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.

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

5 Reasons Infant Formula Isn't The Lazy Option

I seem to have come across loads of comments recently suggesting formula is an easy/lazy option, both from parents using formula and those who don't. And I have to be honest and say it really baffles me.

Sure I can see how in the very early days if a mum has breastfeeding problems, is getting passive support and has problems nobody can seem to resolve - formula is easier in comparison.  Pain stops, a baby who hasn't been feeding well is likely to look more settled when given a bottle, anyone can make up the bottles and feed the baby, mum can sleep!

But let's be honest, this time is but fleeting.  Relatives who may flock to see the new arrival, soon head home.  Partners return back to work, often far less agreeable to making and delivering night feeds when they have a full day of work ahead compared to mum who is at home and can sleep when baby does.  For many, especially if family and friends work - by 3-4 weeks postpartum the days (and often the nights) are mum's alone; yet baby will need milk feeds for a further 11 months +.

Take out these early few weeks and directly compare breast and bottle feeding (in this sense to mean formula), and let's compare how easy it is:

1.  Making A Feed
1. Clean the surface thoroughly on which to prepare the feed  
2. Wash hands with soap and water and then dry.
3. Boil fresh tap water in a kettle.  Alternatively bottled water that is suitable for infants can be used for making up feeds and should be boiled in the same way as tap water.   
4.  Important:  Allow the boiled water to cool to no less than 70º C.  This means in practice using water that has been left covered, for less than 30 minutes after boiling.
5. Pour the amount of boiled water required into the sterilised bottle.
6. Add the exact amount of formula as instructed on the label. Adding more or less powder than instructed could make the baby ill.
7. Re-assemble the bottle following manufacturer’s instructions.
8. Shake the bottle well to mix the contents.
9. Cool quickly to feeding temperature by holding under a running tap, or placing in a container of cold water.
10. Check the temperature by shaking a few drops onto the inside of your wrist – it should feel lukewarm, not hot. 
11. Discard any feed that has not been used within two hours (Department of Health & Food Standards Agency).  Note the Infant Feeding Council recommend feeds are discarded within 1 hour.

1.  Lift/open shirt/top
2.  Unclip Bra

2.  Night Feeds
1. Get up and go to kitchen
2. Follow guidance as above
3. Try and pacify baby whilst waiting for feed to be ready
4. Go back to bed
5. Sit up and feed baby
6. Wind baby
7. Settle baby back to sleep

1.  Roll over before baby fully awakens
Optional stage 2: open nightclothes if wearing

3.  Out And About
Option 1 - Ready to use liquid feeds are sterile and are the safest option.  However, they are a more expensive option and therefore may not suit all parents.

Option 2 - Take & make as required, next safest from microbial contamination/infection point of view
1.  Put boiling water in a sealed vacuum flask and use this to make up fresh formula milk when needed. 
2.  Pack large bag with powder, pre boiled water in a flask & pre sterilised bottles.
2.  Find somewhere to mix and serve.

Note:  Ensure you've packed sufficient bottles/powder/water for the duration of your outing, plus extra in case of travel delays/unforeseen circumstances.  Care should be taken to avoid scalding when making up the feed.

Option 3 - Preparing powdered feeds for later use.  It is the length of time for which the reconstituted formula is stored that increases the risk of bacterial growth. Reducing the storage time will therefore reduce the risk.  

1. Prepare feeds in separate bottles, not in one large container (e.g. a jug)
2.  Follows steps above ‘Making a feed".
3.  Store the feed in the fridge at below 5º C. Prepared bottles are best kept in the back of the fridge and not in the door. 
4.  The temperature of the fridge should be checked regularly.   A fridge that is opened frequently may need to be set at a lower temperature to ensure that it does not rise above 5 ºC during times of frequent access.  The thermostat in older fridges without temperature settings may need to be adjusted to ensure that the temperature is below 5º C. 
5. The risk of infection to a baby will be lower if the feed is only stored for a short time. Feeds should never be stored for longer than 24 hours and this length of time is no longer considered ideal especially for young babies.  

Because of the potential for growth of harmful bacteria during transport, feeds should first be cooled in a fridge (below 5º C) and then transported.

1. Prepare feed(s) and place in the fridge as outlined in section ‘preparing feeds for use later’.
2. Ensure feed has been in the fridge for at least one hour before transporting.
3. Only remove feed from the fridge immediately before transporting.
4. Transport feeds in a cool bag containing a frozen ice brick.
5. Feeds transported in a cool bag should be used within 4 hours.
6. Re-warm at the destination as in section ‘Re-warming stored feeds’.
7. Alternatively if you reach the destination within 4 hours, feeds transported in a cool bag can be placed in a fridge and kept for up to a maximum of 24 hours from the time of preparation - this is not ideal as the risk of illness increases the longer it is stored.

Rewarming stored feeds:
1.  Re-warm using a bottle warmer, or by placing in a container of warm water (if out and about you also need to find somewhere to access this if not carried).
2.  Microwaves should never be used for re-warming a feed.
3.  Never leave a feed warming for more than 15 minutes.
4.  Shake the bottle to ensure the feed has heated evenly.
5. Check the feeding temperature by shaking a few drops onto the inside of the wrist - it should be lukewarm, not hot.

