349

Original leaflet compiled by Wendy Jones MBE Pharmacist and Phyll Buchanan
Breastfeeding Network Supporter and Tutor, in 2015. With thanks to Magda Sachs who
developed earlier versions

This version revised 22 December 2022.

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Information on mastitis and breastfeeding, updated December 2022 and provided by the Breastfeeding Network

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How to make up a bottle of formula milk for your baby | Infant Feeding Team

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A triple feeding plan is sometimes recommended if your baby isn’t able to breastfeed effectively, if there is excessive weight loss, or low milk supply. Our staff will support you with this if this is needed.

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A triple feeding plan is sometimes recommended if your baby isn’t able to breastfeed effectively, if there is excessive weight loss, or low milk supply. Our staff will support you with this if this is needed.

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Learning you are pregnant with twins, triplets or more changes your expectations and plans. But you can still plan to breastfeed. Breastmilk is a complete and perfect food for your baby. It is especially important for multiples, who are often small at birth. Breastfeeding also helps you create a spe…

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Manual therapies can be considered where there are feeding difficulties. 

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Manual therapies can be considered where there are feeding difficulties. 

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The aim during treatment will be, for example:

To relieve the compressions that occur whilst the baby is growing within the womb (uterus), particularly in the later months when space becomes restricted.

To relieve stresses and traumas that might result from the birth process, for example awkward presentations that require interventions such as forceps or ventouse can create trauma in the neck and head areas.

To improve the motion of the thoracic cage which houses the heart and lungs so that breathing is easier.

To improve the movement of the upper neck area so that the nerves that facilitate feeding are not impinged and the baby can physically and comfortably get their head into the right position for feeding, on both right and left side.

Manual Therapy and Infant Feeding (tongue-tie.org.uk)

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There are several healthcare professions that use manual therapy as their modality for treating the human body. Manual therapy is the hands-on method of treating the body, rather than a drug-based approach. The therapist uses a variety of techniques to support the tissues and help return function to a normal level when there has been injury or changes to the areas involved.

The techniques used can have different names depending upon the profession using them, but in general they include:

Mobilising a joint: taking it through a range of motion to promote full use, to ease ligamentous, capsule or muscular restrictions to full movement.

Soft tissue techniques: massage, stretching, inhibition, cross-fibre.

Active tissue techniques: asking the patient to work against the therapist e.g. Muscle Energy Technique.

Nerve stretching: proprioceptive neuromuscular facilitation stretching.

High Velocity/Low Amplitude Thrust: the "clicking" or "popping" noise of a joint when it is adjusted to regain motion.

Cranio-Sacral Techniques and Sacro-Occipital Technique: these are generally very subtle, "quiet" and gentle techniques. This first was developed within Osteopathy and is an extension of osteopathic principles aimed at releasing adverse tension in the tissues of the skull, meninges and other connective tissue, and can be applied to other joints in the body too. The latter is the extension of Chiropractic philosophies and looks at more subtle mechanical ways of dealing with chiropractic "subluxation" patterns. Both of these approaches are popular for use in treating babies and they involve very little strong force to be applied to the body.

Most osteopaths and chiropractors who treat babies have undertaken extensive post-graduate studies in order to gain an in-depth knowledge of the embryological development of the baby. This will include the anatomy of the nerves, vessels, bones, joints and muscles relating to the brain, head, face, neck, back and body and organs during development. They understand the stages of development during embryonic life, the process of birth and the interventions or traumas that may occur during birth, and the developmental stages during the early years of life.

The aim during treatment will be, for example:

To relieve the compressions that occur whilst the baby is growing within the womb (uterus), particularly in the later months when space becomes restricted.

To relieve stresses and traumas that might result from the birth process, for example awkward presentations that require interventions such as forceps or ventouse can create trauma in the neck and head areas.

To improve the motion of the thoracic cage which houses the heart and lungs so that breathing is easier.

To improve the movement of the upper neck area so that the nerves that facilitate feeding are not impinged and the baby can physically and comfortably get their head into the right position for feeding, on both right and left side.

For the mother, osteopaths and chiropractors may assess:

The pelvis to reduce the symptoms of pelvic girdle pain (symphysis pubic dysfunction) that can make walking and daily activities very painful and awkward.

The parts of the thoracic cage (ribs and spine) that relate to the nerves that supply the breast and in turn control the milk supply and milk ejection reflexes.

The mothers muscles and joints to improve their function can help ensure that mother can achieve comfortable positions for birthing, for feeding, for sleeping.

Important Note:

In the United Kingdom there is increasing legislation to protect the general public and to ensure that health practitioners are adequately trained (to B.Sc. degree level or above), insured and continuing their professional development (ongoing training; CPD). Certain professions have their own governing body that regulates the training courses and the individual practitioners on the register, for example, Osteopaths are regulated by the General Osteopathic Council, Chiropractors by the General Chiropractic Council, whilst other professionals, e.g. Physiotherapists, are required to register with the Health and Care Professions Council that regulates many other professions too.

In law, these professional titles are protected and it is a criminal offence to use them if the practitioner is not registered with the relevant governing body.

The protected titles include the following:

However, there are several practitioners of manual therapy who do not enjoy the same legally protected status, but may well be trained to a high level or have a great deal of experience within their chosen field. It is the individual choice of the member of the public who chooses to use a non-regulated person to ensure the level training and experience is to their satisfaction and to be aware that whilst these practitioners may be a member of an association, it is not a governing body that has recourse within law to protect the public. For example, titles commonly seen include massage therapists, physical therapists, manual therapists and cranio-sacral therapists. Where nurses and midwives provide manual therapies they are still regulated by the Nursing and Midwifery Council in these roles.

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Manual Therapy | Infant Feeding | Tongue-Tie Practitioners

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Learn about the role of manual therapy in helping babies with feeding difficulties | Discover how manual therapy techniques can support infant tongue-tie and improve feeding comfort | Association of Tongue-Tie Practitioners

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Inducing lactation and breastfeeding without giving birth

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Inducing lactation and breastfeeding without giving birth

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Alyssa Schnell, St. Louis, Missouri, USA
Alyssa Schnell is an International Board Certified Lactation Consultant (IBCLC) based in the United States. She speaks internationally about inducing lactation and relactation and specializes in helping parents who have not given birth (non-gestational parents) to breastfeed their babies. In this article Alyssa discusses how parents who have not given birth can breastfeed by inducing lactation and how La Leche League Leaders can support them.
Breastfeeding is a special gift a baby receives from their gestational parent. However, many non-gestational parents-adoptive parents, intended parents (through surrogacy), parents whose partner is birthing, and transwomen-are finding out that this wonderful experience is also available to them. Because parents who haven't given birth do not have the hormones of pregnancy to get their bodies started with making milk, they need more information and support to make breastfeeding a reality.

Why Would a Non-Gestational Parent Choose to Breastfeed or Chestfeed?

Attachment. Breastfeeding helps the parent and baby form a secure attachment, a particular concern when babies are separated from their gestational parent or gestational carrier (in surrogacy).

Nutrition. Human milk provides the optimal nutrition and necessary immunities for human babies.
Healing. Breastfeeding can help heal the heartache of infertility, and provides a biological connection between mother/parent and baby. Breastfeeding is much more than breast milk. Breastfeeding is a close, intimate, physical and emotional relationship between two or more people who love each other.

Sharing. When both parents are breastfeeding, they share the caregiving role.

Facts about breastfeeding without birthing

Women have breastfed babies they did not birth throughout history. With the easy availability and common use of bottles and infant formula in modern developed countries, culture has largely lost track of how breastfeeding can also be an option for non-gestational parents.

Non-gestational parents can start preparing for breastfeeding as soon as they decide to grow their family, after an adoption match has occurred or once their partner or gestational carrier is pregnant. They can even wait until the baby is in their arms.

The amount of milk produced when inducing lactation can vary widely. While some parents make no milk and others make all the milk their babies need, most will make a partial milk supply. Fortunately, breastfeeding is possible no matter how much or little milk is produced-even if it is none at all! Human milk feeding can be simulated with a nursing supplementer: a bag or bottle that holds human milk or formula carried to the nipple via a tiny feeding tube. Parents who are not making any milk may also choose to feed with a bottle while their baby comforts and connects with them by suckling at the (dry) breast.

Newborn babies are wired to initiate breastfeeding, but with gentle and patient encouragement, along with a few handy tools and techniques, even older babies can learn to breastfeed.

Some mothers will take medications or herbs to help them make more milk, but this is not essential. The only necessary component to induce lactation-the official term for making milk without pregnancy and birth-is to stimulate and drain the breasts. That stimulation or emptying can happen with baby breastfeeding, with an electric breast pump, or using a variety of manual techniques.

The composition of milk produced by inducing lactation is comparable to that produced following birth., The milk does not contain dangerous levels of artificial hormones-in fact, it very rarely contains any artificial hormones at all. In most cases, the only artificial hormones that are taken are estrogen and/or progesterone before there is milk production (Step 1 below.) Progesterone and estrogen levels are high during pregnancy and taking these hormones artificially may help to make the body think it is pregnant. Estrogen and progesterone play a role in breast development in pregnancy.

It is not necessary to be fertile-or even to have ovaries or a uterus-to breastfeed. The hormones responsible for milk production (prolactin) and milk ejection (oxytocin) are released from the pituitary gland located at the base of the brain.

Both parents, whether or not one has given birth, can share the breastfeeding role. This is called co-nursing.

Step 1: Preparing the Breasts for Lactation
How to induce lactation
Step 2: Starting to Make Milk Before Baby Arrives
As stated above, the primary way to induce lactation is through breast emptying: breastfeeding, pumping, or hand expression. The effectiveness of these physical techniques can be enhanced with the use of galactogogues: medications, herbs and homeopathic remedies that support the production of milk. These tools can be put together in a variety of ways to be effective and applicable to each individual parent. While the use of medications, herbs or homeopathic preparations is an individual choice, parents should always discuss their individual situation with their health care providers.
Step 3: Feeding Baby and Continuing to Grow Milk Production
Generic protocols are available (such as Dr Jack Newman's protocol) or an experienced International Board Certified Lactation Consultant (IBCLC) can work with parents to develop a personalized protocol customized to meet their specific health history, circumstances, and values. The process can be broken down into three steps:

This step mimics the hormonal and breast changes that occur during pregnancy. This step is not about making milk; it is about growing and developing the glandular breast tissue in preparation for making milk. Many parents will take hormone therapy for a period of time to achieve this. However, this step is optional.

Milk is often produced very, very slowly when lactation is induced compared with the sudden increase in milk supply between days 3-5 following birth. In order to have a milk supply by the time baby arrives, parents will often start the process of growing their milk production several weeks or months before. The main component of Step 2 for many parents is frequent pumping. Ideally, parents will express their milk as frequently as a baby nurses-just like for birthing parents, frequent breast drainage "places the order" for healthy milk production. Parents can store any milk they produce for use when baby arrives.

This is the big payoff! Baby is here and the parent can begin feeding baby their milk. This step generally involves putting baby to breast.

Not every parent's protocol will use all three steps. Each parent's needs and circumstances determine which steps will be appropriate for them. For most parents with adequate information and support, milk production begins within 6-8 weeks of beginning the process of inducing lactation.

What is the role of a La Leche League Leader?

Although extremely rewarding, inducing lactation can be a challenging breastfeeding situation. Mothers/parents need and deserve all of the support they can get. While working with an International Board Certified Lactation Consultant (IBCLC) is highly recommended, La Leche League Leaders can also play a very valuable role. As always, Leaders provide essential information and encouragement. More specifically, La Leche League Leaders may:
Alyssa Schnell has been helping parents and babies with breastfeeding for the past 17 years, first as a La Leche League Leader and now as an International Board Certified Lactation Consultant (IBCLC). Her private practice, Sweet Pea Breastfeeding Support, provides individual lactation consultations either in person or by phone or video-conference for parents throughout the United States and beyond. Alyssa is also the co-host of the Breastfeeding Outside the Box podcast, which is devoted to families breastfeeding or chestfeeding in extraordinary situations. Alyssa enjoys working with all parents and babies, but she has a special place in her heart for helping non-gestational parents to breastfeed/chestfeed their babies. She is the author of Breastfeeding Without Birthing: A Breastfeeding Guide for Mothers Through Adoption, Surrogacy, and Other Special Circumstances and is an international speaker on the topics of inducing lactation, relactation, and other related topics. Alyssa lives in St. Louis, Missouri, USA and is the proud mother of three breastfed children-two by birth and one by adoption.

Refer parents to resources on inducing lactation (see below).

Provide support for inducing lactation.

Facilitate La Leche League Group meetings where older babies who are bottle-feeding can observe breastfeeding babies, and parents can participate in a breastfeeding culture. Group meetings are also opportunities for parents to connect with other mothers who are nursing in a variety of situations.

Facilitate healthy social media information and interaction.

Share information about donor milk.

Breastfeeding without birthing may not be easy, but it is possible and it is powerful. La Leche League Leaders can be part of the team supporting these parents and their babies.

Resources for La Leche League Leaders and parents

Some notes about language: The term "gestational" is used throughout this article instead of "biological." In surrogacy, the intended mother is often the biological mother (baby is often conceived with her egg) even though she is not gestating (pregnant with) the baby. And oftentimes same-sex female couples will conceive baby via in vitro fertilization (IVF) using the egg of one parent (biological parent) implanted in the uterus of the other parent (gestational parent). This article also attempts to use gender-inclusive language such as parent versus mother and breastfeeding/chestfeeding versus breastfeeding. Some of the parents referred to in this article may be cis male, trans male, or non-binary.

Note: inducing lactation with medication should not be started unless the parent has an approximate timeline for their baby's arrival. Taking medication without a definite end could be hazardous.

Other manual approaches might include breast massage, nipple manipulation (gently pulling out and twisting of the nipple), and a partner suckling.

Kulski, J. K., Hartmann, P. E., Saint, W. J., Giles, P. F., & Gutteridge, D. H. (1981). Changes in the milk composition of nonpuerperal women. American journal of obstetrics and gynecology, 139(5), 597-604.

Perrin, M. T., Wilson, E., Chetwynd, E., & Fogleman, A. (2015). A pilot study on the protein composition of induced nonpuerperal human milk. Journal of Human Lactation, 31(1), 166-171.

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Inducing Lactation & Breastfeeding Without Giving Birth

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Breastfeeding or chestfeeding can be an option for non-gestational parents. Learn more about inducing lactation, including facts, the 3 steps, and resources.

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How to make sure baby is feeding effectively

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How to make sure baby is feeding effectively

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South Warwickshire University NHS Foundation Trust

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Hands-on physical therapies including cranial techniques such as cranial osteopathy or craniosacral therapy are sometimes suggested for babies with breastfeeding or sucking difficulties. Online searches reveal anecdotal reports from satisfied parents who felt that this type of 'bodywork' helped with their babies' feeding or general comfort levels. But many people are sceptical and doubtful about cranial therapies and would like to see more evidence based research proving its safety record and benefits. This article looks at how cranial therapy might work to help breastfeeding issues and tongue function in very young babies, and directs parents to books and articles that offer more information.

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How could cranial therapy help breastfeeding?

Dee Kassing, IBCLC has written an article describing ways physical therapy from an experienced practitioner might help with sucking issues. She explains that if the 22 bones in the baby's skull are not perfectly in line (often associated with forceps or ventouse delivery), this can affect the way the tongue and facial muscles work which in turn may irritate the nerves in the face. All these factors can affect suckling, swallowing and breathing.

If there is misalignment and imbalance of the skull bones, this can affect the function of the palate, tongue, and other structures of the head. This can cause the palate to be too high or uneven, or the facial muscles to be too tight. Imbalance of the structures of the head, as well as trauma from the birth process itself, can cause constant irritation to the nervous system. This constant irritation may also cause hypersensitivity, which can sometimes be the underlying cause for babies who gag and cannot accept anything in the centre or back of the mouth.

Rule out general breastfeeding difficulties first

Bear in mind that there can be many causes of feeding difficulties in the early days or weeks and they won't all need bodywork or cranial therapy. Your IBCLC lactation consultant is the ideal breastfeeding specialist to check your baby's latch, breastfeeding position and tongue function-often simple changes to how you hold your baby to feed can resolve pain and soreness or help your baby improve their suckling technique. Sometimes self help measures such as skin-to-skin with your baby, tummy time or tongue exercises can help babies who are very tense-see High Muscle Tone for further information. A birth injury, an abnormality, a nervous system disorder or even the after effects of anaesthetics used during the birth can also cause difficulties with feeding and should be checked out with your qualified medical health professional.

When to consider physical assessment

Tow and Vallone and breastfeeding author Cathy Watson Genna recommend referral for a physical assessment (neuromusculoskeletal evaluation) in the following circumstances:

If there was a birth injury or bruising around baby's head, if labour was prolonged or if baby seems in any physical discomfort to feed

If baby has a tongue-tie (a tight membrane restricting the tongue)

If baby's face is not symmetrical, or he uses his muscles asymmetrically

If baby has an abnormal head shape, narrowing of the face, a receding chin or high palate

If baby has a preference to turn his head to one side only or if his mother complains of pain on one nipple only

If baby seems unable to move his head and neck or limbs freely or unable to hold his head in a neutral position

If baby's normal reflexes-rooting, suckling, gaping-are absent or exaggerated

If baby is clamping, biting or chewing the nipple, sucking in his lips, slurping, unable to open his mouth wide or is walking up the nipple (called an incremental latch)

If there is any bunching or thrusting of the tongue, arching away from the breast, pulling on and off breast, spilling milk at the breast, making clicking sounds or losing suction

If baby doesn't breastfeed for comfort or is unable to stay latched, only feeds passively (not actively) or keeps falling asleep after a short time at the breast.

