Baby-led (Paced) Bottlefeeding

  1. Use a bottle with a soft silicone nipple, slow-flow and a straight, not crooked bottle. A standard, reusable bottle with small diameter collar generally works better. A soft longer silicone nipple is preferred. Dr. Brown’s 4 oz with standard (not wide-mouth) is a good choice. The valve in the Dr. Brown’s bottle encourages baby to suck and not remove milk by compression.
  2. Put baby on her side in a flexed position, propped with her head higher than her bottom. Her neck should be naturally curved with the chin sticking out a little. Her head should be lined up with her body, not turned to one side or the other. If your baby is older, you can sit baby upright on your lap, supporting her head behind the neck with one hand. Don’t put her in the crook of your arm or on your forearm – this may lean her back too far, causing the milk to come out of the bottle more quickly when she is not sucking. Remember, baby’s back should be rounded, not arched, hips flexed and chin forward in either position.
  3. Tilt the bottle so milk is NOT in the nipple at first. This will not cause baby to swallow air, but instead get her used to sucking a few sucks without milk, like breastfeeding. Use the nipple of the bottle to tease the baby’s lips, stroking from the top lip to the bottom, trying to get her to stick the tongue out over the bottom lip and open very wide. Stroke down gently from the center of the top lip to the center of the bottom lip. Be patient, as it may take several strokes at first for her to get the idea.  When she starts to get the tongue out, tilt the nipple towards her palate and encourage her to take it in all the way to the back of her tongue. Baby’s tongue should cover her gums and be over her bottom lip  This will encourage her to suck, not bite, the bottle. Her lips should flange out, touching the nipple collar. If she doesn’t take the nipple in very far, gently twist and work it back further onto her tongue until her lips touch the collar. If she gags, take the bottle out and start over. The tip of the nipple should rest on the back of baby’s tongue (like the breast nipple during breastfeeding) and not in the front of her mouth. If baby does not close mouth and cup tongue around the nipple, try supporting her chin with a finger and pressing upward. Do not tip the bottle up and completely fill the nipple as this will cause milk to flow too quickly. Air in the nipple will not cause gassiness! Babies swallow air when milk is flowing too quickly and they attempt to breathe and swallow at the same time.
  4. When baby is older and stronger, you can hold baby in sitting position. Cross your legs or put one foot up on a stool to allow your leg to help support baby’s back. Hold the bottle as level as possible, just allowing milk to come into the nipple. This puts baby in charge and encourages her to use her tongue correctly.
  5. After 30 seconds or so of swallowing, tilt the bottle back so milk is not in the nipple. Allow baby to rest and catch her breath. As baby begins to empty the bottle, you can lean her head back slightly, but no more than 45 degrees. On her side, you can turn her slightly upward to keep milk in the bottle nipple tip.
  6. If your baby is using the side position, you may find she is more efficient on one side than the other. If that is true, use the best position for majority of feeding but finish on the other side. You may also try lying on your back with her lying across your chest.
  7. Watch for swallowing (slight pause in the open-close motion of sucking). Help her to pace herself by removing the bottle if she seems to be pushing it with her tongue, does not pause to breathe, milk is spilling out of her mouth or she needs to burp. It should take her 15-20 minutes to finish a bottle.
  8. Some babies require chin support to get started especially if they have been using bottles that have short nipples, wide bases and where milk comes when baby bites down on the bottle teat. Keep working with above techniques until baby gets the hang of sucking instead of biting the bottle nipple.
  9. Offer the breast after feeding for comfort-nursing as often as possible. This will help improve digestion and keep baby interested in breastfeeding.

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Note: Baby’s head is higher than her bottom.

Baby-Led Bottle-Feeding by Jane Kershaw Revised 10/2019

Adapted from “Bottle-Feeding as a Tool to Reinforce Breastfeeding by Dee Kassing, BS, MLS, IBCLC. J Human Lact 18(1), 2002

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The First 100 Hours – Getting Breastfeeding Off the Ground

Research shows that the number one reason for moms not meeting their breastfeeding goals is low supply. Research shows that milk supply is heavily dependent on what happens in the first 3 days.  Here are a few tips that will protect your supply and ease baby’s transition from womb to world.