1. Lift/open shirt/top
2.  Unclip Bra

4.  Cleaning
1. Wash hands thoroughly before cleaning and sterilising feeding equipment
2. Wash feeding and preparation equipment thoroughly in hot soapy water
3. Bottle and teat brushes should be used to scrub inside and outside of bottles and teats to ensure that all remaining feed is removed
4. After washing feeding equipment rinse it thoroughly under the tap
5. If using a commercial steriliser, follow manufacturer’s instructions.  If your bottles are suitable for sterilising by boiling: fill a large pan with water and completely submerge all feeding equipment, ensuring there are no air bubbles trapped; cover the pan and boil for at least 10 minutes, making sure the pan does not boil dry.
6. Keep the pan covered until equipment is needed.
7. Wash hands thoroughly and clean the surface around the steriliser before removing equipment.
8. It is best to remove the bottles just before they are used. If the bottles are not being used immediately, they should be fully assembled with the teat and lid in place to prevent the inside of the sterilised bottle and the inside and outside of the teat from being contaminated.

Shower/Bath/Wash as desired.

5.  If Baby Needs To Be Left With Friend Or Relative
1. Give baby, formula powder, equipment and full guidelines above about preparing formula safely.
2.  Ensure caregiver understands failure to make appropriately could lead to serious illness for baby.

1.  Express and give fresh breastmilk or frozen previously expressed and relevant feeding equipment (bottle, cup or syringe) with guidance that fresh breastmilk is fine at room temperature for 6 hours, frozen can be stored in the fridge until needed and gently warmed in warm water before use (or is fine served room temp)
2.  Reassure caregiver that breastmilk is antimicrobial and antibacterial and doesn't need high heating to kill bacteria.

Now really - still think formula is a lazy option?

The Breastfeeding Network: Expressing & Storing Breastmilk

Do Attached Parents Get More Sex?

The focus around "attached or attachment parenting" (AP) has been sex orientated recently. Firstly The New York Times published this "piece" (and really, that's code for drivel), closely followed by this offering from Jill Filipovic for Feministe (a feminist blog) by The Guardian.

Whilst I'm sure we could dwell a while discussing possible motivation of these papers or their selection of writers (a bloke who quite rightly was summed up by Jill as "sounds like a total dick", and a 20 something feminist lawyer) - especially given The Guardian have writers such as Annalisa Barbieri on their team, who write with experience and substance on such topics, let's move along.

Jill deftly attacks James' clearly sexist attitude, whilst still getting a dig at attached parenting - just not for the reasons James gives.
"It would have been nice to see a decent take on the impact that attachment parenting can have on a marriage when it becomes a barrier to intimacy, or an article about how attachment parenting very much feeds into traditional ideals about women existing to serve and sacrifice for their children, or a piece on how sharing a bed with a kid until the kid is in third grade really puts the kabosh on sexytimes."
"Breastfeeding for five years can be a real issue; denying that isn't particularly helpful".
"There are certainly lots of good criticisms to be made about attachment parenting" 
And Jill has AP'd how many children exactly?

So let's actually start with what AP is and isn't about.  Whilst I'm sure it's super handy for some to believe there are neat little rows of  parenting labels "attached parenting", "detached parenting" and so on.  This simply isn't the case - not all parents who considered themselves attached bed share or breastfeed, so it hardly seems fair the AP banner seems to be a "catch all" ie a stereotype.   Instead AP is simply a basic foundation of ethics which can and is interpreted differently by each and every family.  Jill herself acknowledges this to some degree, before saying:
"But the whole philosophy was spelled out by a rightwing misogynist who saw women's "natural" roles as mothers and servers of children; his view, basically, was that women should sacrifice everything for their kids and centre their entire worlds around those kids, because that's what good women do. In my view, that's not particularly good for women or for kids (have you met adults who grew up believing they were the centre of the entire universe? They are not pleasant or well-adjusted people)."
But this isn't strictly true.... 
Attachment theory is the joint work of John Bowlby and Mary Ainsworth (Ainsworth & Bowlby, 1991 ). Drawing on concepts from ethology, cybernetics, information processing, developmental psychology, and psychoanalysts, John Bowlby formulated the basic tenets of the theory. 

He thereby revolutionized our thinking about a child’s tie to the mother and its disruption through separation, deprivation, and bereavement. Mary Ainsworth’s innovative methodology not only made it possible to test some of Bowlby’s ideas empirically hut also helped expand the theory itself and is responsible for some of the new directions it is now taking. Ainsworth contributed the concept of the attachment figure as a secure base from which an infant can explore the world. In addition, she formulated the concept of maternal sensitivity to infant signals and its role in the development of infant-mother attachment patterns."

