Battle with the bottle: persistence pays off

bottle_2When C was about 10 weeks old, she started refusing to feed from a bottle. Initial reluctance rapidly turned into violent resistance, and if I actually managed to get the teat near her mouth, it was met only by screams.

My despair at the situation was tempered only by the fact that it turned out not to be particularly unusual. Two mothers I knew had had the same experience – trouble free bottle feeding morphing into complete refusal – and several others (including, ahem, my own mother) had never managed to get their babies to feed from a bottle.

On the web, several discussion forums were devoted to the topic, and here I found a glimmer of hope: many parents who had experienced similar problems had eventually been able to get their babies to accept bottles. Reading the advice was nevertheless confusing. There were a multitude of conditions that apparently dictated whether infants would feed from a bottle: mothers needed to be around to provide comfort/mothers needed to be completely out of the house; babies shouldn’t be really hungry (they might get too upset)/babies should be really hungry (they won’t let themselves starve); silicon teats were better than rubber/rubber teats were better than silicon…

The only thing that all the success stories had in common was that the parents persisted in offering their children bottles. This in itself is not a great revelation – if a bottle isn’t offered, then it cannot be accepted – but it was reassuring to know that just because a baby resolutely refuses a bottle at one point, it doesn’t necessarily mean she always will.

Keeping this in mind, we started to offer C a bottle everyday, containing just an ounce of expressed milk to start with. I abandoned my frustration, and decided not to worry too much whether she took it or left it. Perhaps because I was no longer anxious, C stopped crying when the bottle was near her. Sometimes she drank a little bit of milk, sometimes she just chewed on the teat, sometimes she spat it out. Eventually, she became so comfortable feeding this way that she’d grab the bottle with both hands and help push it into her mouth! Whether it was decoupling the stress from the situation, the increasing familiarity of the bottle, or a sudden turnaround that would have happened regardless of what we had done is impossible to know, but for now at least, bottle refusal is thankfully in the distant past.

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Battle with the bottle

bottleWhen C was a few weeks old, and I was expressing to take the pressure off my beleagured nipple, she would gulp down whatever ended up near her mouth – even milk straight from the fridge. I didn’t enjoy feeding her bottles, but it was a necessary evil, and as the health visitor told me, if I wanted her to take a bottle later on, I needed to introduce it at that point anyway. She also mentioned that if I wanted C to carry on accepting bottles, I’d need to keep it up, giving her at least one per week. I endeavoured to do this, more or less, although I was reluctant to do it really frequently as it seemed to make her windy and more likely to be sick. I have to admit that part of it was laziness as well. Since breastfeeding had become less painful, it was proving to be amazingly convenient, whereas expressing and bottle feeding was a bit of a hassle.

On my husband J’s birthday, we went out for a meal without C for the first time. My sister came over to look after her, and even though we were only going to be a couple of hours, I wanted to have a bit of wine, so thought it would be better to give her a bottle that evening. I expressed milk in the morning, and defrosted some frozen stuff just in case. My sister didn’t need to use the milk in the end (C had a substantial meal just before we left), but I thought my blood-alcohol content was probably a bit high when I got back, so I decided I ought to leave it an hour or so. C seemed pretty peckish, so J settled down to bottle-feed her. Half an hour and a lot of agitation later, very little had gone down, and we ended up trying to distract her until I could feed her again. I wasn’t particularly worried by this turn of events, but realised that we were going to have to make this bottle thing a lot more regular to ensure that C would take one readily when I wasn’t available to feed her.

The plan was for J, who would normally be feeding her in my absence, to give her a bottle of expressed milk each evening. Simple. Except that rather than making bottles appear more desirable, it transformed her into a small bundle of rage who wouldn’t have them anywhere near her. She turned her head and pushed them away with her hand (at least it was helping her motor coordination), refusing to swallow even the milk that happened to leak into her mouth by chance.

After a few nights of this, I was at my wit’s end. I hadn’t really considered that she might refuse to feed from a bottle in my absence. It had been so easy! Now I realised that I might have to accept that she’d reached the point where she might flat out refuse, even if she was really hungry. It wasn’t that she didn’t know how to do it (a couple of times she’d sleepily suckled for a few seconds), but rather that she didn’t want to. C had realised that she could decide what to take into her mouth, and unfortunately for me, milk from a bottle simply wasn’t on the approved list…

Not enough milk? The “symptoms” you don’t need to worry about.

glass of milkA huge proportion of women worry that they aren’t satisfying their babies through breastfeeding alone, and many give up as a result. Much of the time, however, they are worrying about nothing. Although the precise relationship between perceived and actual milk supply isn’t well researched (see insufficient milk: all in the mind?), it is certainly the case that many of the “symptoms” that women think indicate they aren’t producing enough milk are actually completely normal, and can in fact be indicators that breastfeeding is going well.