What To Know:

  1. Babies are not born knowing that sucking is related to hunger satiation. Sucking is a reflex that brings comfort first, food second. Babies do not know hunger before birth.
  2. Caring for babies skin to skin provides warmth, moisture and transfer of protective good bacteria from mom to baby. Research has shown that babies cared for this way have less jaundice, better sugar levels, better temperature maintenance and fewer infections than those cared for away from mom’s skin. Delaying bathing to allow time for vernix (the thick creamy coating in skinfolds and coating skin) helps baby absorb good bacteria from mom. This is especially important for babies who have delivered by Cesarean Section.
  3. Most babies, when placed on mom’s chest immediately after birth, will begin crawling, searching and rooting activities within the first hour after delivery. Interestingly, mother’s milk is most readily available at that time due to birth hormones. Babies who get this early dose of colostrum are protected from low blood sugar and the gut is provided a protective layer of mother’s helpful bacteria. This early latch also starts the milk production process and helps prevent delays in milk coming in.
  4. Baby’s first sucking experiences help develop baby’s sucking behavior. Finding the breast for herself while crawling on her belly encourages a wide-open mouth and tongue forward. Repeated practice sessions – offering the breast with early feeding cues whenever baby demonstrates those – helps the imprinting process. Leaving baby’s hands unwashed and uncovered helps baby find her way to the breast.
  5. Frequent feedings in the first 100 hours (10-12 per 24 hours) encourages a more rapid transition from colostrum to milk production. Tight swaddling may interfere with natural feeding rhythms.
  6. Feeding both breasts, and repeating as necessary, helps a baby associate sucking with obtaining milk.
  7. IV fluids, blood pressure issues etc. can cause the areola around the nipple to be firm and make latching more difficult for the baby. Reverse pressure softening and areolar expression can remedy this and make latching easier.
  8. When babies are latched well, you should be able to hear a few swallows, even in the first day of nursing.
  9. What goes in must come out: that means a baby who is getting milk from the breast will have wet diapers and poop. This starts at one a day and increases by an additional wet and poop for each day of life. By 5 days, a baby should be wetting 6-8 times and pooping 3-5 times per day.
  10. Nipple tenderness should be resolved by day 5.

What To Expect:

First 24 Hours: Baby should nurse within two hours, if placed skin to skin with mom and allowed to remain there.  Some babies will sleep 4-6 hours and then begin nursing every 1.5-3 hours.  Some babies do not take the recovery sleep. Babies may nurse for a few minutes, others for half an hour.

Second 24 Hours: Babies should start waking up more, nursing for longer periods. During the second night of life, babies may nurse more frequently and seem hungrier, wanting to nurse off and on all night. Milk often comes in after this frequent nursing period. Switching breasts frequently and breast compression helps protect nipples and improves supply.

Third 24 Hours:  Milk volumes increase, breasts become firmer. Nursing sessions should last 10-30 minutes. Be sure to nurse both breasts, changing breasts whenever baby starts to fall asleep.

What To Do:

    1. Keep mother and baby together, 24 hours a day. Do not separate unless medically necessary.
    2. Put baby on mom’s chest immediately after birth. Mom’s head should be raised so she can see and follow her instincts to help baby with latch. Delay bathing for at least the first 24 hours. When bath is done, leave hands unwashed.
    3. If mom’s areola is firm or nipple appears flattened, perform Reverse Pressure Softening and/or Areolar Expression to help baby draw nipple far back onto his tongue. http://hopebreastfeedingsupport.com/video-resources/
    4. Use breast compression to keep milk flowing if baby seems to fall asleep quickly after latching. This is a firm but gentle squeezing of the breast a few inches back from the nipple. Squeeze and hold while baby is drinking; release while he rests and repeat until baby is not swallowing.
    5. Change breasts every few minutes when baby slows down on sucking and swallowing. Repeat breasts until baby is satisfied and asleep.
  1. If your baby is too sleepy to latch (this can happen from medications mom is given during labor), express directly into baby’s mouth or hand-express colostrum and syringe or spoon feed to baby. This will help prevent low blood sugar for the baby and prevent unnecessary formula supplementation. Breast milk is more effective at increasing baby’s blood sugar than formula because it is self-digesting. Do this every 2 hours until baby shows interest and starts latching by himself.
  2. If your baby has not started latching by 12 hours after birth, ask for a hospital breast pump and begin pumping as well as manual expression to give your supply a jump start. If your baby begins latching but is still having difficulty after 24 hours (causing nipple pain, no swallowing), start pumping. Pump 10 times/day the first three days, then 8 times/day after that until baby is doing well.  Research shows that moms who begin hand-expressing AND pumping in the first two hours when baby is unable to nurse well, have twice as much milk at 10 days as those who delay.  WATCH THIS VIDEO: http://med.stanford.edu/newborns/professional-education/breastfeeding/maximizing-milk-production.html
  3. Avoid pacifiers and bottles until baby is latching well. It usually takes about 2 weeks for babies to imprint at the breast.
  4. Keep track of baby’s output. The My Medela App is free and will help you keep track of feedings and baby’s wets and poops.
  5. If you are still having trouble with latch or have nipple damage after the 5th day or you have cracked or bleeding nipples, get hands-on individual help.

If you have time and resources, please take a comprehensive prenatal breastfeeding class. Prenatal Classes help get the whole family on the same page and reduce stress. Classes are offered in many locales, including Nova Birth Services at (615) 669-6399 and most Maternity Hospitals. 

Tongue-ties and other Hurdles with Breastfeeding

There has been a lot of discussion among the medical community about the impact of tongue and lip restrictions on breastfeeding and oral health in general. Over my now 45 year career of nursing and lactation support, this discussion has grown from a “no big deal, just fix it” question to an “it’s an imagined problem” to where things stand now – with camps saying it’s overdiagnosed to camps saying that it’s underdiagnosed and undertreated. There are many social media groups for both moms and professionals discussing the issue and in some cases, strong battle lines are drawn. Here is my opinion.

Personally, I have had two children with restricted lingual frenulums. One received a revision at 5 days by the old GP that delivered her. The other delivered many years later, was not diagnosed and was not treated. I nursed them both, the first for 10.5 months (in a day when everyone bottle-fed) and the second 3.5 years. Both had dental issues later in life.  That’s my personal experience and occurred before I was a board certified lactation consultant. My experience says that with a genetic capacity for excellent milk supply and determination, breastfeeding can happen for some moms with babies with oral restrictions, but sometimes it can’t. There was no Facebook back then with thousands of mothers looking for support that they can’t find in their local medical community. I survived. Does that make it ok to not treat oral restrictions?

Professionally, over the course of my career, I have helped thousands and thousands of women breastfeed.  Some of the most difficult cases have been with babies with oral restrictions. And many of these have additional difficulties to overcome, some as secondary issue caused by the oral restrictions, some separate but equally challenging issues. Below are some of my conclusions.

Oral restrictions affect muscles in the body. Babies use their whole bodies to breastfeed. Sucking is the mechanism by which babies get nutrition, comfort and explore their world. When that is disturbed by difficulties of attachment due to weakness or inability to move the tongue (which is another muscle), their world is turned upside down. Compassion and understanding go a long way to increasing patience with a baby who doesn’t understand and who is biologically driven to nurse. All babies want to nurse, but oral restrictions impeded their ability to do with ease.

First, it is important to note that muscle tension can affect tongue effectiveness, giving an appearance of restriction. That is why it is important to have an experienced diagnostician who can distinguish between a mechanical restriction (like a tongue-tie) versus muscles in tension preventing movement and range of motion. Proper diagnosis is the first key to dealing with inhibited tongue function.

Next, if a mechanical restriction is diagnosed, an experienced and knowledgeable provider is the second key in improving function. The provider must know how to do a complete release and be able to show the parents what that looks like when it is accomplished, and give proper guidance for post-revision care.