Other causes

As noted above, there can be more than one cause for some of the symptoms in the above list. For example a baby who keeps falling asleep during a breastfeed might not be getting enough milk and not gaining weight; he may need more milk instead of worrying about the pros and cons of body work. A baby who has missing reflexes may have a neurological problem and should be assessed by your baby's doctor or a paediatrician. A baby who seems to be biting the nipple may need help to breastfeed with a bigger mouthful of breast (deeper latch), and pulling on and off the breast or fussing can have a number of possible causes. An IBCLC lactation consultant can help identify difficulties associated with breastfeeding technique or management.

Tongue function and cranial therapy

Recently published books on tongue tie and breastfeeding now include sections on the ways physical therapies can optimise tongue function .

Bodywork before and after tongue-release

Alison Hazelbaker, PhD, IBCLC, CST, RCST is a lactation consultant and craniosacral therapist. In her book Tongue Tie Morphogenesis, Impact, Assessment and Treatment, 2010 Hazelbaker explains how craniosacral therapy may help improve tongue function before and/or after tongue-tie release (frenotomy). She says that before a frenotomy, cranial therapy can optimise the structural alignment of the mouth, throat and thorax (chest area) and make sure there are no functional tongue restrictions unrelated to the frenulum. Cranial work after the frenotomy, says Hazelbaker, can speed healing, strengthen muscles, and help the communication between nerves and muscles that co-ordinate suck and swallow.

More effective suckling uses less calories

Catherine Watson Genna BS, IBCLC is an International Board Certified Lactation Consultant in private practice in New York City. In her book Supporting Sucking Skills, Cathy discusses how hands-on therapy (also referred to as manual therapy) can help normal function be restored in any structures that may not be working optimally due to injury or disturbance. When all the muscles and nerves associated with feeding are working as they should, a baby will suckle more effectively rather than burning extra calories by using inefficient compensations:

a nursing neonate can burn more calories feeding inefficiently than taken in during the feeding. A qualified manual therapist could help the baby suckle more effectively, thus encouraging the body to use those calories for growth, rather than suckling.

What sort of hands-on therapy may be helpful?

There are several forms of hands-on therapy or bodywork that may be helpful to resolve any physical issues affecting breastfeeding including physiotherapy in mainstream medicine. It is important to find a very skilled therapist with experience of breastfeeding babies and one who is registered with their professional association. Ask other parents for their recommendations or ask your baby's doctor for a referral. See Cranial Osteopathy or Craniosacral Therapy for my Baby? for further information and a comparison between those two types of treatment.

What does research say?

There doesn't appear to be any good research providing evidence that cranial therapy works and most of the information available seems to be case reports submitted by practitioners . A recent article in the Journal of Human Lactation concluded that an osteopathic treatment in conjunction with a lactation consultation could reduce biomechanical sucking difficulties in babies under six weeks of age however it also stated there was no significant difference in nipple pain between the control and treatment groups.

Summary

Cranial therapies and body work are sometimes said to be helpful for babies with breastfeeding or sucking difficulties. Some mothers notice a marked improvement in breastfeeding comfort after these therapies. Some parents felt their baby's personality changed with therapy, from being tense and fussy to calm and happy-finally being able to sleep peacefully. Others don't notice any difference at all and may feel it was not useful or worthwhile. It is important to do some research to find out all you can if cranial therapy is something you are considering and look for a fully qualified, reputable practitioner who is very experienced working with babies. If you are worried about any aspect of your baby's physical wellbeing contact your doctor for advice.

Footnotes & References

1. Supporting Sucking Skills in Breastfeeding Infants 3e, Cathy Watson Genna, 2017

2. TONGUE TIE Morphogenesis, Impact, Assessment and Treatment, 2010, Chapter 7 by Alison Hazelbaker

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Hands-on physical therapies including cranial techniques such as cranial osteopathy or craniosacral therapy are sometimes suggested for babies with breastfeeding or sucking difficulties. Online searches reveal anecdotal reports from satisfied parents who felt that this type of 'bodywork' helped with their babies' feeding or general comfort levels.

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Cranial Osteopathy or Craniosacral therapy?

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Cranial Osteopathy or Craniosacral therapy?

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Some breastfeeding resources and breastfeeding advocates favour cranial work or 'hands-on' therapies as a way to help certain sucking problems in a breastfed baby. See Does Cranial Therapy Work? for a review of how these therapies may help. Cranial osteopathy and craniosacral therapy are two possible cranial treatments said to be helpful alongside other forms of physical therapy. This article compares the differences between cranial osteopathy and craniosacral therapy and considers whether there is any research to guide how these therapies can help breastfeeding.

Find an IBCLC

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Experience is key

Dee Kassing IBCLC suggests that any of several physical therapies may be useful but finding a therapist who is very experienced working with babies is the key.

In recent years, there have been frequent references to CranioSacral Therapy and other bodywork for infants who are having difficulty breastfeeding.

Any of the methods might be helpful to a baby. When choosing a therapist, who could be a certified massage therapist, a physical therapist, a chiropractor, an osteopath, etc., be sure to ask how much training and experience in working with infants the therapist has had.

Some chiropractors are also accredited in pediatric chiropractic. This is a different type of bodywork, but can also be very helpful to infants. Adult chiropractic applied to babies would be dangerous, so again it is necessary to ask about the chiropractor's training and experience.

Cranial osteopathy or craniosacral therapy for my baby?

Cranial osteopathy is a specialised form of osteopathy that is used throughout the body not just the head. Craniosacral therapy stems from cranial osteopathy but works on the 'craniosacral system'. The craniosacral system is said to comprise of the membranes and fluids that surround the brain and spinal cord. The professional associations for cranial osteopathy and craniosacral therapy are named after their developers Dr William Sutherland and Dr John Upledger respectively and excerpts from their websites say the following:

Excerpt From

What is Cranial Osteopathy? Sutherland Cranial College of Osteopathy [accessed 15 June 2023]

Cranial osteopathy is not different to osteopathy, it is the name given to a subtle and refined approach to osteopathy that follows all the principles of osteopathy, but that includes the anatomy and physiology of the head.
Cranial osteopaths use a highly trained sense of touch to feel subtle changes of tension and tissue quality in the living anatomy of the whole body, and to diagnose areas of strain or dysfunction.

CranioSacral Therapy (CST) is a gentle, hands-on method of evaluating and enhancing the functioning of a physiological body system called the craniosacral system - comprised of the membranes and cerebrospinal fluid that surround and protect the brain and spinal cord. Using a soft touch generally no greater than 5 grams, or about the weight of a nickel, practitioners release restrictions in the craniosacral system, which has been shown to improve the functioning of the central nervous system, as well as many other systems of the body, such as digestive, musculoskeletal, respiratory, circulatory, and more.

Training requirements for therapists

A cranial osteopath has to qualify as an osteopath first whereas a craniosacral therapist may not be an osteopath.

A cranial osteopath will train for a four year full time or five year part time degree to initially become an osteopath then post graduate training to become a cranial osteopath. Post graduate training for the cranial osteopathic approach is through the Sutherland Cranial College of Osteopathy (SCCO). A member will have completed two or more modules, a fellow will have completed all of the modules.

Craniosacral therapist training is a one or two year part time diploma

When might these therapies be helpful to babies?

A baby's skull comprises bony plates held together by flexible joints (sutures). The bones in the infant skull need to move over each other to allow for squeezing down the birth canal. After birth, yawning, sucking and crying help to move the cranial bones back into position and the bones will fuse (become fixed) later over time. Sometimes however, yawning, sucking and crying may not completely put everything back in place, perhaps the birth was very traumatic or forceps or ventouse (vacuum assisted vaginal delivery) were used. If any of the skull bones are not aligned correctly this could affect the way a baby can use his mouth, jaw and tongue to latch (attach to the breast) and suckle correctly. If the skull and connective tissues are unbalanced a baby may feel uncomfortable and tense, this is when physical therapies may be useful to free any tension (Kassing, 2014).

For further discussion of how cranial work or other bodywork is thought to help in these situations, see Does Cranial Therapy Work?

Are cranial therapies safe for my baby?

There are not many good quality studies looking specifically at how cranial therapies might help with the mechanics of breastfeeding nor their safety. Herzhaft-Le Roy et al attempted to assess the efficiency of osteopathic treatment on a baby's latch alongside lactation consultant care. The study concluded a single osteopathic treatment combined with a lactation consultation could reduce biomechanical sucking difficulties in babies under six weeks of age although there was no significant difference in nipple pain between the control and treatment groups. Some articles question the lack of an evidence base behind cranial techniques. An article in Chiropractic & Osteopathy 2010 by Kim Humphreys calls for more research on children's therapies:

Conclusions

There is currently insufficient research evidence related to adverse events and manual therapy. However, clinical studies and systematic reviews from adult patients undergoing manual therapy, particularly spinal manipulation report that mild to moderate adverse events are common and self limiting. However serious adverse events are rare and much less than for medication commonly prescribed for these problems. More high quality research specifically addressing adverse events and pediatric manual therapy is needed.

If you are considering trying a physical therapy it is important to find a fully qualified, reputable practitioner who has been recommended to you, is a member of their professional association and is very experienced working with breastfed babies.

Summary

Cranial therapists and some tongue tie practitioners often claim that cranial therapies can help with a baby's tongue function or other physical issues such as opening the jaw widely to attach to the breast. Although there is very little scientific evidence supporting the use of cranial techniques, many parents have felt these therapies were helpful for their baby. Training requirements for cranial osteopathy are longer than for craniosacral therapy. It is important to choose a specialist who is experienced working with babies and comes with recommendations and references. There can be many causes and solutions of breastfeeding difficulties and most will not require physical therapy-for a thorough breastfeeding assessment contact an IBCLC lactation consultant and if you have any concerns about your baby's physical health contact your doctor for advice.

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Cranial Osteopathy or Craniosacral Therapy for my Baby?

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Cranial osteopathy and craniosacral therapy are two possible treatments said to be helpful for certain breastfeeding issues, but which treatment is best?

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1. Start with breastfeeding, observing your baby’s swallowing pattern. Use breast compressions to maximise the flow. When swallowing slows, switch sides and repeat. If your baby has enough energy, you can repeat this process (known as ‘switch nursing’). This part of the feed might take 10–30 minutes, but use swallowing as your guide. A baby who is not swallowing isn’t taking in any milk so move to step 2.

2. Give your supplement with a spoon, syringe, nursing supplementer, finger feeding tube, or bottle. Give stored breastmilk first, then supplement with other milk. Follow your baby’s lead until they are satisfied. A baby who is underweight may become extra hungry for a while. By giving them extra milk, you will help them gain weight and get the energy they need to breastfeed better. To save time, this step could be done by your support person while you express. For more on ways to give your baby more milk, see our article on Bottles and other tools.

3. Express both breasts using a combination of pumping and hand expression, switching back and forth as milk flow slows. Store this milk in the fridge ready for the next feed. By removing the milk your baby couldn’t, you build your future milk production and have milk to supplement the next feed. This is an important step, especially if you are working to eliminate formula supplements.

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Does your baby need more milk?
How to know your baby is getting enough breastmilk
Increasing your milk production
If supplements are needed
Feeding methods
Expressing your milk

Does your baby need more milk?

Although most mothers are able to produce enough milk for their babies' needs, you may have concerns about your own milk production. Perhaps you and your baby had a difficult start, or were not given the support you needed to establish breastfeeding. Or maybe things were going well until your baby's weight gain faltered.

If others question your milk production and your baby is fussy, wants to feed much of the time, seems small, or gains weight slowly, you may be wondering whether you have enough milk.

Follow your baby not the book

Young babies need to nurse frequently to get enough milk and establish their mother's milk production. Following feeding schedules, using regular supplements, nipple shields, or a dummy can really reduce your milk production.

Breastmilk is also a drink and frequent nursing is normal. Adults rarely go longer than two hours without a drink, snack or meal. Your baby's tummy is tiny and breastmilk is quickly digested, so they need frequent feeds to help them grow. It is recommended that your baby is weighed no more than once a month for the first six months, unless there are concerns.

Sleepy Baby
A baby who sleeps a lot rather than waking to feed every 2-3 hours may need to be woken up to nurse, particularly if they have jaundice or aren't gaining enough weight. If this is difficult or your baby is lethargic, ask your midwife, health visitor or GP to check that all is well.

See our article Sleepy Baby - why and what to do for more information.

How to know your baby is getting enough breastmilk

Weight gain
It is normal for newborns to lose up to 7% of their birth weight in the first few days. Once your milk production increases, usually on day 3-4, expect your baby to begin gaining weight. Most babies regain their birth weight by the age of 10-14 days. You may also find it helpful to see Is my baby getting enough milk?

Plot your baby's weight gain on a UK-WHO growth chart based on the growth rates of breastfed babies (see examples below and Further Reading). Although they will be growing at their own individual rate, it will give you an indication of how they are doing.

Monitor your baby's weight over a period of time rather than week by week. Your baby's weight may generally follow the chart, or climb up, crossing the percentile lines. A gradual drop from one percentile line to the next (or the equivalent distance) is unlikely to be a problem unless their weight is low for their age. Heavier newborns often show 'catch-down' growth - they gain weight steadily but drop gradually against the chart lines.

Dropping against the chart is more of a worry for lower weight babies
If your baby's growth curve drops across two lines of the chart (or the equivalent distance), or if their weight is below the lowest line of the chart:

Follow the suggestions here to ensure they get more milk.

Seek help from your GP to rule out an underlying medical reason for your baby's slow weight gain.

If you have doubts about your baby's growth, you may find it reassuring to talk to an LLL Leader.

Wet and dirty nappies
If your baby receives enough milk, the thick and sticky black meconium poos will be passed within three days of birth, followed by at least 6-8 wet and 3-5 dirty nappies in each 24 hours. Expect yellow, loose, unformed poos at least the size of a 2p coin. From about six weeks, some babies have abundant poos once every few days. This isn't a problem when a baby has plenty of wet nappies.

Look at your baby
You may instinctively know how your baby is doing. Are they nursing vigorously? Is their skin firm? Do they look healthy and seem active and alert? Are they meeting developmental milestones?

Remember
Even if your breasts feel empty, there's always some milk there. Full breasts and engorgement slow milk production - you may need to nurse more often. Removing even small amounts of milk from soft breasts increases milk production.

Babies nurse for comfort as well as for food. Those little 'snack' comfort feeds can really increase your milk production and their calorie intake.

Expect your baby to want to breastfeed very often from time to time. Your breasts will quickly adjust to making more milk if you follow your baby's cues.

Every baby has a unique feeding pattern. If your baby is gaining weight adequately, following their own feeding pattern is the best way of ensuring you are meeting their needs. It's rare that a mother cannot produce enough milk for her baby, and there are lots of ways to increase the amount of breastmilk your baby gets.

Increasing your milk production

After the first few weeks, supply and demand drives milk production. To increase your milk supply, focus on feeding more often and getting more milk out at each feed. For more information about how breasts make milk, see our article How milk production works and also How to increase your milk supply.
Breastfeeding basics

Breastfeed as often as possible - at least 10 times in 24 hours. Wake your baby if necessary.

Switch sides when your baby's suck-swallow pattern starts to slow. Continue to switch sides (four times or more) until they reject the breast.

Use breast compression (see below).

Instead of breastfeeding at set intervals, encourage 'cluster feeding' - breastfeeding very often at times when your baby is willing to.

Encourage breastfeeding for comfort as well as for food. It can really help your milk production. Stop using dummies - breastfeed instead.

Ensure you are meeting your baby's needs for milk during the night, feeding at least once every four hours.

Cut back a little on your baby's solid foods if your milk production is dropping (see below).

An effective latch
A baby may spend a long time at the breast but not get very much milk if they are not latched on effectively. Check your baby is well attached - watch and listen for swallowing which is frequent at the start and then slows down.

Contact an LLL Leader for one-to-one support and see Further Reading for more information. It's important to seek skilled help early on if you are finding breastfeeding difficult, uncomfortable or painful.

Take a 'baby moon'
Get some help with the housework and eat simple, easily-prepared meals for a week or two so you can concentrate on breastfeeding your baby. A couple of days' bed rest together, feeding your baby on demand can really boost your milk production. Or at least take some time each day to rest with them and concentrate on breastfeeding.

Try laid-back breastfeeding
Many babies instinctively seek the breast and feed frequently if they can snuggle up close to their mother's chest.

Try letting your baby lie on your body, skin to skin (with a blanket if needed) as you recline, so both their chest and tummy are against you. This close body contact gives your baby lots of opportunity to breastfeed, even in a light sleep, and boosts levels of the hormones that increase your milk. A soft carrier or sling helps to keep your baby close and encourages breastfeeding. (see Positioning and Attachment for more on laid back breastfeeding)

Breast compression
This technique puts pressure on the milk ducts and can help to make feeding more efficient:

1. Support your breast with one hand - thumb on one side, fingers on the other.

2. Wait while your baby breastfeeds actively, their jaw moving all the way to their ear. When their swallowing slows, compress your breast firmly to increase milk flow and encourage swallowing. Hold it squeezed while they continue nursing actively, then release your hand.

