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  1. 1. Breastfeeding 24pp 13/2/06 11:01 am Page 1 breastfeeding A MOTHER’S GUIDE TO Issue 6 2006 Breastfeeding is the healthiest way to feed your baby CHOICES Brian Moody MAKING IT WORK FOR YOU Expressing and Returning to work Written by Mandy Abbett 1997 © Infant Feeding Specialist. Updated yearly.
  2. 2. Breastfeeding 24pp 13/2/06 11:01 am Page 2 feeding YOUR NEW BABY contents 2 YOUR CHOICE Your Guide To Our Local Breastfeeding Policy This booklet has been designed to give you all the information you Breastfeeding: Some of the 3 will need about feeding your baby. We do not expect you to Health Benefits absorb it all at once but gradually during your pregnancy. During Your Pregnancy 4 These guidelines apply only to Positioning - Holding your Baby 5 healthy full term babies. Your midwife will advise you if your Attachment - Giving Your Baby 7 baby is small, premature or ill. a Little Help We hope that you find this guide useful, however, it should not replace the professional Exaggerated Attachment 9 support you can obtain from your midwife, health visitor and GP. Early Days 10 * For ease of understanding, the baby will be called he Questions About Breastfeeding 12 Weaning 17 Returning To Work Plan 18 Eating and Drinking Whilst 21 Breastfeeding Breastfeeding Problems 21 Derby Hospitals NHS Foundation Trust Breastfeeding Problem Solving 22 Charts National Contact Numbers for 24 Local Breastfeeding Support Page 1
  3. 3. Breastfeeding 24pp 13/2/06 11:01 am Page 3 Your guide Breastfeeding is the healthiest way you can feed your baby. We recognise important health benefits exist for both you and your baby and we want to do all we can to support you in your decision to breastfeed. TO OUR LOCAL BREASTFEEDING POLICY Ways in which we will help you All staff supporting breastfeeding mothers 1 are fully trained to help with breastfeeding. Please ask them about breastfeeding queries, or if you feel you need specialised advice, they will be able to give you contact details. 2 During your pregnancy you will have an individual discussion about feeding and caring for your new baby. This usually happens by 32 weeks of pregnancy. 3 You will be encouraged to hold your baby Brian Moody in skin to skin contact as soon as possible after the birth, for as long as you like (ideally more than 45 minutes). 4 Maintaining skin contact with your baby 8 We will encourage baby led feeding, often leads to the first breastfeed. Most where babies are allowed to choose when babies are naturally ready to feed within and for how long they feed. This way you the first hour if left undisturbed. can be sure your baby is getting enough milk. 5 Staff will be available to explain how you can put your baby to the breast correctly 9 We recommend that you avoid using and to help with feeds in the early days. bottles, dummies or nipple shields while your baby is learning to breastfeed. This is You will be shown how to hand express because they can make it more difficult for your milk. your baby to learn to breastfeed 6 Most babies do not need to be given successfully and for you to establish a good anything other than breast milk until they milk supply. are around 6 months old. If for some reason your baby needs some other food 10 We will help you to recognise when your baby is ready for other foods (normally or drink before this, the reason will be fully around 6 months) and explain how these explained to you and your agreement can be introduced. obtained. 7 We recommend that you keep your baby 11 We welcome breastfeeding in all areas of our premises. If you would prefer near you whenever you can so that you can somewhere private please ask a member of get to know each other. We will give you staff. information and advice about bed sharing and infant safety. If any medical procedures 12 We will give you a list of people who can are necessary in hospital, you will always be help if you need extra support with invited to accompany your baby. breastfeeding. Page 2
  4. 4. Breastfeeding 24pp 13/2/06 11:01 am Page 4 breastfeeding SOME OF THE HEALTH BENEFITS FOR YOU AND YOUR BABY FOR BABY Protection against ear infections Protection against chest infections and wheezing Lower risk of diabetes Less allergic disease (eczema, asthma, wheezy) Protection against diarrhoea, gastro-enteritis and tummy upsets Better mental development Better mouth formation and straighter teeth Less obesity FOR MOTHER Lower risk of ovarian cancer Lower risk of pre-menopausal breast cancer Stronger bones in later life “I breastfed my baby because I knew he would get less infections and tummy bugs giving him the best start in life, and that there is goodness you don’t get in bottled milk”. Bravada Bras Did you know? Bras don’t need to be boring! Your milk provides all the nourishment your baby needs until he is around 6 months old. system more acidic, this prevents harmful Your milk is made just right for your baby bacteria (bugs) from growing which leads to and it constantly changes to meet your baby’s tummy upsets (sickness and diarrhoea). needs, as he grows unlike artificial milk. It Babies who receive artificial milk are more provides special factors that promote growth, likely to develop diabetes, eczema and which cannot be found in any other milk. asthma than babies who receive mother’s Your milk contains antibodies, which provide milk. protection for your baby from infection. Breastfeeding your baby reduces the risk of Chest, tummy, ear and urine infections are accidental scalds or burns which can occur more likely in babies who receive artificial when heating up milk. milk, because it does not contain properties which help prevent or fight infection. Breastfeeding should continue for as long as Your milk also makes your baby’s digestive possible. Ideally for a year and beyond. Page 3