The third key is effective and consistent after care done once the baby’s restrictions is released. Babies who can’t suck effectively, often develop muscle tension in other places than the tongue as they try to compensate for poor tongue function. This can result in lots of tension, pulling away from the breast, biting, etc. Some babies will develop or may have accompanying torticollis, high body tone, etc.  Body work, physical therapy, effective and frequent tummy time, baby-wearing, and skin to skin care can help calm and relax a baby. This must be done in a pattern that is effective and rewarding for baby.  Some babies need care from a speech language therapist. If baby is being supplemented, the choice of supplementation device may change as baby improves. See my post http://hopebreastfeedingsupport.com/pacifiers-bottles-and-pumps-oh-my/ for more information on the impact of devices on breastfeeding competency. Protect your milk supply while working on any latch issues as supply is driven by the degree and frequency of emptying the breast. See the link above for more info on that as well.

A lactation consultant should reevaluate baby after a release because latch techniques may need revision once baby has full range of motion of the tongue. It takes time to work through and retrain baby to latch comfortably and effectively. Most moms report it takes 2-4 weeks. Follow-up assessment during this time is important to make sure healing is progressing and function is improving. The IBCLC can further refer to body workers, speech therapy, physical therapy as needed.

Above all, when taking the journey through breastfeeding difficulties, including oral restrictions, remember that the breast is and should be not a battle ground but a sanctuary for babies. Keep baby close and comfortable (that’s skin to skin care). Keep baby at the breast, even if you have to supplement away from the breast. Breastfeeding can be an after meal snack even if your supply is low. Your journey may not be easy, but your bond can be strong as you work through challenges.

Grandmothering the Breastfeeding Baby

I am the grandmother of a newborn baby boy. Born a little over 3 weeks ago, I’m sitting in the living room of his parents mulling over this new role. No, this is not my first grandchild. But it’s the first one I’ve had the joy of spending uninterrupted time getting to know his little personality, observing his parents in their roles and his older brother adapting to his new role – big brother.

As a lactation consultant, I am invited into homes to observe, assist and recommend in an active role.  There are barriers that must be broken down and boundaries to cross and an instant intimacy created by the need of the moment. As a mother-in-law, mother and grandmother, there are boundaries that must be crossed very hesitantly, if at all. My philosophy of breastfeeding applies in this instance – it is the relationship that we must preserve above all. Breastfeeding, with all its benefits, is primarily about establishing the primal relationship, not just getting breast milk into a baby. Relationship is about building love and respect into an unbreakable bond.

So what can a grandmother do to support the new family? I believe that the same three goals apply to this situation as to any other breastfeeding cohort: protect, promote and support. Protect by being positive and avoid offering solutions that interfere with breastfeeding. That means, don’t offer to bottle-feed the baby so mom can get a good night’s rest. Don’t give the baby a pacifier to hold off for a longer interval between feeds. Don’t buy another infant holding device (bouncer, swing, rocknplay). Don’t make negative observations such as: “your breastmilk looks kind of weak” or “he’s crying again – maybe you didn’t feed him enough” or “he has a rash – maybe you are eating something that he’s allergic to.”  Don’t offer to hold the baby while mom does the laundry or fixes your supper. Instead, be encouraging. Let mom know how proud you are of her, how blessed her baby is to have her, how beautiful she looks nursing your grandchild. If she doesn’t have one, get her a sling and help her learn how to use it for carrying baby. Use it yourself when she needs a break. Watch baby while he spends time in tummy position. Fix a meal, do the laundry. Take an older sibling to the park, or play with him. If mom needs you to hold the baby, by all means enjoy. Learn to hold baby chest to chest, a position most babies really enjoy.

If mom or baby are having some latch or fit issues, get help for them and be a cheerleader. Learn all you can about the establishment of milk supply and how that is done. Ask her how you can best help her reach her own personal goals. Breastfeeding is an important building block in a baby’s life foundation – but it is only one of them.  It also helps to remember that it takes babies 6-8 weeks to gain active control over feeding and moms need support during that time as they try to help their babies learn.  Nothing tops patience and perseverance in that journey!

Nothing in my life has been as rewarding as seeing my children grow up, take a marriage partner and become parents. I almost understand how God must feel when we become fruitful and start sharing our gifts and talents with others, and pass the torch along. I keep that in mind and am grateful for that. And as I anticipate great-grandchildren in the future, I hope to be able to give them the benefit of my hard-earned wisdom too!

