Intro

All content of this blog is my own opinion only. It does not represent the views of any organisation or association I may work for, or be associated with. Nothing within this blog should be considered as medical advice and you should always consult your Doctor.

What Is Appropriate Aftercare Following Tongue Tie Treatment? PART 1

NOTE: Tongue ties can be treated in children for various reasons including dental or speech problems.  This post pertains to treating tongue tie in babies (ie younger than 18 months) for feeding purposes.

PART ONE

In the UK there is currently considerable debate about appropriate aftercare following frenulotomy (treatment of tongue tie).  At one end of the scale is the do nothing approach, sometimes not even providing a contact number for parents.  At the other end is an intense schedule of lifting, stretching, "popping" and massage - the aim being to keep the wound open, using force to "tear" healing fibres apart if needs be.

In between are a range of practices: watching the wound but not touching unless significant tightening down occurs; tongue exercises; sweeping the area without pressure.

The general consensus from parents (and often infant feeding specialists too) is confusion. Who is right and what should they do?

I've split this entry into two parts; general discussion of aftercare, and coming up in part two, other things to consider.

Typically when it comes to intervention, the onus is on demonstrating a benefit; in this case that stretching/massage etc proffers better outcome than doing nothing, or waiting and watching.  We can then read through the pros and cons and make an informed choice.

Evidence:
This is where we hit the first roadblock because realistically at the moment there isn't any.

Different practitioners may claim their own clinical experience is evidence, but realistically it's not; it's anecdotal and not free from bias (if someone believes something will or won't work, this can inadvertently influence their judgement).

Their theories may be accurate and intervention important, but without published trials including controls and adjusting for other potential influencing factors, this isn't research but theory.

We must first decide how we define tongue tie and what the overall aims of the initial procedure are, so we have a basis on which to gauge outcome.

Which is where we hit stumbling block number two.

So let's start at the beginning.

When identifying a tongue tie initially, it's not  as simple as identifying a membrane and assuming all problems stem from that.

Many people have some sort of frenulum under their tongue.  Only when it appears tight or short, and impeding full tongue movement , can it be classed as tied or restricted.

To make matters more interesting, even if there is apparent restriction of the tongue this isn't always caused by tongue tie, and even if there is a tie this isn't necessarily the cause of the feeding problems.

Still with me?

The NICE guidelines state:
"Many tongue-ties are asymptomatic and cause no problems. Some babies with tongue-tie have breastfeeding difficulties. Conservative management includes breastfeeding advice, and careful assessment is important to determine whether the frenulum is interfering with feeding and whether its division is appropriate."
and
"It was recognised that breastfeeding is a complex interaction between mother and child, and that many factors can affect the ability to feed. Skilled breastfeeding support is an integral part of the management of breastfeeding difficulties."
I would ideally like to repeat this phrase a thousand times, so many people assume presence of frenum alone is problematic (even if they're not having any problems), and that as long as it's removed problems resolve.

This is why I assume there are now several practitioners treating frenums without needing any sort of referral other than the parents picking up the phone.

In the UK a rationale is required to perform tongue tie revision on babies, one can't just go about dividing frenulums willy-nilly.  It isn't just about what a frenulum looks like, but how it affects feeding and what problems result.  Yet we're in a situation where people are treating for a feeding reason, yet the parents have sometimes not seen a single person qualified in providing feeding support!  Nobody is ensuring adequate feeding assessment or that these mums have someone who specialises in feeding issues to go back to.

Once the frenum is treated, do we have reason to believe that post procedure we should focus purely on whether a single strand of tissue has reattached?  If many people have a frenulum, do we have sufficient evidence we need to be aiming for zero attachment in all cases? No.

A couple of cases spring to mind. First a baby just a few weeks old and mum contacted me regarding a third revision. The mum had been advised (after showing a photo) that the two previous surgeries had apparently failed.

Yet whilst there had been regrowth of tissue at the site of the cut frenulum and there were still issues, ultimately it wasn't the new tissue underneath that was the cause.

If I had seen that tongue prior to any treatment, I wouldn't have considered it tied - so why when it comes to regrowth should different rules apply?

Second was a slightly older baby.  All problems had resolved following treatment, but mum was concerned that she could see regrowth when she lifted the tongue.  Indeed there was a frenulum, but where is the rationale to treat further when life is sweet?

This means any research surrounding appropriate post procedure treatment has to define criteria. 

Is the treatment taking place to resolve feeding issues, or is it to obliterate any trace of frenulum with success being measured based on what we can see?

When it comes to promoting rigorous aftercare, I've heard the argument that lots of medical interventions aren't evidence based and yet work; that lack of evidence don't mean lack of efficacy.  Indeed this is true, but conversely neither can we guarantee lack of harm.

Whilst oral mucosa heals with a less fibrous response than skin, what if aftercare that involves "disturbing the wound" creates deeper scarring than doing nothing, increasing risks of palpable scar tissue and/or reattachment?

Do all babies despite age and position of frenulum need the same post procedure care, and is there the potential to improve outcome in some whilst causing problems for others by intervening?

Is there any risk of rigorous rubbing of a deep revision causing oral damage?  How much do tongue exercises help? How does watching and intervening later compare with forceful disruption from the start or doing nothing?  

Is there risk of causing further inflammation?  Is there an infection risk from rubbing a wound to the point it bleeds without sterile hands or gloves?

Are we absolutely sure this is necessary?

Without studies we simply don't know.  It seems different practitioners have different theories and I personally need more assurance than "because I say so!"

What I do know is that plenty of babies have suffered reattachment even with "hardcore" aftercare, whilst others haven't; similarly some frenulums never reattach even if mum doesn't do anything, whilst others do.

We simply are not in a position to say with any certainty that reattachment or unresolved problems are due to inadequate intervention by caregivers. For me that's just a guilt trip too far.

PART TWO HERE

Why Expressing Breastmilk Isn't A Reliable Way To Tell How Much Milk You're Making

(Or measure the fat content!)

Sometimes mothers are told they can check whether they are producing enough milk.by expressing a feed; if the amount expressed matches what baby takes from a bottle, her supply is deemed OK.

If faced with slow weight gain Claire Byam-Cook suggests mothers offer a supplement post feed and then:
"You could use a breast pump to see how much milk was left in the breast compared with how much he took from the bottle"
Before going a step further to say:
"A simple way of checking is to substitute several breast feeds with a bottle and then use the pump to see how much milk you can express at each feed compared with the amount he took from the bottle."
Before concluding:
"If you can’t express any milk, then your supply is almost certainly low."
To many new mums this logic seems logical, to a qualified Lactation Consultant it contains more holes than Emmental.

First, when feeding a baby at the breast, they attach, suckle and trigger the milk ejection reflex or "letdown".  The touch, scent and sounds of baby along with the suckling all assist this process.  During the feed baby triggers more "milk ejections" until he's full.  Some mums can feel the first whilst others don't feel any.

Teaching your body to "let down" to a pump can for some mums take time; because hormones aren't delivered from contact with plastic, some may need photos or video of baby, or perhaps something that smells of them to help.  Stress is a huge barrier to effective expressing, and so a mum anxious she does not have enough milk may find herself even less able to express well.

Mums have different size nipples and not all flanges (the cup of the pump) fit well enough to stimulate the breast effectively.  Therefore it's not uncommon to meet women with oodles of milk who can't pump more than a few drops.

Second, it assumes a pump is as effective as a baby (who is feeding well) at removing milk, which is where we hit a rather large wall in the above theory.