In an article for Australian Family Physician journal, Dr Lisa Amir summarizes the common misconceptions of low supply. They include your breasts feeling softer, your baby taking less time to feed or feeding more frequently, your baby seeming unsettled or settling better on formula, and your baby’s growth appearing to slow down after three months1. In the absence of any genuine indicators of ill health, none of the above are a cause for concern, yet they perturb many mothers to the extent that they stop breastfeeding. Why do mothers interpret these commonplace occurrences as signs that their milk production is diminishing, and what actually causes them? The sections below address each ‘symptom’ in turn, outlining why they can be misconstrued as a problem with milk supply, and explaining what actually causes them.

•    Your breasts feel softer

After the problems with engorgement that can occur in the post-birth period, it should come as a relief when breasts go back to a softer, more normal consistency. In reality, it can be somewhat unnerving. If you’re used to rapidly filling up with milk, any decline in this can give the impression of a dwindling supply. In fact, your breasts are simply adjusting to maximize their efficiency, by producing as much milk as your baby needs, but not going overboard – an important process, given how energy intensive it is to produce milk. Initially, production is controlled by hormones that are released after giving birth, causing a significant amount of milk to appear regardless of whether a woman intends to breastfeed. Within a few days, however, the amount produced starts to be determined by the amount of milk that your baby takes at a feed2. The quantity of milk required by your baby increases rapidly to start with, but by the end of the first month it has stabilized, and your production becomes fine-tuned too, so you can supply your baby with exactly what she requires, without wasting energy by producing too much3. This isn’t to say you can’t make more if necessary, but simply that you won’t do it unless the demand is there.

•    Your baby takes less time to feed

Whilst the amount of milk a baby has at each feed remains relatively consistent as he gets older, the speed at which he takes it on board increases. A five month old baby sucks more frequently and ingests more milk with each suck than a two-month old, meaning that he can get through a meal much faster4. Although this gives the impression that he isn’t getting as much milk, you can be reassured he is – he’s simply getting it in a shorter time.

•    Your baby is unsettled, or seems to settle better on formula

The research into colic, crying and the type of food a baby receives presents a confusing picture. Some studies show babies sleep longer if they are breastfed5, while others say formula fed infants are more settled6. One problem that frequently arises with the research in this area is that feeding method is confounded with style of care-giving, and cross cultural studies indicate that the the latter might have a much greater impact on how irritable babies are than the former5. The main thing to remember is that there are many factors affecting how much your baby cries: if you are feeding on demand, a problem with your milk supply is unlikely to be one of them.

•    Your baby feeds more often

A long term study in Sweden has shown that the number of feeds a baby takes in a day can vary by a huge amount, both from baby to baby, and for the same baby over time7. A change in feeding frequency is not unusual, and is not associated with a problem with your milk supply.

•    Your baby’s growth slows after three months

What if your baby has been gaining weight steadily, and then suddenly starts to falter?  The amount of weight babies put on may vary over time for many reasons, but an apparent slow-down from around three months should pretty much be expected. Although the new WHO growth charts were published in 2006, many health care providers (including my own) still aren’t using them, so your baby’s growth is being compared with that of formula fed infants. The really important thing to remember in this situation is that it is actually the breastfed babies’ pattern of weight gain that is considered desirable, so formula fed infants whose growth curve continues to climb are actually gaining too much weight. Or at least this is what the WHO states – presumably the rest of the medical profession will catch up in the next few years.

The issues discussed above frequently cause mothers to worry that they aren’t producing enough milk when in reality their supply is absolutely fine. A baby may cry, fuss or feed more frequently because she is hungry, but this does not mean that her mother is unable to provide her with sufficient milk. The efficient nature of milk production means that if a baby indicates that he needs more milk by taking more at a feed, then the breasts will increase production as required.

The only time to worry is if your baby appears physically ill. If her growth has genuinely stalled, or she is continually tired, weak and listless, there may be a problem: if you’re in any doubt, consult a professional. Just keep in mind that any other ‘symptoms’ of low supply are probably nothing of the sort: as long as your baby is healthy, you almost certainly have nothing to worry about.

