Why I'm concerned about Tizzie Hall's Breastfeeding Advice - PART TWO

Continued from PART 1

What we also need to throw into the mix of Tizzie's breastfeeding advice is that she also recommends limiting the duration of feeds too:

Before milk comes in:

"Day 1: Feed every three hours from both breasts - 6 minutes per breast
Day 2: Feed every three hours from both breasts - 9 minutes per breast
Day 3: Feed every three hours from both breasts (if milk not in) 12 minutes per breast
Day 4: Feed every three hours from both breasts (if milk not in) 16 minutes per breast"

We know how important colostrum is for babies, it's often called "liquid gold".  Why would anyone want to limit the amount of this their baby receives?  Containing more white blood cells (antibodies) than blood, examine its properties further and you soon realise if it was bottled and sold we would be advised to encourage baby to consume as much as possible!

Once milk is in the routine is first breast 25 minutes, then second 15 minutes every 3 hours (alternating which you start with) then a shorter gap of 2 hours between 4-6pm followed by a 3 1/2 hr gap to 9.30pm.  By six weeks there is a 4 hour gap between the first and next feed and this extends until the gap is 4 hours throughout the day by 10 weeks (with 3.45 mins before the last feed) although it does switch to 25 minutes each breast at 6-8 weeks and then the timings just vanish from the routine (I'm assuming you can go wild and feed as long as you want at this point!)

Tizzie feels feeds need time limits so nipples can "toughen up" and "helps avoid cracked, sore or bleeding nipples, which can be horribly painful".

"Other babies are very sucky and if given the chance will stay sucking on the breast all day and night.  The mother could end up very sore and even cracked and bleeding nipples, especially if she is too exhausted to correctly latch her baby onto the breast."

To a new mum this may seem to make sense - but I feel it's based on myth as this blog post explores.  

Furthermore, science has examined this theory:

"To investigate the effects of the frequency and duration of breastfeedings on nipple soreness we studied two groups of mother-infant pairs during the first 10 postpartum days. Mothers in the control group fed on a 3- to 4-hour schedule and those in the experimental group were encouraged to breastfeed as frequently as the infants desired. All mothers recorded the time and duration of each breastfeeding for the first 10 days after delivery and gave their own daily assessments of nipple discomfort. Although mothers in the experimental group nursed significantly more frequently (10 vs. 7.4 feedings/24 hours, p >.0001), they did not experience more nipple soreness. There was no significant correlation between the frequency or duration of feedings and the degree of nipple soreness."

Does the Duration and Frequency of Early Breastfeeding Affect Nipple Pain?

Manoel de Carvalho M.D. Steven Robertson Ph.D. Marshall H. Klaus M.D.

Setting these sort of limitations on a newborn is quite mind boggling - but it doesn't seem to give any consideration to a baby not feeding well.  This is the group I'm passionate about as these tend to be the people I see/hear from day in and out.

If a baby is not for whatever reason transferring milk well - it's rather like you or I drinking from a squished straw.  Sure you get some liquid, but it makes your face ache and you stop long before you would if you had a normal straw.

These babies may fall asleep quickly at the breast - yet aren't really asleep and wake showing hunger cues as soon as they've moved.  They can spend an age at the breast and suck and suck, whilst consuming very little - a lot alternating between sucking, crying and cat napping..

In this situation the mum can develop sore/cracked nipples - but not from the constant feeding,  but from constant incorrect feeding.  If something is preventing the baby from performing the correct action, they can compensate with suction!  Some have a crushing very strong suck (as shown on ultrasound) which will absolutely crack and damage nipples.

Some feed very quickly but are hungry again half an hour to an hour later, or even sooner with feeds rolling from one into the next and the baby unable to settle.  I meet parents who say, I don't know what's wrong, it can't be hunger because he's been feeding for two hours!  Yet the baby would need to be attached 24/7 to take enough milk with how inefficiently they're feeding.  If you feel your baby never appears full or settled - seek help from someone appropriately qualified such as a breastfeeding counsellor or lactation consultant (I.B.C.L.C.).  This is not typical, but does not mean the only option is a strict routine.

I found Tizzie's book confusing in how one should deal with this though.

Firstly the baby falling asleep quickly:

Q.  My baby keeps falling asleep during a feed - what should I do?
A.  This is what I call a sleepy feeder.  If she dozes off before taking enough milk to get her to the next feed, you will start to have problems if trying to follow a routine.  Try changing her nappy or taking some clothes off as the cool air might rouse her.  You could also try putting her down somewhere safe to rest for ten minutes and then try the feed again.

Ok so what next?  If baby is not transferring milk well they WILL keep falling asleep - even after a 10 minute rest.  Then what happens if it gets near sleep time?

In one section of the book entitled "settling your new baby to sleep", it discusses a newborn not settling doing the "emotional cry" (ie the one Tizzie feels indicates a need).

