Everything you need to know about breastfeeding...

(before you start breastfeeding!)

Breastfeeding is an interesting topic. I'm not quite sure where to start with it. No doubt you're here having heard many things about breastfeeding from your mum, sisters, friends, grandma, work colleagues etc etc about how good/bad/ugly breastfeeding is. 

But the other thing is - you're here reading this article because you have an interest in breastfeeding, and want to know more about it. Perhaps you're not sure whether you should breastfeed, after hearing some horror stories. Perhaps you want to, but you've heard some failure stories. Well, I'm going to set you straight with everything a midwife wants you to know - before you start!

I'm going to skip the part (mostly) where I tell you about why you should breastfeed because of its benefits to you and bub. Most people are aware of some of the benefits, and nobody really disputes it (plus, it's all available to you with a quick trip to Dr Google!). What I am going to do is go beyond this, to explain some lesser known facts and dispel common misconceptions, so that you are best-prepared to go into this journey!

Breastfeeding is so so lovely, but it's also bloody hard work, and cops a lot of flak. There's plenty of community opinion about what you should and shouldn't be doing, which is totally unnecessary. I remember breastfeeding Emilia at our local pool (by the way, she totally refused to take bottles, so I breastfed out of coercion!), and some old man in his budgie-smugglers walking past says "good on you love, keep it up". I mean - first of all - keep your opinion to yourself! Second of all - keep your eyes off my boobs! I was trying to be discrete but clearly not enough. *Face palm*.

Anyway. I wanted to talk first about how breastfeeding and breastmilk is produced. The reason why I want to start here is: one of the most common reasons mums give up breastfeeding is a (frequently incorrect) assumption that they're not making enough milk.

You see, if a baby so much as sneezes at the wrong time, the wrong person can flippantly remark "oh, he's not getting enough milk". Not enough weight gain? Mustn't be enough milk. Constipated? Not enough milk. Mum's tired? Trying too hard to make not enough milk. Baby fed 15 minutes ago and hungry again? Not enough milk. Baby only slept 20 minutes? Not enough milk. Baby has jaundice? Not enough milk. Baby is cold? Not enough milk. Mum's boobs are soft and comfortable? Oh - must be empty! Baby is unsettled at the breast? It's because there's not enough milk. Couple this with the old wives' tales or cultural assumptions: "they need water as well" (wrong), "breastmilk alone isn't enough for them" (wrong), "formula is exactly the same" (wrong), "I never made enough, so you won't either" (wrong)... you get my gist. So much misinformation, it's no wonder mums are struggling. 

The World Health Organisation (and most other national health agencies around the world) recommend that all babies are breastfed exclusively (meaning - given nothing else) for the first 6 months of their life.  However, 1 in 5 mums is giving up breastfeeding within a month of having their baby. There are many reasons and factors as to why they are giving up, but a perceived inadequate supply is the reason given time and time again. I say 'perceived' meaning that the mum has interpreted her situation as there being a low supply, but possibly not having this confirmed (with health professionals etc). Now, if we take this riiight back to the beginning of how breastmilk is produced by the cells in the boobs, only around 5% of the population don't have adequate 'breast-milk making tissue' in their boobs. Note - this is not the same as 'big boobs make more milk'. That's a myth! Milk production is completely unrelated to breast size.

Nope, there are 3 stages that control breast milk production, and therefore where you might go wrong in making enough milk:

So, if you do have a low supply issue, one of these stages went awry. First stage relates to the breast tissue and cells bit. Now, if in early pregnancy you had any breast changes (perhaps they got bigger, or tingly, or sensitive, or tender, or 'veiny'...) that is your indication that this stage went right, and the hormones did their thing to prep enough milk for a new baby. And often when we are dealing with a true case of low milk supply, mum will report minimal or no breast changes in pregnancy. The second stage is where we health professionals often screw you up, especially by the unnecessary use of formula in the first 5 days. Of course, there's nothing wrong with formula when it's needed. But use of formula in hospital, and in the first month is strongly associated with stopping breastfeeding early. "But what about if the baby needs it?" I hear you say. "My nephew/cousin/goddaughter etc had jaundice/an infection/low blood sugars etc and the midwives and paediatricians told them they had to give formula!". Well, I have a solution for you - more on this later. But if they are insisting on formula...sure. But I've seen plenty of times in my work where a health professional coerced a mum into using formula with a reason that was pretty much unjustified. So - if you're not sure - ask to speak with a lactation consultant (more on this later) so at least you'll get specialist input on not screwing up your supply by starting formula. You see - stimulation is crucial in those first few days. If your bub is not sucking at your breast, then the hormones to produce milk won't be sufficiently produced, and you'll encounter issues. Additionally, this second stage of milk production is affected if you've had a large bleed after birth, or a difficult birth (because your body needs to recover first, before putting maximum energy into making milk), or if any part of the placenta/membranes are left inside in the uterus (even the size of a bee's dick left behind means that progesterone drop that should happen in the second stage doesn't happen. Finally, when your milk's come in and the supply is established, milk production doesn't rely on hormones anymore. It relies on your baby telling it - 'I need this much'. So if not all of the milk is emptied, then less milk is produced, and so on. The only way to increase supply from this point is to empty the breasts more frequently.

Next stop - if you are exclusively breastfeeding (so, not giving anything via bottle - or occasional bottles only) - how do you know if you're actually making enough?

It's easy to see from the above though, how a mum's supply is the first thing to be blamed or suspected. If you have an unsupportive village, or pressure to bottle or formula feed, or have to return to work, you're tired (gosh bottle feeding looks attractive overnight...), are finding breastfeeding inconvenient, awkward or uncomfortable, or have no access/can't afford a lactation consultant...it's also understandable how things quickly lead to formula feeding. And as I've already covered, unless you're still emptying your boobs every time formula is given, your supply will inevitably drop --> you'll need to give more formula --> less milk produced --> vicious cycle...

Ok, so how can you set yourself up for success? Positioning (of you and your babe) and attachment (of baby to breast) is what's key. This is a little thing we midwives shorten to P+A because it's such a big part of our breastfeeding discussions! Breastfeeding is definitely an innate skill for babies - meaning they are born with the ability to breastfeed. But for mums, it is definitely a learned skill. And here we are disadvantaged in the Western world, because we tend to hide away from society when we are breastfeeding, meaning our sisters, girlfriends and daughters aren't frequently exposed to this skill. No wonder a lot of us have no clue where to start with breastfeeding! Let me tell you a little true story to illustrate my point:

Several years back, a gorilla gave birth at a zoo. She'd been in captivity her whole life. Unfortunately, zookeepers had to step in and help rear the baby because the gorilla showed no inclination towards feeding her baby. Some time passed and this gorilla fell pregnant again. This time, zookeepers had a plan: they called up a large maternity hospital and asked the hospital to find some mums who'd be willing to do several breastfeeding sessions in front of the glass of the gorilla enclosure. So a handful of mums came in occasionally to breastfeed in front of the gorillas. Amazingly, when the new gorilla bub was born, mum instinctively began to breastfeed!

How amazing is that! I can't help but think we'd all breastfeed a little easier if we watched other mums do it a lot before we do it ourselves. But back to P+A - how you position yourself, and hold your bub, and how bub attaches, is crucial to breastfeeding success. Poor attachment will almost always lead to low supply if not rectified:
Poor attachment = poor drainage of the milk --> poor supply
Poor attachment = hungry babe --> topped up with formula --> low supply

Poor attachment = nipple damage --> pain and discomfort --> poor feeding/avoidance of feeding/continued poor attachment --> babe topped up with formula = poor drainage of milk --> poor supply

Below you'll see both written and visual outlines of good positioning and attachment!

