Breastfeeding on the move – literally

photo of woman's legs wearing shorts and hiking bootsI’m a great advocate of the right to breastfeed in public places and get extremely annoyed with people who express their ‘distaste’ at the idea. How ludicrous to deny babies the right to eat outside the house, when it’s fine for everyone else? Nevertheless, with my first daughter it was something I found difficult, so I tended to avoid it if I could.

After my second daughter, A, was born, the issue of breastfeeding away from home didn’t arise for some time. Most of our trips were short, and when they did extend beyond a couple of hours, they were usually to the homes of friends or family where I was perfectly comfortable feeding. On a trip to John Lewis, however, where I ended up sitting in the foul-smelling ‘breastfeeding area’ (right next to the ‘changing area’), rather than the cafe — where I had previously got so stressed my let-down reflex refused to kick in — I decided I really had to sort this issue out.

Although I had taken the first step of realising I had a problem, I made no real effort to confront my fears, and continued to avoid breastfeeding away from home as much as I feasibly could. It’s impossible to predict the appetite of a small baby all the time, however, and when I was walking through a wet field several miles from home, the inevitable happened.

The day had started with pretty miserable weather, but by lunchtime the clouds had cleared and we set out on a 2 hour walk through the countryside confident that we wouldn’t get rained on. I had put A in a Baby Bjorn carrier, and as usual, she went to sleep the minute she was ouside. Just as we had reached the point where we were as far away from the house as we could possibly get, A woke up and started to grizzle. This was something that happened from time to time when we were out, and I carried on walking, thinking that she would just go back to sleep as she normally did.

Unfortunately, she didn’t nod off again. Instead she started to howl furiously, in the way she might if she was hungry. Despite the fact that she had been fed just before we left the house, the intervening hour had been enough to work up a hearty appetite again, and it was pretty clear that I was going to have to find a way of getting some milk down her.

This was easier said than done. I looked around for somewhere to perch, and could see nothing but mud and wet grass. How on earth was I going to get A out of the carrier and successfully latched on whilst standing up, and what was I going to do with the carrier? Then I looked down and noticed that A’s mouth was at roughly the same level as my nipple. I had previously complained about the lack of a vomit/drool barrier between A’s mouth and my chest when using this carrier (as opposed to my previous Chicco one), but now I realised this could be an advantage. After a bit of grappling with the numerous layers I was wearing, I managed to expose enough nipple for A to take into her mouth (which she did, quickly). The whole manouveure was significantly more discreet than it sounds, as most of it was shielded from view by the carrier’s head rest.

I didn’t fancy spending the next twenty minutes standing in the middle of a field (other walkers had nodded politely as they passed, but probably wondered what on earth I was doing), so I took a few tentative steps whilst trying to keep A attached. Providing I did it slowly, walking didn’t seem to disrupt her, and I managed to reach a more plausible resting spot.

I’m now quite happy to take A out in the carrier, knowing I can feed her pretty easily if I need to. Interestingly, the confidence I’ve developed through doing this has automatically extended to other situations, and I recently managed to nurse A through an entire wedding breakfast. Psychologically this was quite an achievement for me, as I knew some of the guests weren’t keen on breastfeeding (‘I was bottle fed and it didn’t do me any harm’ etc.), and I had been dreading the prospect of constantly heading to the loo with a hungry baby. In the end, I just stayed at the table and got on with it. I can’t say the experience was wonderful, but that was mainly because I was sitting on a less than comfortable chair and had to negotiate the meal one-handed. Perhaps not surprisingly, breastfeeding in the John Lewis cafe holds no fear for me now.

Will drinking coffee when you’re breastfeeding keep your baby awake?

coffee in disposable cup If you ingest caffeine when you’re breastfeeding it can pass into your milk, and may therefore be consumed by your baby1. From a health perspective, this is not a cause for great concern. Low doses of caffeine are not regarded as harmful, and indeed caffeine is sometimes administered to preterm babies to help reduce apnea (pauses in breathing of more than 20 seconds)2. The stimulant properties of caffeine that make it suitable for therapeutic use, however, could potentially affect babies in a less desirable way — in particular, by making them wakeful and irritable.

So, how likely is it that drinking too much coffee will cause your baby to lose sleep? Research investigating this issue shows that moderate levels of consumption aren’t likely to cause any problems. A study examining the levels of caffeine over a 12 hour period in the milk of women drinking their usual caffeinated beverages found that consumption of less than 100mg (roughly the amount in a single espresso) did not pass into milk at a detectable level3. It also found (as did an earlier study1) that the amount of caffeine that makes it into milk is greatly reduced — between 0.06% and 1.5% of the maternal dose — and that the level peaks an hour after consumption, and then declines, disappearing completely after 12 hours.