Check out this video clip.  This link shows how mums using a double pump alone (not the typical single hand pump most mothers have, but a hospital grade pump that expresses both sides simultaneously thus increasing yield) can typically only access around 50% of the milk mum has.  By single side or hand expressing with massage after double pumping, mum could obtain the same volume of milk again!  This means those who haven't had support to develop advanced expressing techniques described, can't access a good chunk of their milk with a pump.  Many mums are not even shown how to hand express properly or given tips for effective expressing with a manual pump, let alone how to massage their breasts!

Something else we often hear is to let milk stand and separate, and then you can see how much fat is in the milk and thus whether milk is good enough quality.  Now consider the fattiest milk is released as the breast drains, and factor in that as discussed above mums can have as much as 50% more milk they can't access.  Realistically most mums have only expressed a small amount of the total fat produced.

Next we have to consider that how much a mum can express in one go, even with the best hands on expressing techniques, isn't a reliable way to assess total milk production over 24 hours either.

We can think of milk production rather like a tap dripping water constantly into a sink with the plug in.  The body continually makes milk in little sacs which gradually expand as they fill up, rather like balloons placed under a tap would.

When a baby feeds it's like pulling the plug on the sink, the store that has built up can drain (providing baby is feeding effectively).  When you put the plug back in (stop feeding) the dripping again starts to refill the sink; just like a tap, breastmilk never "runs out"; regardless of the size of sink or the speed with which the water drains.

A researcher named Hartmann studied milk production and found that some women had a storage capacity three times larger than others, yet they all produced a similar amount of milk over a 24-hour period.

He also determined that the amount infants removed varied from 50-90% of the total milk available during a feed, and the rate at which milk was made was directly linked with volume taken.  When the baby removed more, the speed at which it was produced increased.  When a smaller amount was taken, production became slower.  The length of time between feeds was also linked to the amount consumed - those who took less per feed fed more frequently.

So, to go back to the sink analogy.  We all have different sinks, with a different rate of drainage.  But let's add the taps.  These aren't any old taps but a super state of the art designer number that has inbuilt sensors.

They drip continuously to try and keep a stable level of water in the sink for your convenience.  If you pull the plug and remove a lot, the tap runs more quickly to replace what was lost.  If you remove just a small amount, it slows down the speed of the drips.  When the sink starts to get quite full, the taps really slow down production to try and prevent over filling.

If your sink is smaller, you may need to empty it more frequently to prevent over-flowing, and if you were trying to fill a bucket from the sink you may need to do so more frequently than someone with a bigger sink.  But that doesn't mean you tap isn't dripping the same volume over 24 hours.

The last hiccup in the logic of the above plan to give a bottle post feed to check hunger is highlighted by Dr Amy Brown in an article she wrote for the ABM.
"Formula-fed babies drink greater volumes of milk by as early as two days old and continue to do so throughout the first six months. Breastfed babies also feed more slowly, spending more time resting in between sucks than formula fed babies which may mean they are more likely to stop feeding before they are too full."
So in fact a baby could potentially over eat with a supplement, especially if they have tummy ache or other discomfort and want to suck for comfort.

If someone suggests pumping to measure supply, give them this link and find someone qualified to help.

The £75 doll that lets girls as young as TWO 'bottlefeed'

A doll designed for girls as young as two to 'bottlefeed' has sparked a backlash from concerned mothers who have labelled it 'weird' and 'creepy'.

Children use a bottle which features a "replica of a human nipple' and the 'Bottle Milk Baby' makes suckling sounds when the girl puts the bottle in its mouth.

There is a second nipple enclosed to "pacify" the baby!

The £75 toys also giggles, coos and cries.

Angry parents have hit out at the doll created by French makers Corolle

The Rumour reported that one mum labelled it 'toe-curlingly gross' on blah-net, while another branded the toy 'disgusting'.

'I think a bottle feeding doll is just weird and gross,' said one mother. 'It is the same as these bras you get for young girls who just don’t need them.'

'Just let kids be kids – there’s plenty of time for them to learn about bottle feeding/birds and bees etc.'

As well as debating about whether the toy was appropriate for children many even wondered whether it was worth buying at all.

One said it was 'pointless and silly' while many others balked at the cost of the toy.

Another mum said: “Why would a little girl need to learn how to bottle feed before she has a baby? Before puberty?"

"This is another disgusting example of forcing adulthood on our children long before they’re ready.”

A bottle-feeding doll advocate said:

"It's about time there was a doll with a bottle, those without only serve to make mothers who had to use a bottle feel guilty.  Sure we all know breast it best, but formula isn't poison and if I want to buy my child a doll with a bottle, the breastfeeding mafia can try their guilt trips elsewhere!"

Verdict on bottle--feeding toy for children

Why do we adults think children want to be like us?  Yet again we have people making money selling things to children they don't need until adulthood.
We’ve had make-up, skimpy clothes, mobile phones and laptops for children – and now a bottle feeding doll.

Children enjoy pushing dollies in prams and if they want to copy their mother bottle feeding then they can do that with an existing doll.

Pretending to bottle feed is not something you’d imagine a child would want to be doing as a regular play activity.  They have play kitchens, play shops,  that's enough.

People seem to miss the point – when children play these games they do it to copy what’s around them, not because they want to be adults.

In case you've been living in a cave, this piece is a parody of recent coverage in UK Newspapers re the Breast-milk doll.  Nobody batted an eye lid at Corolle's £75 bottle feeding doll...

Sources:
Daily Mail: The £60 doll that lets girls as young as TWO 'breastfeed' sparks outrage amongst mums as it goes on sale for Christmas

Why I Ditched Detached Parenting - A Mother's Story

When I read this letter to Dr Sears entitled "Why I choose detached parenting" - I actually said a silent thank you to my first born.  Believe it or not I started out parenting with ideas not a million miles away from those voiced by ex nanny turned author Nicola Kraus; perhaps not quite as hardcore, but then I was never a nanny!

I've learned so much in 9 years, but yet I can remember the difficulty I originally had letting go of what society had deeply ingrained; it's a massive paradigm shift for some.  You see unlike Nicola's child, my first baby had other ideas, and they definitely didn't fit the mainstream model (despite my endless attempts at trying).  Instead my daughter dragged me down an entirely different path - albeit at that point kicking and screaming.

Years of reading, learning and growing later, I'm now grateful to her  - because it's from that I've learnt so much about the emotional, psychological and physical impact of how we care for our infants. The downside?  You want to share it!

And therein lies the problem.  How do we effectively convey the importance of responsive parenting to those who have been suckered by the mainstream baby industry in to believing it doesn't matter?  It's like that part of the matrix where he can choose the red or blue pill
"You take the blue pill, the story ends, you wake up in your bed and believe whatever you want to believe. You take the red pill, you stay in Wonderland, and I show you how deep the rabbit hole goes."
The trouble is whilst your eyes are wide open in Wonderland, the majority of society are still wired up - and a lot want the blue pill.  I can remember how resistant I was to what I perceived as permissive parenting, toddlers that never slept and parents shattered, controlled by the child with a stroppy toddler wedged between them at night (the reality by the way is nothing like how articles such as the above describe!) so what can we say that actually makes a difference?

This week on Facebook during a chat about infant sleep, one mum shared her heartfelt story about why she changed the way she parented.  It felt like a polar opposite to the article above, which is what prompted the title of the blog.  The mum wasn't a detached parent - but she did make the massive mental shift that has turned her parenting style on its head.  Perhaps this will at least provoke thought...

