area of focus:
What you should know about breastfeeding.
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In the UK, the large majority of families start out breastfeeding their babies – more than three quarters. However only around half are still breastfeeding at 6 weeks and only around a third are doing any breastfeeding at 6 months. The recommendation is to exclusively breastfeed for around 6 months before starting your baby on solid food, but in the last national infant feeding survey in 2010 only 1% had reached that goal.
It’s hard to get a reliable picture of breastfeeding rates in the UK as the national survey was cancelled a decade ago. A 2017 survey in Scotland suggested things were moving in a good direction with an increase in babies being breastfed at 6 weeks (55% up from 50%) and at 6 months (43% up from 32%)
But whatever the reality, we know many families aren’t getting the support they need. We know that around 80% of mothers wish they had breastfed for longer. Even though breastfeeding may be what our bodies are planning on doing, it doesn’t mean it’s always easy. It’s important to access support and not feel you have to struggle on if things don’t feel right.
What are the issues where mothers commonly need extra help?
Positioning and latching
How you position and latch the baby at the breast is at the heart of successful breastfeeding. The acronym CHINS is often used. The baby is CLOSE with HEAD FREE (a head able to tilt back and supported around the shoulders and neck only). The head will tilt as the baby comes to the breast so the chin leads. The baby is IN-LINE (so the neck isn’t twisted while attempting to swallow). Mothers are often told NOSE to NIPPLE so that the nipple is above the baby’s top lip to maximise the head tilt and the chin coming to the breast. As the baby opens their mouth wide, the nipple goes back far in their mouth. It needs to be SUSTAINABLE so the mother has whole body comfort, does not feel her arms, hands and back are taking strain and the baby can maintain their position.
There is not one standard breastfeeding position that works for all. We are all different. Variations like the fall of the breasts, the angle of the nipple, the gap between breast and lap and the length of a mother’s arm bones will all mean there isn’t one position or one breastfeeding pillow that is right for everyone. In fact, not using any pillow might be a good plan. Increasingly, mothers are being encouraged to recline either for the first breastfeed or as the baby grows. Baby-led attachment is often effective. Babies will prioritise breathing which is why they should be given the flexibility to move their head. Learning to feed while lying down is also a skill many mothers come to value.
If positioning doesn’t feel right, feeds may be longer and uncomfortable. The baby may take in more air, become unsettled and may take in less milk. The mother risks nipple damage, blocked ducts and mastitis and supply problems.
Nipple pain should not be seen as a part of normal breastfeeding. However, even when the baby’s attachment is effective, there may be some discomfort during the initial latch for the first few days. The nipple shouldn’t come out of baby’s mouth looking misshapen: wedge-shaped, with a compression stripe or flattened. Discomfort should ease once swallowing starts rather than continue at the same level throughout the feed.
Pain can often be corrected by just one or two small changes. It’s not cream that sorts sore nipples, but breastfeeding information and support. When the damage is deeper, moist wound healing is considered good practice. This means keeping the area clean and using something that stops a scab forming: lanolin, Vaseline or coconut oil are some options.
Bacterial and fungal infections on the nipple can be identified with a swab. Again, correcting a baby’s attachment at the breast may still be a key issue as damage caused from positioning has increased the risk of infection. When thrush is suspected, both mother and baby will need treatment.
Any discomfort at the nipple, whether from infection or attachment, can result in deeper breast pain. Referred pain may even be experienced in the shoulders or back. Mothers may be unaware than the milk ejection reflex (or ‘letdown’) can result in some sharp pains at the start of a feed.
When milk is not removed effectively, a mother may develop a blocked duct, often a firm lump or wedge in the breast. Frequent milk removal with improved positioning, massage and warm compresses can alleviate symptoms. A blocked duct may also present on the nipple at the duct ending and is described as a ‘bleb’ or milk blister.
Firmness from a blocked duct can develop into non-infective mastitis and then sometimes, infective mastitis. Infective mastitis may develop suddenly, especially when nipple damage gives a chance for bacteria to get in. Mastitis is a relatively common condition, affecting up to 20% of lactating women and the risk is higher in the first 6 weeks. With paler skin tones, the breast is likely to be red. The breast will contain a firm lump or wedge and the mother will present with a temperature exceeding 38.5c. She may have flu-like symptoms and chills. Antibiotics are likely to be needed if symptoms don’t improve with frequent milk removal, massage, rest and home treatments. It’s important that breastfeeding continues or the mother may be at risk of more severe symptoms.
In the early days as milk ‘comes in’, or if milk is not removed sufficiently later on, engorgement may be experienced and can be uncomfortable. Cool compresses for comfort and heat just before milk removal can help. It may be easier to hand express small amounts to help soften the breast before a feed.
Non-attachment/ breast rejection
The last national infant feeding survey revealed that of the women who gave up breastfeeding in the first two weeks postpartum, a third did so because of the baby’s rejection of the breast.
When breastfeeding is struggling to get established, we talk about the ‘3 keeps’:
Keep baby fed, Keep your milk flowing (which is likely to mean expressing) and keep your baby close. Usually breast refusal is resolved within a few days.
Low milk supply/ perceptions of low milk supply
Perceptions of low milk supply are widespread in cultures where newborn baby behaviour is not always well-understood. The 20th century belief that feeding after three or four hours is expected for a newborn has led to a lot of confusion. A newborn cluster feeding for a continuous period of 3 or more hours, waking frequently, desiring to be held close and to spend time comforting themselves on the breast may be misunderstood as a sign a mother has milk supply problems. In fact, they are behaving like a normal baby. Some mothers are also confused when their breasts start to change as the weeks go by. The only reliable ways to assess milk supply are by looking at baby’s nappies and weight gain and understanding how swallowing looks at the breast.
If you are ever worried about your milk supply, do get help from someone trained in breastfeeding support. In many cases, improving how frequently and effectively milk is removed can make all the difference. We make more milk when more milk is removed so we need to make sure we don’t think breasts need to be left to ‘fill up’. If other milk is given, keep removing milk from your breast so your body doesn’t get signals to make less. Only a very small minority of mothers will have underlying medical issues which means they will struggle to produce a full milk supply without the right support.
Although some parents worry about not having enough milk, an overproduction of breastmilk can bring significant challenges. Babies may be struggling with fast flow or dealing with digestive discomfort. When oversupply is suspected, it’s important to get individual support from someone trained in breastfeeding as sometimes other factors need to be considered.
Getting support and further resources.
In most local areas, you should have access to a local support team who offer drop-ins alongside the services available from NHS healthcare practitioners. These will be run by peer support volunteers or breastfeeding counsellors.
Several helplines are available including the National Breastfeeding Helpline run by the Breastfeeding Network and the Association of Breastfeeding Mothers: https://www.breastfeedingnetwork.org.uk/contact-us/helplines/
The Breastfeeding Network also offer the ‘Drugs in Breastmilk service’ as there is commonly limited understanding about the compatibility of medication with breastfeeding. https://www.breastfeedingnetwork.org.uk/detailed-information/drugs-in-breastmilk/
More specialist help is available from an IBCLC/ Lactation consultant. You can find your local lactation consultants here: www.lcgb.org.
For online information, try:
Emma Pickett IBCLC is a lactation consultant based in North London who supports breastfeeding families in Haringey. She can be found on Twitter as @makesmilk and on Instagram as @emmapickettibclc.
She is chair of the Association of Breastfeeding Mothers and author of ‘You’ve Got It In You: a positive guide to breastfeeding’ and ‘The Breast Book’. https://linktr.ee/emmapickett