3. Rotate your hand around the breast and repeat step 2 on different areas of the breast.

Go gently - this should not hurt.

Other foods
Babies need only human milk for the first six months (human milk is higher in calories than many weaning foods). Too much solid food replacing human milk can affect weight gain in older babies. Breastfeed before offering solid foods if your baby is under 12 months old. Even at 12 months, both human milk and solids are equally important. Breastfeed frequently and, rather than spoon-feeding, offer your baby a variety of foods, letting them feed themselves to ensure they take only what they need.

Continued low milk production
If you've tried all these suggestions and your milk production has not increased enough, there may be a medical reason. Some medical conditions can lead to low milk production, though appropriate treatment can reduce the impact. These situations are rare, but you can discuss possibilities with an LLL Leader. For more information see our article How to increase your milk supply and Further Reading.

Signs your milk is increasing
Watch for weight gain and an increase in your baby's wet and dirty nappies. Your breasts may feel fuller before feeds and begin to leak.

Looking after yourself
Don't forget to be kind to yourself, especially if you're feeling under pressure. Now is the time to call in favours from friends and relatives so you can concentrate on your baby. If your baby needs more milk, talking to your local LLL Leader will help. You can share your concerns with other mothers at an LLL meeting, who will be able to give you encouragement and support.

If supplements are needed

It can be a challenge fitting in breastfeeding, supplementing and expressing. You could try the following approach, aiming for at least 8 feeds in 24 hours. At each feed:

1. Start with breastfeeding, observing your baby's swallowing pattern. Use breast compressions to maximise the flow. When swallowing slows, switch sides and repeat. If your baby has enough energy, you can repeat this process (known as 'switch nursing'). This part of the feed might take 10-30 minutes, but use swallowing as your guide. A baby who is not swallowing isn't taking in any milk so move to step 2.

2. Give your supplement with a spoon, syringe, nursing supplementer, finger feeding tube, or bottle. Give stored breastmilk first, then supplement with other milk. Follow your baby's lead until they are satisfied. A baby who is underweight may become extra hungry for a while. By giving them extra milk, you will help them gain weight and get the energy they need to breastfeed better. To save time, this step could be done by your support person while you express. For more on ways to give your baby more milk, see our article on Bottles and other tools.

3. Express both breasts using a combination of pumping and hand expression, switching back and forth as milk flow slows. Store this milk in the fridge ready for the next feed. By removing the milk your baby couldn't, you build your future milk production and have milk to supplement the next feed. This is an important step, especially if you are working to eliminate formula supplements.

4. Finish at the breast. The whole feed may take 60-90 minutes. If it works for you, you might offer the breast at the end of the feed so your baby associates the breast with being calm, happy and satisfied. Suckling can help them settle to sleep, too.

Keep a record of the amounts of each supplement your baby takes at each feed and also what you express. This can help you see your progress and maybe useful for anyone supporting you with breastfeeding.

Feeding methods

Cup, spoon and syringe feeding can work when small amounts are needed.

A nursing supplementer can be used to give larger amounts while your baby is at the breast. Another option is finger feeding, using an infant feeding tube. One end of the tube is taped to your finger. As your baby sucks on your finger, milk flows along the tube from a container which can be raised or lowered to change flow. An LLL Leader can help you find out more and choose an option that works best for you.

If using a bottle, paced bottle feeding can help ensure your baby doesn't take more milk than they need.

A smaller teat hole prevents a baby taking milk too quickly.

Hold them in an upright position, using your hand to support their neck and head.

To encourage your baby to open wide, place the teat across their lips with the tip between the upper lip and nose.

Allow your baby some control. Let them take the bottle teat into their mouth themself. Avoid pushing the teat into their mouth.

Tilt the bottle just enough to fill the tip of the teat and give a gentle flow so your baby isn't overwhelmed with milk. As the bottle empties, gradually tilt the bottle more and lean your baby back.

Encourage frequent pauses to mimic breastfeeding, and allow your baby to decide when they have had enough.

For more information see Bottles and other tools.

Expressing your milk

A baby nursing well at the breast is more effective than any pump. But while your baby isn't breastfeeding well or you're giving supplements, expressing your milk will stimulate milk production. Give any expressed milk before you give infant formula, so none of your precious breastmilk is wasted.

Nurse your baby frequently so they get the extra milk you make. An increase in the amount you can express is a sign that you can reduce supplements if your baby is nursing well and often.

Hospital-grade pumps are the most effective for mothers needing to increase their milk, but any pump that works well for you is fine.

Try hands-on pumping: use breast massage and breast compressions while pumping, then hand express afterwards to get the last few drops of milk. For more on hand expressing see our article: Hand expression

Pumping on both sides at the same time boosts milk-producing hormones. When pumping one side at a time, switch back and forth several times as milk flow slows.

Consider power pumping: experiment with pumping very frequently for short periods to mimic cluster feeding.

Wash your pump with hot soapy water, or sterilise it once a day. Pump equipment can be left at room temperature for short periods, or stored in the fridge for longer periods. For more information, see our article Expressing Your Milk.
Good times to express milk

After feeds while your baby sleeps - 'putting in an order' for more milk later. Milk expressed after a feed may be small in quantity, but is high in calories.

Between feeds if your baby is too sleepy to nurse frequently.

While holding your baby, or with them nearby. Expressing little and often can be better than long sessions. Try some 'power pumping' during the evening, or fit in some extra pumping sessions one day. You should notice an increase in milk production a couple of days later.

Using donor milk and formula to support breastfeeding
The use of donor milk or infant formula is sometimes essential to meet a baby's nutritional needs. You may need to use donor milk or formula as a short-term measure while you work to increase your milk production. See our article Using donor milk & formula to support breastfeeding for more information.

Supplementing with donor milk or formula without protecting your milk supply may reduce the duration of your breastfeeding journey.

Powdered infant formula is not a sterile product. To reduce health risks associated with using infant formula, carefully follow the NHS guidelines for preparing it. La Leche League does not recommend the use of homemade formula. The NHS guide to bottle feeding is available online (see Further Reading).

Written by Karen Butler and mothers of LLLGB

Further Reading

How to increase your milk supply
How milk production works
Using donor milk and formula to support breastfeeding
Dummies and Breastfeeding
Hand expressing of breastmilk
Comfortable Breastfeeding
Is my baby getting enough milk?
Nursing Supplementers
Positioning & Attachment
Rhythms and Routines
Safe sleep and the Breastfed Baby
Sleep baby - why and what to do
Storing your milk
After a difficult start

Books
The Womanly Art of Breastfeeding, LLLI. London: Pinter & Martin, 2010.
Making more milk, second edition, Marasco, L. and West, D. New York: McGraw-Hill Education, 2019.
Other websites
Natural (laid-back) breastfeeding naturalbreastfeeding.com
Biological nurturing™ www.biologicalnurturing.com
Maximising milk production when expressing https://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html
UK-WHO Growth Charts These charts are based on the growth rates of breastfed babies and can be found in your baby's Personal Child Health Record (red book). Further copies, the more detailed hospital 0-4 charts and specialised charts for low weight babies can all be downloaded from: www.rcpch.ac.uk/growthcharts
NHS guide to bottle feeding

This information is available to buy in printed form from our shop.

Copyright LLLGB 2022

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My baby needs more milk - La Leche League GB

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Does your baby need more milk? How to know your baby is getting enough breastmilk Increasing your milk production If supplements are needed Feeding methods Expressing your milk Does your baby need more milk? Although most mothers are able to produce enough milk for their babies' needs, you may have concerns about your own milk [...]

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If a breastfed baby is gaining very little weight, not gaining, or losing weight due to not getting enough milk, the first priority is to make sure the baby gets more milk. There are several ways to increase a mother's breast milk supply, however, these can take time and the baby may need more milk straight away. Sometimes parents are reluctant to supplement large quantities of donor milk or formula in case this undermines breastfeeding but medically indicated additional calories do not have to mean the end of breastfeeding.

Find an IBCLC

Search for a breastfeeding expert near you

This article

This article discusses a general care plan for supplementing an underweight baby while protecting breastfeeding-with the end goal of returning to full breastfeeding where possible. It is a companion article to read alongside Baby Not Gaining Weight and Understanding Your Baby's Weight Chart. This general plan should never be considered a replacement for medical advice or a tailored care plan from your baby's physician and your own IBCLC lactation consultant as it cannot take into account yours or your baby's medical details. Please discuss the information in this article with the health professional caring for your baby.

Breaking the low weight cycle

When a baby is very underweight he can become too weak to breastfeed. This will mean he cannot "drive" or stimulate his mother's milk supply properly. Milk production slows to meet the weak demand which causes even lower weight gain and so on in a cycle of low weight/low energy/low milk. Breaking this cycle involves checking baby's health, restoring baby's nutritional status and maximising the mother's breast milk supply:

Medical checks. Rule out any underlying health issues for baby with your doctor or paediatrician to establish whether low milk intake is the only cause of poor weight gain. Stay in close contact with your baby's doctor so they can monitor your baby's recovery.

More milk. If a baby is substantially underweight they will need extra calories right away to protect their health, gain weight, and have more energy for breastfeeding. Doctor Marianne Neifert explains:

Excerpt from

Providing appropriate supplemental milk to an underweight infant is necessary to prevent malnutrition, dehydration, electrolyte imbalance, cerebral infarcts, and other complications of inadequate breastfeeding.

Maximise breast milk supply. Although supplements may be needed short term, breastfeeding can be protected by increasing breast milk volume as soon as possible. With a more abundant milk supply a baby will be encouraged to breastfeed more readily (Neifert, 2001).

Supplementing an underweight baby

- A three step plan

The following care plan for rebuilding a baby's weight while protecting breastfeeding is based on lactation consultant Pamela Morrison's five step feeding plan and Marianne Neifert's triple feeding plan :

#1 Breastfeed

Breastfeed often, at least every two to three hours in the day and every four hours at night. Wake a sleepy baby to feed if needed-upright positions can help a baby stay awake to feed.

Latch and position. Check baby's latch (the way they attach to the breast) and positioning with a breastfeeding professional, a good latch is important to drive a milk supply.

Offer both breasts per feed and use breast compressions. Rather than allowing baby to finish each side at their own pace, watch for active sucking and swallowing and help milk flow with breast compressions; a technique made popular by Canadian paediatrician Jack Newman. When active sucking stops despite compressions, switch breasts and repeat.

Limit the feed. Breastfeed for around 10-15 minutes each breast or 20-30 minutes total. A time limit prevents very long ineffective feeds. Long feeds where baby is flutter sucking or sleeping-but not drinking-do not stimulate a milk supply and perpetuate the low gain cycle. Long sessions of poor quality feeding also contribute to baby burning precious calories.

#2 Supplement

When baby isn't swallowing at the breast any more, or after 20-30 minutes, stop breastfeeding. Top your baby up in the easiest way for you and your baby (see below). Use expressed milk first and then donor milk or formula as needed, use enough supplement so that your baby stops drinking of his own accord (see below for a guide to volumes). Settle your baby so that you can pump.

#3 Pump

Pump both breasts as soon as possible after you have breastfed, topped-up and settled your baby. Aim to pump at least six times per day if you can. Using "hands-on-pumping" (gentle light touch breast massage and breast compression while you pump) can stimulate more milk. Pump until the milk stops flowing and only produces drops of milk (around 10-15 minutes). Pumping both breasts at the same time (double pumping) can save time or some mothers may prefer to pump and massage each breast separately. Hand expressing after pumping can really help milk supply. Save any collected milk towards your baby's next top-up, with the end goal of gradually pumping the entire supplement volume. See How Long Does Breast Milk Last? for storage information and How to Increase Milk Supply When Pumping for more pumping tips.

An hour goal

It is helpful to try to keep breastfeeding, topping up and pumping all within a reasonable time interval otherwise it can feel too difficult and time consuming for the mother. Aim to breastfeed for around 20-30 minutes, top baby up to satiety (10-20 minutes), then pump (10-15 minutes) all within an hour. Marianne Neifert recommends:

The mother should pump for 10 to 15 minutes using a dual collection system to drain both breasts simultaneously. The high-fat, calorie-dense hindmilk obtained with the breast pump may be used to supplement the infant, with additional formula as required. This triple-feeding regimen-breastfeeding for approximately 10 minutes per breast, supplementing the infant to satiety, and pumping for approximately 10 minutes-should not exceed 1 hour.

Frequently asked questions

Is my baby really hungry or just small?

The characteristics of a hungry baby can sometimes be mistaken for being either very fussy, very "good" or just small/petite. See Baby Not Gaining Weight for a summary of behaviours you might notice in a hungry baby and check Understanding Your Baby's Weight Chart. Your health professional and/or IBCLC lactation consultant can help to interpret your baby's weight.

Why can't I just breastfeed more?

If breastfeeding has led to your baby not gaining weight, simply doing more of the same, in the same way, is unlikely to help until your baby has more stamina and the reasons for low gain/low milk have been found and addressed. Supplements may be needed to provide enough food, and pumping will help to jump-start your milk supply. There are a couple of situations to be aware of:

If a baby is only slightly underweight but otherwise healthy or for whom growth faltering is a very recent event, appropriate breastfeeding management measures may be sufficient to increase a mother's breast milk supply. Always be guided by and stay in close contact with your baby's doctor or health visitor. If there is no extra weight gain after two to four days, supplements will be needed (Morrison, 2011).

The newborn baby who has lost more than 10% of their bodyweight after birth, is at risk of dehydration or breastfeeding-associated hypernatremia (high sodium levels in the blood). This is a serious condition and babies will need to be assessed by a doctor so that their electrolytes (e.g. sodium levels) can be checked and carefully corrected and supplements provided under medical guidance.

How can I make more breast milk?

The more often milk is removed from the breast and the more thoroughly, the more milk will be made. An underweight baby is not very good at this, help him stimulate your milk supply by:

Review reasons for low supply

In some cases there may be medical reasons for low milk supply, review possible causes for low milk/low weight gain with a breastfeeding expert.

For more information see How to Make More Breast Milk or follow the advice tailored for you by your IBCLC lactation consultant.

Do I have to pump? I can't pump much

Once a baby catches up and is back to the healthy weight-for-age they should be, a baby is often better able to drive his mother's milk supply. Until this time, pumping with an efficient pump can really help to stimulate your milk. Try not to be disheartened if you only get 10-20ml from each breast or less when you first start pumping, you can build on this. The process of pumping an empty breast is putting in the order for more milk tomorrow.

Keeping a record

It can be helpful to keep a record of volumes of breast milk expressed each day and volumes of formula given so you can gauge progress (over time breast milk will go up, formula will go down). Charting the number of wet and dirty nappies can also help gauge whether your baby is getting enough milk, alongside weighing your baby regularly.

What supplement should I give?

The first choice for a supplement is always mothers' own expressed breast milk. However, if a mother is unable to pump enough expressed milk to satisfy her baby, she will need to choose between donor milk where available or using baby formula. Always feed any expressed breast milk first, then donor milk, and finally formula. It is thought that mixing human milk and formula into the same container should be avoided as there are concerns that direct mixing could interfere with the antibacterial benefits of breast milk and mixing could lead to wasted breast milk if baby doesn't finish the bottle. See Supplementing With Formula for more information.

How much supplement should I give?

A general guide used for overall milk intake normally is 150-200ml/Kg/day. How much supplement an individual baby needs will vary with their age, weight, frequency of feeds and depending how much breast milk they get. Krugman and Dubowitz say that infants recovering from faltering growth (failure to thrive) need 150% of the intake for their expected, not actual, weight for catch-up growth. This means the amount of top-up needed may be much higher than expected for a while. A top-up at each feed might be anything from 30ml to 120ml or even more.

Pamela Morrison explains that while 180ml/kg/day above 10 days of age is a normal intake for a healthy baby, some babies will start taking surprisingly large volumes while they catch up. Be guided by a baby's appetite by offering enough supplement until they stop drinking because they are full. She explains:

In consultation with the baby's paediatrician it may be appropriate to feed the baby up to 280-300 ml/kg/day while s/he achieves a "catch-up gain"

If your baby doesn't seem hungry

A very underweight baby may find it hard to drink much at first as they may have become used to very small meals and they might bring back some of the top-up as spit up. If so, try offering smaller volumes more frequently and then follow baby's appetite as it picks up. If your baby is not showing hunger cues Wambach and Spencer suggest aiming for a minimum supplement of 100ml/kg/day divided into eight to twelve feeds. After one to two days increase the supplement gradually until the baby starts to demand his feeds.

My doctor says to give two bottles of formula per day

Your experienced health professional may prefer to prescribe set volumes of top-up to be certain your baby is getting what he needs-particularly if your baby is not showing good hunger cues. If your health professional recommends, let's say, two 150ml (5oz) top-up bottles per day or 300ml/10oz per day this is the same as topping up 50ml after six day time breastfeeds (50 x 6 = 300ml per day). Topping up smaller amounts to make up the same total can be more protective of breastfeeding because:

Baby is not overloaded in one meal which may cause him to sleep for a long time missing potential breastfeeds

Baby is able to satisfy their appetite throughout the day not just twice a day

Too much milk in one go could be brought back as spit up.