Name removed as mum wants to remain anonymous on the blog:
For various reasons my eldest child was a "Gina Ford baby", who I fed to a strict schedule (breastfed until she was 1) and who I kept very separate from me to 'foster her sense of independence'. We also used controlled crying. She was a fabulous sleeper, doing 12 hours a night without making a peep from 16 weeks old. I thought I had the perfect Contented Little Baby and recommended Gina to all my friends and anyone else who'd listen. I was horrified by all these parents making a rod for their own backs by co-sleeping, feeding to sleep and carrying their babies everywhere. How horrible it must be to never have any adult time, and as for their poor children! They're going to grow up to be clingy and insecure and not understand that there are rules that we, as a civilised society, need to abide by. Fast forward 2.5 years and whilst Gina is now a distant memory...
I have an extremely insecure, jealous, aggressive toddler who suffers the most horrendous separation anxiety and WILL NOT SLEEP. And do you know what breaks my heart the most?
A few months ago I put her up for her daytime nap and for the whole two hours she refused to sleep, she just kept playing with her toys and running around her room. She wasn't upset or crying, she just wouldn't sleep! I was annoyed - she had to have her lunchtime nap; I had stuff to do! So I decided that she could stay there for the full time and eventually she'd fall asleep, I was sure of it! After two hours all went quiet. She was finally asleep - I knew I was right all along, she needed that sleep! After all, mummy knows best, right?! A further two hours passed and I thought I'd better check on her as it'd been four hours since she'd gone up to her room...
So up I went and there I found my little girl, just sat on her bed, wide awake, staring at her door. Not making a sound. I asked her if she'd had a lovely sleep and she said "No mummy, I didn't sleep. I'm sorry mummy. That was not good 'haviour".
In that instant my world came crashing down. I'd left my poor girl alone in her room for FOUR HOURS, thinking I'd won the battle. I thought that, because she wasn't making a sound, she was happily asleep. When I was faced with reality; that she'd been wide awake for that entire time but hadn't made a peep because she knew mummy wasn't coming, and she was apologising to ME, I broke down. I questioned all those months where I'd thought I had a wonderfully content baby, who slept perfectly.
Was she really asleep? Or did she just give up all hope of her mummy coming for her? Of course I'll never know, but I have my suspicions, and I'm sure that the way I raised her until that point was in no small way responsible for her crippling separation anxiety and her challenging behaviour.
In that instant I set about changing how I parent and it has resulted in a fundamental shift in who I am.
I immediately dropped any sort of routine for my then 12 week old (who yep, had been sleeping through the night 12 hours from 9 weeks). I read up on Attachment Parenting; I read Sears, I read ‘The Continuum Concept’. I bought a sling, made my youngest's cot into a co-sleeper and adjusted everything about how I parent my eldest: no more ‘naughty step’ and she's welcome in our bed whenever she gets scared of elephants at night.
It's a long old road, but we're slowly seeing an improvement in my eldest's behaviour - and in my youngest (now nearly 6 months) because guess what? She does feed off and on all night now. But I barely register it because I'm not fully awake and I don't believe that she's using me as a dummy, I believe that other babies use dummies as breasts. I know which is more natural and normal and I know which I prefer."

Deny The Super Power Of Your Breasts!

Breasts have super powers.  Honest, many who have breastfed for any length of time can vouch for it.  Tired baby? Got that covered - relaxing sleepy hormones are delivered.  Baby bumps or just feeling full of cold and grotty?  Yep got that too, breastfeeding is recognised as an analgesic by the British Medical Association.  Really under the weather and sick - the vast majority of the time an infant will continue to breastfeed little and often, reducing risks of dehydration and hospital admittance.  Teatime meltdowns from an over stimulated tot - no match for mama's milk.

Why is it then society seems so scared of this fix all, mothers are frequently warned against using this magic tool?
"I spoke to the health visitor today who said I need to not let him use me as a dummy or he will never learn to sleep alone!"
Er hello a nipple is baby's natural pacifier, a dummy is a replica - therefore baby is actually using the dummy as a breast.

Boots have released a "Napping dos & don’ts":
"It’s natural for babies to fall asleep after a feed. Nursing or bottle-feeding newborns to sleep is a great bonding experience, but over time it can become the only way they can fall asleep. Try to separate nursing from naps even by just a few minutes; read a story or change baby’s nappy in between."
That's right Boots it is natural and bonding - would it therefore make any sense then that if we partake in this natural bonding process, our infants will never be able to sleep without it?  Lordy I wonder what happened before there were such warning leaflets and people followed their instincts?  Did we have a nation full of non-sleepers who couldn't settle without a breast?  Thank goodness Boots can save this generation!

But forgive me for finding their information a little confusing, another slide reads:
"Don’t wake baby:
What if baby falls asleep in her car seat? Just carry her in the seat inside. She can finish the nap there. You don’t need to wake her or move her to a cot. If she starts to snooze in her baby swing, just keep an eye on her and don’t let her sleep there overnight."
Right so just to clarify - don't wake baby unless breasts are involved.  Car seats or swings are fine, just keep an eye on the baby; but breasts are a big no no, I mean good heavens we don't want these babies expecting human contact right?

Since Boots, the Health Visitor above and the vast majority of "experts" work from anecdotal data  - here's mine.  I must be raising a blooming child prodigy.

Whilst I bought the above with my first (for the record, it didn't work her sleep was awful despite following all the "rules"), I knew better by the second  - I had a fix all built in and I was going to use it; no way was I picking up and putting down at all hours when I knew the boob would work in minutes. I would deal with whatever panned out as we got there, because realistically it couldn't get any harder than the first time around.


I carried and cuddled him lots, nursed him to sleep, offered him the breast if he was grumpy, hurt, unwell or just because he wanted it.  We co-slept with a side car cot and he helped himself during the night, was that a Godsend sanity wise compared to the hours spent trailing room to room with my first.

Yet - he dropped his night feeds of his own accord, slept well following being fed to sleep, transitioned through sleep cycles just fine and dandy i.e. didn't need to rouse for breast every 40 minutes as some suggest! (Some babies do, but there are in my opinion other underlying reasons for this that get ignored in favour of the breastfeeding scapegoat and sleep training).  Dropped his day feeds gradually and finally self weaned; recognises when he's tired, asks to go to bed, sleeps 11 hours straight.

How?  I mean according to many he should be a walking recipe for sleep problems and inability to function without contact from a parent.


I wonder if these same people also expect to see an adult ape carrying and nursing their fully grown offspring, after all they're a carrying species (like humans) all - and they don't get a manual on how to train their young!

The reality is that ALL babies, just like other mammals will transition to independence without being pushed or forced - it's a developmental step like sitting, standing, walking or talking.

We can even accept that in these other areas babies can vary hugely.  Both walking and talking typically occur somewhere between 9-18 months, and other parents support each other with "(s)he will walk/talk when he's ready".  But when it comes to sleeping alone for long periods, it's totally different - they apparently must all develop this skill ASAP after birth, with lists galore of how to achieve this adult driven desire.

Imagine if a "gross motor skills Guru" (self proclaimed, no qualifications) decided all babies should stand by 8 months.  This wasn't an evidence based guideline (anymore than any of the sleep advice is) someone just decided it was so and put this in a book that sold well.  Furthermore they then recommended if baby wasn't standing by this designated age, the parents should teach their baby, in fact it was their responsibility as parents to ensure their child developed this skill ASAP.  Really they should have been introducing stretching and toning techniques from birth, and practicing standing frequently to prevent such reliance on parents having to reach things above infant height; if some can do it at 8 months they all can with the right training.  So the Guru introduced leaflets about how best to do this and even became an advisor for high street shops who agreed to disseminate this information to parents on their databases.

If baby had reached 8 months or was getting close and still hadn't shown signs they were meeting the  expectations, action was called for.  Parents were advised they should put something the infant really wanted and needed at a height that meant they had to stand for it, and to not give in even if the baby cried and cried (this was considered manipulation from baby who would surely quickly learn you would pass him stuff every time and never learn to stand if you gave in) instead the parents had to hold fast.  They could comfort their baby without eye contact for brief intervals at set times as decided by said Guru, but nothing more.  Who wants a baby dependent on things being passed for heavens sake?  As the trend really took hold people would ask each other, "is your baby good?" which was actually code for can they stand alone yet?  After all with books saying all babies should do it with training, how early your baby mastered it became seen as a mark of how good your parenting skills actually were.