  5. 5. Breastfeeding 24pp 13/2/06 11:01 am Page 5 during your pregnancy, IT WILL HELP IF…. Your midwife talks to you about the following topics: I Skin to skin contact I Offering help with first feed as soon as possible after birth I Baby led feeding I Keeping your baby close to you 24 Derby Hospitals NHS Foundation Trust hours a day (in hospital and at home) I Importance of good positioning and attachment for breastfeeding I Avoiding teats and dummies I Not giving your baby anything other than breast milk for the first six months Skin to skin contact When your baby sucks at your breast it stimulates the nipple, a message is sent to a This is when you hold your baby in skin gland in your brain called the pituitary. One contact as soon as possible after birth. Ideally part of the gland sends out prolactin, this this should last for more than 45 minutes. If your baby is left undisturbed he will slowly goes into the blood stream to the milk move towards your breast and self attach and producing cells. The other part of the gland feed. sends out oxytocin, which makes the muscle cells around the milk producing cells squeeze All mothers, irrespective of their ultimate the milk down the ducts. This is called the feeding choice, will be encouraged to offer “let down” reflex. this first feed. This period of alertness usually lasts for an Your breast size is unrelated to the amount hour or so. After this it may be some time of milk they produce. before your baby wakes again. Your milk production will be reduced if your baby does not suckle at the breast. This is How your body works to produce milk because there is a special substance found in breast milk which, if not removed, will tell The breast produces small amounts of milk your breast to stop producing milk. This from 16 weeks of pregnancy. Once your baby substance allows each breast to individually is born and the afterbirth (placenta) is produce its own volume of milk. expelled, your pregnancy hormone levels (oestrogen and progesterone) start to fall. If you stop breastfeeding or choose not to This allows another hormone, prolactin, to breastfeed your milk supply will gradually start to produce milk. This is helped by reduce over a few days. You can get more offering the first feed as soon as possible information from your health care worker. after birth. (see page 24). Page 4
  6. 6. Breastfeeding 24pp 13/2/06 11:02 am Page 6 Positioning THERE ARE MANY DIFFERENT WAYS TO HOLD YOUR BABY WHILST BREASTFEEDING Remember Cross Cradle hold However you choose to hold your baby make sure: I You support his whole body I His body is turned towards you I His forehead, shoulders and hips should be in a straight line. I You hold your baby close I His nose is opposite your nipple before he attaches to your breast. Here are the 4 most commonly used holds. Cradle hold Chesterfield Sure Start This is a hold successfully used by many first time breastfeeding mothers. You may find it easier to support and guide your baby onto your breast. Once your baby is feeding, it will be more comfortable to bring your other arm to rest under the arm which supports your baby’s body. Start off by holding your baby horizontally with your baby’s nose opposite your nipple. Chesterfield Sure Start Turn your baby completely on his side. Tuck his legs under your arm (if possible). With your elbow, bring his bottom close to you. Support your baby’s neck and shoulder This is the most instinctive position that a between your spread out finger and thumb. mother uses. Your baby is turned towards Your baby’s head should fall back gently your body and his shoulders are supported on between the V shape your finger and thumb your forearm to allow his head to tilt back so makes. This helps raise his chin off his chest he can open his mouth wide and self attach. so that he can open his mouth wide. Page 5
  7. 7. Breastfeeding 24pp 13/2/06 11:02 am Page 7 Underarm hold (Rugby Ball) Side lying hold Derby Hospitals NHS Foundation Trust This position may be useful if you have had a: This allows you to rest whilst your baby I caesarean section, feeds, it may be useful if you have had a: I small or premature baby I caesarean section I find it uncomfortable to sit or if you have: I larger breasts or inverted nipples Start off by lying on your side, with a pillow between your head and lower arm. Turn your I difficulty attaching your baby using other baby completely on his side to face you. Bring holds. his body close to you making sure his head is Start off by holding your baby at your side tilting back and can then attach. with your baby’s head at the level of the nipple. Your baby should lie on his back. You may need to use a pillow to support baby. Make sure that your baby cannot push away with his legs whilst feeding. Support your baby’s neck and shoulder between your spread out finger and thumb. Your baby’s head should fall back gently between the V shape your finger and thumb makes. This helps raise your baby’s head off his chest so that he can open his mouth wide and his chin is close to the breast. Your breast should always be supported by the baby’s chest. All finished! Page 6
  8. 8. Breastfeeding 24pp 13/2/06 11:02 am Page 8 Attachment GIVING YOUR BABY A LITTLE HELP B 1 If you are going to feed from your left breast, cup your breast underneath with your left hand. Your fingers should be away from the areola (that is the brown area) and nipple. Your small finger should just be touching your ribs. Your thumb should rest on top of your breast (usually on the edge of the areola). Your nipple should then be lined up with your baby’s nose. Your nipple should not be aimed centrally into the baby’s mouth. He will smell the 1 milk and open his mouth wide. 2 His bottom lip should make contact with the areola, well away from the base of the nipple. Try to imagine a piece of Velcro attached to his bottom lip and a matching piece of Velcro attached about 2.5cms (1 inch) from the base of the nipple. These pieces of Velcro need to be matched together first. 2 3 Then your thumb needs to quickly slide or roll the nipple forward under the roof of his mouth. Photographs courtesy of Mother Baby picture library 3 Relax your shoulders and enjoy watching your baby feed contentedly. You should feel a drawing sensation and after the initial attachment you should not feel any discomfort. If you feel pain, take your baby off by releasing the suction between the baby’s gums with your finger and try again. A midwife will be available to help you. Page 7
  9. 9. Breastfeeding 24pp 13/2/06 11:02 am Page 9 There are three possible ways your baby may attach to your breast. A Your baby attaches himself naturally. When brought to the breast he spontaneously attaches and feeds without any help. He should start rhythmically sucking and swallowing and it should not hurt. THIS IS THE IDEAL B You may need to give him a little help C You may need to use an exaggerated technique 4 It may be necessary sometimes to maintain a slight pressure with your thumb above the areola until your baby is rhythmically feeding. This usually applies when your breast is very full i.e. when your milk volume increases. 4 5 6 Once your baby has established a good feeding rhythm, your hand should be slowly released from your breast and brought to rest under him. Signs of good attachment I Babies mouth is open wide. I Cheeks are ‘full’ and rounded. I Chin is tucked closely into the breast with 5 nose free allowing baby to breathe I More of the lower part of the areola is in the Photographs courtesy of Mother Baby picture library baby’s mouth than the upper part. I Bottom lip should be curled back (this may be difficult to see and you do not need to check this). I Suckling pattern will change to long deep sucks and swallows with pauses. I After the initial drawing in of the attachment, it should feel comfortable. 6 I Lots of wet dirty nappies. Whilst your baby is feeding ask your midwife to explain and show you the difference between nutritive and non-nutritive feeding (this means when your baby is taking milk, or not.) Once the feed has been completed apply some expressed breast milk to your nipples. REMEMBER! Breastfeeding is natural, BUT it is not always instinctive. Some babies need to learn how and some learn faster than others. You may need a lot of patience in the early days. Page 8