In practice, find the pattern that works for you and keeps your baby well fed-monitor baby's weight gain closely. If a breastfeed is missed out, remember to pump during the interval.

How should I give the supplement?

It is important to find an easy way for the low weight baby to take his supplement. Options include

Cup feeding-baby must be awake and alert which can be problematic with a very weak and sleepy underweight baby

Supplemental tube-either at breast or by finger-feeding. This may work for some babies but may be too difficult or slow and consume too much energy for others who are very weak

A bottle can be the most efficient and least stressful feeding method for an underweight, sleepy baby until they have gained their expected catch-up weight (Neifert, 2001). There are several ways to make a bottle feed more like a breastfeed and reduce nipple confusion but avoid overly pacing a feed for an underweight baby, their appetite needs encouraging!

My lactation consultant says supplement first, then breastfeed?

The three step plan above discusses breastfeeding first and then supplementing your baby. Alternatively some lactation consultants favour giving a limited amount of supplement before breastfeeding. The rationale being that the baby receives some calories to give them energy to breastfeed well and then baby associates the breast with feeling full as they fall asleep. This may work well for some babies. It can be difficult to gauge the top up volume before a breastfeed so that a baby is well fed yet not too full or sleepy to breastfeed efficiently. Another variation is to start and finish at the breast with the top up in the middle. As long as an underweight baby is getting the additional calories they need, is still getting plenty of chances to breastfeed, and mother has time to pump, parents can find what works best for them.

When can I get back to exclusive breastfeeding?

The time taken to get back to exclusive breastfeeding will vary depending on a number of factors including how well your milk supply rebounds, the age of your baby and how underweight they were. Some mothers will find supplements are only needed for a few weeks or months while others may still need to top up until solid foods become a regular part of baby's diet. If supplements are stopped too soon, a baby's weight can falter again. As a mother's breast milk supply increases and baby has more stamina to take more direct at breast, baby will gradually take less and less supplement after they have breastfed until it isn't needed. Marianne Neifert suggests continuing to pump after breastfeeds until the baby is gaining weight well with exclusive breastfeeding, and then gradually reduce pumping sessions.

How quickly will my baby gain weight?

Although this will vary between babies, once they are getting more milk it is common for an underweight baby to have a few days of weight gains up to 120g a day while they replenish body fluids (Smillie, 2016). They will usually continue to steadily gain weight and gradually move up one or more centile lines on their weight chart until they reach a healthier weight for their age. The baby's initial ravenous appetite will settle down again into the normal pattern of weight gain for their age once they have caught up. See Understanding Your Baby's Weight Chart and Baby Not Gaining Weight to know what to expect as time goes on and keep a close eye on your baby's weight gain as they recover from faltering growth.

Summary

When a baby has growth faltering due to not getting enough breast milk, a plan of care that includes breastfeeding, supplementing and pumping ensures baby is well fed while protecting the breastfeeding relationship. Such a plan should always be under the guidance of your baby's medical team who will monitor your baby's recovery and weight gain. By finding the reasons for low milk intake and starting measures to maximise a milk supply, supplements do not have to mean the end of breastfeeding. Supplementation should not be withdrawn too soon or baby might start to lose weight again. Once a baby is back to the weight he should have been, and the original causes for low milk supply addressed, exclusive breastfeeding can often continue. Occasionally a mother may not be able to provide a full milk supply for her baby.

Thank you
Special thanks to Pamela Morrison IBCLC who first introduced me to this plan and shared her extensive experience with low weight gain babies making this article possible.

Footnotes & References

1. Breastfeeding and Human Lactation, Wambach and Spencer, 2021, p 342

2. Breastfeeding and Human Lactation, Wambach and Spencer, 2021, p 342

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If a breastfed baby is gaining very little weight, not gaining, or losing weight due to not getting enough milk,

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If your baby was born at Warwick hospital, or is under SWFT community care and is under 8 weeks old, we can offer a tongue tie assessment. Referral from your Community Midwife, Health Visitor or GP is required. They can use Badgernet, or alternatively email us. 

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If your baby was born at Warwick hospital, or is under SWFT community care and is under 8 weeks old, we can offer a tongue tie assessment. Referral from your Community Midwife, Health Visitor or GP is required. They can use Badgernet, or alternatively email us. 

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A tongue-tie (also known as Ankyloglossia) is caused by a short or tight membrane under the tongue (the lingual frenulum).

Where the membrane is attached at, or close to the tongue tip, the tongue tip may look blunt, forked or have a heart shaped appearance. However, where the membrane is attached further back the tongue may look normal in appearance.

Research suggests that approximately 1 in 10 babies may be born with some restrictive membrane under the tongue. But only about half of those babies display significantly reduced tongue function, making breast or bottle feeding difficult.

These babies may benefit from treatment to release the restriction that the membrane is having on the tongue and enable a baby to feed effectively.

Tongue-tie assessment

Tongue-tie practitioners often talk to parents who have had conflicting advice around whether or not their baby has a tongue-tie so it may be helpful for parents, and professionals who do not assess and divide tongue-ties, to have an understanding of what an assessment for tongue-tie involves.

The decision on whether or not a tongue-tie is impacting on feeding and whether it is appropriate to offer to divide it should be made after a detailed feeding history has been taken. This will usually include information about the pregnancy and birth and the medical history of both mum and baby. The baby is usually observed at the breast. This may be done by the person who divides tongue-ties or by someone who has been supporting you with feeding, prior to you being referred for division, such as a midwife, Health Visitor or breastfeeding counsellor/lactation consultant. The function of the tongue will also be assessed to establish if the baby is tongue-tied and if this is impacting on feeding.

The video clip shows part of an assessment for tongue-tie: Assessment of a Tongue Tie video curtesy of Sarah Oakley .

Assessment for tongue-tie requires training and skill and involves placing a finger in the baby's mouth. It cannot be done by just taking a look. Assessment is usually carried out with the baby on the assessor's lap or a flat surface such as a table or couch. It involves observing how the baby uses their tongue.

Professionals assessing babies for tongue-ties should assess elevation, lateralisation and extension. Elevation can most easily be assessed when baby cries. With the mouth wide open, the tongue tip should lift up to at least the mid mouth. In tongue-tied babies the tongue often stays quite flat in the floor of the mouth or the edges curl up to form a bowl shape or 'v' shape. Babies should be able to poke their tongue tip out well over the bottom lip when the bottom lip is stimulated. When the assessor runs their finger along the top ridge of the bottom gum the tip of the baby's tongue should follow the finger so the tongue sweeps side to side (lateralisation).

Some assessors perform a suck assessment by placing their finger in the baby's mouth (pad side up, nail side down) and feeling how the baby is cupping and using their tongue. Assessors sweep their finger under the baby's tongue so they can feel the extent of the tongue tie and the tongue will also be lifted to visualise the frenulum. The appearance of the frenulum is also documented including the shape of the tongue tip, where it attaches to the floor of the mouth and the underside of the tongue and how long and elasticated it is.

Problems which may be due to a restrictive tongue-tie:

Breast/Chest Feeding Parent:

Sore/damaged nipples

Nipples which look misshapen or blanched after feeds

Low milk supply or fast, quick let-down

Exhaustion from frequent/constant feeding

Distress from failing to establish breastfeeding

Infant/Baby:

Restricted tongue movement

Small gape resulting in biting/grinding behaviour

Unsettled behaviour during feeds

Difficulty staying attached to the breast or bottle

Frequent or very long feeds

Excessive early weight loss/ poor weight gain/faltering growth

Clicking noises and/ or dribbling during feeds

Colic, wind, hiccoughs

Reflux (vomiting after feeds)

Your baby may not display all of these signs and there can be other causes for these symptoms too so a thorough assessment by a practitioner skilled in breastfeeding is essential.

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A tongue-tie (also known as Ankyloglossia) is caused by a short or tight membrane under the tongue (the lingual frenulum). Where the membrane is attached at, or close to the tongue tip, the tongue tip may look blunt, forked or have a heart shaped appearance.

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Aftercare advice following surgical Tongue-Tie Release

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Aftercare advice following surgical Tongue-Tie Release

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Some people choose to look at private options for tongue tie divisions. These can be viewed on the link below: 

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Some people choose to look at private options for tongue tie divisions. These can be viewed on the link below: 

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Are you experiencing pain while breastfeeding, possibly combined with slow weight gain for your baby? While the vast majority of such breastfeeding problems can be resolved by adjusting positioning and attachment, and with good breastfeeding management, occasionally tongue tie might be the cause of the problem.

Tongue tie (ankyloglossia) is caused by a tight or short lingual frenulum (the membrane that anchors the tongue to the floor of the mouth). The frenulum normally thins and recedes before birth. Where this doesn't happen, the frenulum may restrict tongue mobility. Tongue tie often runs in families and is thought to be more common in boys than girls. There is an association between high or unusual palates and tongue tie, because restricted tongue movement can affect the shape of the palate.

Breastfeeding challenges can also occur for other reasons. Identifying the cause is important when deciding on appropriate solutions, so seek help from someone skilled.

Identifying tongue tie

When your baby tries to lift their tongue or move it forwards it may appear misshapen, short or heart-shaped, with the frenulum clearly pulling its centre down and restricting its movement. Or you may be able to see or feel firm tissue where their tongue meets the floor of his mouth. Degrees of tongue tie vary and it can be difficult to diagnose accurately. A short, tight, posterior tongue tie is rarer, but may be particularly hard to spot.

How breastfeeding may be affected

Tongue tie affects tongue movement to varying degrees. The shorter and tighter it is, the more likely it is to affect breastfeeding. Some babies with a tongue tie breastfeed well from the start, others do so when positioning and attachment are improved. But any tongue tie that restricts normal tongue movement can lead to breastfeeding difficulties. A baby needs to be able to move their tongue freely and extend it over the lower gum with their mouth open wide to be able to breastfeed well. The symptoms below are all associated with poor attachment that may be caused by tongue tie.

A baby may:
* Be unable to latch on to the breast at all.
* Be unable to latch on deeply, causing nipple pain and damage.
* Have difficulties staying on the breast, making a clicking sound as he loses suction.
* Splutter and choke when coping with fast flowing milk.
* Breastfeed constantly to get enough milk.
* Have poor weight gain or need supplementation to maintain adequate weight gain.
* Develop jaundice that needs treating.
* Be fussy at the breast when the milk flow slows.
* Develop colic.

A mother may experience:
* Pain during feeds, with damaged nipples. Her nipple may be compressed or distorted into a wedge shape like that of a new lipstick immediately after feeding, often with a stripe at its tip.
* Engorgement, blocked ducts and mastitis because of ineffective milk removal.
* Low milk production because of ineffective milk removal.
* Oversupply-if her baby compensates for not being able to breastfeed well by nursing very frequently.
* Tiredness, frustration and discouragement.
* A premature end to breastfeeding.

Breastfeeding is important for every baby

Though sometimes needed as a temporary supplement if your milk production is very low, introducing infant formula is not the answer. It has short-term and long-term health risks for both your baby and you. A baby with tongue tie can also have difficulties with bottlefeeding. Milk may leak from his mouth during feeds and he may suffer from colic.

Treatment

Where a tongue tie is causing breastfeeding problems, treatment options are available and effective- especially if the treatment is prompt. Although attention to positioning and attachment can help maintain breastfeeding and improve comfort to a certain extent, there is evidence that treating tongue tie by frenotomy (see below) is effective in resolving breastfeeding difficulties. Weight gain can improve dramatically. As well as the continued breastfeeding benefits, continuing to breastfeed after frenotomy maximises a baby's chance of normal mouth (palate), speech and dental development. This includes tongue mobility for licking and moving particles of food around the mouth, helping prevent tooth decay.

Keeping breastfeeding going

Mastering the art of breastfeeding can sometimes be a challenge and it takes determination to keep going if you are in pain. The information here can help you keep breastfeeding, both before and after treatment.

Soften your breast

A baby with tongue tie may find it easier to latch on if your breast is soft so breastfeed frequently to avoid engorgement. When your baby bobs their head and licks the nipple, they naturally makes it easier to latch on. Or you can use reverse pressure softening to move fluids away from the nipple area so your baby can latch on well. Press all five fingertips of one hand around the base of the nipple. Apply gentle steady pressure for about a minute to leave a ring of small dimples on the areola. You can also press with the sides of your fingers. Place your thumb on one side of the nipple and two fingers on the other side where your baby's lips will be. Gently hand express a little milk if needed.

Biological nurturing™
A baby often instinctively attaches more deeply and comfortably if they can snuggle up close to their mother's chest for periods of time. Try letting your baby lie on your body as you recline so both their chest and tummy are against you. This kind of 'laid-back' breastfeeding contact is known as Biological Nurturing™ and can be done skin-to-skin or with you and your baby lightly clothed-whatever is more comfortable and convenient for you both. Because gravity helps a baby keep their tongue forwards, this can make a real difference to how well your baby feeds and how much milk you make. See picture above and Online Information section for details of an online video.

A deeper latch
Help your baby get as deep a latch as possible at the breast. This will maximise the amount of milk they get and minimise nipple pain.

If your baby retracts (pulls back) their tongue when they open their mouth, try sliding their chin a little further from the nipple so he can feel the 'fatter' part of the breast with his tongue. Denting the breast at the edge of the areola with a finger and placing your baby's chin in the dent may also help.

You could also try placing your thumb or finger near the base of the nipple where your baby's upper lip will be. If you press, your nipple will tilt away from your baby, presenting them with your breast rather than your nipple. 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. If needed, you can then slip your finger out. An LLL Leader can give you further suggestions to help you improve your baby's positioning and attachment

Encourage tongue mobility

To encourage your baby to move their tongue forward, you can also try:
* Reclining with your baby on top of you. Try leaning forward and back yourself to understand how gravity affects tongue position.
* Encouraging them to lick milk from their lips or from your nipple before and after feeds.
* Sticking your tongue out at your baby to encourage them to copy you.

Maintain milk production

If your baby is sleepy or has jaundice, or if you have engorgement or inverted nipples, then a tongue tie can make things worse. If they are not able to take enough milk directly at the breast then you will need to express it and give it to your baby until they are able to breastfeed effectively. Express by hand and/or with a pump at least 8 times a day if your baby is not draining the breast well. This will maintain your milk production and ensure they get enough milk.

Small amounts of expressed milk can be offered by spoon, cup or syringe while you both learn how to breastfeed. Bottles or dummies can confuse your baby's sucking technique so consult an LLL Leader about breastfeeding friendly ways to bottlefeed or about using a nursing supplementer. This device delivers extra milk through a tube along your breast as your baby nurses, avoiding the need for bottles.

An unusual palate

Restricted tongue movement caused by tongue tie may affect the shape of a baby's palate, leading to a high palate or a bubble palate with a high spot. These may be a factor in broken suction, a clicking sound and pain during breastfeeding. A baby with an unusual palate may also resist a deeper latch due to gagging.
The following may help.
* Start with a clean finger with closely trimmed nail.
* Touch your baby's lips and wait until they open their mouth.
* Gently slide in your finger, pad side up along his hard palate, stopping just before the gag reflex is triggered.

Make this a pleasant game and, over a few days, gradually move your finger back to overcome sensitivity. After a tongue tie is divided, a baby's increased tongue movement helps the palate shape become more normal

Treating Tongue Tie

What can be done?
Frenotomy-dividing the tongue tie-can dramatically improve breastfeeding comfort and efficiency for both mother and baby. Dividing a tongue tie is a quick and simple procedure. No anaesthetic is needed for a baby under six months of age.

There are health professionals around the UK who have been specifically trained to divide tongue ties. For treatment on the NHS, you will need a referral from your midwife, health visitor or GP. Knowledge about tongue ties and how they affect breastfeeding varies, so it is worth persisting and seeking a second opinion. In areas where only GPs can refer, your midwife or health visitor may be able to give a recommendation to your GP or suggest seeing a particular GP. Private treatment may also be an option. See Further Reading for information on finding a practitioner trained to divide tongue ties

Is waiting an option?
Sometimes a very thin tongue tie breaks spontaneously or can be stretched by gentle massage of the frenulum. The earlier a tongue tie is divided, the easier it is to resolve any breastfeeding difficulties. Dividing a tongue tie in a baby over six months old is also a more complicated procedure and usually requires a general anaesthetic.

Frenotomy-what will happen?
After the health professional's initial assessment, your baby will be swaddled and held (often by an assistant) so they stay still during the procedure, which only takes a minute or two. The health professional lifts the tongue and divides the frenulum by cutting it with a pair of round-ended sterile scissors or by cauterising it.

Does it hurt?
No anaesthetic is needed for a very young baby as having a tongue tie divided only hurts a little, if at all. Some babies protest more at being swaddled than about the treatment. Others sleep right through the procedure! You will be asked to breastfeed your baby as soon as the procedure is over, to offer comfort, clean the wound and get their tongue moving as soon as possible. The inside of a baby's mouth heals very quickly. The only treatment usually needed is to breastfeed to keep the wound clean and keep his tongue mobile. There may be a white patch under your baby's tongue, but this heals within 24 to 48 hours.