About Bowlby personally:
"After graduating from the University of Cambridge in 1928, where he received rigorous scientific training and some instruction in what is now called developmental psychology, Bowlby performed volunteer work at a school for maladjusted children while reconsidering his career goals. His experiences with two children at the school set his professional life on course. One  as a very isolated, remote, affectionless teenager who had been expelled from his previous school for theft and had had no stable mother figure. The second child was an anxious boy of 7 or 8 who trailed Bowlby around and who was known as his shadow (Ainsworth, 1974). Persuaded by this experience of the effects of early family relationships on personality development, Bowlby decided to embark on a career as a child psychiatrist (Senn, 1977h) Concurrently with his studies in medicine and psychiatry, Bowlby undertook training at the British Psychoanalytic Institute."
What's also interesting is that Mary Ainsworth was in her time considered somewhat of a feminist - she   enrolled at the University of Toronto in 1929 and was only one of four to complete an honors degree in psychology. After completing a PHD and serving in the American corps, Mary returned to the University of Toronto as assistant professor and taught introductory psychology, experimental psychology, and personality assessment. After meeting her husband Mary moved to London and secured a research position at the Tavistock Clinic under John Bowlby. After a stint and a study in Uganda, they moved to Maryland and Johns Hopkins offered Ainsworth work as a lecturer. But it wasn't plain sailing:
"Ainswirth did face salary discrimination during her first years at Johns Hopkins, receiving less money than her male colleagues. She was responsible for integrating the John Hopkins Club, where the male faculty lunched in the main dining room, while the females ate in a smaller, separate one. One day, she dressed in her best, pinned on a corsage, and took a table in the middle of the male-only room and waited until she was eventually served." here
Of the relationship of her research to the women's movement, Mary Ainsworth acknowledged that her work might be interpreted as a dictate to mothers to stay home with their children during the early years. And while she emphasized the importance of a secure attachment between infant and caregiver, and that full-time mothering may be the usual way of ensuring a secure attachment, she did not deny that alternative arrangements were possible. She said, "Had I myself had the children for whom I vainly longed, I like to believe I could have arrived at some satisfactory combination of mothering and a career, but I do not believe that there is any universal, easy, ready-made solution to the problem" (Ainsworth, 1983, p. 216).
So this wasn't merely one unqualified woman hater tossing around a few random ideas.  Anyone interested in AP may enjoy  THE ORIGINS OF ATTACHMENT THEORY:  JOHN BOWLBY AND MARY AINSWORTH here

Furthermore there is ample evidence should anyone care to delve, that shows children who have their needs responded to when small actually grow up to be more secure, independent, empathic etc.  Are these traits you typically associate with self centered people?  Let's be clear there is a distinct difference in responsive and permissive, buying little Jimmy everything they want and never saying no is not AP.

Don't the numerous cultures who practice AP as standard demonstrate the above is clearly bluster?  Mongolia is just one example.

I absolutely don't think AP is at all about "women existing to serve and sacrifice for their children" - otherwise how come some parents work outside the home?  How come in some families it's the dad/partner who does the attached parenting?  

 In fact one of the principles as outlined by  Attached Parenting International is:

"Strive for Balance in Personal and Family Life - it is easier to be emotionally responsive when you feel in balance. Create a support network, set realistic goals, put people before things, and don't be afraid to say "no". Recognize individual needs within the family and meet them to the greatest extent possible without compromising your physical and emotional health. Be creative, have fun with parenting, and take time to care for yourself."
Consider for a moment that a mum who chooses to stay at home with her children might feel the only thing she has sacrificed is perhaps a job she may not have actually liked that much anyway!  That by being responsive to their child's needs as a couple, doesn't in turn automatically means their needs or those of their partner are not met (in fact the opposite may be true).  Even if the mother does consider her parenting style a sacrifice, isn't that her choice if she feels the payoff is worth it?

As Charlene noted on Facebook:
"It's ok to make sacrifices for career apart for a job, work and go to school...or for a nation's deployed and you're a hero...but make sacrifices for a few years for your children and woah nelly, we can't have that. Why is it that traditionally feminine things are still looked down upon? How is it equal rights if we have to change our life choices to the ones they attribute with value in order to be seen as worthy?"
I also wonder how often AP is a barrier to intimacy as Jill suggests.  If only one parent is on board with any parenting style, this in itself may cause a barrier between parents,  I've heard this being the case for couples where dad wants to leave baby to cry it out and the mum feels this is instinctively wrong.  But do we really not think "detached parents" don't have differing opinions too?

If both parents share the same principles around raising children, and can listen and acknowledge their child's needs, does it make sense they then ignore each others?

As another Facebook reader said:
"We AP big time, but we also have a very attached marriage, and this article is very far from reality. =P My husband and I have been an "every day" couple from the beginning and that won't be changing anytime soon. ;)"
Something else rarely mentioned is that breastfeeding bedsharing mums often get more sleep and of a better quality ie they are more well rested.  From my own experience this is certainly true - with number one, several night wanderings to the "nursery" plus time spent then trying to get baby to settle alone, meant the only thing I was interested in on hitting the sheets was sleep - and pretty please let it be for more than 1 1/2 hours!

Several mums commented that breastfeeding gives them a super quick easy way to get their baby back to sleep in the evenings, also freeing up more "couple time".  Those that had followed a more detached parenting style with some babies, but used more attached techniques with others -  all commented that the latter was so convenient, easy and ultimately less time consuming that again more "sexy time" was on the cards.

And seriously, is having a toddler in the bed really likely to be a barrier to sex if two people want it?  Lordy I'm gagging but darn the toddlers in the bed, that's that then...With that knowledge we should be able to eradicate teen pregnancy by banning the bedroom right?

Or sigh who has the energy when they've been looking after children, breastfeeding and APing all day, I was so much more up for it when I was making up 10 bottles per day according to DOH guidelines, sterilising them, doing a nursery run before commuting to my high powered full time job, right before coming home and sleep training the baby...

For real?

