I can't tell you how often people have said "I thought breastfeeding was just simple, you pick baby up if you want to do it - hold them tummy to tummy, nose to nipple and away you go". Or "wow your training takes that long? How much can there even be to learn about breastfeeding?"
From thrush to tongue tie, we want to reduce two totally unique human bodies to a bottle of nystatin and a frenulotomy. If that doesn't work, clearly another frenulum somewhere must need removing, because we're still having problems.
Sometimes, we don't know what we don't know - until we know it.
Without knowledge absolutes are easy, in daily practice things are rarely so black and white.
In just one session recently we had two opposite examples.
The first a mum convinced her baby needed formula, all because he had been born on and was now tracking a lower centile on the growth chart. His average gain per week was well within normal range, he had regained his birthweight by the expected 10 days and every other indicator suggested her was doing just fine; yet this mum and her body had been unnecessarily undermined.
These are the cases where I want to shout about the risks of supplements that aren't needed; how we're not striving for everyone to achieve the 50th percentile on a chart that is based on average healthy infants, how formula in this position is potentially going to jeopardise supply and so on.
Just a few cases later came a baby at the opposite end of the spectrum. A gaunt figure before me, baggy skin where baby fat had previously filled out his thighs and wrists. His head now looked slightly too big for his long lean body, as we frequently see with premature babies and a slight frown permanently wrinkled his brow.
At nearly 6 weeks he had just about regained his birth-weight (when weighed on a good day with a full bowel), he had gained some small amounts, lost at some weigh ins and remained static at others.
"We don't want to use formula", the dad tells me almost immediately and with a defensive edge. "We've read about the risks to his gut, how it will impact on my wife's supply and we know from the things we've read online the best thing is to just feed, feed, feed at the breast."
Mum latches baby and he sucks purposefully for a few moments, before his eyelids become heavy and he's almost immediately returned to solid slumber.
"The midwife is happy with his gain because he's developing normally", the dad quickly continues, "plus he sleeps really well which he wouldn't do if hungry would he?".
I try and find the words to gently explain to these anxious parents that their baby simply doesn't have enough energy to rouse and feed well. How do you tell someone their baby is starving when others supporting them are clearly reassuring them otherwise, despite their situation raising every red flag there is in the book to raise? That yes there may be impact to the virgin gut, but there is also potentially negative consequences from taking significantly less milk than is needed.
When we've tried every trick in the bag of two experienced International Board Certified Lactation Consultants to help mum facilitate a feed with milk (and believe me we have a lot) we discuss how if they don't feel comfortable with donor milk and mum can't express more than a few mls, where do we go in terms of options?
These are the cases where I want to shout about the risks of infant dehydration and blindly telling parents to withhold or cut supplements that are needed; how we're not striving for everyone to achieve the 50th percentile on a chart that is based on average healthy infants - but how sliding down the centiles or plotting a straight line carries risks too. How formula in this position is not going to jeopardise supply and so on.
Because I'm pretty sure that those who give the wrong advice, have no idea how hard it is to breastfeed a lethargic baby. They don't understand that their advice to withhold milk when a baby is clearly continually signalling hunger, can trigger a whole cascade of events as is well documented in many lactation text books.
A baby who consistently takes less milk than is needed becomes more and more disorganised when they next feed, compounding the problem as intake is further reduced. At the next feed the baby is even less organised and this time falls asleep after 5 minutes instead of 10, taking less milk and perhaps sleeping a longer stretch now to regain some energy. This means mum has more milk stored and easily available when he wakes, or she wakes him, so perhaps this feed is slightly better and he gets a bit more than last time, but still not quite enough- and so the cycle continues.
Quite simply not having enough calories can cause a disorganised, ineffective feeder.
Of course this is all on a scale - if a small newborn can't get anywhere near enough milk, they will quickly "shut down" to preserve their vital systems. They will begin sleeping long stretches, may become jaundiced and even more difficult to rouse to feed adequately. These babies are at increased risk of hypernatremic dehydration; a rare but potentially fatal condition; luckily these babies are often identified by midwives in the early days of feeding.
Sometimes though babies dance a line, and they are far more likely to fall through the cracks when it comes to appropriate care. These babies may not have a huge loss that causes an initial concern, instead their loss may be modest and problems only become more apparent after the first week or so. Some days they get just enough to remain hydrated, other times having a little excess to gain an ounce here or there, two days later there's a small loss - perhaps mum has been out and missed a feed or two out of the many many he needs to try and get enough milk.
I'm sure many who give the advice to tickle baby's toes and blow on them, use a wet flannel or strip them off - don't understand that very few healthy term babies fall asleep in the middle of a good milk flow. They fall asleep when they start expending more energy than they're removing, when the flow becomes too slow to be of interest....
And here's the thing we all need to understand about supply:
- If we take a baby who is drinking well from the breast and replace that feed with formula, the breasts don't get that milk removed and thus they may respond by make less - particularly if they become overfull and engorged.
- If a baby is spending an hour on the breast sucking and snoozing, but not transferring milk well - similarly that lack of milk removal may result in mum becoming engorged before responding by making less. The only difference being baby goes hungry as he doesn't get milk from any source.
If the problem is identified, mum can use techniques to maximise transfer, express to protect her milk supply and feed that back to baby if needs be. However when this problem isn't identified quickly, mum may find by the time it is she initially can't express enough milk to provide the supplement needed. As a result using a mix of breastmilk and another milk may be needed to meet baby's needs.
The dad in our session above returned a few moments later with some breastmilk substitute and carefully gave baby a small amount (avoiding artificial teats). The baby roused, attached to the breast and took "the best feed he's had all week". He did finish off with some more formula, however he has some catching up to do and so mum plans to work to replace the supplements with her expressed milk until he regains the weight he should have gained. He then snuggled up to his parents, gazing at them in a beautiful quiet alert state - it was the first time in six weeks he hadn't been either crying, trying to feed or sleeping. We did of course also establish why the problem arose initially and how to resolve things moving forward - not just mask the symptoms with supplements.
I've been told recently midwives have avoided weighing low gaining babies so as "not to worry parents further"; yet from experience most parents who have low gaining babies are anxious and concerned at the situation. Waiting another week or two before finally someone has to intervene - sometimes with a referral to a paediatrician, helps who exactly? The baby going hungry or the mum who now has to work twice as hard to rebuild the supply she didn't need to lose?
Please remember there is no one size fits all approach to feeding - the best thing you can do for someone struggling with feeding is to help them find effective, qualified, timely support.