If things don't resolve
Usually a mother notices an instant improvement in her comfort during breastfeeds. Sometimes it takes a week or two for a baby to adjust to their tongue's greater mobility. An older baby may find it harder to adjust to increased tongue mobility and tongue exercises may be recommended. Occasionally a baby's frenulum needs dividing a second time, usually because the division was not quite extensive enough the first time. If you suspect that the initial procedure has not resolved your baby's breastfeeding problems arrange another consultation. Do persist with finding solutions. If several factors are involved it can take time and expertise to resolve the problem. An LLL Leader can suggest further paths to explore and provide ongoing support.

Painful nipples

Using different feeding positions can help if breastfeeding is painful. Or use the position you find most comfortable until your nipples heal. Check your baby's attachment later in the feed-if they slip down your nipple, this may cause you pain. Reclining breastfeeding positions or extra support under your arms may help.

Ask your LLL Leader about breast compression, which can help your baby get more milk quicker. An increase in milk flow may also help them breastfeed more effectively.

Hand express to stimulate milk flow before feeding. Or start on the least painful side, switching sides once your milk lets down. Pain can reduce milk flow, leading to engorgement and mastitis. Ask your doctor, midwife or health visitor about using a suitable painkiller. Applying warmth and using gentle massage and relaxation exercises just before feeds can help milk to flow.

Moist wound healing

When the underlying problem is corrected, moist wound healing can help your nipples heal without scab formation. After each feed gently pat your nipples dry to remove surface wetness. Apply a tiny smear of ultra pure modified lanolin to each nipple, dabbing it on rather than rubbing. Hydrogel pads without a cloth backing can also be used.

Blood from cracked nipples
Blood from cracked nipples is not harmful to your baby. You can continue to breastfeed whilst working to improve positioning and attachment.

If healing is slow
Once your baby starts latching on well you should feel more comfortable and notice signs of healing within a few days. If not, visit your GP-sometimes a bacterial or fungal infection can prevent healing. Continued pain may be a sign that treatment (or further treatment) of your baby's tongue tie is needed.

Seek support

This is a time when the support of other mothers in your local LLL group can be invaluable. You can find your nearest Leader or by calling our Helpline.

Further Reading

Find a tongue tie practitioner- Association of Tongue Tie Practitioners, has details of both NHS and Private Practitioners
Biological Nurturing™
Lactation Consultants of Great Britain

The Womanly Art of Breastfeeding. LLLI. London: Pinter & Martin, 2010: p63-81, 428-430.
Comfortable Breastfeeding
Engorged Breasts - Avoiding & Treating
Expressing Your Milk
Hand Expression of Breastmilk
My Baby Needs More Milk
Nipple Know-How
Nipple pain
Nursing Supplementers
Sleep Baby - Why and What To Do
Storing Your Milk
LLLI Resources
Tongue Tie & the Breastfed Baby
References

Hazelbaker, AK. Tongue-Tie: Morphogenesis, Impact, Assessment and Treatment. Columbus, OH: Aidan and Eva Press, 2010.

Mohrbacher, N. Breastfeeding Answers Made Simple. Amarillo Tx: Hale Publishing, 2010.

Watson Genna, C. Supporting Sucking Skills in Breastfeeding Infants. Burlington, MA. Jones & Bartlett, 2012.

Geddes, DT. et al. Frenulotomy for breastfeeding infants with ankyloglossia: Effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics 2008; 12(1):e188-94.

Hogan, M. Westcott, C. and Griffiths, M. Randomized, controlled trial of division of tongue-tie in infants with feeding problems. J Paediatr Child Health 2005; 41:246-50.

Hong, P. et al. Defining ankyloglossia: A case series of anterior and posterior tongue ties. Int J Ped Otorhinolaryngology 2010; 74:1003-6.

Knox, I. Tongue tie and frenotomy in the breastfeeding newborn. Neoreviews 11 (9) Sept 2010.

Miranda, BH. and Milroy, CJ. A quick snip-a study of the impact of outpatient tongue tie release on neonatal growth and breastfeeding. JPRAS 2010; 63:e683-5.

NICE Guideline s

Watson Genna, C. And Coryllos, EV. Breastfeeding and tongue-tie. J Hum Lact 2009; 25(1):111-2.

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

Copyright LLLGB 2016

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Treating and coping with breastfeeding a baby with tongue tie

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What medicines are considered safe with breastfeeding? 

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What medicines are considered safe with breastfeeding? 

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Drugs in Breastmilk factsheets - The Breastfeeding Network

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

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When using a breast pump, some parents may find that the size of the shield does not suit them. Measuring your nipple using the tool below can help you to find a flange size that is comfortable and more effective for emptying the breast.

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Recent News: Dutch researchers find Covid-19 antibodies in human milk

'We think when drinking the milk, the antibodies attach themselves to the surface of our mucous membranes,' Hans van Goudoever, head of the Emma children's hospital at the UMC, said. 'Then they attack the virus particles before they force their way into the body.' The UMC has now started a campaign to find 1,000 women who are willing to donate 100ml of breast milk for the research project. 'Women who may have had coronavirus without noticing it may also have made antibodies which can be found in milk,'

Here you'll find references and research supporting the information in the advert.

"Nature has been researching your milk for hundreds of millions of years"

"Your milk contains ingredients that kill cancerous cells"

"Your milk contains stem cells. These are cells that create and repair the body, and are being researched worldwide to cure conditions like Alzheimers and diabetes."

"Your body identifies bacteria and viruses found in your baby's body and environment. You then produce antibodies specifically tailored for those infections, and deliver them to your baby through your milk. The more milk she drinks, the more antibodies she receives."

"Your milk appears to switch on a gene in your baby's body, which produces a hormone called Leptin. This hormone tells your baby when his tummy is full, protecting him against over eating."

"Your milk contains Oxytocin, a hormone that induces relaxation, and feelings of well-being in your child and in you."

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The science of human milk and breastfeeding

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Should you need to give extra milk to your breastfed baby in the early days, it is recommended to give it by syringe, spoon or cup, rather than by bottle. This is to protect your baby's breastfeeding instincts and reduce their chance of developing a bottle preference, please see examples below. 

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Should you need to give extra milk to your breastfed baby in the early days, it is recommended to give it by syringe, spoon or cup, rather than by bottle. This is to protect your baby's breastfeeding instincts and reduce their chance of developing a bottle preference, please see examples below. 

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If you are needing to give your baby extra milk, please ensure you are accessing feeding support from your community midwife or call the Infant Feeding Team

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Expressing Breastmilk - Patient Information Video

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This video was produced in collaboration with University Hospital Southampton as part of a project funded by NHSE South West. The project focuses on equity of access to appropriate equipment for expressing maternal breastmilk.

This video is designed to help breastfeeding parents to express breastmilk. The topics covered include:

The importance of correctly fitted equipment.
How to measure your nipple for flange sizing.
How to tell if you have the correct or incorrect fit. 
Variations in sizing depending on type or brand of breast pump.
How to prepare for expressing breastmilk.
How to assemble and use a breast pump.
Troubleshooting common issues in expressing breastmilk.

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Free online pregnancy and parenting courses

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Free online pregnancy and parenting courses

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This programme consists of a range of online courses designed to increase the confidence of parents-to-be, mums, dads, grandparents and carers. They have been developed by NHS experts and parents through an evidence-based model known as the Solihull Approach.

All of the courses are FREE for Warwickshire residents using the access code BEAR.

All of the courses can be completed flexibly, at your own pace. Each of the course modules takes around 15 to 20 minutes to complete. Each course contains several modules.

There is a built-in voiceover feature available if you prefer to listen and your device supports audio.

These courses are designed to help build a strong relationship between you and your baby, infant or child.

Using the access code BEAR on registration will provide access to all the courses listed above for a lifetime and it will never expire.

There's also a selection of other online and face to face courses for parents, covering a wide range of topics.

Technical support

Email: solihull.approach-parenting@heartofengland.nhs.uk

Tel: 0121 296 4448

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Free online courses to help parents feel more confident - Warwickshire County Council

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Free online parenting courses to help build up confidence of parents-to-be, mums, dads, grandparents and carers.

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Flange sizing - printable nipple ruler - please note that shields can go down to 10mm

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Flange sizing - printable nipple ruler - please note that shields can go down to 10mm

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How to Increase Milk Supply When Pumping

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How to Increase Milk Supply When Pumping

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How to Increase Milk Supply When Pumping

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How often should a mother pump to build up her milk supply and how long for? When is the best

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This information can also be viewed as a PDF by clicking here.
The information provided is taken from various reference sources. It is provided as a guideline. No responsibility can be taken by the author or the Breastfeeding Network for the way in which the information is used. Clinical decisions remain the responsibility of medical and breastfeeding practitioners. The data presented here is intended to provide some immediate information but cannot replace input from professionals.
X rays are used to look at bones and other structures within the body e.g. to identify fractures, to look at the state of teeth, to determine damage to joints, pneumonia etc.

As they pass through the body, the energy from X-rays is absorbed at different rates by different parts of the body. A detector on the other side of the body picks up the X-rays after they've passed through and turns them into an image.

Dense parts of your body that X-rays find it more difficult to pass through, such as bone, show up as clear white areas on the image. Softer parts that X-rays can pass through more easily, such as your heart and lungs, show up as darker areas.( http://www.nhs.uk/conditions/X-ray/Pages/Introduction.aspx).

Where possible X rays are avoided during pregnancy but there is no reason to avoid them during breastfeeding. Diagnostic X-rays have no known effect on the milk in the breast at the time of imaging, nor on milk production. No special precautions are required (LactMed).

In some situations a contrast agent may be used in addition to the X-ray. This can help show soft tissues more clearly on the X-ray. These include:

barium swallow - a substance called barium is swallowed to help highlight the upper digestive system

barium enema - barium is passed into your bowel through your bottom

Barium is an inert agent which shows up under the X ray but is not absorbed into the body so would not affect the breastfed baby.

Because barium sulfate is not absorbed after oral or rectal administration, it will not enter the milk, reach the bloodstream of the infant or cause any adverse effects in breastfed infants. No special precautions are required (LactMed).

©Dr Wendy Jones MBE, MRPharmS and the Breastfeeding Network Sept 2019

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X rays and Breastfeeding - The Breastfeeding Network

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

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Dr. Justice Reilly on Instagram: "There's probably no other piece of baby equipment that is more confusing to choose than a breast pump.  When I do antenatal consultations I am usually asked 
"What pump do I need for breastfeeding?"
🤱🏽
I love this because it shows someone is willing to invest in breastfeeding, and they want to be prepared. 
🎓
Unfortunately there isn't a simple answer.  I promise lactation consultants and peer supporters arent TRYING to be evasive or brush off your question, but the answer will depend on your circumstances and needs. You may need one, two or no pumps at all. 

Check out the scenarios in the tiles and let me know if you have any questions 👇🏽🤍

#breastfeeding #chestfeeding #beginningbreastfeeding #newborn #babyprep #baby #duedate #babyonboard #babybump #glasgowlife #rainbowbaby #ig_glasgow #bumpphotography #pregnancy #12weeks #6weeks #bfp #firsttrimester #pregnancyannouncement #maternitystyle #lactation #breastfeedingmedicine #ibclc #doctormum"

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Dr. Justice Reilly on Instagram: "There's probably no other piece of baby equipment that is more confusing to choose than a breast pump.  When I do antenatal consultations I am usually asked 
"What pump do I need for breastfeeding?"
🤱🏽
I love this because it shows someone is willing to invest in breastfeeding, and they want to be prepared. 
🎓
Unfortunately there isn't a simple answer.  I promise lactation consultants and peer supporters arent TRYING to be evasive or brush off your question, but the answer will depend on your circumstances and needs. You may need one, two or no pumps at all. 

Check out the scenarios in the tiles and let me know if you have any questions 👇🏽🤍

#breastfeeding #chestfeeding #beginningbreastfeeding #newborn #babyprep #baby #duedate #babyonboard #babybump #glasgowlife #rainbowbaby #ig_glasgow #bumpphotography #pregnancy #12weeks #6weeks #bfp #firsttrimester #pregnancyannouncement #maternitystyle #lactation #breastfeedingmedicine #ibclc #doctormum"

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22 likes, 12 comments - breastmed on October 19, 2023: "There's probably no other piece of baby equipment that is more confusing to choose than a breast ..."

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View this post on Instagram

A post shared by Dr. Justice Reilly (@breastmed)

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How to Use Nipple Shields | Infant Feeding Team

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Being able to respond to your baby's feeding cues as early as possible will help them to feed more effectively. Feeding your baby will be easier when they are calm and starting to rouse, rather than when they are upset/crying.

Source: Metro North Health Queensland

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Breast compression
This technique puts pressure on the milk ducts and can help to make feeding more efficient:

1. Support your breast with one hand – thumb on one side, fingers on the other.

2. Wait while your baby breastfeeds actively, their jaw moving all the way to their ear. When their swallowing slows, compress your breast firmly to increase milk flow and encourage swallowing. Hold it squeezed while they continue nursing actively, then release your hand.

3. Rotate your hand around the breast and repeat step 2 on different areas of the breast.

Go gently – this should not hurt.

(La Leche League - "My baby needs more milk" webpage)

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South Warwickshire University NHS Foundation Trust

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Breastfeeding positions and holds - video

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Breastfeeding positions and holds - video

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Best Beginnings - creators of Baby Buddy

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Breastfeeding positions - written information

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Breastfeeding positions - written information

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1. Cradle hold

This is the probably the most popular breastfeeding position.

However, if you've had a caesarean, it may be uncomfortable because your baby lies across your tummy near the scar (try lying on your side or the rugby hold instead).

For the cradle hold, sit in a comfy chair with arm rests, or a bed with cushions or pillows around you.

1. Lie your baby across your lap, facing you.

2. Place your baby's head on your forearm - nose towards your nipple. Your hand should support the length of their body.

3. Place your baby's lower arm under yours.

4. Check to make sure your baby's ear, shoulder and hip are in a straight line.

Cradle hold tip

If you're sitting on a chair, rest your feet on a stool or small table - this will stop you from leaning forward which can make your back ache.

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Breastfeeding positions - Start for Life

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Find out about the different ways you can breastfeed with our step-by-step guide to breastfeeding positions.

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Attaching Your Baby at the Breast – Breastfeeding Series

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South Warwickshire University NHS Foundation Trust

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Breastfeeding position - Football/Rugby hold

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Breastfeeding position - Football/Rugby hold

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Unicef UK Baby Friendly Initiative | Meeting baby for the first time

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Unicef UK Baby Friendly Initiative | Meeting baby for the first time

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Colostrum Collection in Pregnancy: When to start and how to do it

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Safe Sleeping Information - Lullaby Trust

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Safe Sleeping Information - Lullaby Trust

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Safer sleep for babies, Support for families

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Breastfeeding position - Laidback feeding/Koala hold

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Breastfeeding position - Laidback feeding/Koala hold

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South Warwickshire University NHS Foundation Trust

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Babiesincommon.com

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National Breastfeeding Helpline – Helpline

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National Breastfeeding Helpline - Helpline

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South Warwickshire University NHS Foundation Trust

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Unicef UK Baby Friendly Initiative | Hand expression

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Unicef UK Baby Friendly Initiative | Hand expression

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Kathryn Stagg IBCLC on Instagram: "Combination feeding: how to protect breastfeeding when you are mixed feeding. 

People combination feed for all sorts of reasons, whether through choice or necessity. By combination feeding I mean breastfeeding directly alongside giving milk from another source, whether that be formula or donor milk. This is not a post about pumping your milk to give baby. 

So we know that combination fed babies who have bottles can be at higher chance of rejecting the breast, so how do we manage a combination feeding journey whilst protecting the breastfeeding relationship? Here are some ideas: 

* Pace the bottle feeds. This is probably the most important thing you can do. Bottles flow fast and it is very easy to get the milk. Sometimes babies will prefer the ease of bottle feeding. Pacing the feed will slow down the flow and make them work a bit more for the milk.

* Try to minimise the amount of bottles. If combination feeding is for supply issues then trying to minimise the number of top ups to as few as you can get away with, or consider having a couple of bottle feeds in 24 hours and breastfeed frequently in between.  If combination feeding to have a break then one or two set feeds in 24 hours works really well. Just make sure the timing is useful for you so you can actually have a break!

* Consider another vessel. Top ups or full feeds can be given in all sorts of ways. Syringe feeding, finger feeding and spoon feeding are great for small quantities. Cups work well for larger feeds and especially useful if baby refuses the bottle. A supplementary nursing system (tube at the breast) is a great option if you have quite a big difference between your milk production and the baby's milk intake. It means you can give them a larger volume of extra milk during the breastfeed

* Make sure to breastfeed responsively. If baby has a fussy day when they are feeding loads, it can be tempting to reach for the bottle. But if you do, your breasts won't get the message to make more milk and so can fall further behind. This may cause baby to be fussier at the breast and they may start to reject. Breastfeeding responsively for the majority of the time helps protect against breast refusal"

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Kathryn Stagg IBCLC on Instagram: "Combination feeding: how to protect breastfeeding when you are mixed feeding. 

People combination feed for all sorts of reasons, whether through choice or necessity. By combination feeding I mean breastfeeding directly alongside giving milk from another source, whether that be formula or donor milk. This is not a post about pumping your milk to give baby. 