I'm sure lots of AP couples have less sex than one or the other would like, but I'm equally sure that's the case for couples with an opposing parenting style.  One mum raised a good point on Facebook:
"I do actually wonder if these men aren't "Getting enough" because they are general arses rather than their wife's breastfeeding habits   You have to feel an attraction to someone mentally and physically to want to have sex with them"
And perhaps for men not getting it, blaming the parenting style might seem logical and convenient - rather than considering other possibilities.

A dad on Facebook summed up the first article well
"I would suggest that, because he may not want to look too closely at other aspects of his relationship, he may be oversimplifying things down to this one issue."
Or perhaps a bit more bluntly by this mum:
"Sounds like he needs to up his game and learn the art of seduction... Being a twat is a major turn off to most women, including breastfeeding women"
Another added:

"The problem he described was not that his wife didn't want to have sex with him, or that he wasn't allowed to touch her breasts, it was that the sight of her breastfeeding made him physically ill. Sounds like he needs professional help. He's the one causing the marriage to be sexless."
And surely no self respecting feminist would suggest a woman sacrifices something so significant to her own health because it turns a man off? (well this particular "man" anyway!)  Burn your bra's but heaven forbid a man can't find his wife erotic if she also uses that breast to feed a baby.  Back to the seemingly "single function" of breasts.

Another mum tackled Jill's comment of "Breastfeeding for five years can be a real issue; denying that isn't particularly helpful." head on:
"for whom the issue??
where are these miserable husbands??
'oh no, we hate doing sex on the couch/kitchen counter/stairs/in the shower/spare room/living
room rug in front of the fire!' I hear them cry
'it's so terrible for me to see that my child is secure, nourished and healthy, and I hate watching those loving snuggles!' they moan
'and knowing that my wife's risks of cancer are reduced every day she continues makes me so sad!'
oh? there are none of these?
well that may be because we try to marry the sane fellas. The mad ones are all out there holding their wife back from comforting their crying offspring."
What's also fascinating is that nearly one in four American couples sleep in separate bedrooms or beds, the National Sleep Foundation reported in a 2005 survey. Recent studies in England and Japan have found similar results. And the National Association of Home Builders says it expects 60 percent of custom homes to have dual master bedrooms by 2015.

Better quality sleep and "keeping the marriage fresh and frisky" are just two reasons cited here and here - nothing to do with children.  Yet throw children into the mix and mention your husband heads off to a separate space whilst you sleep with the toddler, and most are gasping, breaking out in a cold sweat and offering marriage guidance.

So is AP code for neglected relationships in favour of the children?  I will let Facebook fans again sum up:
"Hmm... well I co-slept with all of them... including twins and... let's put it this way... I have five children!"
"I think it has spiced up our sex life. We have to be more creative. Like I saw on a t-shirt once, "Co-sleepers get dirty... in the garden." Lol "
"I always wonder do these people not have sofas? or, a la postman always rings twice, kitchen tables? ;-D"
"Do these people not have any imagination? DH and I have not slept in the same bed for the last 13 years. He got kicked out after baby no 4, because he snores and no one got any sleep. We have managed another five babies since then, def hasn't caused us any issues ;-)"
"Being too tired to do the deed with a small person to take care of is a FAR bigger reason for less frequent nooky than co-sleeping could ever be. If you both WANT to get amorous, you will find a location to do it. If one of you doesn't, you will find an excuse - and 'the bed is occupied' is an excuse - not a reason "
"This article is complete balls. Sexless marriage? Really? Are any of us co-sleeping, breastfeeding, AP mothers in a sexless relationship because of our parenting choices? REALLY? Utterly ridiculous."
"Erm I've been bfing for 6 years continuously and am pg with my 4th child (3rd pg since I started bfing) so I really don't think 5ys of bfing causes a sexless marriage and neither would my husband!!"
"Clearly this author has no idea that AP practices are how millions of people have parented from before we came down from the trees." 

Further reading: 

Is TAMBA failing mums of multiples for profit?

Head meet DeskWhen a mum of twins dropped off an article from the latest edition of the TAMBA magaazine.  It was time for head to yet again meet desk.

The "Twins and Multiple Births Association" (TAMBA) is (according to their website) a charity set up by parents of twins, triplets and higher multiples and interested professionals. They state:
"Our campaigns, research and support services directly help thousands of parents and professionals meet the unique challenges that multiple birth families face."
I think it's safe to say that TAMBA are pretty influential in the world of multiples, the vast majority expecting more than one baby will be given their details by someone  Which to be honest only makes the following even more depressing...

The piece is entitled "Breast, Bottle or Both"; but in reality it's basically an advert for the "Yoomi" feeding system - so much so that I scanned the page twice to look for the word "advertisement" that usually lurks somewhere on a page such as this.  In short it's a "you have twins FGS, don't feel bad if you can't feed them both! and instead say Hurrah for Yoomi!" (again)

And of course mother's shouldn't feel bad, particularly when articles like this are being dished out by people like TAMBA.

So why would TAMBA promote Yoomi in this way?

A visit to Yoomi's site reveals:
"This year yoomi is turning Red for Tamba and donating 10% of all red collar sales to the charity dedicated to help families raise multiple bundles of joy."
"To support multiple birth families, yoomi has just launched an exclusive online ‘Twin Set’ that includes enough bottles, warmers and teats for your little ones!"
"Here at yoomi, we’re really pleased that our bottles are fast becoming a feeding time essential for all parents but especially for families facing the challenges of quickly and safely warming 2 (or more!) bottles." 
Yeah I bet - kerching!