"This cry I would never ignore.  Get the baby up and look for a problem, and if there's no visible problem I would offer some more milk".

I was quite heartened to read this although I did wonder which breast and how many minutes.

However still under "feeding in the first two weeks" it says:

"If you believe he is hungry between feeds and you have no expressed milk, just offer an extra feed for a few days no closer than two and a half hours after the last one."

Which suggests expressed milk is preferable if possible, but also seems to contradict the statement before?

The trouble with tiny babies is when they take insufficient calories the first thing they do is signal to feed; if this is ignored or their intake has dropped for another reason, they do one thing - sleep.  The more calories drop, the harder it is to rouse them to feed - especially at night. They stop spontaneously waking, and a mum has to start setting the alarm to "remind" her infant to feed.  It's also easy for a mum to think she has a "good" or "content" baby (because how long they will sleep now seems to define that in our society) who can't be hungry otherwise he would wake.  When she tries to wake him he struggles to rouse, compounding her belief he simply doesn't need to feed.

Whilst on Tizzie's Facebook group, I've read parents of young infants 7/8/9 weeks announce hurrah, their infant is sleeping 12 hours!  The response is often "great parenting", yet Dr Sears suggests otherwise:

"One thing we have learned during our years in pediatrics is that babies do what they do because they're designed that way. In the case of infant sleep, research suggests that active sleep protects babies. Suppose your baby sleeps like an adult, meaning predominantly deep sleep. Sounds wonderful! For you, perhaps, but not for baby. Suppose baby had a need for warmth, food, or even unobstructed air, but because he was sleeping so deeply he couldn't arouse to recognize and act on these needs. Baby's well being could be threatened. It appears that babies come wired with sleep patterns that enable them to awaken in response to circumstances that threaten their well being. We believe, and research supports, that frequent stages of active (REM) sleep serve the best physiologic interest of babies during the early months, when their well being is most threatened."

Dr Sears, 8 Infant Sleep Facts Every Parent Should Know

As clearly the above would for many ring alarm bells about supply, Tizzie recommends expressing alongside for the first 8 weeks.

In addition for the first two weeks until baby has regained their birthweight, mum has to set an alarm at night allowing a sleep of no longer than 5 hours.  After this mum can stop waking baby, but until 4 weeks she has to express after 6 hours if baby hasn't woken for a feed - but only needs to remove an oz (I'm not sure what this figure is based on)

"I strongly believe expressing in the early days is a key factor to having a good milk supply while following a routine."

and

"I encourage all my clients to express first thing in the morning and at other times in the day.  This is for two reasons.  One, this milk can be given in the bottle later in the day and some of it an be frozen and stored for when your baby has a growth spurt"

and

"After a few days your breasts will start to regulate and produce only the amount he is taking.  This is fine initially, but when your baby goes through a growth spurt in the early weeks you may not have enough milk to satisfy his needs.  This would result in you having to feed him more often and will get your routine off track.  It may also result in you feeding your baby too close to sleep time resulting in him using the feed as a going-to-sleep-aid."

Tell me, if it's so normal for a baby to follow the routine, why does one need to express to maintain a good milk supply?  Isn't expressing a lot more time consuming than just feeding more frequently when baby wants to up supply - the way he's supposed to?  Really is the world going to end if the routine goes out of the window for a few days?

The other issue I notice when young babies feed from very full breasts (which may happen following a 3-4 hour gap) is wind.  It seems Tizzie has noticed this too as she suggests mums should wind their baby every three minutes during a breastfeed.  By my calculations if a feed is as Tizzie advises 25 mins one breast and 15 the other - that's 13/14 windings per session!

My OH asked an interesting question after reading this entry, he said if you have to feed for 40 mins as per the routine, and you have to wind 13 times, if each winding is only 2 minutes - this is 26 minutes of winding.  Is this on top of the 40 mins feeding making each feed 1hr and 6 minutes or is it included?  ie 14 minutes actually feeding?

Looking at the routine

But none of it considers how unique each breastfeeding dyad is; that we know some mums have a larger initial store than others (although most can make roughly the same over 24 hours), that babies feed with different levels of effectiveness and that some mums have a bullet proof supply whilst others don't.

The last reason Tizzie gives for suggesting scheduled feeds is quality of milk - we are compared to cows in a dairy and our milk is claimed to be "similar to that of a cow" - which is eyebrow raising on so many levels.  Tizzie proposes that dairy farmers say the quality and quantity of milk increases if they stick to two set expressing times per day -" is it such a leap to assume that's so for babies?"

Tizzie that's not a leap, it's a freaking pole vault, of Olympic standard.

A dairy is not the normal environment for a cow you know?  When they have calves the farmer doesn't stand in the field with a stop watch, signalling when to start a feed and when to swap udders!