This is the reality of mainstream sleep support.

Humans strive to learn, develop and grow and whilst some need more support in some areas than others, they all get there, in their own time.

Dummies, Thrush & Decay - What Every Parent Needs To Know

Pacifiers, Dummies, Binkies whatever you want to call them (and there are 160 options here!) chat to any parent and you will find they're rather like Marmite - either loved or loathed.

Some (myself included before number one) just think all babies have them!  They like to suck and that does the job right?

As discussed in this post - a pacifier is ultimately an attempt at replicating the breast, and indeed babies use them as a replacement nipple, not the other way around (ie to say baby is using mum like a dummy actually makes no sense).

Like most discussions surrounding something truly normalised in our culture, it often turns anecdotal ie I had one and I'm fine, my children had them and their teeth are perfectly straight after they were breastfed for two years, it's personal preference - and so on and so forth.

But something I'm yet to hear mentioned is the rather more compelling evidence linking pacifiers to Candida (thrush) and ultimately tooth decay.  Yup caries, holes, decay, bad teeth! (I wonder if there are 160 alternatives to describe that?)

You're expecting evidence right?

A study that considered infants under 18 months of age detected Candida in 58%.  Pacifiers were positively associated with both frequency and severity of yeast infections, whilst no relationship was detected between the prevalence of yeast and breast-feeding or bottle-feeding habits.
"The results suggest that use of a pacifier is an important local factor in the colonization and proliferation of yeast in the oral cavity." (1)
Another assessed the surface of 25 pacifiers in a daycare setting and found 80% had a biofilm.  The two main genera isolated were Staphylococcus and Candida.
"Our results confirm that pacifiers can be seen as potential reservoirs of infections" (2)
A third swabbed the mouth and dummies of 100 children under 18 months and found Forty four per cent of dummies were colonised by Candida.
"Children who sucked dummies had clinical thrush and positive mouth swabs for candida more frequently than those who did not." (3)
A 2006 study found:
Infants who routinely sucked a pacifier had a significantly higher rate of oral candidal carriage, suggesting a reservoir of infection. (4)
Candida & Its Relationship To Pacifiers & Caries

The Brazilian Journal of Oral Sciences in 2007 reviewed the literature surrounding Candida in the mouth of infants and its association with early childhood caries (ECC).  They concluded that colonisation of Candida could be related to pacifier usage, feeding habits and caries lesions(5)

A study that analysed 166 children aged 1-4 years found candida in 24% of samples:
"The results of the study suggest that the use of a pacifier increases the occurrence of both salivary lactobacilli and candida. It could therefore be a factor influencing caries susceptibility and activity in children." (6)
Another study examining children over 2 years old for a period of 2 years, found that although both pacifier sucking and using a bottle at night increased the occurrence of both candida and oral lactobacilli - bottle use was less significant than dummy use
"The results of the logistic regression analysis showed prolonged pacifier-sucking (≥24 months) to be a significant risk factor for caries development in children, with a rather high relative risk (RR) of 3.5 (95% confidence interval (CI), 1.5–8.2; P = 0.003). (7)
A 2012 study took 30 children with caries (group 1) and 30 children without and found Candida levels were "remarkably higher" in group 1.  They concluded:
"This study supports the active role of Candida species in dental caries." (8)
In 2009 a study noted candida are frequently detected in the mouths of children with extensive caries compared to those without:
"Samples of saliva from 14 children with caries lesions and from 13 caries-free subjects were evaluated for the presence of mutans streptococci, lactobacilli and Candida spp. by culture. Eleven of 14 carious subjects hosted Candida spp. in their saliva as against only 2 out of 13 subjects without caries lesions." (9)
Another in 2006 considered plaque and dentine from from 56 children aged 1–5 years - which were divided them into three groups early childhood caries (ECC); caries and caries-free.  They concluded:
"There is a significant association between the presence of C. albicans and early childhood caries." (10) 
Whilst pacifier manufacturers have created orthodontic dummies to try and combat the effect of abnormal pressures caused by pacifiers on teeth and gums, it seems to me problems such as thrush and caries are just as significant, yet don't appear to have been well publicised.  

Surely parents have a right to all the facts when deciding whether to introduce one?  


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References
1.  ASDC J Dent Child. 2001 Jan-Feb;68(1):33-6, 10
2.  Nursing & Health Sciences Volume 8, Issue 4, pages 216–223, December 2006
3.  Arch Dis Child 1985;60:381-382 doi:10.1136/adc.60.4.381
4.  Oral candidal flora in healthy infants, Journal of Oral Pathology & Medicine, Volume 24, Issue 8, pages 361–364
5.  Brazilian Journal of Oral Sciences, Vol. 6, No. 20, January - March 2007, pp. 1249 - 1253
6.  Acta Odontologica Scandinavica, 1997, Vol. 55, No. 1 , Pages 9-13
7.  Acta Odontologica Scandinavica, Department of Preventive Dentistry and Cariology, Institute of Dentistry, and Department of Pediatrics, University of Oulu, Oulu, Finland 1998, Vol. 56, No. 4 , Pages 233-237
8. Comparative Evaluation of Oral Candida Albicans in Children with and without dental caries.  Int J Clin Pediatr Dent 2012;5(2):108-112
9. Support for the role of Candida spp. in extensive caries lesions of children.  NEW MICROBIOLOGICA, 32, 101-107, 2009
10. Archives of Oral Biology Volume 51, Issue 11, November 2006, Pages 1024–1028

Breastfeeding - Certainties V Risks

When discussing the implications of not receiving human milk, it never ceases to amaze me how many rush to answer with details of how they didn't breastfeed - yet them/their child doesn't have XYZ (whatever is being discussed); thus they can conclude the study/discussion in question is "rubbish".

Generally no other supporting evidence follows, the conclusion is reached purely based up on their personal experience.

This is quite typical of human nature I think.  We base our "norms" on what we see around us, we are less likely to believe negative implications of something unless we see/experience it first hand.  Furthermore it's very difficult for a mother to begin to contemplate negative implications that may relate to her own child - believing it's rubbish is an inherently more comfortable position.

But it doesn't take a genius to establish this logic is fatally flawed.  If you don't know anyone who smokes and has died of lung cancer, is it accurate to conclude smoking doesn't cause harm?  Many of us were raised without booster seats in the car for older toddlers/children - I didn't come to harm in a crash therefore does that mean nobody else has?  That we can abandon safety in the fact of anecdotal evidence?

The reality is that when discussing infant feeding, we are talking risks not certainties.

Risk
Noun: The possibility of suffering harm or loss; danger.

Cer·tain·ty
Noun: Firm conviction that something is the case.


Saying not breastfeeding is linked with increased risk of obesity or SIDS or diabetes does not, I repeat does not, thrice I will say does not mean every non breastfed infant will turn out fat, suffer SIDS or end up diabetic.  Nor does it mean no breastfed baby will become overweight, not become a victim of SIDS or develop diabetes.

What it does mean is if you take two groups - one breastfed and one not, those not breastfed would be more likely or have a higher chance of developing XYZ.  Sometimes this risk is slight, other times more significant - but it remains a risk not a given.

If we can maintain this perspective, perhaps it may lead to more progressive dialogue whereby instead of debate over whether one has/hasn't had experience something that tallies with what evidence is telling us - we could instead move on to discuss how to reduce whatever risk is in question.

Stop Weighing Babies Like Stranded Beetles!