In fact Yoomi go as far as to post the following comment from one mother:
“This is the next stage of baby care and should be handed out to every twin mother on the NHS. It saved time, money and my sanity!"
The NHS should give mums of multiples self warming bottles, really?  The priority for a state funded healthcare system shouldn't be curing cancer or easing the suffering of many by reducing waiting times - it should instead dish out a product that serves to undermine infant health?  Delusional much?

The lovely mum who gave me the article, has written her own complaint which highlights much of what I wanted to address - and has kindly agreed to share:
I was dismayed and disappointed to read the article “Breast, bottle or both?” in the latest issue of Multiple Matters. The article is unethical, inaccurate and undermines mothers’ efforts to breastfeed their babies. Mothers must of course make their own choices about feeding method, but this should be an informed choice. This article’s misrepresentation of the facts damages informed choice.

The article contravenes the International Code of Marketing of Breastmilk Substitutes. As I am sure you are aware, this Code seeks to ensure feeding choices are not distorted by commercial marketing. Bottles and teats such as those made by Yoomi fall within the scope of the Code, which states:

“5.1 There should be no advertising or other form of promotion to the general public of products within the scope of this Code.”

An article apparently written by a bottle manufacturer and which lauds the benefits of their bottles and teats (the “How can Yoomi help?” section) is clearly promoting bottles and teats to the general public in contravention of the Code. The Code exists to protect parents from inaccurate marketing information. As a TAMBA member I am horrified that you are allowing marketing of a product to come before unbiased, accurate information. TAMBA’s own feeding policy states that it complies with the Code, and states that “informing and empowering our parents was of paramount importance”, yet this article fails to comply with the Code and gives partial and misleading information – hardly empowering.

The article itself is full of negativity about breastfeeding under a thin veneer of “breast is best” rhetoric. If I knew little about breastfeeding I would come away from the article with the impression that breastfeeding is the gold standard, but that only a few lucky people can make it work. Let me give you some examples:

- “… for some women breastfeeding… is too much with multiple babies”. This statement suggests that breastfeeding is more effort than bottle feeding. Breastfeeding twins can be intense, but washing and sterilizing bottles and making up feeds is also a lot of work. This is especially so with the new guidelines for making up formula, to reduce the risk of bacterial contamination making babies ill. The guidelines recommend making up one feed at a time and have very specific requirements which are onerous. The recommended 14-step (!) process can be found at The article omits to mention the new guidelines and the need to make up formula safely, which seems bizarre in a discussion of the issues around feeding methods.

- “…Asa had a poor sucking reflex and tongue tie. Asa is now bottlefed…”. Leaving this mum’s story at that suggests that a poor sucking reflex and/ or tongue tie are problems to which the solution is to move onto bottles. In fact, with treatment of the tongue tie and good breastfeeding support these problems can be overcome. I should know, as both my twin girls were tongue tied and one had a disorganized suck. Both are breastfed.

- “Laura’s twin girls were six weeks premature and needed feeding every three hours”. This statement implies that because the babies were premature, they needed feeding more frequently than term babies, and that every three hours is unusually frequent. In fact, three hours is a long time to go between feeds for even a healthy newborn. Newborn babies need to feed at least 8 – 12 times in every 24 hour period, and (for example) feeding every hour at certain times of day is normal. Misrepresenting the biological norm for babies’ need to feed frequently is likely to lead to mothers believing that they don’t have enough milk because their babies cluster feed in the evenings, or to insufficiently frequent feedings in the early days because mothers think their baby shouldn’t be hungry as “it’s only been 2 hours since she fed”.

- “Luckily, both Cuba and Lucia breastfed well, but after six weeks Laura introduced a single bottle…By the time she moved onto weaning, both were used to a bottle and it was an easy transition.” This mum may have had good reasons for introducing a bottle and then weaning, but because the article didn’t explain these it implies that weaning to formula milk is necessary (something you need to do, and earlier than a year if bottles are going to be needed), and that introducing a bottle from six weeks will make the process easier. Neither of these things is true.

Another important omission from the article is that there are alternatives to bottle use if top-ups are needed which can be less disruptive to breastfeeding e.g. cup or syringe feeding, supplementers. But then Yoomi doesn’t make cups, syringes or supplementers…

Finally, there is a great deal of emphasis in the article on not feeling guilty if you don’t manage to avoid using formula. There is an excellent article by Diane Weissinger, first published in the Journal of Human Lactation, (it can be found here) which covers the guilt issue, as well as the problems of bias I’ve given examples of above. I think TAMBA’s trustees would find it interesting and thought-provoking.

I acknowledge that TAMBA has become more supportive of breastfeeding in recent times and I was pleased to see several new initiatives highlighted in the same issue of Multiple Matters in which the “Breast, Bottle or Both” article appeared. Unfortunately the Yoomi advertorial and other Code contraventions (e.g. 20% off NUK teats) undermine the credibility of these efforts. TAMBA’s positive contributions to breastfeeding support for mothers of multiples do not excuse its error of judgment in publishing the “Breast, Bottle or Both” article.