  1. Aust Fam Physician. 2006 Sep;35(9):686-9.
  2. Exp Physiol. 1993 Mar;78(2):209-20
  3. J Midwifery Womens Health. 2007 Nov-Dec;52(6):564-70.
  4. J Reprod Fertil. 1999 Mar;115(2):193-200.
  5. Early Hum Dev. 2000 May;58(2):133-40.
  6. Early Hum Dev. 1998 Nov;53(1):9-18.
  7. Acta Paediatr. 1999 Feb;88(2):203-11.

Insufficient milk: all in the mind?

milk pouring from bottle to glassIf you’ve ever felt that your baby isn’t satisfied with your breast milk, you’re not alone: ‘not enough milk’ is the reason mothers provide more than any other for giving up on breastfeeding1. A recent review in the Journal of Nursing Scholarship reports that the problem is huge2: Insufficient Milk Supply (IMS) is the primary cause of 35% of instances of early breastfeeding termination. If we apply this figure to the UK, where 51% of women start breastfeeding initially, but have stopped by 6 months3, it equates to an alarming 1 in 6 babies being potentially malnourished, were it not for the option of formula milk.

Or does it? The review, which collates the research in this area over the last 10 years, reveals that the term IMS is actually used interchangeably with PIM – Perceived Insufficient Milk – making it very difficult to determine how many women really aren’t providing enough milk for their babies, as opposed to those who just believe they aren’t.

Although research in this area is lacking (according to the review, ‘the accuracy of maternal perceptions, or PIM, in relation to actual milk supply has not been determined’), there is some data that gives an idea of the relationship between the two. A study conducted in Chicago followed 96 mothers who planned to exclusively breastfeed for at least 12 weeks4. To determine how much milk their babies were taking on board, the women were asked to weigh them before and after every feed and record the results in a log book. Whether or not the women thought their milk supply was adequate was determined in a series of telephone interviews.

Unfortunately, the paper doesn’t report exactly how the mothers’ perception of their milk supply related to their actual output (the goal of the study was to identify factors that predicted whether women were breast or formula feeding at 12 weeks). It is, however, possible to work out roughly from the data they do include that at least 17% of the women whose supply was adequate at the final recorded weighing session went on to report PIM in the interview two weeks later. Whilst the possibility that the milk supply of all these mothers suddenly dropped cannot be ruled out, neither can the possibility that it was the perception of their supply, rather than their actual supply, which suffered.

One thing that the Chicago study did demonstrate strongly, as did the other research in the review, is that if women think they aren’t producing enough milk (regardless of how accurate this perception is), they are more likely to stop breastfeeding, or supplement with formula. The study also showed that the women most likely to report PIM (and to have a genuinely inadequate supply) were those who breastfed their babies fewer than 8 times a day. As breastfeeding regularly is itself vital to maintain production1, anything that compromises this (such as formula supplementation) can quickly reduce supply, turning the perception of insufficient milk into a reality. If you’re genuinely worried, you should see your doctor. In the meantime, keep in mind that the best way to stop supply dwindling is to increase, rather than decrease, the frequency of your breastfeeding.

For further information about this problem, see not enough milk: the ‘symptoms’ you don’t need to worry about.

At the end of the study (12 weeks postpartum), 28 mothers were using formula either completely or partially, and 69 were breastfeeding exclusively. At week 6, (when actual milk output was calculated for the final time), 19 of the formula feeders, and 65 of the breastfeeders were shown to have an adequate supply. In the 8 week interview, however, 20 of the formula feeders and 6 of the breastfeeders reported PIM, which means that assuming that the 13 women whose supply was genuinely low at week 6 reported PIM at week 8, the other 13 mothers (11 formula feeders and 2 breastfeeders) perceived their supply to be low when not long before it had been shown to be fine. Unfortunately, as the measures of actual and perceived insufficiency weren’t taken at the same time, it isn’t possible to work out exactly how much of the insufficiency is imagined rather than real (more research in this area please!). On the plus side, 6 women who reported PIM at week 8 were breastfeeding exclusively at week 12, so it isn’t impossible to overcome this problem.

  1. Aust Fam Physician. 2006 Sep;35(9):686-9.
  2. J Nurs Scholarsh. 2008;40(4):355-63.
  3. Infant Feeding Survey 2005
  4. J Perinat Neonatal Nurs. 2007 Jul-Sep;21(3):250-5.