  10. 10. Breastfeeding 24pp 13/2/06 11:02 am Page 10 Attachment EXAGGERATED ATTACHMENT C piece of Velcro attached to your baby’s When to use an exaggerated attachment: If bottom lip and a matching piece attached your baby: about 2.5-5cm from the base of the nipple, I is unable to attach and feed this length will vary depending whether your I has a “tongue tie” and has difficulty baby is large or small. An easy way to staying attached. measure this is to use your thumbs knuckle to nail as a guide. I has a cleft palate I is premature I weighed a lot at birth and feeding is painful, even if he looks well attached I your nipples are sore or cracked and feeding is almost unbearable Nottingham City Hospital How to use an exaggerated attachment at the breast. If you are going to feed from your left breast, cup your breast underneath with your left hand. Keep your fingers well away from the areola (that is the brown area). There is These imaginary pieces of Velcro need to be always a tendency you will want to move matched together first. Then your thumb your fingers up but if you do this it will affect needs to QUICKLY roll the nipple forward the success of your attachment. Your thumb under the roof of your baby’s mouth should tilt the nipple back so it looks like its You must maintain the pressure with your pointing away from your baby. This will have thumb above the areola until your baby is the effect of making the breast under the rhythmically feeding. Before you remove nipple bulge forwards. your hand make sure that you are holding your baby really snuggly into you and you can see that his cheek is touching your breast with his nose free to enable him to breathe Nottingham City Hospital Nottingham City Hospital The baby’s bottom lip should make contact with the breast well away from the base of the nipple as in photo 1. Try to imagine a Page 9
  11. 11. Breastfeeding 24pp 13/2/06 11:02 am Page 11 early days Early days At home it is recommended that your baby Healthy term babies may not feed very much in sleeps in a cot in your room until he is at the first 48 hours; they have energy stores that least 6 months old. Research suggests that they can use until your milk volume increases, most mothers and babies share their bed at so try not to worry about this. However, they some time, and may unintentionally fall may cry for cuddles if they feel insecure at this asleep together. The joint UNICEF/FSID leaflet time. Do not be afraid to cuddle, stroke or talk 'Sharing a bed with your baby' provides to your baby, as this will give him added clear, comprehensive and evidence-based security. You cannot ‘spoil’ babies with lots of information for parents (obtained from love and cuddles! www.babyfriendly.org.uk or ask your Babies systems are not designed to take large midwife health visitor). amounts of fluid during the early days, as their kidneys are very immature. Your breast will Never share a bed with your baby if you or provide the exact amount of colostrum that your partner; your baby needs, so do not feel that there is • smoke ‘not enough there’. • have been using alcohol Your midwife will offer help with the second breastfeed within six hours of birth. Pain relief • are taking medication or drugs that make given in labour (e.g. pethidine or morphine) you drowsy can make babies extra sleepy. If you feel that • are excessively tired your baby needs extra encouragement to feed, it can be helpful to offer your baby breast NEVER SLEEP WITH YOUR BABY ON A SOFA contact at regular intervals and give him hand OR ARM CHAIR. expressed colostrum. After about 48 hours your baby may then come The first week into a busy feeding period. Do not panic and do Breastfeeding your baby can be a rewarding not give up! Frequent feeds according to your and satisfying experience for both you and your baby‘s demands will lessen the chance of your baby. However, some mothers and babies need breasts becoming overfull, letting your body a little more help than others. Each know how much milk to provide for the future. mother/baby partnership is unique and even This is ‘programming’ time and it is very mums who have successfully breastfed before important and it soon passes. may need a little help. Your baby will stay with you all the time whilst All babies differ in their needs and therefore you are in hospital. This will help you to get to each mother/baby experience will be different. know each other and enable you to recognise Knowing what is normal and why it is your baby’s early feeding signals, before your happening helps mothers develop their own baby becomes too unhappy. Staying together is coping strategies. especially beneficial for night feeds. You can easily lift your baby for feeding without your Your midwife/neonatal nurse will give you extra sleep being disturbed too much. information if your baby is small, premature or ill. Page 10
  12. 12. Breastfeeding 24pp 13/2/06 11:02 am Page 12 early days EMPTY OR FULL? HOW CAN I TELL? This is such a common question... Here is a little tip for the early days for the majority of babies. Whilst feeding observe your baby. He will be giving you clues not only from his sucking pattern but also from his body language. For example, look at these photos. This baby has just started the feed. Note the position of his arm. This is the ‘empty’ sign. Now look at the position of the arm as the baby progresses through the feed. It gradually moves through 180 degrees. When the breast is almost completed, you can see the arm is completely relaxed and is at rest. This is the ‘full’ sign. This is often repeated when the second side is offered. Page 11