 

When There’s Not Enough Milk

Sometimes, despite doing all the right things, there’s just not enough milk to totally sustain a baby with exclusive, mama-only, straight from the tap, breastfeeding.  Whatever the reason – genetic, environmental, iatrogenic, mother-baby separation, illness, etc., all that can be done has been done and there’s still not enough. What to do?

  1. Realize that breastfeeding is more about the relationship than it is about the volume of milk. Once a baby has made the connection between mom and comfort at the breast, the volume of milk obtained is not as important as the emotional connection that occurs. This is an important concept to grasp. Many babies nurse 3 or even more years. Older babies get a full diet of family-friendly foods, still need and want that connection with mom. But it’s not about the volume of milk, it’s about getting mom’s undivided attention and the feeling of security at the breast.
  2. For a baby to make that connection between breastfeeding and safety in the arms of mama, breastfeeding needs to continue even when full breastfeeding does not provide all the baby’s nutritional needs. Giving up breastfeeding for breast pumping may seem like a solution to address issues of low supply when a baby is an inefficient feeder for some reason, but exclusive pumping does not allow for that connection and interaction to continue. Think hard before you give up direct breastfeeding.
  3. If supplementation is required, and donor milk is available, use that to support baby’s nutritional needs as long as possible. If baby is able to breastfeed well enough, use a lactation aid at breast as much as possible for supplementation. If supplementation must be done away from the breast, use bottles in a manner that supports baby-led feeding.  See http://hopebreastfeedingsupport.com/pacifiers-bottles-and-pumps-oh-my/ for more information on selecting pumps and bottles that may interfere less with continuing the at-breast feeding bond.
  4. Recognize that babies use suckling time at the breast to help with digestion, to comfort and settle. Large volumes of milk are not needed, or even desired for this activity. Breastfeed your baby after supplementing to allow for this benefit. Breastfeed whenever possible instead of giving a pacifier. Some people call this “comfort-feeding.” In the early days, combine comfort-feeding with skin-to-skin care to build the connection between you and baby.
  5. Accept the fact that breastfeeding length and milk volumes do not have to correlate. Adoptive mothers may not have a full supply of milk, but they can still breastfeed. Mothers of toddlers aren’t exclusive breastfeeders, but they can still breastfeed. Mothers with insufficient glandular tissue may not be able to provide 100% of their babies nutritional needs, but they can still breastfeed.

When It’s Time to Wean – Mothering After Breastfeeding

All babies wean eventually.  Some have to be weaned early because of circumstances beyond control. Some wean by themselves. In cultures where breastfeeding is the normal way of feeding a baby, many children nurse until 3 or 4.  Some tandem nurse when a new baby is born. Different circumstances may bring up different issues for mom or baby.

Sudden Weaning

When baby weans or must wean suddenly, and mom still has milk, the goal is to reduce milk supply comfortably and safely. Some measures are well known such as wearing a supportive but non-binding bra, using cool packs such as disposable diapers that have been wet and then frozen, cabbage leaves that have been crushed and placed on the skin of the breasts and changed out when limp. Hand-expression or very short pump sessions can be used to gradually reduce milk supply. This may take a week or more. When in the shower, stand with your back to the shower. Only express milk if absolutely necessary. Herbal remedies for drying up milk include peppermint, sage, oregano, lemon balm, chickweed and black walnut. Sudafed is an over the counter medication that has been shown to decrease milk production in mothers 6 weeks or more past delivery. It can take months for breasts to completely involute. Once breasts are comfortable, avoid hand-expressing “just to see”, as this may stimulate additional milk production for some women.

If baby did not choose to wean, but weaning is necessary, and she is 6 months or under, consider paced or baby-led bottlefeeding to allow him or her to be in control of the feeding as much as possible. See my printable baby-led-bottlefeeding for instructions on this method of feeding. For older babies, try a sippy cup without the spill-proof valve, a straw cup etc,  These may be preferred. If you are using formula, see my printable preparing-infant-formula-2016 for safe handling of formula.