Nipple solutions 3: pumping

bottleIn addition to using a nipple shield, both the health visitor and the NCT helpline lady suggested I try expressing milk and feeding it from a bottle, to give my nipples a bit of a rest. C’s response to the shield was not encouraging, so using a breast pump was really the only option I had left if I wanted to carry on. So far I’d just about been able to put up with the pain: if I gritted my teeth through the initial agony, the remainder of the feed was just about bearable. The sight of my nipples, however, was really quite perturbing. The open wound on the outside edge of one was so deep it looked as if the nipple were in danger of detaching. The psychological effects of seeing this type of damage were considerably worse than the pain. I could only assume it was getting worse with each feed, and therefore that I was mutilating myself further.

Despite the obvious arguments for using a pump, and possessing one that was bought before C even arrived, it took me another couple of days to get around to using it. I don’t know quite why I was so reticent, but I think it had something to do with feeling guilty and inadequate not being able to get it right on my own. The turning point was speaking to my friend Zara. It turned out that she’d had exactly the same problem – right down to the fissures in the same place – and had pumped to help with the healing. She’d also had the same feelings of guilt and inadequacy, but had come through the other side and said that it made a massive difference. I wasn’t going to get any extra points for prolonging the pain, so I should just get on with it.

Some women find expressing milk easier than others. The key is prompting the letdown reflex – after that getting milk out is reasonably straight forward. Without your baby actually suckling, however, letdown isn’t always that easy to initiate. Looking at a picture of your baby (or indeed your baby herself) is one way of getting the vital oxytocin flowing. The solution for me was pumping from the really mangled left hand side, while C fed from the slightly less injured right hand side. For about four days, I expressed on the left and fed on the right, feeding C the expressed milk in a bottle if she was still hungry.

Using the pump and feeding simultaneously gave me an interesting way to monitor the extent to which the expressing helped. I had the same injury on both sides (albeit not as badly on the right), but only used the pump on one. It definitely provided me with some relief – expressing was much less painful than feeding – and the nipple did heal eventually, but the right side also healed completely, without any intervention. The healing actually occurred slightly faster on the right hand side, although this might be expected, as the injury wasn’t quite so serious. It seemed that the midwife who told me that things would eventually improve of their own accord was right after all. I think the problem for me was caused by the fact that my nipples weren’t quite the right shape initially (for C’s mouth at any rate – I don’t know if it would be different with another baby) and the skin broke so they could be stretched into a better one. Certainly, they now look quite different to how they did originally – pointy where they were once quite flat. When they healed, extra skin grew over the fissures where they’d stretched, rather than the skin knitting together at the point where it was originally joined, providing further evidence that my nipples were simply going through a (very painful!) transitional process.

Although it seems that both nipples would probably have recovered of their own accord if I’d continued feeding C as normal, I would strongly recommend using a pump if your nipples are suffering. It really helps to relieve the pain, and if you plan to bottle feed later on (whether with expressed milk or formula), introducing it early (and continuing regularly) means you should meet less resistance later on. Even if you take into account the constant pump dismantling, sterilizing and constructing, it’s a win-win situation!

Using formula might stop you sleeping at night

bed

One of the common myths perpetuated about breastfeeding is that it causes your baby (and you) to sleep less soundly at night. Formula is said to be heavier and harder to digest, knocking your baby out for longer, whilst ‘weaker’ breast milk just isn’t as satisfying. A friend of mine was criticized for not using formula (by her mother, of all people) for this very reason. I’ve met lots of breastfeeding mothers who are doing fine sleep-wise, and bottle feeding ones who are knackered, and have always thought this was nonsense, so I was happy to hear recently about some research that confirms what I always expected1.

The study examined the sleeping patterns of 133 parents of three month old babies over a 48 hour period. The parents were asked to report how much sleep they got, while the actual amount was measured using a special device called a wrist actiograph. Mothers who breastfed exclusively reported getting a greater amount of sleep than those who supplemented with formula at night, and the actiograph confirmed that they did indeed get on average an extra 40-45 minutes. As it can take a while to prepare formula, this isn’t entirely surprising – the extra time might be due to the fact of having to make up the bottle. Here’s the really interesting thing, though: mothers whose partners shared the night feeds (in theory allowing them to sleep longer) STILL slept less than mothers exclusively breastfeeding. It seems that when the baby wakes, the mother does too (thanks, biology!) and when she doesn’t need to feed the baby, she instead lies there worrying about whether her partner is doing it properly… So, although the results confirm how hard it is for mothers to sleep easily (even if they have a partner willing to help out), they are very encouraging for breastfeeders – an extra 40 minutes can make a BIG difference!

  1. J Perinat Neonatal Nurs. 2007 Jul-Sep;21(3):200-6.