  13. 13. Breastfeeding 24pp 13/2/06 11:02 am Page 13 your questions ABOUT BREASTFEEDING One breast or two? What is a growth spurt? Always offer both breasts at each feed, but both may Your breast fullness will gradually settle down and your not be taken. Your baby should be allowed to finish the breasts will feel very soft most of the time. This is first breast completely. Many babies, after completing natural. It does not mean that your milk is ‘going’ or is the first breast, may look full and sleepy, but do not be ‘too thin’ neither does it indicate that you do not have fooled! If you leave them to sleep, they are likely to enough milk for your baby. However, there will be times wake soon again wanting the other breast. in the future when your baby will need to make extra milk for his growing needs. This is often referred to as a After the first breast, let your baby stretch out growth spurt. somewhere safe. You can use this break to get a drink Your baby changes his normal feeding pattern and and now is also an ideal time to change your baby’s starts to feed more frequently i.e. feed, short rest, feed, nappy. If your baby stays asleep, following the nappy short rest, etc. This only lasts for about 24 hours, so for change he is showing you that he is satisfied and that this short time it is important to relax and respond to the feed is complete. If he “roots” around then offer your baby’s needs. Growth spurts, which soon pass, can the second side. occur at any stage. Which breast do I use first at each feed? My baby is very unsettled in the evening, is there Start on a different breast to the one you started on last something wrong? time. Many mothers say their babies have very unsettled How long and frequent should feeds be? evenings and this is quite normal. It may be referred to Feeding should be baby led which means feeding by others as evening colic but this has not been proven. whenever your baby wants, for as long as he wants. If It is difficult to know why babies do this but it is very feed times appear very long ask your midwife, health common. Try and work with it. It does pass ! Here some visitor or breastfeeding counsellor to check the way things you can try. your baby is attached to the breast. 1. Follow your baby and let him have short feeds and sleeps. This can help boost your milk supply. Can I give my baby a dummy? 2. Place him in a baby sling (you or partner) and go for If you introduce a dummy at a very early stage it may a walk around the house. discourage your baby from feeding. If your baby does 3. Give him a nice relaxing bath. not breastfeed often enough you may not make enough milk to meet his future needs. 4. You, your partner or helper can have skin to skin contact with your baby How do I know my baby is getting enough milk? 5. Plan what you are going to have for tea and prepare 1. Plenty of pale wet nappies, with no orange/pink as much as possible earlier in the day. If anyone asks if crystals staining the nappy. they can do anything to help then say putting a meal in 2. The baby passes stools (poo) regularly and the colour the freezer would be very useful. has changed to a bright yellow (within the first week) If it happens all through the day and evening, look at 3. The baby is contented after feeds. the problem solving charts initially then seek help as 4. The baby starts to gain weight and looks well. there are other things you can do. Does my baby need extra drinks? If I get sore could I use a nipple shield? No - the milk that you produce at the start of a feed is Sore nipples are caused by poor attachment; seek help more watery and very thirst quenching. During hot as soon as possible to overcome this (see problem weather babies tend to have shorter, more frequent solving guide and telephone contact numbers). Nipple feeds. This prevents him from becoming thirsty. shields are not recommended because they reduce the Therefore, extra drinks are not needed and if given may quality and quantity of milk the baby receives and affect your future milk supply. ideally should not be used in the long term. Page 12
  14. 14. Breastfeeding 24pp 13/2/06 11:02 am Page 14 your questions ABOUT BREASTFEEDING Feeding patterns All babies are individuals and really should not be compared to each other. Here are some of the individual differences. All these babies are thriving, happy and contented but their feeding patterns are very different. Lauren - She fed well for fifteen Jessica - She fed for twenty minutes minutes and then started to fuss from the first breast and then around. She was offered the second dozed off. breast and fed for ten minutes and She then had her nappy changed went to sleep totally satisfied after and fed for fifteen minutes from her nappy change. the second breast, and then she went to sleep. Marzen - He fed for five minutes on his least favourite breast. He then lost interest. He had his Nathanial - He fed relentlessly for nappy changed and was still rooting thirty minutes from the first breast around. He was offered his favourite and he came off the breast breast and fed contentedly for thirty himself. He had a “blissful” look minutes. His mother always had to and did not wake during his offer his least favourite breast first; nappy change. He was left to otherwise he would refuse it if it sleep contentedly. were offered as the second breast. Milk changes High quality, low volume colostrum is present first. Which photo; A, B or C contains the most fat? When your milk volume starts to increase this The Answer is C Despite its pale colour this milk has combines with colostrum to give your baby ongoing the most fat. protection. The colostrum remains there for up to 14 days. Your baby may still feed frequently as the milk The amount of fatty milk your baby receives is has not yet matured. As your milk matures, the fat dependent on three main factors: levels increase to meet the growing needs of your 1. A good attachment on the breast baby. This may take a few weeks. Babies then may establish a routine, but not necessarily. 2. Allowing the baby to finish one breast completely Hand expressing 3. Regular use of both breasts according to what he Hand expressing, is a useful technique to learn, needs. especially if it has been practised antenatally. This is because: Picture A Picture B Picture C I It is a more effective method of removing your colostrum in the first few days than breast pumps. I You can tempt your baby to feed help your milk start to flow I It can help your baby attach if your breasts are full, or to clear blocked ducts or to relieve mastitis. However, when your milk increases some mothers may prefer to use a breast pump (see next section). Colostrum Changing milk Mature milk When hand expressing, the best method for These photographs show how your milk matures obtaining the greatest amount of milk is to use each breast twice. Page 13