Here, mum is bringing bub to the breast with a wide open mouth. Baby needs to have as much breast tissue in the mouth as possible, and the nipple right at the back of the mouth, for the latch to be comfortable and for optimal milk transfer

Bub is well-latched: a lot of breast tissue in the mouth, both lips splayed outwards (looks like a K!), head tilted back and nose is clear of breast.

Here's another well-latched babe. Again, lips are splayed outwards, you can tell the other cheek will be touching the boob, lots of the breast tissue in the mouth, head tilted back, bub looks content.

Here are some poor latches. Both babies are pinching their lips in, you can see a lot of mum's areola, and the image below shows bub almost hanging off the boob (not close at all)

Here are some common breastfeeding positions, although you can breastfeed in any position that works for you and gets your baby well latched! Just ensure you are comfortable before you pop baby on...you might have to be in that position for a looooong time!

"Football" hold

Side lying - take a bit to master but you'll figure out which way works for you and bub

Cradle hold

Don't let anyone tell you that you won't be able to feed after a Caesarean section! This mumma is lying back and still has bub attached!

And just to highlight that a tough pregnancy, premature bub or bub in NICU doesn't have to get in the way of a happy breastfeeding journey, here is a pic of my first breastfeed with Emilia (she was 5 weeks prem, just under 1.6kg and absolutely desperate to suck!)

And here's another of her, well latched, this time at home at one month old (but only weighing about 2.5kg!). And yes, my bazookas were ginormous compared to her! But you can see her cheeks are touching my breast tissue, and her nostrils splay outwards (normal newborn anatomy!) to ensure there is airflow. 

And this, my friends, is worth every breastfeeding battle: that look after feeds that says "you are the absolute shiz, do you know that?" before they settle off for a lovely little snooze...

With thanks and acknowledgement to Christina Hardcastle Photography for these treasured images

My top  tips for breastfeeding!

(you are almost at the end, promise!)

Well done for making it this far! This article is far longer than I intended but you've almost covered breastfeeding 101 so you're well on your way to breastfeeding success. Now here are my top (simple!) tips for you to set up your journey:

1. Skin to skin as much as possible! From as soon as possible after birth, as often and as long as you want. You can see the benefits of skin to skin here (just 1 image, no other text!)

2. Support your back/neck - position yourself comfortably first before you latch baby. You might be in this position for a long time, and you don't want to add muscle strains or more aches and pains to your recovery!

3. Like tip 2 - set up a little station where you do most of your breastfeeds. Keep things like snacks, water, tissues, burp clothes, TV remote, phone etc within hand's reach. Anything that might be necessary to ensure you can stay in that position for a long time (other than toilet...!)

4. Give it 6 weeks...the vast majority of mums experience some bumps in their breastfeeding road. It might be nipple pain at the start, engorgement and difficult latch day 3, slow weight gain at 2 weeks, mastitis at 4 weeks...whatever your journey, I urge you to persist for 6 weeks. It can take several weeks to fully establish your supply, so it's just not fair to your hard work and your bub to try and quit before you've reached your full potential! Similarly, ceasing breastfeeding quickly can lead to more complications, like mastitis...so at the first sign of issues, I highly recommend my tip 5 below! My point with this tip is - if you get the professional help to work through any issues, generally things have worked out by 6 weeks, and then you are on the wonderful breastfeeding journey - closeness, love, quick and easy settling, no sterilising etc etc etc!