I am currently minded to resign my membership of TAMBA, but I will await your response to this letter before making a decision.
Joanne Whistler 
If there are "booby traps" when it comes to feeding a singleton, these are often amplified the more babies you are having (a mum of triplets recently told me not a single person had presumed she would be breastfeeding them!).

So I wondered what those who had multiples felt. Had they found generally people were supportive of breastfeeding? Did they get lots of positive affirmations they could do it?  Lots of practical support and tips?.

The replies:
"My gosh, no! I heard so much "oh well there's NO WAY you can breastfeed them both! You'll have to supplement for sure!" So I did. Then I just stopped BFing altogether. I was 18. They were my first children and I had no idea formula was not "equal" to breastmilk. I sure was told it "just as good" several times by medical professionals though. :/"
"Nope. Most mamas I meet in mother's group think they can't. 
No. Quite a few people said "well you won't be breastfeeding then" despite the fact i'd already bf successfully twice before."

"I found that many people think that you can't possibly nurse twins. When I was in the hospital, the attending pediatrician said that most of her twin moms didn't nurse, nursing twins is too much of a hassle. Most people I can into assumed that I bottle fed my twins.
I just had the attitude that I would do it, there was no question about if I 'could'. Some of my biggest supporters of nursing my first child were doubting that I would be able to 'keep up' for more than a couple months."

"I can't recall any negative comments, but I have gotten a lot of (positive) "Whoa, I can't believe you're doing that!" comments. Individuals, interacting with me specifically, have been great. However, there is *not* a whole lot of support out there, and even other twin moms dole out horrible advice on dealing with breastfeeding twins (like having to pump in order to have enough of a supply, which is totally unnecessary if your babies are nursing well)."

"Most people just assumed I would or did bottle feed, they were surprised when I said I bf'ed both, but also really impressed."

"This will be interesting as I am due to be induced with my id twins on Saturday and will be breastfeeding them. I have recently cancelled my tamba subscription as I've not found them much use in general and was disappointed with their attitude to bf."

"When I found out I was expecting twins I was really terrified at the idea of attempting and failing to BF again, and then having to deal with formula and bottles x2. Tamba's advice just made me feel worse, it seemed geared towards letting mums down gently :s Antenatally the midwife didn't talk to me about feeding at all and in the ward after having them the nurses kept telling me I could use the nursery/top-up and not to 'be a martyr'. Both the at home MW and then the HV seemed shocked that they were BFing, and then that they put on weight. I even got accused of lying by one HV at 12 weeks when they'd put on so well!"
"From a peer support point of view a common misconseption is that especially if you have older children, it's impossible to ebf or bf at all your twins, regardless of birth age. People have and share harmful "quiet knowledge" whereby mum is set to fail by the well meaning "Oh, don't tire yourself out, give lots of quality time to older sib, share the feeding with x (grandparents etc.)". Somehow especially twins are expected to be like trophies to be passed around to every lap in the house and fed there too."

"The first night after I had my twins following a long and traumatic labour they were taken off by a nurse. She told me not to ridiculous, that I couldn't bf twins as an exhausted mummy was no good to anyone. I agreed she could give them formula, but asked that they were cup fed. They weren't."

"Most of the people I encountered were either unsupportive (pediatrician- who sent me home with a plentiful supply of ready made formula and wouldn't take no for an anwer...and yes, I have since left this practice) or didn't seem to care (staff at the OB practice)"

"I was repeatedly told that I wouldn't be able to bf my twins as I wouldn't produce enough milk. No one encouraged me and many told me that I would be too tired to keep up the early stage of bf then topping up (both lost weight and were quite poorly, I insisted all top ups by cup only) and then expressing but I did and got them both exclusively bf, much to everyone's surprise!!"

"I am exclusively bf my twins (11 weeks now) . They've never had any formula, but the health visitors, midwives and lots of other mums (including one twin mum who tried but was fully formula feeding by 3 months) told me I couldn't do it, or shouldn't, that I was making it way harder than it needed to be and the odd formula bottle was no problem. Just to add - the comments were mostly from friends and family. All health care professionals, or nearly all, were fully supportive and did everything they could to help me establish breastfeeding. I never felt undermined or forced to top up with formula because of inadequate supply." 
‎'You can't breastfeed twins - you won't have enough milk'. Errr, yes I can and yes I have. I breastfed my first set of twins for 20 months and I'm still breastfeeding my second set of twins who are just turned two. It's lovely!"

"I'm ebf my 11 week twin girls. I've had "you'll be supplementing" from another mum & "are you supplementing yet?" from a hv. Everyone else has been supportive but surprised, well maybe incredulous might be a better word for the looks HVs & midwives gave me! Everyone else has been very positive & admiring."

"Very disappointed with tambas lacklustre attitude towards breast feeding. So didn't bother getting involved. I attended one seminar and it was pro section - commented heavily on likliehood of being early and not going full term or having natural birth."

"I've had nothing but positive comments from MWs, HV etc that I'm EBF my 10 week old girls. However as with other comments it's been more amazed pats on the back as opposed to any real practical advise [sic]. All the knowledge I've gleaned has been from my own research while I was pregnant and previous experience with my now 3 yr old daughter."

