Dr Ilana Levene ¦ Dr Victoria Thomas
When I started my paediatric career I was a bit at a loss for how to deal with breastfeeding mothers and babies. I wanted simple rules, I liked measuring and calculating. I had no idea how to get a feel for how much milk a breastfed baby was getting. I was mystified by the mysterious ‘latch’ and what to do for the sobbing mothers with cracked nipples coming into ED at 3am.
Two babies later, having come through a fair amount of sobbing and cracked nipples myself, I’ve realised two things. The first is, there are some easy rules doctors can learn to help breastfeeding families, regardless of their own breastfeeding experience (I’ve boiled it down to four – positioning & attachment, how to tell when breastfeeding is going well, protecting milk supply and knowing what’s normal). The second is, the UK is really crap at breastfeeding and doctors are often part of the problem. Read on to educate yourselves, learn the rules and be part of the solution! This blog covers the basics for doctors working with breastfed babies and children in all settings.
Are we crap at breastfeeding in the UK?
The last national infant feeding survey showed that less than half of all babies were exclusively breastfed by ONE WEEK of age. Half of 6 week-old babies are getting exclusive formula. I don’t think anyone could argue that by these figures the UK is amazingly crap at breastfeeding. And this isn’t an issue of mothers not wanting to breastfeed – 81% initiated breastfeeding and more than 80% who stopped said they wanted to continue.
Why should we care?
Breastfeeding is probably the most powerful public health intervention that paediatricians have an impact on (Ok, ok, vaccinations might be even better). A recent series in the Lancet systematically reviewed all the evidence but basically, the most consistent association of infant formula is increased childhood infections, including hospitalisations (and no, that’s not just in the developing world). More important to families are the associations of infant formula with higher rates of sudden infant death syndrome (SIDS) and childhood leukaemia, maternal breast cancer and postnatal depression. For example, breastfeeding for at least 2 months is associated with half the risk of SIDS and ever breastfeeding leads to a 22% reduction in triple negative breast cancer. Mothers who intend to breastfeed and end up formula feeding have more than double the rate of postnatal depression than those who intend to breastfeed and succeed.
OK, we’re crap and it’s important, but is this my job?
Yes. Doctors are an important part of the multidisciplinary team that can support and promote breastfeeding. Our attitudes and advice are highly valued, and when young infants are sick (or sometimes normal but not acting in the ways their families expect – more on that later), the explanations we give, the interventions we choose and the way we present them can have a big impact on continued breastfeeding. We’re also the safety net when mothers have fallen through holes in midwifery and health visitor support.
A word on your own experiences
Many of us have had personal breastfeeding experiences. When mothers want to breastfeed and end up not fulfilling their goals, it can cause guilt, grief and a feeling of being judged by society (trust me, I’ve been there). If we don’t get a chance to work through our experiences, it can colour how we support and advise breastfeeding families. Even if we have had positive experiences we may worry that breastfeeding promotion is interpreted as pressure to breastfeed. However, the reason there are such strong emotions around feeding is because most mothers strongly want to breastfeed. We should be doing all we can to help mothers reach those goals, while being sensitive to those who have chosen not to breastfeed, or decide that continuing to breastfeed in the face of challenges is no longer best for their family.
Rule 1 – Positioning and attachment is the key
OK, too much fluffy stuff, lets get to the nitty-gritty. Every breastfeeding problem should first of all (or alongside medical assessment) trigger an expert face-to-face assessment of positioning and attachment. Obviously this is not you, but actually it’s not A.N.Other midwife or health visitor either – make sure that you are referring or advising mothers to self-refer to your local infant feeding lead, breastfeeding clinic or specific community breastfeeding support groups – they should have a list in their discharge pack or red book. If it’s out of hours, they can always ring a breastfeeding telephone helpline. If they are happy to pay they could find a private lactation consultant.
Think of this with all problems that could relate to feeding in small babies – support with positioning and attachment is so important that NICE recommends it as the first line management strategy in suspected reflux and suspected colic.
Rule 2 – How to see if a baby is breastfeeding well
So we don’t have nice, simple volumes to measure. But we can get a good feel of how breastfeeding is going by looking at weight gain, nappies and the nature of feeds, as shown here:
So if you have a baby on day 3 who’s pooing once a day, having 2 wet nappies a day and whose mum is crying at each hour-long feed because of the nipple damage, you’re in trouble, and you won’t need to wait for the 13% weight loss on day 5 to make sure that she is getting intensive face to face breastfeeding support (rule 1).
The only extra thing to note is that after about 5-6 weeks of age breastfed babies may reduce the frequency of pooing, down to as little as once a week – the poo rules above only apply in the first few weeks of life.