Could this small amount of caffeine cause sleeplessness? The available evidence indicates this is unlikely. In a study examining this issue, 11 breastfeeding mothers drank 5 cups of decaffeinated coffee a day over a 5 day period, and 5 cups a day of decaffeinated coffee with 100mg caffeine added over another 5 days4. The results showed that the babies’ average heart rates and the amount of sleep they got over a 24 hour period remained the same, regardless of whether their mothers had consumed caffeine.

According to the American Academy of Pediatrics, ‘moderate consumption of tea, coffee and caffeinated sodas is fine when you’re breastfeeding’. Although babies can ingest caffeine through breast milk, if their mothers are drinking around 5 cups of coffee a day it is unlikely to impact on sleep levels. People metabolize caffeine at different rates, of course, and young babies do it much more slowly than adults5, so it’s not impossible that drinking coffee will affect your baby, particularly if you consume it in large amounts. At low levels of consumption the chances of this being a problem are small, however, so most breastfeeding mothers can enjoy a coffee, tea or cola safe in the knowledge that is keeping them, but not their baby, awake.

  1. Arch Dis Child. 1979 Oct;54(10):787-9
  2. Cochrane Database Syst Rev. 2000;(2):CD000273.
  3. Pediatrics. 1984 Jan;73(1):59-63.
  4. Dev Pharmacol Ther. 1985;8(6):355-63.
  5. Arch Dis Child. 1979 December; 54(12): 946–949.

Breastfeeding a newborn: round two

The nightmare I experienced breastfeeding my first daughter C is well documented. Although we eventually came through it, the first few weeks were really terrible, and if I’m honest, the first few months weren’t brilliant either. It was therefore with some trepidation that I approached feeding my new daughter, A. Was it going to be as difficult the second time round? I hoped not – if nothing else, the knowledge I’d gained about breastfeeding over the last two years meant I’d at least be better equipped to deal with problems, should they arise.

Several weeks down the line, I’m happy to report that nursing A is going as well as it possibly could. The minor nipple soreness I experienced initially disappeared within a few days, and there has been no recurrence of the cracking, bleeding or fissures I suffered with C. It’s impossible to know precisely why breastfeeding is so much easier with A than it was with C. It could be that my technique has improved through months of practice, so A is simply attached better. It could be that I’ve taken a slightly different approach to latching on, sometimes (though not always) using the biological nurturing method. There are two other factors that I can’t ignore, however, both relating to anatomy.

The first major difference between now and then is that my nipples are a completely different shape. When I first started breastfeeding, they were pretty flat – now they are anything but. The second difference is that I’m feeding another baby. While A’s cute little pout looks very similar to C’s from the outside, inside her mouth could be a completely different shape. Tongue tie is known to affect breastfeeding, but I until recently I wasn’t aware that upper labial tie could as well. I don’t have any reason to believe that C suffered from either of these, but it isn’t impossible that some of the problems I had with C related to the shape of her mouth.

We are told that breastfeeding difficulties are nearly always caused by a poor technique. While helping mothers and babies to latch on more effectively will often improve matters greatly, ignoring the fact that it may be harder for some than for others for reasons outside their control is less helpful. Breastfeeding can be difficult for lots of reasons, and discussing some of these – whilst helping mothers and babies to hone their techniques – may lead to fewer women feeling incompetent, and more feeling empowered that breastfeeding is something they can achieve, even if they have a tough time getting there.

You’ll return to your pre-pregnancy cup size a year after giving birth… even if you’re still breastfeeding

bra and pants

For many women, an increase in cup size as breasts get ready for providing food is one of the first signs of pregnancy. After giving birth, they expand even further as they fill up with milk, but even after a feed, they remain bigger than they were previously, due to the increase in breast tissue required for milk production.

If you continue to breastfeed after solids have been introduced and cut down gradually, your breasts will slowly decrease in size, until you get to the point where you fit back into your old bras. At this point, you’d be forgiven for thinking they can’t possibly be providing your baby with much sustenance, but in fact they are probably doing more than you think. An intriguing article published in Experimental Physiology shows that whilst breast size is related to to the amount of milk produced for the first 12 months of breastfeeding, after this point breasts return to and stay at their pre-pregnancy size, even if they are still manufacturing milk1.

The study followed 8 mothers who breastfed exclusively for 6 months, and weaned after 18 months. Milk production over a 24 hour period was measured by test-weighing the mother2 and breast volume (their actual size minus the amount of milk produced) was calculated using a special ‘Computerized Breast Measurement’ system3 at 1, 2, 4 and 6 months after giving birth, and then at three monthly intervals until weaning.

