Experience of Breastfeeding, Does Not a Lactation Consultant Make...

Warning, graphic medical image of a damaged nipple follows.

I apply makeup and give myself a facial, but I'm not a beauty therapist.  I have feet and rub off the dead skin, but I'm not a chiropodist.  I eat food and plan my own meals, but I'm not a nutritionist.  I've planted up my garden, but I'm not a landscape gardener.  I've made tinctures, but I'm not a herbalist.  I can wash out and stick a plaster on an injury, but I'm not a nurse.

Using the last example - should someone ask me if I can recommend a good brand of band-aid, I'm happy to share my opinion.  Should they ask what my experience was of dealing with an injury, I'm happy to share tips I found helpful.  I would feel comfortable encouraging them that with the right help, the wound will heal just fine - yes mine was painful too (and here's how I coped with that), but long-term we got through and now there's just a tiny scar.

However should someone ask me why their wound isn't healing and what the best course of action would be - I would refer them to an appropriately qualified person to help.

Why?

Because I could (inadvertently and with the best intentions) give incorrect advice that could potentially make it worse.  I might not recognise the early signs of infection or be up to date with the latest best practice for wound healing.  I might recommend just leaving it to heal itself without doing anything more, using the affected area as normal and battling through the pain - because I did this and it worked out fine.

Because I don't know enough, I don't recognise what I don't know...

Breastfeeding is no different.

Lactation is a pretty sound science, it's not random luck based on old wives tales and myths (despite what half the books I've read over the years suggest).  Actions early on impact on outcome - how many times do we hear that effective, timely support is key?

Unless you have breastfed hundreds of babies, your experience of breastfeeding is likely microscopic compared to those who work daily supporting infant feeding.  Even then you breastfed your baby with your body and every dyad is unique; just like understanding my diet doesn't mean I'm in a position to extrapolate that to every other human being who eats food.

Yet should a mum post online that her nipples are cracked and bleeding and her baby appears constantly hungry, the stream of contradicting advice that follows must leave many reeling:

"Just feed, feed, feed, yes it hurts but it will pass"
"Use a nipple shield"
"Use a nipple shield for the first minute then take it off"
"Don't use a nipple shield it will mess with your supply"
"Express and feed back"
"Don't express it will mess up milk supply"
"Don't use a bottle it will mess up feeding technique"
"Use formula for a break"
"Don't use formula it will mess up your supply"
"It's normal for breastfed babies to feed constantly, co-sleep and wear a sling"
"It's not normal for any baby to want to feed constantly"
"Wake them up to feed"
"Never wake them unless they go more than 6 hours"
"Leave sore nipples to air dry"
"Use Lanolin for soreness"
"Use breastmilk for soreness"
"Use coconut/olive oil for soreness"
"Take a homeopathic remedy for soreness"
"Make nipples moist for effective healing"
"Don't make nipples moist as it may harbour thrush"
"Your pain probably is thrush"
"Ask your GP to treat you for thrush just in case"
"Don't use thrush medication, use coconut oil"

And on and on and on....

Given many mothers typically post their problem in multiple online forums, how helpful are the 3000 random suggestions really?

So let's quickly consider a potential worst case scenario.

Baby is attaching sub-optimally hindering milk transfer and causing damage.

Feed feed feed, if the baby is causing physical damage with their sucking style, can result in this:

And how long do you think a mum can realistically sustain feeding with that level of damage?

An intervention like introducing a nipple shield to a baby who already latches, may result in a whole host of unforseen consequences too - as well as not resolving the pain for many.  Some do get reduced pain, then remove the shield to find half their nipple damaged. Some get no further pain but the baby still doesn't get a good transfer, leaving them hungry.

Recommending a shield isn't something that should be done lightly, but as a tool a lactation consultant uses as one of many i.e. with specific cases, at a specific time, they can similarly save a breastfeeding relationship.

The other area of concern in the above scenario is the constantly feeding baby.  "Constant" needs defining as sometimes this is frequent but normal and it's the parents expectations that are unrealistic.  Baby may be feeding every 2-2 1/2 hours, when parents were expecting a 4 hour gap from the end of a feed.  However other times the baby is literally feeding all.the.time; one mum recently had an app that showed over 18 hours per 24.  This is not normal as an everyday feeding pattern, who could sustain that?

#freethenipple

Some babies, when feeding for such long periods, will get enough over 24 hours to grow and baby is declared "a snacker".  Others won't. So potentially we have a newborn baby not getting enough food.

Advice to ignore the problem and continue blindly on is surely negligent if you aren't 100% sure baby is getting enough milk.. Otherwise all you may actually be doing is setting the parents up for a lethargic baby later and even admittance to hospital a few days later due to Hypernatremia - a fast track route to breastfeeding cessation for many, not to mention potential long term health consequences for baby.

What's more, even if we don't have absolute worst case but other ongoing problems - mothers tell me blind
reassurance doesn't help.  Instead their gut instinct is something isn't right, and so they either stop breastfeeding thinking if that's "normal" I can't do it, or they continue to breastfeed but feel uneasy there's still an underlying issue, even if they can't quite put their finger on what it is.

When you give advice, rather than information and support,  you're taking responsibility for the outcome if things go wrong.  When you tell a mum to ignore advice given to her by a midwife or health visitor - you better be absolutely sure you absolutely have a handle on things, or you could be making a difficult situation ten times worse.

A prime example of this was a mum I saw last year.  A gorgeous baby arrived for a consultation with mum in a panic.  She had just taken baby to the GP due to a referral for growth concerns at nearly 8 weeks of age, only to discover baby was below birth-weight.  The GP arranged for them to go straight to hospital and mum told him she had a session booked with a lactation consultant; she asked if she could attend before the hospital or was it critical she attend immediately.  He agreed since it was feeding related, the baby had gained some small amounts of weight, and appeared healthy in all other respects, he was happy for her to see me and then go straight to paediatrics.