"I did go to a twins group at one point, still in pain from bfing them both, and the general consensus there was 'what they need most is a happy mum', and 'it's not the end of the world if you can't do it'. I smiled as much as I could, carried on feeding them and never went back. I decided I needed to surround myself with like-minded people and get as much support as possible."

"I just joined TAMBA because I thought it was good They are very good at some things And to be fair, their Breastfeeding Twins Triplets and more pamphlet you can get for free when u join or buy afterwards is actually very good I use it quite a bit I am hoping for great things from them Breastfeeding-wise with these new country-wide roles they are developing I hope so anyway They could be such a massive support"
Positive support reported was often midwives or breastfeeding support groups such as Babycafe (who are often in the current climate even struggling to stay running!)

 It seems to me that mums of multiples are more vulnerable to myths and marketing than the mainstream, and ultimately twice as lucrative to manufacturers. I struggle to believe an organisation like TAMBA undertakes such associations without consideration of ethical implications - the question many will be asking is what will they do next, stick or twist?


Yoomi Feeding System - Genius or Germ Fest?

Discussing "feeding systems" isn't typical fodder on this blog, but the reason I decided to cover it now will become clearer when I post the next entry.  I was tempted to roll the two together, but I thought discussion of this product deserved its own entry, in case you get asked about it...

So for those who haven't heard of Yoomi, it is according to the manufacturers a bottle and warmer in one.   You pop in the milk, add a warmer,  press the button and bingo - 60 seconds later it's ready to drink.  Sounds genius right? 

Don't get me wrong I can totally understand the demand and market for something such as this.  Formula feeding is a lot of faffing about; there's a shed load of work involved washing, sterilising and making up each meal as required - something that can make the middle of the night feeds quicker has to be a winner right?  Who wants to be stood in the kitchen at 3am with a crying baby waiting for its bottle to be made up and warmed?

I was therefore a bit confused to read the Yoomi only heats the bottle to 32 - 34 degrees.  In fact what Yoomi actually say is:
"Your yoomi warmer gives you perfect breast-milk temperature feed in 60 seconds."
And yes the "breastmilk temperature" is emboldened on their website, nice marketing Yoomi!

But you can't make powdered formula at 34 degrees....
I assumed I was missing something obvious, after all Yoomi's homepage boasts a "Mother & Baby Best Buy" badge (Best Product for Bottle Feeding, twice) and the following comment from a Health Visitor:

"Congratulations on a very clever product. I have been a health visitor for the past 15 years and this is exactly what is needed"

Ann Guindi, Health Visitor and mum of 4

Which is interesting given the NMC state:

"You must ensure that your registration status is not used in the promotion of commercial products or services"

Whoops looks like someone forgot to read their code of ethics.

A click later I discovered Yoomi is literally just a bottle warmer and a bottle in one, it doesn't do anything more exciting - and how many people do you know bought a bottle warmer and never used it?  
"Perfect to warm expressed breast milk (ebm) and pre-mixed formula. We always follow DOH guidelines on how to prepare and store feeds."
Interesting choice of language. Pre mixed isn't the same as "ready to use" (RTU) is it?  As Yoomi refer to RTU further down the page.    Yet the DOH guidelines Yoomi themselves link to state:

"To reduce the risk of infection, make up each feed as your baby needs it, using boiled water at a temperature of 70oC or above. Water at this temperature will kill any harmful bacteria that may be present."
So if Yoomi always follow DOH guidelines about preparing feeds as required - why would one need this "perfect" item to warm it back up?

Under FAQ Yoomi then state:
"How can I prepare and store feeds in advance safely?"
If ready to use formula feed is not practical, the FSA suggest you prepare feeds in separate bottles and store in the back of the fridge at below 5°C. Feeds should never be stored for longer than 24 hours. The feed can then be warmed gently and safely using the yoomi bottle and warmer.
So if you can't follow the guidelines, shrug and hurrah for the Yoomi?

For the system you need a Yoomi bottle, A Yoomi teat and a Yoomi warmer - you can remove the warmer and use like a normal bottle.  However you have to "charge" the warmers before use, and then again before each subsequent use.  You can do this by putting in a pan or steam steriliser for 25 minutes, or using the new "pod" that can go in the microwave for 2 mins - however you then need to wait 75 minutes for it to cool down... 

Yoomi state it is cost effective as it can be recharged 150 times - but as young babies take 8-12 feeds per day, if we consider an average of 10, this gives 15 days use.  Each warmer costs £16, which equates to £32 per 30 days for "warming".   Of course having to charge the warmer, wait two hours before use etc before each feed isn't really practical - so you really need multiple bottles and warmers if you want to consistently use the system, then factor in time at the end of the day to prepare them all for the next.

Cost effective compared to what?

Eg the "Momma By Tomy" bottle warmer costs £29.99, takes 1 min 45 seconds and doesn't need replacing monthly..  OK so it isn't portable, but if out and about with baby - the guidance is to use a flask and make up feeds as required.  Breastmilk or RTU is just fine either chilled or at room temp - and so is formula, if there has been some reason it is essential to premake.

Lane Franche, pediatrician says:
"Warming baby formula is something we do out of habit rather than for any medical or safety reason.  Warming a bottle can be a real hassle, especially if you're traveling. Instead, take away the chill by holding the bottle of formula in your hands for a few minutes. Chances are your baby will never notice the difference."
Bet Yoomi aren't keen on that plan...