Milk production – and breast volume - remained constant for the first 6 months, and both started to decline after this point as other food was introduced. By 15 months, however, breast volume had reduced to the level it was before the women gave birth, and remained at this point from then on even though the mothers were still producing on average 200g of milk a day. When the mothers weaned their babies completely, there was no significant further reduction in breast size.

The authors state that this occurs because breasts become able to make milk more efficiently: although an increase in breast tissue is necessary to initiate and sustain a high level of milk production, when it naturally declines as milk output falls, the remaining tissue is still able to produce a significant amount of milk.

For any mothers who are nursing past the 12 month mark but sceptical that their breasts are still up to the job, this will make interesting reading. Even though it may sometimes seem as if you don’t have anything left for milk production, the chances are you’re more than capable.

  1. Exp Physiol. 1999 Mar;84(2):435-47.
  2. J Pediatr Gastroenterol Nutr. 1987 Sep-Oct;6(5):758-63.
  3. Exp Physiol. 1992 Jan;77(1):79-87.

Breastfeeding and biting

When C was about 2 months old, I exchanged baby-related pleasantries with a lady in a shoe shop. After she had made the standard enquiries — how old was C, what was her name — she asked me whether I was breastfeeding. Although this was a fairly impertinent question, I was still in the midst of 2-hourly feeds, and therefore quite happy to talk to strangers about nursing. She then started telling me about her own grandchild, who was a few months older than C, and teething. I mentioned an acquaintance who’s son had just cut a tooth at three months. ‘That is early,’ she said, ‘and it’ll mean the end of breastfeeding!’

I knew, of course, that it meant nothing of the sort: from a physiological perspective teeth pose no problem at all, and  it is perfectly possible to breastfeed babies who have any number of them. My sister and I were both early teethers, and there was a possibility that C would be too. There was no way I was going to let that stop me from breastfeeding prematurely, and it simply wasn’t something I worried about.

I was right, of course, not to worry about teething and breastfeeding. Unfortunately, that didn’t mean it was going to be quite as trouble-free as I expected. When C’s bottom teeth came through, it was fine — I genuinely couldn’t tell when I was nursing. This is not altogether surprising, as the tongue extends over the bottom teeth during suckling, making biting pretty much impossible. When her top teeth started to appear, she let me know about it, however. Problems ranged from the odd isolated nip, to scraping her teeth along my nipple when she drew it into her mouth, to looking me in the eye and chomping down quite deliberately.

While I could tolerate the first two, the third I found both upsetting and eye-wateringly painful. I also took it personally. I could accept on a rational level that C probably wasn’t trying to hurt me deliberately, but it really didn’t feel like that. Tears and remonstrations followed these early biting episodes, and neither of us was very happy at the end of them.

I searched hard for a scientific perspective on the problem. How common was biting, how long would it last, and most importantly, was there anything I could do about it? Unfortunately, I couldn’t find any research addressing these issues. There were plenty of midwives voicing their thoughts on the issue, but none backing it up with any evidence.

Opinions about the appropriate course of action can be divided roughly into two camps: tell your baby quite clearly not to do it and stop nursing immediately; or pretend it hasn’t happened and carry on. I tried both, and I have no idea which, if either, worked. All I do know, is that after a difficult few weeks of C biting on and off, she finally stopped sinking her teeth in, and hasn’t done it now for several months.

Many mothers find biting understandably difficult to cope with, and view it as a reason to stop breastfeeding, often because it appears to be a deliberate rejection of the breast. I took the view that although this might have been the reason C was doing it, a more likely scenario was that she was ill, tired, irritable, and/or just wanting to try out her freshly-grown teeth. As she’s got older, she indicates that she doesn’t want to feed by pulling away, shaking her head, and in certain extremely cute moments, waving goodbye to me. I’m optimistic that from now on, biting will remain a thing of the past.

Nipple shields and milk yields: an update

In a previous post I questioned the received wisdom that using nipple shields will have a negative impact on your ability to nurse your baby (see nipple shields: always a bad thing?). The post challenged one of the main criticisms made of shields — that they slow milk transfer and may therefore mean your baby is inadequately nourished — on the grounds that most of the studies demonstrating this were conducted a long time ago, and more recent research indicates that this problem does not exist for modern shields1.

The researchers who conducted the study in question concluded that nipple shields do not affect the amount of milk babies consumed in a feed by weighing before them before and after they nursed: when a mother was using a shield, the amount by which her baby had increased in weight at the end of the feed was roughly the same as when she was breastfeeding directly. Whilst this result looks positive for nipple shields, ‘test-weighing’ babies in this way is not without its critics, so one could argue that concluding nipple shields have no effect on milk consumption based solely on this evidence is a little premature.