Imagine the scene - you're a tiny baby and not long ago your home was warm and cosy, cushioned in every sense from the outside world.  Suddenly you're shunted into a bright environment, noises are no longer muffled and food is no longer delivered around the clock.

But it's OK, you're snuggled up with mum and her familiar voice, her skin and now her scent help you adjust as she tends your every need.  You've just settled down for a nap when out of the blue someone strips you starkers, then plonks you on a thin piece of paper, on top of cold hard plastic scale like a stranded beetle.  Your startle reflex is triggered, your hands come up to your face and you let out a big shout, WTF is going on?
You might kick your legs and wave your arms, why is nobody moving me you shout? Hello! I'm letting you know I'm really not OK with this!

As a result the numbers on the display dance a Cha Cha up and down as watchful eyes wait to see where it will land (if you lay still long enough).

Why do many insist on weighing babies in this way? I don't get it, especially given we don't use analogue scales for weighing anymore.

When I'm baking I could weigh fluid by tipping it all over my digital dinky number, or I could put a bowl on first - tare the scale and then add the liquid. 
The liquid weighs exactly the same whether it is in a suitable receptacle or not, yet one is far more practical than the other.

Why is weighing a baby different?

Why can't we pop a snuggly blanket on the scale, tare them and then place baby prone, a position they are generally much happier in.  Arms and legs are less likely to flail as the startle reflex isn't triggered - making everything quicker.

In fact do we even have to undress baby at all?

I'm not convinced we do and for some babies this may be even more important.  Premature infants for example need a cardigan, hat and blankets - even in a hospital.  Their skin is thinner and maintaining body temperature is something that can be hard work for them - stripping them off also often prompts lots of crying in these babies too, burning energy and generally stressing their system.

So, back to the baking analogy above.  If I put a bowl on the scale, a cup inside that, an egg cup inside that - tare them and then add fluid; the reading is just as accurate as it would be just with the bowl.

Applied to babies, if parents are aware their baby will be weighed why can't they dress baby in a vest and/or babygrow and/or hat depending on the weather/baby's age, and have a spare set of identical items on hand (as per multipacks)

Place the above along with a new identical nappy and a snuggly blanket on the scale and then tare   Remove the vest, romper and nappy and they will tip to a negative balance.

If you then place baby dressed in a clean nappy (ie change it immediately before weighing), vest and romper as above on top of the blanket prone - tada, you have the same reading as if you stripped baby butt naked and laid him flailing on his back.

Even if you do want to strip baby down, placing a young baby on his tummy on a soft surface, tucking his arms and legs underneath him if he is still quite fetal and curled can help lots.

Really, the stranded beetle is not an essential part of weighing your baby - remember, tummy to the scale if you don't want them to flail...

Slumber Bear - Depriving Newborns Of Contact?


I stumbled upon a forum the other day where "baby essentials" were being discussed. As you know I think there are very few things that are truly essential when baby is small - and as the discussion following the above entry highlighted, essential varies widely parent to parent, baby to baby.

But I did notice the "Slumber Bear" was mentioned several times so I went to check it out.

The description from Amazon:
"Designed by a doctor and used successfully in maternity wards for over 30 years, the Prince Lionheart Slumber Bear Plus has helped millions of newborns (and their parents) get a good night's sleep. The Slumber Bear Plus features a multi-function sound box playing womb sounds, lullabies, ocean waves and white noise. There is also a recordable feature allowing you to save your own unique message for baby. Comforting sounds lull baby to sleep in minutes and sound and motion sensors reactivate the recording when your baby cries or jostles the bear.
Each Slumber Bear Plus arrives with its own silkie. Parents can bond with baby by keeping silkie close to their skin, transferring their scent to the blanket. The scent then comforts and reassures baby when parents are out of reach and the soft, smooth texture provides beneficial tactile stimulation."
and

"How it was designed ... By placing a specially designed 8mm microphone inside a pregnant mother's uterus, directly next to the unborn infant's ear. Insertion of the microphone moments before the mother went into labor enabled Dr. Eller to record the major intrauterine sounds that the baby had been hearing for the last four to five months prior to birth. The recorded sounds were then clinically tested on thousands of babies in hospital nurseries, and proved to be a natural audio baby pacifier. Based on the knowledge that the birth experience and transition from the peaceful, quiet existence inside the mother's body is a very traumatic time for the newborn, it has been proved that the recorded intrauterine sounds produce a calming effect on the newborn infant after birth."
  Firstly I wonder how they define a "good night's sleep", is that by the newborn standards or parental norms?   Secondly why on earth do parents need to bond with baby via a piece of cheap cloth?  You can hold the cloth to transfer your scent, then this cloth can be reassuring to the baby?

Seriously how did the human race bond before?

Perhaps (just throwing random ideas out there) they held the baby, he was in turn comforted by the scent, touch and sounds of his mother or father - oxytocin was released all round and thus they bonded?

Now babies can't have free access to their parents, instead they have to learn to soothe themselves to sleep alone - with parent smelling material and a machine making parental sounds?

The trouble is it seems, that newborns need their parents - but that doesn't make money!  As is highlighted above, transition to the outside world can be traumatic for newborns; as a result they are meant to stay close to their mother - her scent, milk, voice all serving to ease that transition.

If a baby needed to hear womb sounds to settle appropriately, wouldn't our bodies make this sound?  Or maybe babies actually only need this if separated from their parents - if they can't have the real thing.  Doesn't it kind of trick babies into thinking they're close?

And is this a risk free plan?

Earlier this year a study by Nils Bergman published in Biological Psychiatry found:
Heart rate variability in 2-day-old sleeping babies for one hour each during skin-to-skin contact with mother and alone in a cot next to mother's bed. Neonatal autonomic activity was 176% higher and quiet sleep 86% lower during maternal separation compared to skin-to-skin contact."
Indeed Dr. John Krystal, Editor of Biological Psychiatry, commented on the study's findings:
"This paper highlights the profound impact of maternal separation on the infant. We knew that this was stressful, but the current study suggests that this is major physiologic stressor for the infant."
 Read more here

From the description above, note how the product was developed and tested in hospital nurseries - places where babies are separated from their mother and placed alone in cots.

Read the reviews on Amazon and it's noted how great that when the baby makes a sound it restarts and soothes them!  No parental effort required, genius.  If the cot is next to you, give it a tap and away it goes.  I don't see any reviews from those sleeping with their baby, only from those having trouble putting their baby down alone or settling/sleeping alone.
"His Mummy wore the snuggle blanket down her top for a night to make it smell of her and now the combination works a treat.  The little man keeps hold of his snuggle blanket while asleep and if ever he wakes with a start the noise machine kicks in and soothes him back to sleep"
and
"Firstly I should state that this has been absolutely instrumental in getting my baby to sleep in her own bed and I would recommend it to anyone who's baby has trouble self soothing."
and
"Bought this as a last resort for our baby who would only ever settle in our bed, as soon as we tried to put him down he would scream. Now he falls asleep to the womb noises and also settles very quickly."
and
"We bought this for our son when he was 4 days old as he wouldn't settle in his crib at night."
and
"Slumber bear - only thing that got her to sleep in her basket"
Notice the pattern?

Plus some rather worrying ones:
"We had an eight week old baby who wasn't sleeping and thought, what the hell, we will try anything! Within a few nights we could see her settle."
and
"I credit this with helping my baby learn how to sleep. He is 4 months old now and has slept through the night (12 hours a night without waking up) since he was 2 and a half months old because each time he woke up at the end of his short sleep cycles not for a feed it helped him get straight back to sleep."
8 week old human infants aren't supposed to sleep for 12 hours without waking up - they're meant to wake and rouse (for a whole myriad of reasons).  Using something like this to induce abnormal sleep/wake cycles isn't "natural" or beneficial to the baby - even if it's convenient to parents who want their 12 hours!