So we know that combination fed babies who have bottles can be at higher chance of rejecting the breast, so how do we manage a combination feeding journey whilst protecting the breastfeeding relationship? Here are some ideas: 

* Pace the bottle feeds. This is probably the most important thing you can do. Bottles flow fast and it is very easy to get the milk. Sometimes babies will prefer the ease of bottle feeding. Pacing the feed will slow down the flow and make them work a bit more for the milk.

* Try to minimise the amount of bottles. If combination feeding is for supply issues then trying to minimise the number of top ups to as few as you can get away with, or consider having a couple of bottle feeds in 24 hours and breastfeed frequently in between.  If combination feeding to have a break then one or two set feeds in 24 hours works really well. Just make sure the timing is useful for you so you can actually have a break!

* Consider another vessel. Top ups or full feeds can be given in all sorts of ways. Syringe feeding, finger feeding and spoon feeding are great for small quantities. Cups work well for larger feeds and especially useful if baby refuses the bottle. A supplementary nursing system (tube at the breast) is a great option if you have quite a big difference between your milk production and the baby's milk intake. It means you can give them a larger volume of extra milk during the breastfeed

* Make sure to breastfeed responsively. If baby has a fussy day when they are feeding loads, it can be tempting to reach for the bottle. But if you do, your breasts won't get the message to make more milk and so can fall further behind. This may cause baby to be fussier at the breast and they may start to reject. Breastfeeding responsively for the majority of the time helps protect against breast refusal"

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51 likes, 6 comments - kathrynstaggibclc on September 27, 2023: "Combination feeding: how to protect breastfeeding when you are mixed feeding. 

People combinatio..."

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There are a range of ways LLLGB can offer you support with breastfeeding, by telephone, in writing, or using our online information and printed materials. If the blue "chat now" button is showing, then you can also use our online chat service to have an instant conversation with one of our breastfeeding counsellors.

LLLGB Breastfeeding Information

Getting breastfeeding started

Life with a new baby

Common Concerns

Milk supply issues

Milk expression and storage

Family Foods

Working and separation

Breastfeeding an older baby

Can I breastfeed if...?

Issues

Breastfeeding Today (LLLI)
Information & stories
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Please note: The breastfeeding information on this website has been put together by La Leche League Leaders, who are accredited by La Leche League to provide breastfeeding information. Please note that Leaders have a wide knowledge and experience of breastfeeding but are not medically trained. If you have a medical query, or are concerned about your health or the health of your child please consult your doctor.

Information, references and links on this website are taken from La Leche League resources, unless stated otherwise. Please note that La Leche League GB does not endorse information from outside sources, extra information is provided for you to consider.

Information supplied is not intended as advice. You are in the best position to make a decision as to how the information offered will affect you and your baby.

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There are a range of ways LLLGB can offer you support with breastfeeding, by telephone, in writing, or using our online information and printed materials. If the blue "chat now" button is showing, then you can also use our online chat service to have an instant conversation with one of our breastfeeding counsellors.

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Syringe feeding must ONLY be used for expressed breast milk (not for formula)

Please note - the syringes featured in this video with small round caps are no longer used for feeding your baby directly, following a recommendation by the Medicines Health Regulatory Authority. An alternative will be provided - please ask your Community Midwife or Antenatal Clinic Midwife for this.

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Colostrum Collection in Pregnancy: When to start and how to do it

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You don't need to eat anything special while you're breastfeeding. But it's a good idea for you, just like everyone else, to eat a healthy diet.
A healthy diet includes:

at least 5 portions of a variety of fruit and vegetables a day, including fresh, frozen, tinned and dried fruit and vegetables, and no more than one 150ml glass of 100% unsweetened juice

starchy foods, such as wholemeal bread, pasta, rice and potatoes

plenty of fibre from wholemeal bread and pasta, breakfast cereals, rice, pulses such as beans and lentils, and fruit and vegetables - after having a baby, some women have bowel problems and constipation, and fibre helps with both of these

protein, such as lean meat and chicken, fish, eggs, nuts, seeds, soya foods and pulses - no more than 2 portions of fish a week is recommended, including 1 portion of oily fish

dairy foods, such as milk, cheese and yoghurt - these contain calcium and are a source of protein

non-dairy sources of calcium suitable for vegans include tofu, brown bread, pulses and dried fruit

drinking plenty of fluids - have a drink beside you when you settle down to breastfeed: water and skimmed or semi-skimmed milk are all good choices

See more detailed advice about healthy eating.

Small amounts of what you're eating and drinking can pass to your baby through your breast milk.

If you think a food you're eating is affecting your baby and they're unsettled, talk to your GP or health visitor, or contact the National Breastfeeding Helpline on 0300 100 0212.

Find out more about the helpline on the National Breastfeeding Helpline website.

Vitamins and breastfeeding

Everyone, including pregnant and breastfeeding women, should consider taking a daily supplement containing 10mcg of vitamin D.

From late March to the end of September, the majority of people aged 5 years and above will probably get enough vitamin D from sunlight when they are outdoors. So you might choose not to take a vitamin D supplement during these months

You can get all the other vitamins and minerals you need by eating a varied and balanced diet.

Ask your GP or health visitor where to get vitamin D supplements. You may be able to get free vitamin supplements without a prescription if you're eligible for the Healthy Start scheme.

Find out more about getting vitamins on the Healthy Start website.

You're entitled to free NHS prescriptions for 12 months after your baby is born. You will need to show a valid maternity exemption certificate to prove your entitlement.

If you did not apply for a maternity exemption certificate while you were pregnant, you can still apply at any time in the 12 months after your baby is born.

Healthy snack ideas for breastfeeding mums

The following snacks are quick and simple to make, and will give you energy and strength:

fresh fruit

sandwiches filled with salad, grated cheese, mashed salmon or cold meat

yoghurts and fromage frais

hummus with bread or vegetable sticks

ready-to-eat dried apricots, figs or prunes

vegetable and bean soups

fortified unsweetened breakfast cereals, muesli and other wholegrain cereals with milk

milky drinks or a 150ml glass of 100% unsweetened fruit juice

baked beans on toast or a baked potato

Healthy Start vouchers

You can get Healthy Start vouchers if you're pregnant or have a young child under 4 and are getting certain benefits or tax credits, or you're pregnant and under 18.

These can be spent on milk and fresh or frozen fruit and vegetables, or they can be put towards formula milk if you're not breastfeeding.

You can't use vouchers to buy fruit and veg with added fat, sugar and salt or flavourings, such as oven chips and seasoned stir fries. You can also get Healthy Start vouchers for free vitamin supplements.

For more information or an application leaflet, visit the Healthy Start website, or call the helpline on 0300 330 7010.

If you're already receiving Healthy Start vouchers, ask your midwife or health visitor where you can exchange the vouchers for vitamins.

Eating fish while breastfeeding

Eating fish is good for your and your baby's health, but while you are breastfeeding you should have no more than 2 portions of fish a week. A portion is around 140g.

Make 1 of them oily fish such as fresh mackerel, sardines, trout or salmon.

All adults should also eat no more than 1 portion a week of shark, swordfish or marlin.

Caffeine and breastfeeding

Caffeine can reach your baby through your breast milk. Caffeine is a stimulant, so if you have a lot, it may make your baby restless and keep them awake.

Caffeine occurs naturally in lots of foods and drinks, including coffee, tea and chocolate. It's also added to some soft drinks and energy drinks, as well as some cold and flu remedies.

There's not enough information to say how much caffeine is too much, and babies respond to caffeine differently. But it's a good idea to reduce how much caffeine you drink, especially when your baby is less than 6 months old.

If you're breastfeeding, it's recommended that you have no more than 200mg a day. This may include 1 mug, 1 can or 1 bar of:

instant coffee (100mg)

filter coffee (140mg)

tea (including green tea, which can have the same amount of caffeine as regular tea) (75mg)

cola (40mg)

energy drink (a 250ml can is 80mg)

plain dark chocolate (a 50g bar is less than 25mg)

plain milk chocolate (a 50g bar is less than 10mg)

You could also try herbal teas, 100% fruit juice (but no more than one 150ml glass per day) or mineral water.

Peanuts and breastfeeding

If you'd like to eat peanuts or foods containing peanuts, such as peanut butter, while breastfeeding, you can do so as part of a healthy, balanced diet (unless, of course, you are allergic to them).

There's no clear evidence that eating peanuts while breastfeeding affects your baby's chances of developing a peanut allergy. If you have any questions or concerns, you can talk to your GP, midwife or health visitor.

See more about food allergies.

Got a breastfeeding question?

You can message the Start4Life Breastfeeding Friend chatbot on Facebook Messenger for fast, friendly, trusted NHS advice anytime, day or night.

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Advice on eating a healthy diet while you are breastfeeding, including advice on what vitamins you need.

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

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

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Solihull.IFT | Instagram, Facebook | Linktree

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An NHS team offering feeding support and online classes to families in Solihull.

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Getting breastfeeding off to a good start

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Getting breastfeeding off to a good start

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Getting breastfeeding off to a good start

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Support with breastfeeding or bottle feeding: our infant feeding line | Baby & toddler, Feeding articles & support | NCT

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Support with breastfeeding or bottle feeding: our infant feeding line | Baby & toddler, Feeding articles & support | NCT

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Find out more here about our infant feeding support line and the help available if you have any questions or concerns about feeding your baby.

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Trained breastfeeding counsellors are available at:National Breastfeeding Helpline, Find a local support group, Access web chat or email us.

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The Breastfeeding Show is made by Frances Attenborough, Karen Hall and Megan Stephenson, who are all NCT-trained Breastfeeding Counsellors, with at least ten years' each of experience helping parents both through antenatal sessions, and group and 1:1 postnatal support. This show is for anyone with an interest in feeding babies, whether they're exclusively breastfeeding, chestfeeding, mixed feeding, expressing, still waiting for their baby to arrive, or thinking about stopping.

In our first series, we cover the basics of how to get started, establishing a milk supply, positioning and attachment, expressing, common challenges, and we bust a few myths. We hope our informal style keeps things interesting and useful, as we chat about our absolute favourite subject.

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The Breastfeeding Show is made by Frances Attenborough, Karen Hall and Megan Stephenson, who are all NCT-trained Breastfeeding Counsellors, with at least ten years' each of experience helping parents both through antenatal sessions, and group and 1:1 postnatal support.

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Baby Buddy is a free, award-winning app with expert advice and self-care tools to support parents through pregnancy, birth, and your baby’s first year.

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I was a bit scared when we found out we were having a baby, obviously happy, but a bit scared and in the beginning I was a bit clueless. The child development part is my favourite bit, but there's things in there, like things about mental health, that I didn't know about and that I didn't know you needed to know about.

Ross, 22

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DadPad | The Essential Guide for New Dads | Support Guide for New Dads

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Developed with the NHS, DadPad gives new dads and dads-to-be the knowledge and skills needed to gain confidence and give their baby the best start in life.

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Unicef UK Baby Friendly Initiative | Importance of relationship building

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Unicef UK Baby Friendly Initiative | Importance of relationship building

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NHS-Trusted 24/7 Infant Feeding Support | Specialist Guidance.

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Explore Anya's expert-led infant feeding support: 24/7 guidance, tools, and resources to help families overcome feeding challenges.

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Transitioning your premature baby onto the breast - Kathryn Stagg IBCLC

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Transitioning your premature baby onto the breast - Kathryn Stagg IBCLC

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When a baby or babies have arrived early, Mum often feel stressed and helpless and feel one of the few things they can do is to provide breast milk. Preterm breast milk is different to that of a mum who delivers at term. It has higher levels of energy, fats, protein, vitamins and minerals, and most importantly it has higher levels of immune factors. It is highly valued in the neonatal unit and mums are usually supported to hand express colostrum within the first 6 hours after birth, and then move onto the pump to provide breast milk for tube feeds. The hospital should be able to advise on renting a hospital grade double pump for when mum is discharged. It is important to pump frequently; we recommend 8-12 times in 24 hours making sure at least one is between 2-5am when hormone levels are at their highest. There will be a more detailed blog on establishing milk supply through pumping soon.

But what next? How do we go about actually breastfeeding? Is it possible to move to exclusively breastfeeding when you have had such a traumatic entrance to the world? The answer is yes, but it will take time.

Once premature babies hit around 32-33 weeks gestation they often begin to start developing a suck, swallow, breathe pattern in short bursts and may start rooting for the breast. Hopefully mum will have already been given the chance to have lots of kangaroo care with her baby before now, but at this point it can really help transition the baby from tube feeds onto breastfeeding.

Learning to breastfeed when you are a premature baby is a long, slow, tiring process and it requires everybody to have lots of patience. To start with babies can have skin to skin time, or kangaroo care, be encouraged to lick the nipple and if they are ready to possibly have a few sucks. A baby can begin with non-nutritive sucking at the mum's recently pumped breast to provide a gentle experience without an overwhelming flow of milk. Then a fuller breast can be introduced. But at this early stage the majority of any feed will still be expressed milk through the feeding tube. The staff will encourage mum to maybe try baby once or twice a day at the breast so as not to tire them out too much. Once they become stronger and start to suck and swallow more efficiently its time to move to more frequent feeds. It can be a good plan to try baby at the breast during their tube feed as they will begin to associate the act of breastfeeding with the feeling of having a nice full tummy. A nipple shield can help the smaller baby to latch onto the breast, especially if they have been given bottles. There is evidence that suggests shields can incease milk intake in preterm infants in the early days. Remember ask for lots of support from the hospital staff during this time. This is actually one of the benefits of having babies in special care.

When the babies appear to be feeding better and getting much more milk we can move on to the next stage. This can be at different ages for different babies. For some it can be around the 36-37 week gestation mark, others need to get to near full term. The hospital staff will help give confidence that it is time to move to the next stage. Whilst some babies will be able to move straight on to exclusive breastfeeding from tube feeding, this new enthusiasm for feeding can be a bit misleading as the suck can still be uncoordinated and inefficient and the babies can still tire easily. If we move on to exclusive breastfeeding too quickly, it can cause problems with babies not taking enough milk, becoming too tired and then starting to reduce their weight gain. So for many babies its advisable to continue to top up with expressed for a while. A lot of mums choose to top up by a different method than tube so the babies can get home. Hospital staff may use a tool like the Breastfeeding Assessment Score below to calculate how much top up to give baby. They will calculate to work out exactly how much milk depending on baby's weight, gestation, growth about how much a full feed is.

For twins and triplets it is important to remember that they are individuals. One baby may be much better at feeding than the other. It can be hard not to compare and be worried and frustrated if one baby is not managing to feed as well. But, with time, it is very likely that they will catch up and both will feed well from the breast when ready.

Generally hospitals prefer to use bottles to feed babies their top ups, or during the night when mum is not there. They are easier, there's less waste and staff are pushed for time so go for the easier option. So to minimise the impact of using a bottle on breastfeeding, it is important to use a paced bottle feeding technique. Paced bottle feeding means letting the baby take control of the speed of the feed and when to take breaks and when to finish. Sit baby in an upright position and keep the bottle as horizontal as possible whilst still filling the teat with milk to avoid intake of air. Baby should be encouraged to latch on to the bottle like the breast, so touching the top lip to encourage baby to route and bring baby onto the bottle chin first, teat into the roof of the mouth. Stop frequently and make sure you do not force baby to have a certain amount. With this slower feeding technique, the baby will be able to tell it is full and finish the feed when satisfied. And baby will be more able to transfer between bottle and the slower flow of the breast.

Mum and baby will hopefully be given the chance to 'room in' for a night or two before they are discharged. During this time they're often encouraged to move on to more baby-led feeding as opposed to hospital routine based feeding. But babies can still be sleepy and not wake for feeds at this stage so its important to make sure that they feed at least every 3 hours as a minimum. 3 hours is measured from the start of each feed.

For a lot of preemie mums, their first experience of being at home with their early baby is to be in an intense breastfeed, top up, express routine, every 3 hours or more, day and night. This is utterly exhausting and overwhelming and mums can often not see past this stage. However with good feeding support from health visitors and breastfeeding specialists and the discharge team from NICU, mums can move on to exclusive breastfeeding.

Whilst the baby still needs top ups it is imperative that there should be somebody to look after mum. This routine is so full on that there is not much time for anything else, especially sleep! Somebody to do the top up whilst mum expresses can be a life saver as this can save time and could give mum half an hour extra break before she has to start the process again. Breastfeeding makes you hungry and for mum's energy levels it is important that she eats properly, so having someone to feed her whilst she feeds the babies is a great idea. Every single breastfeed given and every single drop of expressed milk should be valued and encouraged. Emotional support reassuring her that she is doing a brilliant job and that soon it will become much easier can keep everyone going through this incredibly tough time.

Support can be invaluable at this time but a lot of mums feel unsure about taking their preterm baby out to groups due to risk of infections. This is where home visits from well informed health care professionals and good online support can step in. Online support especially can be great, as long as it is properly moderated, as mums can make contact with others who have been in the same position or are going through it at the same time. Peer to peer support is incredibly important. There is also often somebody around at 3am during the night feeds to sympathise!