Since writing the post, a follow-up study has been published, this time looking at the relationship between shield use and infant weight gain over a much longer period2. 54 mothers who used a nipple shield provided by a nurse or lactation consultant in the period just after the birth of their babies were recruited for the study, and completed interviews when their babies were 2 weeks, 1 month and 2 months old. Over time, the proportion of mothers using shields diminished (at 2 weeks,  69% of the mothers were still doing it, at 1 month 48%, and at 2 months 33%) and at each stage the responses of women who were still using the shields were compared with those who weren’t.

The main aim of the study was to determine whether nipple shields had a negative impact on weight gain — if babies whose mothers were still using shields grew more slowly than those whose mothers had stopped, then this could be taken as an indication that medium to long term use of shields was causing a real problem. Happily, there was no difference between the groups: whether a mother used a shield made no difference to her baby’s pattern of weight gain.

There were a few complaints about nipple shields: 8 women thought they caused nipple soreness; 2 found them messy; 2 found them inconvenient and 3 had problems with them falling off. In spite of this, 90% of the mothers in the study said that using the shield was a positive experience, and 67% felt it helped prevent them from giving up breastfeeding.

If you are a mother who relies on a nipple shield to breastfeed, these results make reassuring reading. Although shields appeared to cause difficulties for a few women, these were generally minor, and crucially they concerned practical issues, not the health of their babies. As most women felt that shields helped to prolong the period that they were able to breastfeed, this study ultimately supports the view they could be an important intervention for mothers who are having problems, rather than something that will make them worse.

  1. J Obstet Gynecol Neonatal Nurs. 2006 Mar-Apr;35(2):265-72.
  2. J Clin Nurs. 2009 Nov;18(21):2949-55.

Nursing strike: self-weaning or a sore throat?

thermometerSince starting solid food, C had had a remarkably relaxed attitude to breastfeeding: she never gave any indication she actually wanted to do it, but when offered the chance she was always happy to tuck in. This was particularly true when she was ill. Often she would go off solids, but would still be happy to breastfeed frequently, which reassured me she was receiving at least some form of nutrition.

When C was got a particularly nasty cold at around 11 months, I didn’t worry too much about her loss of appetite, assuming that I would be able to top her up with breast milk as usual.  Unfortunately, C had other ideas. After a few tentative sucks, she turned her head and pushed me away with a resounding, ‘no!’ Although part of me was delighted at how well she had articulated her refusal, the rest of me was upset, almost alarmed at the suddenness of it. C had never refused to breastfeed before. Certainly, some days she was keener than others, but this outright rejection was completely new. Although the following morning I managed to feed her again when she was half-asleep, it was the only time she nursed in a 24-hour period.

This pattern repeated itself the following day, leaving me frantic with worry. What had happened to put her off? Was it something I’d done? Was it simply her time to wean? How would I know the difference? Obviously if C genuinely did want to wean, I didn’t want to pressure her to carry on breastfeeding, but as stopping was pretty final, I didn’t want to do it unless I was absolutely sure it was what she wanted.

I was shocked at how C’s nursing strike impacted on me emotionally. I was teary, overwrought and pretty much incapable of thinking about anything else. It seemed important to get it into perspective, however, so I eventually pulled myself together enough to consider the issue rationally. One major clue to the source of refusal was staring me in the face: not only was she shunning breast milk, but she was also refusing bottles, and with the exception of yoghurt, pretty much any food or drink. Whilst this was incredibly worrying in some respects, it did point to the fact that the problem may be less to do with breast milk, and more to do with consumption generally. I then started to think about the nature of her illness, and concluded her symptoms were pretty similar to the ones that I had at the time – a runny nose, cough… and a sore throat. I didn’t know whether C’s throat was also sore of course, but if it were, then it would be a pretty convincing reason for not swallowing unless it was absolutely necessary. The cold I was suffering from had left the roof of my mouth pretty tender too, which, if you think about it, could make breastfeeding particularly unappealing.

I continued to offer C feeds, which she would sleepily accept once a day, and after a week or so she was almost back to her normal routine. I can only assume that the strike occurred because of her illness, and now she was feeling better, she was happy to breastfeed again. Although the incident was traumatic in some ways, it did at least leave me confident that if C goes off breastfeeding because she’s ill, it’s something we can get through, and if she’s stopped because she wants to stop… well, that’s something we can get through too. When the time comes for her to genuinely wean herself, I now think I’ll be able to cope with it a little bit better, and simply be happy that she’s growing up and gaining independence.

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