Perhaps someone will come up with something so the parents don't even have to faff around feeding baby themselves, the other big newborn need.  Depriving baby of even more contact...

Oh wait, they did already!


So there may be risks baby will choke, but you know parents are busy nowadays!  Who has time to stop and feed a baby anyway - let alone get up and soothe one when you can kick the cot and have it done for you.  Babies are hardy, they will adapt with lots of gadgets to replace their parents right?

Nappy changing robot anyone?

PS - white noise can be settling to an overtired unsettled infant; vacuum cleaners, untuned radios, hairdryers, white noise machines and white noise phone apps are all available. Sure they wont restart when your baby murmurs, wont play womb noises but if these are more than occasional use items it makes more sense to address the cause of the fussyness and consider whether expectations are realistic.

Bottle Symbols V Breasts

Recently there seems to have been lots of posts on Facebook complaining about the bottle symbol being used to identify something baby related.  From phone apps to feeding rooms, children's TV shows to T shirts it's everywhere.

Without fail the comments that follow include things along the lines of:

"I don't see the problem, there are bigger things to worry about"
"It could be expressed breastmilk in the bottle, what's the big deal?"
"It's no big deal, they can hardly use a a giant breast!"
"Not sure they could pictures of boobs up in department stores..."

Here's the most ironic example I've seen:

Google "Nursing a baby" and the information relates to breastfeeding.  I haven't heard a non breastfeeding mum use the term "nursing" to mean bottle feeding.  It can mean cuddling/holding in some areas, but I'm pretty sure this isn't a designated cuddling room!

So even when advertising a breastfeeding room, we have a picture of a bottle?

I don't get it.  What is a bottle but a replica of a breast, nipple and all?  (although we Brits call them teats not nipples, as that would be a bit too breast like thank you very much!)

So if we can use an icon of a bottle and it not cause offense, is an icon of the real thing really that "out there"?  Let's take a look:

Gosh yes, see how offensive that is?  

I can see why that plastic container bit at the bottom makes it so much more acceptable that a real breast icon, the round fullness of the breast positively perverse compared to the tall sleek container!

Oh but wait we can't use a real breast anyway, because that might make bottle feeding mums feel guilty right?  You can put breastmilk in a bottle but not vice versa so the first is more inclusive?  Because we often see mums hiding their bottles under fancy covers or feeding shut away in dirty rooms with nappy bins...

Perhaps we should introduce the viagra logo as the international symbol for sex so as not to offend those who can't "perform"?

I contacted John Lewis last week, and asked if the bottle picture on the baby feeding room meant the room was just for bottle feeders.  Their reply:
"Although a bottle is used as it is a universally understood symbol for baby feeding, we encourage breastfeeding in all of our stores." 
Is it really universal?  do Norway, Sweden etc use bottles to symbolise a baby feeding room?

The very fact John Lewis feel a bottle is the universal symbol for feeding in itself speaks volumes about the culture we live in.

Then consider we need a special room for mums to go and do it in! If they're lucky we even give them little cubicles so everyone is spared the sight of a human infant feeding:



I don't actually think the logo should be a breast, there is an International breastfeeding symbol shown here on the right which I think is pretty inoffensive all round:

But ultimately the point is that it's only in a bottle feeding culture the above would even be debated or relevant.  As individual stand alone symbols, it seems reasonable to suggest it's not a big deal, but add together all the little things and soon we have a big thing.

Think of it like this - take a child being confrontational.  As one stand alone incident, it's not be a huge deal if your child typically is co-operative and communicates well.  But if the same child was confrontational every time you spoke to him - it becomes a big deal.

The culmination of all the ways bottle feeding is drip fed as normal within our society, is significant, it does matter.  In order to effectively support women who want to breastfeed to do so, we have to create a breastfeeding culture - a society where feeding human infants milk of their own species is normal, not special, best or optimal.  Breastfeeding advocates realised this in the early eighties as this fascinating piece highlights.

It's illogical to say these things don't matter, we need to just focus on helping mothers succeed - because societal norms are ultimately key to this success

If you don't want Health Professionals undermining breastfeeding by suggesting bottles at every turn, if you want them to understand breastfeeding and know how to resolve problems - we need to create a breastfeeding culture.

If you want Doctors to have more than a bare bones knowledge of breastfeeding and to consider feeding as more than a "lifestyle choice" - we need to create a breastfeeding culture.

If you want research and media to hold breastfeeding as the normal way to feed a baby, with alternatives compared to this norm rather than vice versa - we need to create a breastfeeding culture.

Still not convinced?  Here is an excerpt from an email I received recently from an amazing young mum trying to establish breastfeeding:
"I went to see my GP because of the pain and she started ranting about how disgusting it was for new mums to feel so guilty they HAD to breastfeed, that there was too much pressure. I said I didn't want to stop I wanted to feed him myself because I knew it was best but I just wanted to know why it hurt so much. She said that he'd had the best stuff and I shouldn't feel bad if I wanted to stop now. Might be because I'm a young mum but she was no help at all."
I wish I was surprised, but look at the quality of information provided by celebrity Doctors and pretty soon you might find yourself overwhelmed by the urge to introduce your head to the nearest hard surface.

We simply can't change this within the current culture, we can't expect quality advice, for people to accept and treat breastfeeding as the norm - if those same people ultimately perceive bottle feeding as the "normal"way to feed an infant - the two clearly are simply not compatible.  The truth is if we want women to succeed at breastfeeding we need a breastfeeding culture - nothing less will cut the mustard.

UPDATE: John Lewis have been in touch to say they are in the process of updating all their store feeding room logos to be an image of a baby, rather than a feeding related icon!

Related Links:
Taking Down The Almighty Bottle
The International Breastfeeding Symbol

AA Answers The Daily Mail Question - How To Keep A Hungry Baby Happy

Health: How to keep a hungry baby happy - Daily Mail

I didn't like Sarah Stacey's answer in the Daily Mail on the link above to the question below
. So I decided to reply myself.

Q: I am a first-time mum and don’t produce enough milk for my hungry six-week-old baby boy at night, which makes us both stressed. I want to avoid using formula if possible so the health visitor advised expressing milk with a pump in the mornings – when I have plenty – but I find a manual pump very difficult to use.

A.  What makes you think you don't produce enough milk at night? During the evening it's very normal for babies of this age to cluster feed, which is when they take multiple feeds with shorter spacings in between, sometimes back to back.

In the early days, hunger is driven partly by a hormone called CCK - the same hormone that induces relaxation and sleep. After a feed baby has a high level of CCK, which tells him he’s full, but it drops after another 10 or 20 minutes, so he thinks he’s hungry again. He may go through this loop several times, in what’s known as cluster feeding, before dropping into a solid, longer sleep. This is thought to allow baby to fill their whole digestive system, so excess hunger doesn't occur during a longer sleep spell.


The other thing to consider is that babies often have something called a "growth spurt" at 5-6 weeks ish (sometimes termed "fussy spell"), which can last anywhere from a couple of days to a week or so. This is when a previously settled baby has a sudden increase in appetite and wants to feed feed feed, sometimes appearing insatiable and generally fussy.  It's a normal developmental step seen in both breast and bottle fed infants and they may have a few days sleeping lots after the spurt, which is when some suggest the growing (physically or mentally) occurs.

Therefore the first thing to ascertain is whether you really are not producing enough, or whether you actually have a perfectly normal supply and your baby is just doing what  babies do (but which many "experts" fail to tell parents about).

You mention you have plenty in the mornings, enough to express - which wouldn't suggest a shortage of milk?  It is though totally normal for milk volume to be greatest in the morning and fall gradually as the day progresses, which can leave mums concerned there isn't enough.  But it's also worth knowing that if we measure the fat content of feeds this increases during the day as volume decreases - magic!