So how do we know when a baby is feeding well enough to move on from this routine? Often around due date or just after, babies suddenly 'get' feeding. Their suck becomes more coordinated and they can remove more milk from the breast. You can watch for the full term feeding pattern of sucking fast for a minute to stimulate the let down, and then move on to deep slower jaw movements with pauses in between. You may be able to hear swallowing. Breast compressions can help to get a bit more milk into the baby if they are still seeming a little inefficent or sleepy at the breast. They often have a big feeding frenzy at around due date and sometimes want to cluster feed. This can be very unnerving for a preterm mum who is used to having a sleepy baby who needs to be woken for feeds. Cluster feeding should be encouraged and explaining to mum that it is completely normal behaviour and will help baby get lots of milk. However it does not necessarily translate in to weight gain immediately. It can be very discouraging when baby has been feeding all night and only put on a small amount the next day. However you often find a day or two later and it pays off.

For twins or triplets it may be a good plan to get some support with tandem feeding. Tandem feeding maximizes the time spent feeding as there's less waiting time for babies and it is a more efficient use of time. It helps synchronize the babies' feeding times and more importantly sleeping times! A strong feeder can help a weak feeder by stimulating the let down and getting the milk flowing. It also increases milk supply and the milk has a higher fat content.

Dropping or reducing the top ups gradually can make it a bit less stressful. For more detailed info in reducing top ups see our other blog here

But here's an overview: Mums can reduce the volume of top ups and put babies back on to the breast if not settled. Mums often find that babies are more settled during certain times of day or night and these can be the first feeds to just breastfeed. Encourage mums to allow the baby to have a second or third go on the breast if they do not settle after the first feed. Offer the other breast so baby gets a nice fast flow of milk. For twins or triplets you can just put them back on the same one and mum will get another let down of milk.

Aiming for maybe 3 top ups of expressed a day and being baby led in between is a good starting point. Mum can keep an eye on nappy output during this time to give her peace of mind and she may prefer to weigh the baby before moving on from this stage to give her confidence that everything is going well. Sometimes when babies move on to more direct breastfeeding, their weight gain can flatten off a little bit. This can be really discouraging but it can take a bit more energy to fully breastfeed and they can tire themselves out and burn more calories. As long as they are still gaining this is usually ok and they will set off following their curve again given a bit of time. This may be a good time to get some reassurance from a breastfeeding specialist.

Once mum is feeling confident and babies are feeding well it is relatively easy to drop the last few top ups . Mum can either stop them all at once or drop one at a time. It is often a relief to have the relative simplicity of just breastfeeding without all the faff of expressing and washing bottles. Some prefer to still keep an expressed feed in their routine so that they can have a break.

Breastfeeding is so important for babies, but even more so for premature babies. But establishing breastfeeding in the neonatal unit is like a marathon, not a sprint. It is a slow process taking every ounce of patience and determination. But it is worth every bit of stress.

Kathryn Stagg IBCLC, Aug 2017

References

Breastfeeding and Human Lactation, enhanced 5 th edition, Wambach & Riordan, 2016

The Breastfeeding Atlas, 6 th edition, Wilson-Clay and Hoover, 2017

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Transitioning your premature baby onto the breast- a parent's guide

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When a baby or babies have arrived early, Mum often feel stressed and helpless and feel one of the few things they can do is to provide breast milk. Preterm breast milk is different to that of a mum who delivers at term. It has higher levels of energy, fats, protein, vitamins and minerals, and most...

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Baby Friendly Initiative | The constituents of breastmilk and formula

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Baby Friendly Initiative | The constituents of breastmilk and formula

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La Leche League Inducing Lactation group 

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La Leche League Inducing Lactation group 

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La Leche League - Inducing Lactation & Relactation has 7,627 members. This is an inclusive support group for those looking for information and support on how to induce lactation (bring in a milk...

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While it's good to have plenty of milk, some mothers produce more milk than their babies need. This is usually called oversupply.

Some babies cope very well with a generous milk supply; however, others will be unhappy and uncomfortable even though they are gaining weight and appearing to thrive. Oversupply can also make feeding uncomfortable and increase the risk of mastitis.

Symptoms of oversupply
How does oversupply happen?
How is your milk supply established?
A note about foremilk and hindmilk
What can I do about the symptoms of oversupply?
Reducing your milk supply
If you still have problems
Breast compression
Adjusting to the new normal

Symptoms of oversupply

The main symptoms of oversupply for a baby are:

Very fast weight gain, moving upwards through centile lines

Explosive green frothy poos

Struggling to control milk flow

Pain and excessive wind or 'gas'

You may also notice the following:

Choking, coughing, and pulling on and off the breast

Clamping down and biting to slow the flow of milk

Frequent spitting up

Always appearing hungry and unsatisfied despite large weight gain

Unwillingness to nurse to sleep

Breast refusal

Faltering weight gain due to breast refusal

Lots of wet and dirty nappies

General 'colicky' behaviour

A mother with oversupply may have the following symptoms:

Some of these symptoms may have other causes; allergies and reflux, for example, can have similar symptoms to oversupply. They may also fall within the normal range. Therefore, it is important to rule out other possibilities before taking steps to reduce your milk supply, as this can have longer term consequences.

How does oversupply happen?

Some mothers naturally produce large quantities of milk, and we tend to produce more milk with each baby. Occasionally, there are medical reasons for having much more milk than your baby needs. Oversupply can also occur as a result of breastfeeding management, for example, when a baby's feeds are scheduled, or if a mother is told to feed from each breast for a certain amount of time. It can happen if a pump is used too often, or used in a way that overstimulates the breast.

Milk production is best regulated by your baby's appetite. When you breastfeed responsively, rather than by following a schedule, your milk production adapts to their needs. Occasionally, a poor latch can contribute to oversupply as a baby might feed very frequently to get the volume they need. However, this tends to reduce milk supply over time.

How is your milk supply established?

After your baby is born, milk production is regulated on a supply and demand basis. Put simply, the more milk you remove, the more milk you are likely to make. How quickly or slowly milk is made depends on the fullness of the breast - an 'empty' breast makes milk more quickly, a full breast makes milk more slowly.

It takes a few weeks for your supply to settle down to what your baby actually needs. It is not unusual in the early weeks to feel as if you have too much milk, and to have times when the breasts feel full or even engorged. This is not the same as oversupply.

Feeding frequently and removing milk from the breasts is essential to resolving engorgement - it won't make the engorgement worse or result in too much milk.

Babies usually nurse more during developmental leaps and growth spurts, and many mothers find there are changes to their baby's nursing pattern during holidays and family get-togethers, or during periods of stress. Milk supply is very adaptable - if you follow your baby and your body, your supply will most likely regulate itself.

Read more about how milk production works.

A note about foremilk and hindmilk

One of the symptoms of oversupply in a baby is green frothy poos, gas, and pain. This is sometimes called lactose overload or a foremilk-hindmilk imbalance.

You may be given confusing information about foremilk and hindmilk, and how long a feed 'should' last. Or think that there are two different kinds of milk - lower-fat and fat-rich - and that one is better than the other.

Typically, the fat content does increase during a feed, as the fat globules tend to be drawn down towards the end of a feed. However, it is not the length of a feed that is important, but the length of time between feeds. Fat content is determined mostly by the fullness of the breast. If there is a long gap between feeds and the breast is full, the baby may get a large quantity of lower-fat milk before much of the fat starts getting pulled down. The same may be true if a mother naturally produces very large quantities of milk. In the absence of fat-rich milk, the lower-fat milk moves through the gut faster than it can be digested, causing green poos, gas, and pain.

All breastmilk is good! What matters most to weight gain is overall milk volume.

What can I do about the symptoms of oversupply?

To start with, you might like to:

adjust your position and your baby's attachment to help them manage a fast letdown

feed responsively (as often as your baby wants) and/or offer more frequent feeds

use breast massage

avoid overpumping

Managing a Fast letdown
A fast letdown can be one symptom of oversupply. It is possible to have a fast letdown with an 'average' milk production. When your baby nurses, a hormonal reflex causes milk to release, (what is known as 'letdown'). When this happens, it is not unusual for milk to spray out quickly. Some babies like this fast flow, but others are upset by it and struggle to coordinate sucking, swallowing, and breathing. You may find it helpful to:

Ensure that your baby is deeply attached at the breast. This will make it easier for them to manage a fast flow.

Try different positions. Some parents use gravity to help them by feeding in a 'laid-back' (reclined) position. Others find it helps to feed in a more upright position such as a 'koala hold', or to feed while using a sling or baby carrier. Side-lying may also be helpful as excess milk can easily leak out.

Allow your baby to come off the breast when they need to catch their breath, and use a muslin to catch the spray.

Some mothers hand express a little to slow the flow before bringing the baby to the breast (however, if this is done frequently, it may make oversupply worse).

If your breast is very full and engorged, you might try 'reverse pressure softening' to move fluids away from the nipple area as this can help your baby to latch more deeply.

Feed frequently so that the milk spray doesn't have quite so much volume and force behind it.

Try breastfeeding before your baby is really hungry, or while they are slightly sleepy.

Responsive feeding
How do you know how often or how long to feed your baby for? Let your baby tell you! We all have different milk storage capacities and this may determine how frequently your baby feeds, and whether they feed from one side or two. Allow your baby to feed from the first breast for as long as they want to before offering the second breast - they may or may not take it.

Sometimes babies will only take one breast, and sometimes two (or three or four!). Most babies will take both breasts, at least some of the time. Babies are very good at letting us know how often they want to feed, and if in doubt, it is always fine to offer.
Breast massage
You could do what is sometimes called the 'breast milkshake'. This involves massaging each breast very gently for half a minute or so before feeding, then using a combination of massage and breast compression (see below) during a feed to help dislodge some of the fat. Any massage should use a light fingertip pressure such as you would use to apply body lotion.
Expressing
Overuse of pumps - or using a pump in a way that unintentionally stimulates milk production (such as a silicone pump to collect dripping milk) - can make oversupply worse. If you've been expressing regularly, reduce this gradually to avoid further problems.

Reducing your milk supply

If your baby is gaining more weight than average and you and your baby are happy, then you don't need to change anything. It is not possible to overfeed a breastfed baby.

If you or your baby are struggling with some of the above symptoms, you have ruled out other causes and changes to breastfeeding management do not help, then you may want to consider taking steps to gradually slow milk production.

Consult an LLL Leader before using these approaches. This is especially important if your baby is under one month old, or you are experiencing other problems such as sore nipples or mastitis.

Monitor your baby's weight gain to ensure it doesn't drop below expected levels, and keep a close eye on nappy output.

One side per feed
Limit your baby to one breast per feed. If your baby wants to have a short rest during a feed, then offer the same breast again. When a mother has a generous milk storage capacity, their baby may only need to feed on one side. This approach may help milk production to reduce in line with their baby's demand.

Block feeding
Block feeding involves feeding on the same side for a set period of time (block), e.g. for two or three hours. If your baby wants to feed again within that time block, offer the same side. As a starting point, you might like to:

Limit your baby to one breast for about two hours, allowing them to nurse as often and for as long as they like, but only on that one side.

Continue in this way, switching breasts every two hours. If your baby is asleep, switch breasts when they wake.

It is important not to have a rigid approach to block feeding: read your breasts and your baby, not just the clock. By doing this, you will find the time block that works best for both of you. If the unused breast feels uncomfortably full before the next feed then 'express to comfort' only.

It is possible to experience oversupply in just one breast, in which case you could nurse for longer periods on the unaffected side.

Full drainage and block feeding method
For more severe oversupply - for example, if you are suffering from recurrent blocked ducts or mastitis and your breasts never feel soft and comfortable even after a breastfeed - you will need to keep your breasts well drained while you take steps to reduce milk production.

You could try the following, in consultation with an infant feeding specialist, in addition to block feeding:

Express from both sides thoroughly to 'empty' your breasts as fully as possible.

After expressing, immediately offer both 'empty' breasts to your baby.

Next, limit your baby to one breast changing sides every two or three hours (see block feeding above).

Some mothers will need to use this approach only once. However, if your breasts feel uncomfortably full, you may need to repeat it, increasing the interval between each pump for your breasts to readjust.

Medications and herbs to reduce milk production
There are herbs and medications that can help dry up your milk production. Talk with your health care provider or a lactation consultant.

If you still have problems

After 4-7 days, your breasts may be more comfortable. If you and your baby still have trouble coping with the supply of milk, you can gradually increase the time block you keep your baby to one breast. Some women with extreme oversupply have gone as long as six or more hours before switching breasts to adjust milk production. A hormonal imbalance may cause overproduction of milk, but this is rare. A visit to your doctor may be helpful if the suggestions offered here aren't enough.

Block feeding should be a temporary measure. In practice, it is suggested that it is done for no more than one week, and only when babies are gaining double (or more) the average weight for their age. Once supply has settled, you can return to a more normal feeding pattern, following and trusting your baby and your body.

Breast compression

Babies used to a generous milk flow can become fussy at the breast when milk flow slows. They may have to work harder at the breast and deepen their latch to remove milk effectively. Breast compression will increase milk flow and encourage your baby to keep feeding actively:

1. Support your breast with one hand - thumb on one side, fingers on the other.

2. Wait while your baby breastfeeds actively (slow, rhythmic sucking, lots of swallowing). When their swallowing slows, compress your breast gently to increase milk flow and encourage swallowing. Hold it squeezed while they continue nursing actively, then release your hand.

3. Rotate your hand around your breast and repeat step 2 on different areas of the breast as needed. Be gentle - this shouldn't hurt.

Adjusting to the new normal

Always monitor your baby's weight gain, wet and dirty nappies, and overall well-being while following these strategies. Monitor their weight over a period of several weeks to see a trend. If your baby had been gaining weight very quickly, you may see 'catch-down' growth. Your baby will gain weight steadily, but may gradually drop against the percentile lines as your milk production adjusts. Their weight should then settle into following a new percentile line on the chart.

As your supply reduces, your breasts will feel softer and more comfortable, and leaking will be reduced. Soft comfortable breasts between feeds during the early weeks are normal and a sign that your milk production is in tune with your baby's needs.

Written by Charlotte Allam

Last updated May 2023

Kimberly Seals Allers' photos on this site are used under a creative commons license of Black Breastfeeding 360° http://mochamanual.com/bb/

Further Reading
Mastitis
Engorged Breasts - Avoiding & Treating
Hand Expression of Breastmilk
Is My Baby Getting Enough Milk
Comfortable Breastfeeding
Rhythms & Routines
The Unhappy Breastfed Baby
Reflux
Allergies and Intolerances
Fat Content of Breastmilk - FAQs
Positioning and Attachment

Other websites
UK-WHO Growth Charts: www.rcpch.ac.uk/growthcharts
Block Feeding Dos and Don'ts: http://www.nancymohrbacher.com/articles/2013/10/9/block-feeding-dos-donts.html?rq=oversupply

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

Copyright LLLGB 2023

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While it's good to have plenty of milk, some mothers produce more milk than their babies need. This is usually called oversupply. Some babies cope very well with a generous milk supply; however, others will be unhappy and uncomfortable even though they are gaining weight and appearing to thrive.

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All babies should have plenty of wet and dirty nappies. If your baby is not opening their bowels every day, this can be an indicator of needing feeding support - please get in touch

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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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Sleep: Bedshare - La Leche League International

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

Mothers can have general anaesthetic and breastfeed as normal as soon as they are awake and alert following surgery. Care should be taken with co-sleeping that evening.

For information on the use of Local anaesthetics whilst breastfeeding please see https://www.breastfeedingnetwork.org.uk/local-anaesthetics/

For information on the use of Local anaesthetics during dental procedures whilst breastfeeding please see https://www.breastfeedingnetwork.org.uk/dental-treatment/

Some women need to have operations under general anaesthetic whilst they are breastfeeding. Some healthcare professionals and mothers are concerned about the safety of the baby who may be exposed to anaesthetic agents via their mother's breastmilk. This adds to the stress of many mothers undergoing procedures - minor or major. The risks of mastitis in the mother should not be ignored if she is told to pump. There is no evidence of the need to dump any milk expressed following anaesthesia.

Mothers who undergo caesarean sections under general anaesthetic (usually as an emergency procedure) are encouraged to breastfeed as soon as possible after delivery. In some cases babies are helped to latch whilst the mother is still in the recovery room and drowsy. Anecdotally many mothers are advised to pump and dump their breastmilk for 24-48 hours after anaesthetic even for a short operation in order to clear the body of the drugs rather than simply to maintain supply. This is not necessary.

General anaesthetics have very short half-lives and are redistributed in the body within minutes which is why they have to be infused continuously during operations. Some is stored within the fat cells of the body and gradually released over the following 24-48 hours but the level of drug released from a short procedure is unlikely to cause any greater effect than drowsiness in the baby.

In most cases of minor surgery the mother is wide awake within minutes of the end of the operation. Even with major surgery recovery from the anaesthetic is short although drowsiness may then result from opiate pain killers injected in theatre. Once a mother is awake enough to recognise that she has a baby who needs to be breastfed the level of anaesthetic in her blood is likely to be small.

Consideration does however need to be given to;

Who will look after the baby whilst mum is in surgery?

If the mother is to remain in hospital overnight are there facilities for the baby to remain with her?

If so is she happy for the baby to be there?

Is there someone who is available to look after the baby but bring it to mum when a feed is needed?