On "Circle of Moms", some agree:
"My children are 6 and 4 and neither one would take a bottle from day one unless it was straight from the fridge."
"Neither of my daughters care if it is warmed up or not. Both have had it ice cold straight out of the fridge if they are really hungry and I haven't had a chance to warm it, but they prefer it room temperature or cool."

"my daughter HATED her milk warmed and wouldn't drink it"
So before splashing out it may be worth seeing whether you can avoid the expense and hassle heating altogether!

A bit more digging revealed that "Yoomi's midwife" is not a registered midwife, but a retired one - I bet you will be shocked by this, no really try not to fall off your chair:
"Many of my new mums and dads who are out and about get in rather a panic about how to transport the milk, how to warm it up, how to store it and so on. A bottle like the yoomi, which enables one to be self-sufficient - heating it easily and rapidly in under a minute - is all you need."  Clare Byam-Cook, Former Nurse and Midwife, Independent Breast Feeding Counsellor and Author
Mums get in a panic about carrying a bottle of breastmilk or a carton of ready made formula and either taking the lid off or cutting the top off and tipping it out before use?  Yikes best fasten seatbelts for toddlerhood!  Isn't transporting, storing it "and so on" identical whichever bottle you use for your breastmilk or ready to use formula?  It's purely the ability to heat to body temp that makes this product any different?

I can understand mums getting in a panic about travelling with powdered formula, when the guidelines suggest each bottle should be made as required with water that is at least 70 degrees.  I see mums juggling containers of powder, flasks of water sitting in insulated pockets to try and maintain temperature etc - but this product really the ideal for addressing that dilemma is it?  Well unless you ignore guidelines and make bottles in advance.

Given we are still in a position of some mums using microwaves to nuke bottles of powder mixed with cold water, it concerns me that mums could be under the misconception a system like this is as safe as mixing when required - that carrying a flask of water and pressing the Yoomi button are comparable:

From Netmums:
"I make up 2 feeds in advance, put them in the fridge and warm them up in the yoomi bottle - takes 60 seconds .. just press the button, wait and feed. Has made night time feeding much easier! great for out and about too - saves carrying a flask of hot water"
From Mumstreet:
"The Best Bits: Warms the bottle in 60 seconds so you don’t need to worry about being near a bottle warmer or carrying boiling water around in a flask."
 Something else that really grates, and what probably provoked this piece -  is the constant associations with breastfeeding.  Why can the bottle not just be marketed upon it's own merits, why do manufacturers need to make constant links with breastfeeding (that's rhetorical by the way, clearly I know why £$) but ethically it sucks.
  • "Makes combining breast and bottle easier" - How? How does a bottle that replaces a bowl of hot water make combining feeds easier
  • "Breast-like anti-colic teat" - Huh?  My breasts aren't silicone?  Furthermore nipples are pulled back towards the point the hard/soft palate meet, this short silicone teat wont and will land much further in the mouth.  Something which can encourage "humping" of the posterior tongue - a technique that doesn't work at the breast.  Medela attempt to combat this with their Calma bottle and a longer teat and you can see how short the Yoomi is in comparison.  Are there clinical trials showing the yoomi is "anti colic"? 
  • " Yoomi bottles have a clever breast-like anti-colic teat for easy latch on, perfect for bottle only, combination feeding or transitioning your baby from breast to bottle." (on their site the "easy latch on" and "transitioning from breast to bottle are bolded".)
  • "Yoomi warms baby's feed to the natural temperature of breast milk at the touch of a button"
  • " We both feel that yoomi made the transition from breast to bottle possible."
And from the "Read what parents say" section (ie posted by Yoomi as "testimonials")
  • " Harry was a breastfed baby so it was a real challenge to find a bottle that he would take" Lots of breastfed babies take bottles no problem, so why the implication that it was challenging because he was breastfed - I see lots of bottle feeding parents who have a challenge trying to find a bottle baby can use well!
  • "Conrad had his first bottle feed last night and my wife, Natalie was a bit upset… he was quite happy to take yoomi without any problem whatsoever! However, I’m sure she will appreciate the extra sleep now I can do the late night feeds"- cos that's what every good dad  does right?  Never mind Natalie was upset,  he's sure she will appreciate the sleep...
  • "Although my daughter is only 7 weeks old, I wish I would have had my Yoomi from day one. This bottle is a must for breastfeeding moms on the go!" - a bottle is a must for a breastfeeding mum?  Er nope, breasts are pretty perfect for mums on the go, no heating elements required ;)  Plus advice isn't to introduce a bottle from day one if you are establishing breast feeding.
  • "I only introduced Harry to a bottle around 6 months and I was concerned that he would reject the bottle as he was so used to being breastfed. Thankfully he took to the yoomi straight away and I have been able to combine both bottle and breastfeeding really successfully. I find the yoomi especially handy during the day when I’m out and about " - Yes SO much handier than putting baby to the breast - or are we supposed to be re-emphasising the message it's good to breastfeeding at home but use a handy bottle in public?
  • The transition from breast feeding to a bottle can be a difficult one, but the clever design of these bottles solves many of the common problems.  But does it?  Really?  Or did you just buy the marketing?
Those familiar with the marketing of breastmilk substitutes will recognise much of the above feels familiar - the baby market is so lucrative, but what do you think?  Another flash in the pan trend or a practical product?