  15. 15. Breastfeeding 24pp 13/2/06 11:02 am Page 15 How to hand express You should be shown how to hand express your milk either antenatally or soon after your baby is born. Please ask for help. Breast massage Gentle breast massage can be used at any time to start or improve the milk flow. Find where you need to press to express your milk. The correct place to press is a few centimetres away from the nipple where the breast changes in texture, it may feel a little firmer. Position the thumb and the first finger opposite each other, so that this area lies beneath them. Expressing (removing) the milk. Derby Hospitals NHS Foundation Trust Compress and release your When milk stops flowing, move finger and thumb rhythmically your fingers and thumbs to a to obtain milk. It may take a new position and repeat until few minutes until the let down milk stops flowing. reflex works. Repeat on second breast. Expressing Your Milk What are the different types of breast pump? Is it necessary? Advantages Disadvantages Points to consider Hand Low cost May be time Easy when breast It is not necessary unless you plan to be Pump consuming is full but separated from your baby at any time before (for Quiet sometimes difficult occasional Hand action later on when he is having solid food, e.g. going to work. use) No need for may be tiring breast is soft electric When to Start supply Requires both hands If you wish, you can start expressing as early Mini Quick and Can be noisy Facility for double Electric efficient pumping action as 7 – 10 days after the birth. This is because Pumps More costly can save time there is plenty of extra milk available at this (for Not tiring long term If battery run Check if battery time, as your breasts produce more than your use) Requires only, may or mains options baby needs. This milk can then be frozen one hand need frequent are available only battery until it is needed. changes Good for long term use If you decide to express when your baby is Large Quiet Large to Good for long older, your body’s milk supply will have Electric carry around term use Pump Efficient settled down to your baby’s requirements so (for More expensive Variable suction you may find it more difficult at this time long term As above to hire over useful, if available use) long periods You can increase your supply of milk, this can Available than mini in hospitals electric take a few days so be patient. Page 14
  16. 16. Breastfeeding 24pp 13/2/06 11:02 am Page 16 your questions ABOUT BREASTFEEDING Good Times to Express When expressing you may find these times most successful: I About 30 minutes after your baby has been fed. (Express both breasts once or twice if required). I In the morning after your baby’s first feed. I If your baby only takes 1 breast at a feed express from the unused one or both if more milk is required. I In between feeds or when your breasts feel particularly full. I When the baby is feeding from one side express the other at the same time ( this can be the most successful) Single Breast Pumping How much milk should I express 1. Massage first breast and stimulate the nipple, each time? express that breast until the milk slows to a This is going to vary quite considerably from drip. mother to mother depending on the reasons 2 Swap over to the second breast, massage, why you are expressing. If you are expressing stimulate and express again. because your baby is not breastfeeding you I When the milk flow slows to a drip, return to really need to express as much as you can each the first breast and repeat steps 1 2. time. If you are expressing for social reasons, I Expressing is complete when your breasts are here is a very rough guide on how much your baby will need each feed: soft or the required amount of milk is obtained. Baby’s weight in kilos x 150mls = amount in 24 hours. Divide this by number of feeds in 24 hours. Double breast pumping i.e. 5 kg baby x 150mls = 750mls divided by 8 = Expressing both breasts together. The fat 93 mls approx. content of your milk can be increased if double Remember, every baby is an individual so ideally pumping is accompanied by breast massage. express more than you think he is going to take. This is useful if you: I intend to express for a long time (i.e. if you Storage of breast milk in your home have a baby on the Neonatal Unit) You may read differing times but the I have a premature baby recommendations from The Breastfeeding I have had Twins or Triplets Network are as follows: Fresh breastmilk I Refrigerate as soon as possible but can be If your baby is unable to breast feed, it is important that you start expressing as soon as possible after delivery, i.e. within 6 hours. If you stored at room temperature for use within 6 hours. I Store in the Fridge have a baby, or babies in the Neonatal Unit it is important to express at least 6 to 8 times in 24 hours and at least once during the night. - 5 to 10°C, use within 3 days Prolactin (the hormone that produces milk) is at - 0 to 4°C, use within 8 days its highest between 2 am and 4 am and - Low down and towards the back expressing at this time may ensure a good on- Try and use fresh milk wherever possible as going supply. some qualities are lost during freezing. Page 15
  17. 17. Breastfeeding 24pp 13/2/06 11:02 am Page 17 Frozen breastmilk How do I give expressed breastmilk to I Store in Freezer -18°C or lower for 6 months my baby? I Use immediately if defrosted outside fridge. In the early days small amounts of breastmilk If you have expressed small amounts and want to can be given by using a small cup. Ask your mix them, ideally chill to the same temperature Midwife or Health Visitor about this. Early before mixing. introduction of a teat may confuse the baby and may result in a poor breastfeeding To defrost milk. technique which may reduce your milk supply. I Thaw in the fridge and use within 12 hours. However, if you are going to be separated from I If needed quickly stand the bottle in a jug of your baby, you may choose to give baby your warm water, replacing the water when it milk in preparation via a teat once daily, once becomes cold use immediately breastfeeding is established. When introducing I Shake to mix the creamy separated particles. a teat it is important to remember that every baby is unique. If problems have been Microwaves should never be used to heat encountered with breastfeeding it is important breast milk. to delay this for as long as possible. Effects of offering artificial milk to a breast fed baby Breastfeeding works on a supply demand basis. If this is interrupted with milk feed, you may not produce enough milk. Suckling from