Rule 3 – Protecting milk supply
The amount of milk a mother produces in the 1-2 weeks postnatally is directly correlated to long-term milk supply and breastfeeding success. This is because of the way breast physiology works – firstly, breast stimulation is needed to activate milk producing cells and hormone receptor sites. Secondly, if milk doesn’t get expressed from a full breast, an inhibitory feedback loop is activated that reduces supply. Therefore if baby isn’t frequently stimulating and draining the breast in the first few weeks, a mother may be left with a low milk supply and baby will struggle to gain weight without supplementation later on. If there is any concern in the first few weeks, mothers should be advised to express milk to secure their supply. That means expressing at least 8 times per 24 hours, including once at night. Getting breast milk to use as supplements is an added bonus.
Rule 4 – overcoming bottle feeding expectations
The final rule is about knowing when to butt out, and when to reassure parents that their baby is normal. Because we live in a bottle-feeding society, understanding of ‘normal’ breastfed behaviour has been lost. We tend to live in tiny nuclear families, and many parents have never interacted with a newborn baby before their own.
The major thing to know is that babies will want to feed frequently and irregularly for a long period of time (weeks, months, years!). It is completely normal for infants to wake (and feed) frequently in the night for many months (a third of babies do not sleep through the night by 1 year and more than 10% are not regularly sleeping for 5 hours in a row by 1 year. Babies may also cry for hours (peaking around 2 months of age), without a clear reason. We should be careful with our language to parents to avoid inadvertently setting up or reinforcing the wrong expectations – don’t ask how often the baby feeds, ask how many times they tend to feed in 24 hours. Don’t ask if they are a ‘good baby’ or if they are sleeping through ‘yet’.
All of these NORMAL BABY things – frequent feeds, crying, fussing, not sleeping for long periods – are often interpreted by parents as hunger and a reason to stop breastfeeding. They also trigger many healthcare contacts in the first months of life, with potential overdiagnosis of reflux, cows milk protein allergy and colic in response to parental anxiety and repeat attendances.
So, reassure parents that they can feed responsively from birth (some limits apply in ‘at risk’ babies in hospital, which we will discuss in part 2 of this series).
“Responsive breastfeeding involves a mother responding to her baby’s cues, as well as her own desire to feed her baby. Crucially, feeding responsively recognises that feeds are not just for nutrition, but also for love, comfort and reassurance between baby and mother” – Unicef Baby Friendly Initiative
Listen to their tales of woe, validate how shitty it is and how hard they are trying and then help them to understand that this isn’t something they are doing wrong, and it will pass. Direct them to sources of peer support – local or online breastfeeding support groups. Remember to mention self-care, taking time out if they feel they might hurt the baby because of excessive crying, and give information about sources of support.
OK, we’re done! For those who are still reading, I hope you have a better understanding on what the problem is (UK crap at breastfeeding, bottle feeding culture, doctors don’t know much, accidental sabotaging of breastfeeding relationships), and the key points to take forward to your paediatric practice:
- For any breastfeeding concern, advise mothers to get expert help with positioning and attachment
- To assess whether breastfeeding is effective, look at the number of wet and dirty nappies, the nature and frequency of the feeds, and weight gain
- If there is any concern over whether breastfeeding is effective in the first few weeks of life, advise the mother to express frequently
- It’s normal for babies to feed frequently and irregularly.
- It’s normal for babies to wake and feed during the night throughout the first year.
- Help mothers who are concerned about milk supply look for objective signs such as nappies and weight.
Dr Ilana Levene, Paediatric Registrar – Oxford Deanery; Dr Victoria Thomas, Consultant Paediatrician – Great North Children’s Hospital
Resources for you
- GP Infant Feeding Network
- Unicef Baby Friendly Initiative breastfeeding assessment tools
- Library of information leaflets from the Association of Breastfeeding Mothers La Leche League
- First Steps Nutrition independent information on formula, and breastfeeding
- NHS specialist medications in breastfeeding service
- Drug factsheets from the Breastfeeding Network
Resources for parents
- Baby Buddy App – RCPCH and Department of Health accredited app for pregnant women and those with babies up to six months old. Gives evidence based advice on common issues, including feeding, in a user-friendly way
- Unicef UK Baby Friendly Initiative video on hand expressing technique
- Unicef UK Baby Friendly Initiative parental checklist of whether breastfeeding is going well
- Breastfeeding Hub MK app – information on issues like mastitis, positioning and attachment
- Videos of positioning and attachment and overcoming problems
- (also available in seven other languages to order from the website)
- Comprehensive information on breastfeeding and life with a new baby
- General advice, including sore nipples, engorgement and tongue tie
- Free meditation track for expressing breast milk
- Live online webchat breastfeeding support (when volunteers available)
- NCT images of what normal baby poo looks like in the first week of life
Telephone volunteer helplines:
National Breastfeeding Helpline (930am to 930pm daily. English, Welsh & Polish, other languages sometimes available) 0300 100 0212
La Leche League (8am to 11pm daily) 0345 120 2918