According to a dairy farmer, modern equipment allows the cows to choose their own milking times - and stated the times were set previously because of how long it takes to put a full herd through the milking process.  Hand reared calves are fed two - three times per day, and then also are offered hay and grains within a few weeks!  Bovine milk is designed to develop bulk not brains, because they're cows not humans.  In contrast, gorillas feed on demand as frequently as the guidelines suggest humans do.

Humans don't drink cow's milk because it's vaguely comparable (don't know about you, but I have just the one stomach!)  The protein size is cow sized not human, in fact sheep and goat's milk would be more comparable in some ways to human (although still not close)  Humans drink cow's milk because cows can produce vast amounts of milk whilst being cost effective to keep and docile enough to allow it.  Cow's milk has to be massively modified so a human infant can tolerate it and along with wheat is listed amongst the most common allergens.  Each mammals milk is species specific, the antibodies, hormones and everything else is only of use to the same species.  This is why there is a movement of mothers sharing human milk.

I appreciate Tizzie's book is opinion not a "science journal", but when your opinion is influencing how people raise babies isn't there some sort of ethical or moral obligation to at least consider how this sits with  the evidence?   I can understand areas where there is mixed evidence that it can come down to opinion, but some throw away comments are I think misleading:


When talking about prems:

"Often these babies are fed by tube or parents are advised to give their feeds from a bottle until the babies are strong enough to suck from the breast".

In an effort to refute the widely held assumption bottles are easier than the breast, one study sequenced babies to alternative between feedings at the breast and by bottle.  During bottle feeding infants showed:

• Poorer coordination of sucking, swallowing and breathing
• A greater number of oxygen desaturations
• A significant fall in skin temperature
• Shorter duration of feeding.

Meier P, Bottle and breastfeeding: effects on transcutaneous oxygen pressure and temperature in preterm infants.

Another study found bottle feeding increased the incidence of desaturation episodes compared to cup feeding (1) whilst another found a 10 fold increase in desaturation episodes to <90%, compared to "no change" whilst cup feeding (2)

When talking about multiples:

"Most mothers are capable of producing enough milk for more than one baby.  But it's also important to look at both your individual situation and your family's needs.  There is no point trying to breastfeed if you are finding yourself too tired to enjoy your babies, or you spend all your time worrying about whether they are getting enough food.  If you are concerned about this, talk to your health professional about their weight gain.  If they are all gaining enough weight, settling and sleeping well, then you know you are producing enough milk,  And remember, some breastmilk is better than none.  With this in mind, a lot of my clients have decided to give a mixture of breastmilk and formula."

Hang on, I thought the whole point of the routine was supposedly to "stop mothers feeling too tired to enjoy their babies?"  But to suggest there is "no point" if tired or concerned about weight seems really quite bizarre to me.  Mums don't need to stress about whether their infants are "getting enough" if they are peeing, pooping and gaining as expected, just like with a singleton; why does "sleep and settling" come into play?

To Tizzie's credit she does suggest mums struggling can contact the breastfeeding organisations, and gives further details of who they are - my only concern is that if mums contact them, they may end up extremely confused as the first thing they will say is "have you considered feeding your baby by cue, not a routine?"  The training to man these helplines includes looking at all the reasons a routine isn't the ideal for a breastfed baby.

Lastly here are the recommendations from the World's main sources of health care advice:

UNICEF's Baby Friendly Approach clearly states: 

"There should be no restrictions on the frequency or length of breastfeeds."

The NHS breastfeeding website reads:

"Feed your baby as often as they want. This is called baby-led feeding (it's also known as 'on-demand'). Let your baby decide when they’ve had enough. It's not necessary to time the feeds. In the beginning, it can seem that you're doing nothing but feeding, but gradually, you and your baby will get into a pattern of feeding, and the amount of milk you produce will settle.

It's important to breastfeed at night because this is when you produce more hormones (prolactin) to build up your milk supply. At night, your baby will be safest sleeping in a cot in the same room as you."

The Department of Health lists good practice as:

"Encourage breastfeeding on demand."

The American Academy of Paediatrics' breastfeeding policy states:

"To nurse whenever the newborn shows early signs of hunger, such as increased alertness, physical activity, mouthing, or rooting. Crying is a late sign of hunger. Nondemanding babies should be aroused to feed if 4 hours have elapsed since the beginning of the last nursing. Time limits for breastfeeding will be avoided"

The World Health Organisation recommends:

"Breastfeeding on demand – that is as often as the child wants, day and night."

You can read more discussion about cue feeding and its importance here.

1.  Rocha NM et al.  Cup or bottle for preterm infants: effects on oxygen saturation, weight gain, and breastfeeding.
2.  Marinelli KA et al.  A comparison of the safety of cupfeedings and bottlefeedings in premature infants whose mothers intend to breastfeed,