If the baby is not to stay with the mother does she have access to a breast pump and somewhere to store the milk safely for it to be given to the baby later?

Is she able to express milk for the baby? We need to avoid the risk of mastitis if mother and baby are separated.

Is it possible to delay the operation until after weaning? This may not be an option nor should a mother be pressurised into weaning in order to have an operation. Breastfeeding and anaesthetic are not normally mutually exclusive.

Mitchell J, Jones W, Winkley E, Kinsella. S.M Guideline on anaesthesia and sedation in breastfeeding women 2020. Guideline from the Association of Anaesthetists. First published: 01 August 2020 https://doi.org/10.1111/anae.15179

Spigset O. Anaesthetic agents and excretion in breast milk. Acta Anaesthesiol Scand. 1994 Feb;38(2):94-103

Nitsun M, Szokol JW, Saleh HJ, Murphy GS, Vender JS, Luong L, Raikoff K, Avram MJ. Pharmacokinetics of midazolam, propofol, and fentanyl transfer to human breast milk. Clin Pharmacol Ther. 2006 Jun; 79(6):549-57.

Schneider P, Reinhold P. Anesthesia in breast feeding. Which restrictions are justified? Anasthesiol Intensivmed Notfallmed Schmerzther 2000 Jun;35(6):356-74.

Hale T.W Anaesthetic Medications in Breastfeeding Mothers.

ilca.org/education/Anesthetic%20Meds.pdf

Jones W Breastfeeding and Medication 2nd Ed Routledge 2018

© Wendy Jones PhD, MRPharmS and the Breastfeeding Network March 2022

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Anaesthetics and Breastfeeding - The Breastfeeding Network

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

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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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South Warwickshire University NHS Foundation Trust

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Bonding with your baby Becoming a parent

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Bonding with your baby.. Becoming a parent

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Bonding with your baby.. Becoming a parent

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1. How to use this padlet, 1a. Kingsway Support Group, 1b. Resources in other languages

2. Building close and loving relationships

3. The value of human milk

4. Antenatal expression/colostrum harvesting

5. Skin to skin

6. Off to the best start

7. Positioning and attachment

8. How to know that baby is getting enough

9. Switchfeeding and breast compressions

10. Giving supplements to your baby when needed

11. Nipple shields

12. Bottle feeding and sterilising feeding equipment

13. Common breastfeeding problems

14. Mixed feeding

15. Safe Sleeping

16. Infant feeding support

17. Local breastfeeding support

18. Pumps

19. LGBTQ+

20. Feeding multiple babies

21. Drugs in Breastmilk factsheets

22. Breastfeeding and diet

23. Triple feeding

24. Tongue tie

25. Manual therapies for babies

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Using a Calypso Breast Pump | Infant Feeding Team

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Support for Transgender & Non-binary Parents

La Leche League is an international, nonprofit, nonsectarian organisation. ¹
LLL supports everyone who wants to breastfeed or chestfeed in reaching their goals.
We at La Leche League have all nursed our babies. If you want to do the same, whoever you are, whatever your story is, we're here to help. LLLI is committed to serving everyone inclusive of race, ethnicity, religion, sex, national origin, ancestry, age, marital status, physical or mental ability, socio-economic status, political views, gender identity, sexual orientation, family structure, or other protected status.
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.

Retired Canadian LLL Leader and 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 It is also the case that some parents with gender dysphoria choose to pump and bottlefeed their milk to their baby. Whether you are pregnant, nursing your baby, pumping your milk, using donor milk, mixed feeding or considering your options La Leche League is here for you.

Please note that some of the links in this post will take you to articles or websites where you may notice gendered language.

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 or non-binary individual 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 and here. A number of different protocols are described here. Our article about Breastfeeding Without Giving Birth may also be useful. Transfeminine nursing parents may also need to take the hormone spironolactone to suppress their testosterone. Read a case report of induced lactation in a transgender woman here.

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, you may notice gendered language in them:

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, you may notice gendered language in them:

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.

Read about a transgender dad's experience of using a supplementer here.

Read a mother's story about the long term use of a supplementer here.

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. In some countries (for example the US) it may be pooled - this means milk from different donors is mixed. In some countries, and individual milk banks, milk pooling is not carried out.

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. Another organisation is Eats On Feets, it offers more information about safe milksharing practices, you can find resources here http://www.eatsonfeetsresources.org/ and a world map with milksharing chapters around the world here http://www.eatsonfeets.org/

LLL Support

All nursing parents need support and La Leche League is a great place to find it.

There are LLL groups in over 80 countries across the world, many offer meetings open to all - contact your local group to find out how they can support you.

Many groups also have private Facebook groups where you can ask questions and connect with other nursing parents.

LLL meetings are held in a wide range of venues - LLL is not affiliated to, and does not endorse or support, any business, organisation or religion whose premises we use.

Other support

Queer and genderqueer inclusive LLL Facebook group for support 'Inducing Lactation & Relactation'International Facebook group for 'Birthing and Breast or Chestfeeding Trans People and Allies'
International Facebook group for 'Trans Feminine Breastfeeding and Lactation Support'
Please ask to join the 'Trans Feminine Breastfeeding and Lactation Support' group from within the 'Birthing and Breast or Chestfeeding Parents and Allies' group.

LLL Resources

Breastfeeding Without Giving Birth
My journey: non-binary nursing, a story from LLLUSA
Sostengo per genitori transgender e non binari, LLL Italia
Información general: Transgénero/transexual/ Género fluido, La Liga de la Leche de Euskadi
Lactancia materna. Apoyando a mujeres transexuales, La Liga de la Leche de Euskadi
Lactancia. Apoyando a hombres transexuales, La Liga de la Leche de Euskadi Apoyo Para Parentalidades Transgénero Y No-Binarias, LLLI

OTHER RESOURCES

Adapted from an article first published by LLLGB - https://www.laleche.org.uk/support-transgender-non-binary-parents/
References
1 La Leche League International Bylaws, Section 1: General Purpose
2 http://kellymom.com/bf/got-milk/transgender-parents-chestbreastfeeding/?fref=gc
3 https://llli.org/breastfeeding-info/milk-donation/#Milk

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Transgender & Non-binary Parents - La Leche League International

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Support for Transgender & Non-binary Parents La Leche League is an international, nonprofit, nonsectarian organisation.1 LLL supports everyone who

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A nipple shield is a thin, silicone teat that can be placed over a mother's nipple and may help a baby who is having difficulty learning to breastfeed. Holes in the tip allow milk to flow into the baby's mouth. A nipple shield can be used temporarily to help establish breastfeeding or in some cases to help ensure that breastfeeding continues. A shield provides a firm stimulus at the roof of a baby's mouth where the soft and hard palate meet. This can help him suckle more effectively.

If your baby is not nursing at all, or is nursing ineffectively despite improving attachment and increasing milk flow, a nipple shield may help by providing a firmer stimulus in your baby's mouth. A nipple shield may be a useful tool in some situations. When nothing else works, it can be a temporary way to establish and maintain breastfeeding.

A nipple shield may be helpful if

Your baby is struggling to learn how to breastfeed

You have flat or inverted nipples, or very soft breasts as it can help maintain nipple shape

Your baby thrusts his tongue, has a retracted tongue or has neurological problems

Your baby was born prematurely

Your baby needs extra stimulus to prompt sucking

In these situations, a nipple shield can

Give a baby the opportunity to learn to breastfeed

Allow a baby who breastfeeds ineffectively to take more milk directly at the breast. This can be particularly helpful for premature babies

Avoid or reduce the need to express milk and use cups or bottles

Help keep breastfeeding going

Not a magic solution

It is very important to seek skilled help with positioning, attachment and any other problems if you are planning to use nipple shields or are already using them. Helping your baby get a deep latch at the breast is the key to effective and comfortable nursing with or without a nipple shield. A shield cannot correct underlying problems, especially those of sore and damaged nipples or low milk production. And if your baby is not attached well he may compress your nipple, causing damage and intense pain. When your baby latches on deeply at the breast he gets plenty of milk. Also, as you wean from the shield he will be able to adapt to breastfeeding effectively and comfortably without it.

Even with a nipple shield, your baby may still need help to learn to breastfeed well. Sometimes just a small adjustment to the way you hold your baby makes a big difference. You may find the suggestions and pictures in Comfortable Breastfeeding helpful. If you cannot get comfortable or breastfeeds are taking an hour or more, seek help from an LLL Leader who can give you personalised suggestions.

Holding your baby in skin-to-skin contact can make a big difference too. With or without a shield, laid back or 'natural' breastfeeding positions (see above) can be a great help in encouraging your baby to latch on effectively, as well as being comfortable for you. You can either lie down or recline with your baby on top of you and with his whole front against you and his body completely supported by yours. Such positions also leave both your hands free to shape your breast and help him latch.

If your baby won't breastfeed

Don't panic! Some babies take time to learn. However, babies will often latch on and suckle spontaneously if they can snuggle up close to their mother's bare chest for periods of time. Try letting your baby lie on your body as you recline so that both his chest and tummy are against you. This kind of contact, known as Biological Nurturing ™, or laid back breastfeeding usually stimulates a baby's instinct to attach and suckle well at the breast. In such positions, babies can also latch on when sleepy or even asleep. Watch for signs your baby is stirring and gently encourage feeding. If he is not breastfeeding effectively or at all you will need to express your milk for him. This will help maintain your milk production while he learns to breastfeed. An LLL Leader can give you tips for effective milk expression.

Is he getting enough milk?

Offer frequent feeds and monitor wet and dirty nappies for evidence your baby is getting plenty of milk. His weight will need checking regularly-as often as every three days for premature babies. For more information see Is My Baby Getting Enough Milk?

Check your breasts

Areas that aren't being drained well may appear swollen, sore or red. Treat early signs of localised engorgement to avoid a blocked duct or mastitis.

Practicaliti es
Type and fit
Modern nipple shields are made of clear ultra thin silicone. Different makes vary in flexibility. Some shields have a cut out section, but these may not stay in place as well as a full nipple shield. Full nipple shields do not bother babies or affect their breathing. Nipple shields come in different sizes but choice is limited. Both the width of the tip section and the shape of the flat part vary and you may need to experiment to find which size and shape you prefer. A comfortable fit is very important and some mothers need more than one size of nipple shield due to differences between their breasts.

Applying
Stretching the shield onto the breast can help it stay in place. You can also moisten the shield's edges or warm it with hot water to help prevent it moving. Turn the nipple shield almost inside out before applying it. Smooth it onto the breast, starting well away from the nipple in the area where your baby's lower jaw will latch on. Stretch the shield over your breast, with the tip centred over your nipple. The nipple shield should be tight against your breast with your nipple extending into the tip. If necessary, you can express milk into the tip or drip expressed milk onto the outside to encourage your baby to latch on.

Cleaning
If you and/or your baby are in hospital, wash the nipple shield thoroughly in hot soapy water and sterilise it before each use. If you have a healthy, full-term baby and are at home, cleaning with hot soapy water or washing in a dishwasher on a hot cycle will be sufficient. Shields should be dried thoroughly before use and stored in a clean, sealed container or bag.

A faster flow
Swallowing encourages sucking, which will help keep milk flowing. A baby who has become used to a continuous fast flow from a bottle may need help to persist with breastfeeding. Hand expressing for a few minutes can encourage a good flow of milk before your baby latches on. You can even hand express milk into your baby's mouth to encourage him to latch on or keep him nursing when your milk flows more slowly.

Try breast compression

1. Support your breast with one hand-thumb on one side, fingers on the other.

2. Wait while your baby breastfeeds actively, his jaw moving all the way to his ear. When he stops swallowing, compress your breast firmly. Hold it squeezed until he stops nursing actively and then release your hand.

3. Rotate your hand around your breast and repeat step 2 on different areas of the breast as needed. Go gently-this should not hurt.

Use a shield with a nursing supplementer

If your baby needs extra milk, a nursing supplementer can be used to deliver this through a tube as your baby breastfeeds. This avoids the need to bottle feed. The end of the supplementer tube can be placed either inside or outside the shield. Consult an LLL Leader if you think a nursing supplementer may be helpful.

Giving up the shields

Nipple shields are intended to be a temporary solution until your baby learns to breastfeed without them. When using a shield, help your baby to latch on by himself with a wide open mouth. This will help him to learn to breastfeed without a shield. Offer your baby some time in skin-to-skin contact every day without a nipple shield so he has the opportunity to latch on if he is able. It can take time to wean from shields but do keep gently trying. Try at times when you and your baby are most comfortable and relaxed and there are fewest distractions. You can try different methods to see what suits your baby.

Start with skin-to-skin next to breast without the nipple shield before nursing with the shield.

Start a feed with a shield, removing it part way through nursing from one breast or when switching breasts.

Gradually offer the breast without the shield.

DO NOT CUT a silicone shield as this could leave sharp edges that would hurt you and your baby.

Seek support

Whilst you may be relieved that a nipple shield is enabling your baby to breastfeed, it can be frustrating if he will not feed without it. However, given time and patience, it is usually possible for a baby to learn to breastfeed without the shield. An LLL Leader can be a useful source of support if you need to choose, use and wean from nipple shields.

Written by Karen Butler, Sue Upstone and mothers of La Leche League GB.

Further Reading

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

Positioning & attachment
Comfortable breastfeeding
Engorged breasts - avoiding and treating
Hand expression of breastmilk
Inverted nipples?
Is my baby getting enough milk?
My baby needs more milk
My baby won't breastfeed
Nipple confusion?
Nipple pain - why and what to do

References
The Breastfeeding Answer Book. Third edition. Schaumburg IL: LLLI, 2003.
Breastfeeding and Human Lactation. Fourth Edition. Sudbury, MA: Jones and Bartlett, 2010.
Supporting Sucking Skills in Breastfeeding Infants. Watson Genna, C. Sudbury, MA: Jones and Bartlett, 2008.
This information is available in printed form from the LLLGB Shop
Copyright LLLGB 2016

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how an when to use nipple shields to support successful breastfeeding

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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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First Steps Nutrition - Evidence based information about different formula milks

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First Steps Nutrition - Evidence based information about different formula milks

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Infant milks for parents & carers — First Steps Nutrition Trust

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

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Feeding will take up a lot of your time in the first few months of your babies' lives.
Whether you breastfeed or formula feed, you'll need to create a routine that suits you and your babies.

Some mothers can feed 2 babies at the same time, while some prefer to feed 1 after the other.

Others feed whenever their babies seem hungry (on demand).

If 1 baby is smaller and needs to feed more often, you will not be able to feed them at the same time at first.

If you want, you can work towards bringing their feeding routines together as your babies grow.

If you have any concerns about your babies' growth, you can take them to your local baby clinic to have them weighed and measured.

Your health visitor can tell you where to find your nearest baby clinic.

Some health visitors will visit you regularly at home to keep an eye on your babies' progress.

Breastfeeding twins or more

It's important not to be put off breastfeeding because you're having more than 1 baby.

Breastfeeding is a great way to soothe your babies and helps you build a strong bond with them.

It's perfectly possible to breastfeed twins, triplets or more. Lots of twins are breastfed until they start eating solid foods.

You may like to try a few breastfeeding positions to see which suits you best.

You'll get support with breastfeeding at the hospital and also when you take your babies home.

The benefits of breast milk for your babies are the same as for single babies.

But as multiple babies are more likely to be born prematurely, there are extra benefits.

Breastfeeding premature twins

Breast milk is better for premature babies as their gut is immature and it's easier for them to tolerate and digest.

Breast milk also contains proteins and antibodies to protect your babies against infections.

If your babies are very tiny or sick when they're born, you may need to express your breast milk to begin with.

Your expressed milk may be fed to your babies through a thin tube that passes through the nose and into the stomach.

Visit the Twins Trust website for more information on breastfeeding twins or more.
Watch videos of mums talking about breastfeeding more than 1 baby

Formula feeding multiples

You may need to combine formula feeding with breastfeeding if, for example, you have triplets or more, or you may choose to only formula feed your babies.

Formula feeding is more expensive than breastfeeding when you have twins or more.

But it does mean that other people can help with feeding your babies.

As with breastfeeding, you'll need to decide whether you're going to feed your babies together or separately.

Bottles need to be freshly prepared for each feed. This can be quite time consuming with twins or more, so you may want to ask your partner or someone else to help with this.

As with breastfeeding, formula feeding your babies can help you build a close and loving bond.

Hold your babies close during feeds, look into their eyes and talk to them.

Learn to notice their cues when they want to be fed and when they have had enough.

Visit the Twins Trust website for more information on formula feeding twins or more.

Weaning twins on to solids

When your babies are around 6 months old, you can give them their first solid foods.

It's not unusual for 1 baby to be ready to begin solids before the other.
Find out more about your baby's first solid foods
If your babies were born prematurely, your health visitor can give you advice on the best time to start solids.

Unless 1 of your babies has a serious infection, it's safe for them to share spoons and bowls.

Visit the Multiple Births Foundation website for more advice on all aspects of feeding twins, triplets or more (PDF, 5.96kb).

# data[].attributes.attachment_link.description
Feeding will take up a lot of your time in the first few months of your babies' lives. Whether you breastfeed or formula feed, you'll need to create a routine that suits you and your babies. Some mothers can feed 2 babies at the same time, while some prefer to feed 1 after the other.