Really you need to look at the big picture.  Does baby pee, poop and gain weight as expected, was he previously settled after feeds and you felt things were going well prior to this point?  Is feeding pain free?  If you answer yes to the above, following your baby's lead and feeding on cue is the quickest way through a fussy spell without using formula (which you mention you would like to avoid using). 

If not and your baby remains unsettled or you're experiencing any pain or discomfort,  there is specialist help out there.  From Lactation Consultants to Breastfeeding Counsellors there are lots of options if you know where to look.  Ask your Midwife or Health Visitor for details of local groups and breastfeeding counsellors, find out who is your local Infant Feeding Advisor or call one of the helplines.  If you prefer there are also private Lactation Consultants who charge for their one to one services.  Keep hunting for effective support, with which the vast majority of mums can make enough milk to satisfy even the hungriest of babies.

When The Breastfeeding Baby Bites

Common advice for a biting breastfed baby is to say no firmly, show baby you mean it and sometimes even sternly place them on the floor.  Indeed Babycentre say:
"Say no firmly, look him in the eye with displeasure and stop the feed. He needs to associate biting with losing the breast - most babies will dislike this separation.  If he persists, put him on the floor for a short time immediately after he bites."
Other advice varies, La Leche League say:
"A mother's natural response to pain may discourage further biting. Many babies startle at their mother's loud exclamation and immediately release the nipple. Some may even cry. This negative reinforcement seems to make many babies stop completely."
Although they do acknowledge:
"Such prompt and direct responses occasionally backfire with sensitive babies, who may react by refusing the breast altogether. This sudden disinterest in nursing or outright rejection of the breast is called a nursing strike. A nursing strike can be distinguished from actual weaning by its sudden onset and the fact that the baby seems miserable. It may take lots of coaxing to persuade a baby who has been "on strike" that it's okay to resume nursing. Therefore, it is wise not to exaggerate your response to biting beyond what is natural for you."
but even they add:
"Some mothers may want to take firmer action after a bite and quickly sit baby down on the floor. After a few seconds of distress, baby can then be comforted and should get the message that biting brings negative consequences."
nursingbaby.com sensibly point out:
"Try not to scream. While it will get baby's attention, it may also be a "reward" for that high need baby who likes lots of action. Of course, sometimes, screaming can't be controlled!"
Is being firm and strict the only way?

To me the above all seems a bit Supernanny, the baby equivalent of time out.  Firm, displeasure, forced separation (rejection) distress, negative consequences all feature in the above.  For babies?  Saying no sternly, showing them you "mean it" etc is very different in the context of nursing than it is if you say no for other trivial things.   Some babies as discussed above can seem to think the act of them nursing has caused the displeasure, or simply don't know and become distressed - responding by ceasing nursing rather than stopping biting.

If we work from the basis a baby knows that biting hurts and he shouldn't do it and thus is deliberately causing someone pain - perhaps the above logic makes more sense.  But I've seen these suggestions for babies 3 months and over, not a 2yr old .  If the potential result is a nursing strike, shouldn't we be exploring if there are other ways of solving the problem?

Is the important message we want to convey that biting causes them to "lose the breast"?  Or is it actually that biting hurts and so we shouldn't bite people?  Which message is the baby able to apply to other situations as they grow?  Do we want our children to not do something because they recognise it's the wrong thing to do, or for a self centered reason ie to prevent something they have being taken away?

The age of the baby and the timing of the bite is also key.

If baby bites at the start of a feed, it can indicate the tongue is not moving forward over the gums as required.  When a young baby gets something in their mouth it triggers the clamp and bite reflex - if the tongue is forward as it should be for nursing, this prevents biting.

For this reason we find babies who have a shallow latch are far more likely to bite, as are tongue tied infants.  Some babies with tongue tie will extend their tongue, but it retracts when touched - this means they come to the breast tongue forward, go to latch - the tongue retracts and they inadvertently bite.

Biting mid feed can be an attempt to increase flow of milk, and a baby having difficulty effectively transferring milk can try this trick, particularly if they have a sippy cup that requires biting to release liquid (such as the leak proof ones with a valve).

Just like above, if the baby starts to slip down the nipple when feeding - the bite reflex may again kick in.

End of feed biting may be something baby tries out when he's finished nursing, just to see what it's like or perhaps because they're teething and gums are sore.  Remember though they have no concept that it hurts - they may like the feeling of biting but babies simply aren't capable of maliciously intending to cause pain.

So let's think about the above again from the perspective of a baby.  Someone who has no idea what being bitten feels like, and even if they have been on the receiving end from another child - still don't make the connection until older that they are causing similar discomfort.

If you accidentally did something that hurt someone, would you prefer them to sternly and curtly reject you with a "no" or would you prefer them to explain that it really hurt and that they really would like you to not to do it again.  Wouldn't the first leave you confused?   What would "no" teach you?  Surely far less than understanding your actions caused pain..

As the second website highlights - baby may find it all a bit bemusing and so try different things he did around that time to provoke a similar response or just repeat the exciting noise he got mummy to make.  That's as far as baby logic goes...

Alternatives
  • Check positioning - if baby is straining slightly to reach the breast, as he tires he can slip back a little prompting his bite reflex (this can also happen if baby falls asleep and starts to fall off).  Holding baby nice and close can help.
  • Feed baby on cue - a schedule fed baby may be more likely to bite if they don't want to feed when offered.
  • Excessive biting is worth checking out with a Lactation Consultant or suchlike, because as discussed above if the tongue is restricted we note baby may be more likely to bite when younger, but also when bigger.  The nipple is more likely to slip causing biting, and some use a compensatory technique to get around the restricted tongue which works until teeth appear!  It can also be a technique to try and increase milk flow.
  • Stop the feed -  but swap stern and showing who is boss, for hurt/pain ie the genuine emotion you feel in that situation.  How you express this depends on the nature and age of your baby.  For some a sad face can suffice, particularly the more sensitive type; some respond better to a pretend cry (as they do to indicate their discomfort).  Some may smile/laugh, although with babies this isn't always genuine amusement - they may instead dislike the emotion you're conveying and so try smiling/laughing in an attempt to encourage you to mimic them.
  • Express it hurts - sadly/genuinely/gently, not angrily.  For a younger baby a simple "ouch, biting hurts mummy", can suffice.  For an older nursling you can explain "biting hurts, please be gentle" or "if you need to bite, you can bite this (giving a teether or suchlike) not mummy" etc
  • Offer something else they can bite - a damp (clean!) facecloth placed in the freezer for a short period can make an instant teether a younger baby can hold on to.  Some mums find something cold before a feed (or applying typical teething remedies if used) can prevent biting during feeding, others find it makes it worse..
  • If they repeat - some may find all the response to the biting so interesting they go straight back for another go.  This isn't your baby being naughty or challenging you, it's normal learning about cause and effect, how/why etc.  Instead of stopping the feed and placing baby elsewhere, again calmly repeat the above and then isntead of re-offering immediately distract with something else or find something else interesting for you both to do. This still sends the message biting hurt and can't continue, without distress and rejection.
"Pain" or "Ouch" 
  • Try baby sign - I believe signing is a fantastic way of babies understanding big concepts like pain.  You can sign it when they bump or hurt themselves, if someone else hurts themselves and shows distress and so when you sign it, it can help them link everything together.
The pain sign is directional so you can move it to the appropriate point of pain ie if it's a painful foot you sign pain over the foot, a hurt breast the same. As a result I've seen preverbal babies able to convey their gums hurt by signing in their mouth or one 13 month old tell the doctor his throat hurt - it can be invaluable in other ways too!
If my youngest nibbled during feeding and I explained it hurt, from around 10/11 months he would sign sorry and reattach super carefully -

  • Hawk eyes - as discussed a baby has to shift from a good attachment to one with his tongue retracted to bite (which he may do by pulling backwards), so watch closely and remove him quickly as soon as he starts to adjust.
How to remove a biting baby from the breast
Simply pulling a baby from the breast can cause damage to the nipple and potentially further clamping

1. Pop your finger in the corner of your baby's mouth between his gums (or teeth!) Keep your finger
there to prevent further clamping whilst you pull nipple away.