a teat is different to breastfeeding and may confuse the baby, making it more difficult for your baby to attach to your breast correctly. Breasts can become full and uncomfortable (engorged) if your baby does not feed frequently enough. This can make it painful and more difficult to attach your baby to your breast. Babies given large amounts of artificial milk may be less satisfied with subsequent breast feeds. Baby’s digestive system contains a range of normal bacteria. Artificial milk destroys the protective coating in the gut that your milk provides. This can increase the risk of your baby getting infections. If there is a history of diabetes, asthma, eczema allergy in the family, giving artificial milk may increase the risk of baby developing allergies. Breastfeeding works on a supply and demand basis. If this is interrupted with an artificial milk or water, the breast may not produce enough milk. Before giving your baby artificial milk, please speak to your midwife or health visitor. Page 16
  18. 18. Breastfeeding 24pp 13/2/06 11:02 am Page 18 weaning I It considerably reduces the risk of gastroenteritis (diarrhoea and sickness) I It protects the baby’s immune system so there is less chance of getting infections. I It reduces the risk of developing food related allergies eg asthma and eczema and intolerances because the baby’s bowel has matured enough to prevent larger molecules passing through the wall of the bowel, which may trigger an allergy. I It increases the ability of your baby to digest solids, as younger infants do not actually produce all the enzymes needed to digest Chesterfield Sure Start starchy foods and fat. I It decreases the risk of developing obesity. Leaving solid foods until around 6 months means that less time is spent preparing purees, as babies can move onto mashed/lumpier foods Your breast milk is the perfect first food. The quicker. This makes going out with a weaning Department of Health recommends waiting baby much easier as they can eat your food. until your baby is around 6 months (26 weeks) There is no need to take food with you and of age before giving any other food or drink. worry about how you are going to safely At around 6 months most babies show signs of reheat it. readiness for starting solids, which include: I The ability to sit up with minimal support I The ability to hold his head steady I When his tongue stops pushing food out of the mouth (fading of the tongue-thrust reflex) I Ability to pick up food and put it in his mouth I Readiness to chew. It is also much better for your baby’s long- term health if you wait until 6 months because; I Younger infants are more likely to choke on solid foods. I Your baby’s kidneys need to be mature enough to cope with an increased concentration of different nutrients. Extra stress is put on them if they are given solid Breastfeeding should continue for as long as foods too soon. possible, ideally for a year and beyond. Page 17
  19. 19. Breastfeeding 24pp 13/2/06 11:02 am Page 19 returning to work Make a plan as early as possible to help things I Breastfeed immediately before leaving your go smoothly. This may depend on your personal baby, and on return, it will reduce the number feelings, family circumstances, type of job, of times you need to express. You will need to number of hours worked, and the facilities express regularly to prevent your breasts available at work and also when you plan to becoming full and to maintain your milk supply. I Ensure you are aware of correct methods of return to work. However soon you plan to return to work after sterilising equipment. I If you are having problems with your milk the birth of your baby, breastfeeding is possible and very beneficial to you both. supply, please seek further advice. Exclusive breastfeeding for around 6 months Plan 3 Using artificial milk when you are provides the maximum health benefits to both not there and continue breastfeeding at you and your baby. Continuing to breastfeed other times for a year and beyond has added health benefits. I If you wish to use artificial milk whilst you You may wish to discuss your individual needs are away at work, it is wise to replace those with your midwife, health visitor or a breastfeeds gradually with a whey based breastfeeding supporter so that you can make artificial milk. informed decisions about the best way to return to work. I Substituting one feed every 4 days to allow your supply to gradually reduce. Plan 1 To maintain breastfeeding entirely I You will usually need to allow 2 weeks to I Ideal if crêche facilities are provided at work make the change. Many mothers manage to or the baby’s caregiver is situated near the maintain breastfeeding at other times. This workplace. You may either go to your baby, will provide some protection from infections. or arrange for the caregiver to bring your baby to the workplace for breastfeeds. Plan 4 - Changing over gradually to artificial I To maintain your milk supply, express when milk before returning to work. your breasts feel full. If you wish to change completely to artificial Plan 2 To provide expressed breast milk milk before returning to work, you may need to (EBM) whilst you are separated from allow 3 - 4 weeks. This allows your supply to your baby gradually reduce and will prevent problems I When expressing you need to consider the occurring such as engorgement. entire time you will be away from your baby It is important to choose a whey based milk, ie and should make plans to express as per usual ‘First Stage’. Progressing to other milks is not feeding times. necessary. Page 18
  20. 20. Breastfeeding 24pp 13/2/06 11:02 am Page 20 returning to work Plan 5 - Returning to work after 6 months baby can be a most amazing experience! The Most babies will show signs of readiness to excitement on his face followed by the wean around 6 months but remember contentment, as you both snuggle down breastfeeds should still be offered on a demand together is very special. feed basis. However you may find that his feeds Your breastfeeding rights at work I Tell your employer in writing you are are much shorter than when he was younger. In preparation for returning to work you can breastfeeding, before returning to work. start practising giving him a beaker of expressed Your employer must carry out a risk breastmilk or water. He may be reluctant at first assessment to identify any causes of harm to so persevere. Often they will take it better you or your infant. when given by a carer. If not, in reality, some weaned babies do manage on very little fluid I Discuss further needs with your employer when they are away from their mothers and before returning