Gradual Weaning

If your baby is older and you are preparing for weaning at a later date, start by limiting your feeding locations to a special area or chair. If you are nursing your baby to sleep at night, begin to develop a bedtime ritual that can be continued after weaning. Turn on white noise, rub his back and rock after you take him off the breast. If possible, as you get closer to planned weaning date, start the back rubbing and take him off the breast but hold him close as he falls asleep. Trust your instincts. The biggest hurdle is to have clear in your mind why you want to wean and when you want to wean. Start a bedtime ritual that can be transitioned to not include breastfeeding as soon as you feel it is helpful.  Every child is different.

The Relationship Goes On

The close relationship you have started with breastfeeding can easily transfer to other activities that will provide comfort through your child’s senses.  Touch, warmth, soothing sounds can all happen with you, even when breastfeeding is over. And the benefits of a strong immune system will last as long as he lives!

 

For Helpful Information on Introducing Solids –

Check out this website:  http://www.babyledweaning.com/

 

 

 

Employment and Breastfeeding – Continuing the Breastfeeding Relationship When Separation Must Happen

So you made it to the 6 weeks mark. You’ve overcome the breastfeeding learning hurdles and are starting to feel a little more confident about this new relationship. Your healthcare provider has released you from care and you are feeling better physically. But now comes the challenge of dealing with the realities of your life. You have to go back to work. Many women, and especially first time moms, fear this pending separation.

Some of the questions that may run through your mind include:  What if my baby won’t take a bottle while I’m gone? What if my baby likes the bottle better than me? What if I don’t have enough milk? What if my boss won’t allow me time to pump? Can I juggle my work and all the responsibilities of being a mother? And what about my other relationships – partner, family and friends – can I fit all of this into my life?

Let’s take these questions one at a time.

  1. Baby won’t take a bottle? See my post on how to bottle-feed a baby.
  2. Wondering about pumps and choosing the right bottle?  See my post on pacifiers, pumps and choosing bottles.
  3. What about the workplace that doesn’t support breastfeeding?  See this article on Federal law and the workplace. Here is an article that you can use to talk to your employer about supporting breastfeeding.  http://www.cdc.gov/breastfeeding/pdf/BF_guide_2.pdf
  4. Start saving milk for your “stash” early. Most moms have more milk than babies require by the 3rd to 4th week after birth. Get your pump and learn how to use it and start saving. Many moms find they have an abundance of milk in the morning. Nurse first, then express the remaining milk and freeze. This will serve as your back up supply for any emergencies and when you first return to work.  After you start back to work, what you pump one day will be the feeding for the next day to work. Freeze what you pump on the last day before a stretch off work and use some of your stash on your first day back.
  5. If you haven’t learned to nurse in bed, it’s time to learn. By the time a baby is 6 weeks old, she should have enough head control so you don’t have to hold her head and her latch should be secure. Check out side-lying positions. Put your co-sleeper crib next to your bed so it’s easy to transfer her into her own bed once she has nursed to sleep. Keep things simple so nighttime feedings are short and uncomplicated. Unless absolutely necessary to maintain your milk supply, do not pump in the middle of the night.
  6. If your baby starts sleeping longer than 5 hours at night, pump right before you go to bed to keep your breasts from getting uncomfortably full during the night. You will rest better and the extra milk goes to your stash.
  7. Try to make life simpler at home. Crockpots and quick meals will save time in the kitchen. Simplify clean up and household duties and of course, enlist help from anyone available to you. There are lots of websites out there that have suggestions for this.
  8. Make sure you continue recommended vitamins for yourself, including adequate Vitamin D. Here’s a technical article supporting the recommendation for nursing mothers to get an extra 6000 IU of vitamin D daily for improving their own and their baby’s health.  https://www.ncbi.nlm.nih.gov/pubmed/17661565
  9. Most importantly, try to take some time for refreshment for yourself. Eat healthy as you can. Take naps. Put baby in a front carrier and get outside when the weather permits. And take lots of selfies! This time will pass quickly!
  10. Remember that breastfeeding is not just about the milk you provide your baby. It’s about the special closeness that comes when your baby looks in your eyes while you are nursing her and she begins to realize that YOU are her source of life and nourishment, when she smiles at you and then buries her head in your breast as if to say, “I’m home!”