As we unpicked the previous 8 weeks, I discovered concerns had first been raised about baby's weight gain weeks before.  The health visitor had suggested expressing and giving back, and topping up with formula if necessary until baby was full.

However mum's online support groups disagreed.  Some babies are just meant to be petite, the charts aren't even based on breastfed babies (they are), my baby was very slow gaining and he was just fine, it's normal for it to take some babies much longer to gain weight (it isn't), a gain is a gain no-matter how small and fine as long as baby hasn't lost, any health professional recommending formula isn't supportive of breastfeeding, ignore the health visitor and just feed, feed feed, express what you can and just give that back".

And so that's what mum had done.

Initially the 10-40 mls expressed was a good supplement, however by 8 weeks and with no improvement in breastfeeding effectiveness, these supplements were by now barely touching the sides.

For those who haven't seen an 8 week baby not back at birthweight (which should be regained by day 10, or day 14ish if loss was larger than typical, but baby is now gaining well), let me give you a rough picture.

Length and head growth continue in babies until they're severely malnourished.  This can confuse some that actually baby is getting enough to grow, and they're clearly just meant to be long and thin.

If lack of gain continues, their head starts to look excessively big on their body - resembling a premature baby.  Their limbs become thinner and the skin hangs loosely, sometimes looking "baggy" in places.  Their bottom disappears, and their eyes appear large and often sunken.  You pick them up in a babygrow and instead of baby squidge, you just feel bones.

So back to the above mum.  A feed assessment highlighted baby was only actively transferring milk for the first few minutes of a feed, after that there was lots of sucking (burning calories) and lots of snoozing (attempting to conserve them), but little swallowing.  In this situation our best chance of keeping baby out of hospital is to feed the baby, and then set a plan of supplements to be given - so the consultant can see a guaranteed intake of food.

First we try expression.  But after 8 weeks of poor transfer, and no doubt the stress of the current situation, that's not successful enough to give more than a few mls.  We then discuss donor milk, and mum makes a few calls to try and see if we can get any in the next half hour or so.  No go.  The only option in this situation is to give formula.  Am I also therefore someone to be ignored too?

Sure there are risks to formula, but do you know what else there are risks to?  Not getting enough food to function.  Babies are well programmed to survive and will usually try and alert their caregiver they're not getting enough food, with constant crying/showing feeding cues.  If intake doesn't increase, their mouth and lips can become dry, their cry can sound hoarse (like the pterodactyl screech on Jurassic park) - most lactation consultants instantly recognise this cry.  They can start shutting down to conserve energy and preserve their vital systems, becoming lethargic and more difficult to rouse to feed, sleeping longer periods.

Jaundice might follow, compounding the sleepiness.  As my colleague pointed out, this is how babies can be pulled from the wreckage of earthquakes and suchlike, days later still alive - they "shut down" for self preservation purposes.

It's absolutely right to say a baby shouldn't need formula, so often breastfeeding just needs a tweak to improve gain, not a breastmilk substitute.  I see babies that are gaining fine, but mums are told they need to top them up to get to a specific centile, or because baby is waking more than expected.   And, in a case like the above, if the problem had been identified early when milk is abundant why top up with formula instead?

However that's not the situation for many.  Instead they receive passive breastfeeding support, and eventually when weight becomes concerning enough, are advised to supplement to protect the health of the baby. Beyond positioning and attachment, even the health professionals might not figure out why baby isn't gaining and so aren't sure what else to do.

There is also a significant difference between an older baby gaining slightly less than expected, and a newborn struggling to take enough to survive; both in terms of the urgency of the situation, and the most appropriate course of action

The mum above gave a supplement slowly, the baby's eyes popping open as he swallowed hungrily.  We set a plan to gradually increase the volumes over the next 48 hours, along with an expressing plan to start to swap the formula for breastmilk.  The feed assessment highlighting baby hadn't been feeding well, along with the suggested supplement plan, were printed and added to baby's notes before mum set off to the hospital

The consultant did the usual health checks, said the plan was agreeable, saw baby rouse and take a feed with a supplement and basically if mum felt happy baby was taking the top ups, didn't need to stay in - he would instead see them at a follow up appointment 48 hours later.  The baby had gained significantly by this point and they were discharged.  (In case you're interested, baby was tongue tied - mum had no pain or nipple damage at all).

The fact is breastfeeding mums are passionate.  Many have succeeded with sheer grit and determination, and now realise just how important breastfeeding is to them, and how many booby-traps exist.  They get that there is pervasive marketing and an unsupportive society, undermining breastfeeding at every turn - and without these mums, breastfeeding support would collapse in the UK.

The volunteer helplines take tens of thousands of calls per year, support groups across the country are typically heavily volunteer led, mums at home try and help online via groups, and even offer to pop round if local.  As Ayala Ochert said on Facebook in response to the "mummy wars" advert currently circulating:

"The real "sisterhood of motherhood" is all the breastfeeding peer supporters who voluntarily give up their time to help other mums achieve their breastfeeding goals."

So, if we're ditching giving a gazillion suggestions, what should we do?

Encourage, support, empathise, and help them obtain effective, qualified support.  Be that a Facebook group of peer support workers (who have the structure in place to refer to a breastfeeding counsellor or lactation consultant as needed), an NHS infant feeding advisor, a local group run by the NHS or a breastfeeding charity, or an independent lactation consultant.  Groups that include other local mums can be invaluable, as they often know who to see and where, and when the best groups run.  Share resources that parents can use to identify themselves if baby is getting enough, and what to do if not, recognise what the red flags are there might be a more significant problem and if you're not sure, always suggest they see someone who is.