to work. tend to make up for it on their return! I If the nature of your job is not conducive to Once back at work you can express your milk breastfeeding or expressing milk, your and use the fresh expressed breastmilk for the employer must find a suitable alternative next day’s drinks with the same terms and conditions. I Breastfeeding can then continue at all other times when you are with your baby. This is I If your working conditions prevent you from particularly important as when your milk continuing to breastfeed successfully, your supply decreases, the antibody levels in your employer has a legal duty to make milk increase, this gives your baby added reasonable adjustments to your job. Examples protection against infection. may include breaks for expressing milk or visiting your baby if cared nearby, offering This is especially important if your baby goes to hours conducive to breastfeeding or allowing a nursery where they may be more likely to a shorter working day. catch an infection. On returning home from work the I Employers are obliged to provide a suitable breastfeeding reunion between you and your place of ‘rest’ for breastfeeding mothers. Page 19
  21. 21. Breastfeeding 24pp 13/2/06 11:02 am Page 21 your personal RETURN TO WORK PLAN Use page 18 and 19 to help identify your best plan discuss with your midwife or health visitor. The following checklist may help you plan your return to work. Discuss expressing - how, when, where, best times milk storage ________________________________________________________________________________________________ Discuss equipment - Breast pumps, hand or electric (double pumping), containers. ________________________________________________________________________________________________ When will I be returning to work? _______________________________________________________________ How old will my baby be when I return to work? __________________________________________________ What type of work (shifts)? _____________________________________________________________________ No of hours/ days each week ___________________________________________________________________ Who will be looking after my baby where? ____________________________________________________ What facilities will I need at work? (Fridge, area to breastfeed or express my milk) ________________________________________________________________________________________________ Send a letter to my employer stating that I will be breastfeeding/expressing my milk when I return to work (very important to protect your rights) ________________________________________________________________________________________________ Discussion with my employer ___________________________________________________________________ Risk assessment performed by my employer _____________________________________________________ Five good reasons why employers should recognise that breastfeeding is good for business! 1. You are less likely to feel stressed about returning to work if your employer supports you in combining work and breastfeeding. 2. If you carry on breastfeeding your baby is less likely to become ill so you are less likely to need time off work to look after him. 3. Employers who enable their staff to continue breastfeeding find that their staff are more committed to the company. 4. If your employer believes in equal opportunities point out that support for breastfeeding is crucial to enable women to combine work family. 5. It is good for public relations for your employer to be a family friendly employer. Your employer has legal obligations to enable you to continue breastfeeding once you have returned to work. In 2000 the European Commission issued guidelines (COM2000 466 final) which are intended to form the basis of risk assessments for pregnant and breastfeeding workers in the UK. Page 20
  22. 22. Breastfeeding 24pp 13/2/06 11:02 am Page 22 eating drinking breastfeeding WHILST BREASTFEEDING PROBLEMS I There is some evidence that lactation increases the Most breastfeeding problems that mothers experience mother’s need for calories. This is why mothers can be linked to the way your baby attaches to the often feel more hungry when breastfeeding. A breast. varied healthy diet is as important at this time as any other. There is no need to avoid any particular IF YOU THINK THAT ANY OF THESE APPLY TO YOU THEN food, be guided by your own hunger and thirst. YOU MUST ASK FOR HELP. (see problem solving chart). I Caffeine can pass into breast milk and can cause irritability in your baby. So try to avoid large Signs of poor attachment as seen in photograph below I Discomfort or pain amounts of tea, coffee, chocolate and cola. I Foods restricted during pregnancy can now be I His mouth not opening very wide enjoyed freely without any adverse effects on your baby eg raw/undercooked egg, soft cheeses I Cheeks sucking in with each jaw movement and liver. However, there are still the same risks to I Your baby appears not to have sufficient breast in mothers (ie salmonella from eggs). his mouth Alcohol and smoking I There is a space between the chin and breast I Smoking is unhealthy for both you and your baby. I He keeps sliding off the breast If you have been successful in giving up smoking I Rapid sucking with not many swallows I Noisy feeding (usually clicking noises) during pregnancy, it is important not to start smoking again. I Nicotine gets into breast milk. If you smoke, avoid smoking just before breastfeeding, as this is when nicotine will be at the highest level. If you require help to stop smoking please phone the free Quitline number 0800 002200. I It is advisable not to drink alcohol as it passes into breast milk. If you do have a drink it is recommended that your intake should not exceed 2 units per day eg 1 unit = 1/2 pint of beer / 1 glass of wine. Peanuts I The Department of Health is advising, ‘that pregnant or breastfeeding women who suffer Derby Hospitals NHS Foundation Trust from diagnosed allergic conditions, or where the father or any brother or sister has a clinical history of such conditions, may wish to avoid eating peanut products. However, many mums choose not to eat them, to avoid sensitisation. Vitamin D Supplementation Mothers who choose to cover up and/ or receive little exposure to sunlight (e.g, using sun screens) are less likely to be effectively producing vitamin D. Because of this, recently the number of children developing rickets has increased. You can see the baby’s bottom lip just under the base of the nipple. Therefore the Department of Health recommends, that There doesn’t appear to be much breast inside the baby’s pregnant and breastfeeding women in these groups take mouth. a supplement of Vitamin D (10µg daily). You can discuss The chin is not close to the breast. This can result in a this with your midwife, health visitor or GP. number of problems. Page 21