2.  When you notice baby starting to slip backwards, pull baby closer to the breast - this can prevent biting and prompt an open mouth to extract your nipple.

14 Tips For Expressing To Increase/Maintain Breastmilk Supply

1.  Consider Which Method Is Best For You:
In the first few days after your baby is born when colostrum is being produced, hand expressing is typically the most effective way to express. Typical volumes are around a tsp or two and can get lost in the mechanics of a breastpump.  Using a pump after hand expression is shown in one study to be beneficial to milk supply.

One volumes increase, double pumping with a hospital grade pump (such as the Ameda Elite) is for many the most effective in terms of removing milk as well as stimulating higher levels of prolactin.(1) It is also faster - therefore if you're exclusvely pumping, trying to increase supply or need to express regularly and want to reduce time they can be great to have.  In the UK your hospital or Surestart Centre may be able to loan you one, or you can hire them privately via pump agents and online.

Some mums do find they can hand express particularly well, but using both hands on techniques and pumps as outlined in point 2 appears particularly effective where possible.  Other mums struggle to hand express, and this video clip is well worth a watch if your current technique isn't working well.

If you're using a double pump, many will also allow either one or two collection sets to be attached - so you can start out with both and then switch to single if you want to use hands on.

An alternative is a hands free expressing bra such as this - you can see this demonstrated if you click the link in point 2.  


2.  Hands On Expressing:  View this clip   Yes it's aimed at mothers expressing for their premature infant, but anyone expressing can use these techniques.  Not only will you obtain more milk per express (the mothers in the video got double), but as the clip describes also increases supply as the breasts are well drained.

3.  Power Pumping: Some mums find "power pumping" can give supply a boost.  It is basically expressing more frequently mimicking a baby having a growth spurt.

Pump for 10-20 minutes

Rest for 10 minutes

Pump for 10 minutes

Rest for 10 minutes

Pump for 10 minutes.

This can be done once per day with standard pumping at other sessions, or back to back over a day or two before returning to typical pumping.

4.  To save washing flanges etc after each use: Pop in a ziplock bag or airtight tub and store in the fridge between uses (remember to rinse under hot water to warm them up before use!)  Then wash well with hot soapy water at the end of the day.  Sterilisation is not normally needed, one study that compared bacterial contamination of  milk when collection by sterile kits and a mother’s own kit, found no difference (2)

5.  If you're trying to build additional milk: Say for building a stash ready for returning to work (but don't need the milk immediately on demand for the baby) or are maintaining supply by pump, where feasible choose set times to express and try and stick within a 2 hour window of this time.  Ie if you pick 1pm, try and express as close to that time as possible - at least between 12-2.

6.  If pumping to supplement ie you need the milk now and want to increase supply, expressing around an hour after feeding your baby can give more milk than expressing immediately after, and still allow a gap before the next feed.

Mums with chronically low supply may find their breasts refill more slowly and if baby is feeding every 1 1/2 - 2 hours, expressing after an hour can leave them feeling emptier than usual for the next feed - in this instance expressing straight after the feed (or after the supplement is given if appropriate) may work better.

7. Some mum find starting with a faster speed yet low suction help trigger the milk ejection reflex (letdown):  You can then slow the cycle down, but gradually increase the vacuum to the maximum level that is comfortable.  Some pumps have cycles that automatically follow this pattern, others require manual adjustment.  Never turn the suction up more than is comfortable.

8.  Create sensory triggers:  When a baby is feeding, the contact, smell, sounds of baby can help the milk to flow.  Pumping is in comparison mechanical, and a learnt art that can take practice - introducing sensory stimulation can therefore help.  Some ideas include applying warmth to the breast before feeding, smelling/touching/stroking baby if possible, if not a photograph and an item that smells of them can help, perhaps even a recording of sounds they make on a phone, a video clip or suchlike.

Many mums find visualising flowing milk to be surprisingly effective, and light massage to the breast as shown in the video in clip 2.  Some mums find that they literally have to tune out and watch a film, read a book or magazine once letdown has been triggered - others find they yield more by watching or visualising; play around and see what works for you.

9.  Create positive associations:  Very few mothers love expressing and a lot hate it!  Therefore trying to link a positive association to pumping can help with the psychological aspect.  One mum saved her "trashy mags" for pumping time, another had a chocolate each time she expressed and a rather nice partner recently gave mum a shoulder/neck/foot massage when she expressed.  It of course depends on age of baby, whether partners are around, how long you are expressing for etc but as they say a spoonful of sugar...

10. Night pumping:  It's best to pump when you naturally wake during the night to tend to baby if possible, if you're apart from baby or struggle to wake some recommend drinking a large glass of water to prompt a middle of the night waking.  The logic is that waking naturally occurs during a lighter sleep cycle and thus you feel more well rested by morning than if disturbed by an alarm when in a deep sleep.

Night expressing is important for most mums trying to build or maintain supply with a pump, as prolactin levels are higher in the early hours.

Keep a cool bag/box next to the bed so you can pop expressed milk and pump parts in their until morning to save trekking to the fridge, and invest in a nightlight so you don't need to turn bright lights on to find everything.

11.  Pump frequently enough:
"A normal newborn baby nurses on average 8 to 12 times in a 24 hour period. Most experts suggest it is best if mom can come close to matching what the normal nursing baby would do at the breast, and recommend she pump about every two hours, not going longer than three hours between sessions. Understanding how milk production works can help moms in their efforts to establish good milk supply. The more frequently the breasts are emptied, the more milk mother should have. Therefore, if she were to pump at least every 3 hours, for about 20 minutes, she should establish and maintain a good milk supply. In the first couple of weeks, she may also want to pump at least twice at night, but not all mothers do this." Kellymom
12.  Pump for long enough:
This is typically 15-20 minutes, some suggest 5 minutes after last drops of milk.  If your baby needs you mid express however don't panic, you can try and slot an extra express in later if needs be - or perhaps do a few shorter expressions closer together (a variation of power pumping)  there has to be some degree of flexibility if mum is home alone and expressing longer term.

13.  If you have larger breasts play around with positioning.
I supported a mum recently who expressed with massage, yet applying slightly more pressure to the flange (not an uncomfortable amount) delivered even more milk still, so play around with pressure, positioning etc during different parts of the feed for maximum production.  Similarly try not to spend long periods expressing leaning forward too much - or you can end up with sore shoulders and back.  Get some pillows, cushions and get comfy.

14.  Use heat
Evidence suggests applying heat to the breasts prior to feeding increases expressing levels.  Heat packs that can be reheated in the microwave can be an easy and affordable option.

Remember the amount you can express is not an accurate reflection of the volume produced.  As the video clip in point 2 highlights, mother's can as much as double milk production after using an electric pump - highlighting they do not alone drain the breasts well.  Oxytocin levels are typically naturally lower when pumping (hence the additional sensory stimulation) and some mums do struggle to express well, even when they have lots of milk.

Do you have any other tips and tricks that worked for you?

1. Auerbach, K. Sequential and simultaneous breast pumping: a comparison. Int J Nurs Stud 1990; 27(3):257-65.
2. Mohrbacher, N. and Stock, J. The Breastfeeding Answer Book, 3rd Rev Ed. Schaumburg, IL: LLLI, 2007