5. Have a full assessment by a qualified International Board Certified Lactation Consultant [IBCLC] in the event you run into issues. You might get to see one during your stay in hospital, but if you're at home, having a consult ASAP after problems arise is well worth the expense. IBCLCs undergo extensive training and education in order to earn their title, and will undertake an extremely comprehensive assessment of you and your babe and are worth their salt when they can diagnose the cause of your issues and help you rectify them. They are much more educated and expert in all things breastfeeding than any registered midwife or obstetrician. So I would always take (and seek out!) the opinion of an IBCLC over a midwife or obstetrician. You can find a qualified IBCLC here, or if you want a recommendation, Jen Butler is an early parenting specialist, qualified IBCLC and sleep consultant who does consults locally, over the phone or video consults, and she has saved my bacon several times when I have run into breastfeeding issues! You can see more about Jen's services here, or follow her over on the 'Gram @jenbutlerearlyparenting!

6. Build up a stash of breast milk during pregnancy! Remember at the start of this article how I talked about how common a perceived low supply is, and how often you might be encouraged to give formula in the early days (which can really cripple your supply)? Here's an easy solution: start hand expressing in pregnancy and build your freezer stash! That way you are ahead of the game before you even start: your supply will benefit and you'll have some go-to liquid gold ready for if bubs needs a bit extra early on. If you take a few frozen syringes into hospital with you, and keep some at home, you can use them as you need without wastage. To illustrate my point - I knew my bub would be having a NICU stay. I began expressing (with my OB's clearance) 2 weeks before she was born. I had 60mls frozen by the time she was born, and she never needed to have formula. The nurses were amazed! You may run into some negative attitudes about this practice, however this large randomised controlled trial showed that expressing breastmilk from 36 weeks of pregnancy is not associated with any increased risk [9]. If you have questions about your own individual circumstances however, definitely chat with your midwife or OB.

7. If you do want to boost your supply, naturally, healthily and deliciously, check out these yummo lactation cookies here!

I hope this has been a helpful read. Please share the love by sending this post to a supermum or supermum-to-be, who might benefit from this article. And I would love to hear your thoughts and experiences in the comments below!

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Sources:

1.Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews

2016, Issue 11. Art. No.: CD003519. DOI: 10.1002/14651858. CD003519.pub4.

2.Li,R.; Fein, S.B.; Chen, J.; & Grummer-Strawn, L.M. Sara B. Fein, Jian Chen and Laurence M. Grummer-Strawn (2008). Why Mothers Stop Breastfeeding: Mothers' Self-reported Reasons for Stopping During the First Year. Pediatrics 122:S69 DOI: 10.1542/peds.2008-1315i

3. Forster, D.A.; McLachlan, H.L.; & Lumley, J. (2006). Factors associated with breastfeeding at six months postpartum in a group of Australian women. International Breastfeeding Journal 1:18 doi:10.1186/1746-4358-1-18

4. Hauck, Y.L., Fenwick, J., Dhaliwal, S.S. et al. (2011). A Western Australian Survey of Breastfeeding Initiation, Prevalence and Early Cessation Patterns. Matern Child Health J  15: 260. https://doi.org/10.1007/s10995-009-0554-2

5. Hauck, Y. L., Fenwick, J., Dhaliwal, S. S., Butt, J., & Schmied, V. (2011). The Association Between Women’s Perceptions of Professional Support and Problems Experienced on Breastfeeding Cessation: A Western Australian Study. Journal of Human Lactation, 27(1), 49–57. https://doi.org/10.1177/0890334410386956

6. Thulier, D.; & Mercer, J. (2009). Variables associated with breastfeeding duration. Journal of Obstetric, Gynecologic & Neonatal Nursing 3:259 - 268

7. Brown, C.R.L., Dodds, L., Legge, A. et al. (2014).  Factors influencing the reasons why mothers stop breastfeeding. Can J Public Health 105: e179. https://doi.org/10.17269/cjph.105.4244

8. Baxter, J.; Cooklin, A.R.; & Smith, J. (2009). Which mothers wean their babies prematurely from full breastfeeding? An Australian cohort study. Acta Paediatrica 98(8): 1274-1277

9.  Forster, D.A et al (2017). Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME]): a multicentre, unblinded, randomised controlled trial. The Lancet 389(10085): P2204-2213

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