  23. 23. Breastfeeding 24pp 13/2/06 11:02 am Page 23 Breastfeeding problem solving charts This is to help you do some initial troubleshooting. It should not replace contacting any of the people below that have been specially trained in breastfeeding. This symbol means you should seek additional help from feeding advisor, midwife, health visitor or breastfeeding supporter. Mother Problem Symptom Causes Solutions Inverted Difficulty in getting the Seek help antenatally Nipple baby to attach on the Need a very good attachment, breast properly avoid dummies, nipple shields Sore Nipples Feels uncomfortable, Due to: 1. Nipple stretching 1. None - soon passes no damage 2. Poor attachment 2. Improve attachment Nipple damage 3. Tongue tie in baby 3. asap exaggerated attachment needed, Nipple soreness, should express at least once daily looks pink and shiny 4. Thrush 4. Treatment needed CONTACT GP HV ASAP Breast Pain Shooting pains at/after 1. Thrush in milk ducts 1. Treatment needed CONTACT GP HV ASAP feeding 2. High caffeine levels 2. Reduce caffeine - found in tea, coffee, cola, chocolate Milk Arrival Red, painful breasts 1. Poor attachment 1. Hot flannels aid milk flow, Remove backlog, Engorgement express breasts after feed, use ice packs with care. Improve attachment. 2. Restricting feeds or 2. Encourage baby to feed more frequently baby not waking enough (and follow above) Cessation Red, painful breasts Abruptly Not recommended to stop suddenly. Engorgement stopped Try to gradually replace feeds with formula, breastfeeding this will prevent mastitis / abscess Blocked Duct Painful lump 1. Poor attachment 1. Improve attachment, massage whilst feeding. Check for white spot on nipple (fatty blockage) 2. Bra pressure 2. Check bra Mastitis Red, lumpy area of breast. 1. Blocked duct untreated. 1. Submerge breast in hot bath, massage (Non-infected) Pain and flu symptoms and express. Massage whilst feeding. and / or high temperature. 2. Poor attachment 2. Improve attachment, feed under arm, express after feed until resolved. 3. Bra pressure 3. Find cause please see back page for helpline telephone numbers Mastitis As above but will become As above but will become CONTACT GP ASAP (infected) infective if left untreated infective if left untreated Baby Problem Symptom Causes Solutions Prolonged Feeding more than 1. Poor attachment 1. Improve, even if it looks OK feeding 30 minutes each breast 2. Not recognising when 2. Baby does not release breast spontaneously, (after early weeks) to change breasts no swallowing heard. Move to second breast Frequent Baby not settling 1. Poor attachment 1. Improve attachment feeding 2. Unrealistic expectations 2. Seek reassurance Derby Hospitals NHS Foundation Trust 3. Insufficient milk 3. Very rare, seek help 4. Not offering both breasts 4. Change nappy after first breast, wake up and offer second breast 5. Over tired/anxious 5. Seek help Poor weight Weight static or slow increase 1. Poor attachment 1. Improve attachment gain - healthy 2. Too good baby 2. Encourage more feeds baby 3. Not offering both breasts 3. See page 7: quot;One breast or two?quot; 4. Slow lactation 4. Increase stimulation by expressing, top up with EMB - not formula unless baby at risk. Switch feed Colic Unsettled baby Babies normally unsettled Find coping strategy. (Evening only) in the evening Keep to one breast during evening only, use different breast next evening Colic (All day) Fretful baby, appears to have Various causes, Contact discomfort, windy, watery stools need specialist advice Page 22
  24. 24. Breastfeeding 24pp 13/2/06 11:02 am Page 24 Contributors to this booklet: You’re never (Revised and adapted in 2001, 2003, 2004 2005). Mandy Abbett. Infant Feeding Specialist. Sure Start Chesterfield. 07876 351 389 alone... Karen Payne. Clinical Specialist: Lead in Infant Feeding, Derby Hospitals Foundation NHS Trust. Rachel McClean. Infant Feeding Advisor, Derby Hospitals Foundation NATIONAL NUMBERS FOR LOCAL NHS Trust. BREASTFEEDING SUPPORT With acknowledgement to past and present members of the Trent Regional Breastfeeding Group from 1999-2005. Automatic Connection to a local breastfeeding Photographs provided with thanks to: support person. This system recognises the area Derby Hospital Foundation NHS Trust code of your phone to do this. You will Pregnancy and Birth Magazine therefore not be connected to a local supporter if your Bravado Bras. telephone number is withheld or you use a mobile Brian Moody telephone. Sure Start Chesterfield Nottingham City Hospital National Childbirth Trust BREAST PUMP HIRE © Copyright 2006 All rights reserved. No part of this publication may be reproduced in any form or by any (8am-10pm) Medela UK means. Published and designed by RL Advertising. 0870 444 8708 0161 7760400 La Leche League For further copies, contact: Egnell Ameda RL Advertising, Publishing Division 0845 120 2918 01823 336362 Tel: 0115 938 9858 rladvertising@i12.com Breastfeeding Network 0870 900 8787 References and suggested reading list Akre, J. (1992) Infant Feeding. The Physiological Association of Basis World Health Organisation Breastfeeding Mothers Derby Hospitals Foundation NHS Trust (2004) 0870 401 771 Feeding Your Baby, Derby Hospitals Foundation NHS Trust. WEBSITES FOR FURTHER INFORMATION: www.babyfriendly.org.uk www.multiplebirths.org.uk Howie P.W., Forsyth J.S. (1990) Protective effect of www.nctpregnancyandbabycare.com www.bravadodesigns.com breastfeeding against infection BMJ; 300: pp 11-16 www.laleche.org.uk www.expressyourselfmums.co.uk BMJ; 300: pp 11-16 www.breastfeedingnetwork.org.uk Henschel, D., Inch, S. (1996) Breastfeeding; A www.abm.me.uk Guide for Midwives La Leche League International (2005) The Your Local Contact Numbers: Womanly Art of Breastfeeding Community Midwife; Health Visitor; Lawrence R.A. (1994) 3rd Edition Breastfeeding – Peer breastfeeding supporter A guide for the Medical Profession Minchin M (1999) Breastfeeding Matters. What we need to know about Infant Feeding Mohrbacher N and Stock J (1997) La Leche League Answer Guide Royal College of Midwives Successful Breastfeeding Infant Feeding Advisor for specialist advice World Health Organisation (1998) Evidence for the (if one available) Ten Steps to Successful Breastfeeding Woollridge, M. (1996) The anatomy of Infant Sucking 2 (4): 164 – 171 Midwifery DH (2004) National Service Framework for Children, Young People and Maternity Services. Department of Health, Wellington House