What Breastfeeding “Cluster Feeding” Is and Isn’t...

Cluster feeding. 

We hear these words a lot in clinic. Sometimes, quite often in fact  - what the person is describing is NOT cluster feeding; it’s a feeding problem that is being mislabelled and like an epidemic it’s spreading.

First if you’re breastfeeding fine, you’re happy, baby is happy and they’re gaining normally - you don’t need to worry about this post at all.

This post is for those who have either a baby who is growing much more slowly than expected, or who is gaining normally but consistently needs a million feeds per day to do so (outside of normal growth spurt behaviours which we’ll come onto). In short the pattern really isn’t sustainable.

Cluster feeding is a process term, healthy babies who are gaining weight well - typically start (in my experience from around 3-5 weeks of age).

Because breastmilk is rapidly digested, babies need to feed frequently - every few hours. If baby wants to sleep a longer stretch of say 5/6 hours, baby may need more food to last this long.

Baby therefore takes several or more full feeds quite close together, often around early evening time, signalling again (typically) 20-30 mins after the last feed- before dropping into a longer sleep spell. This is thought to allow baby to fill their whole digestive system, so excess hunger doesn't occur during this longer gap.

Babies tend to fall into two camps - those who cluster feed and have a longer sleep stretch, and those that don’t and keep to them same pattern during the day of 2-4 hours. I can once remember dad of newborn baby number 3 - asking when they started that cluster feeding so you get more sleep?!

Cluster feeding can also occur during growth spurts. This tends to be more random, can happen any time of day or night but is short-lived.  If baby is feeding well, settled and suddenly has a day or two of crazy manic feeding before things settle again - this is often what people refer to as a “growth spurt”, as this behaviour drives up mum’s milk supply with more frequent and effective milk removal.  Cluster feeding can also be comforting if baby needs some help to sleep, is unwell or just because.

I don’t believe many babies not back at birthweight at the appropriate time (10-14 days for an average sized baby) cluster feed - these babies are feeding frequently to get a longer stretch, but in a bid to try and pull enough calories.

They may fall asleep quickly, rouse when put down and for all their intense efforts they’re prone to getting the label “lazy”. Instead of clustering, these babies are interjecting their feeds with a powernap.

Sure they may take a longer sleep stretch if they’re exhausted from very frequent feeding during the day, but this isn’t the same as that outlined above. It can however be difficult to tell apart, which is why ensuring your support team has at least one certified person.

Feeding every 20-30 mins all day with the occasional hour gap IS NOT clustering. 

Not gaining enough to track a centile despite feeding frequently IS NOT clustering.

Growing normally but with a feeding frequency day in and out that isn’t sustainable, IS NOT cluster feeding.

I keep hearing parents fobbed off with the claim it’s just what breastfed babies do. Leaving parents feeling guilty they can’t sustain these intense demands. Since we’ve normalised a problem, the risk is mum things she’s not able to sustain what others clearly can.

I overheard a conversation recently in our waiting room between a mum who had called back for a quick check, and one who had just arrived with a feeding problem. As the new mum was outlining the problems they were experiencing, she kept diminishing with - but I’ve not had one before it’s probably just what babies do, or it’s probably something I’m doing or I probably just need to learn to wind him better and so on.

When the other mum said she’d had all those problems and then outlined what feeding was like now - the first replied it gave her such hope and she’d been told it was just was breastfed babies do, or perhaps he’d just “prefer” the bottle.

There are always the exceptions to the above, but you can seek support and chat it through with someone if you’re unsure or things feel unmanageable :)

No You Can't See Antibodies In Your Breastmilk - Myth Busted

"My milk is really poor quality and doesn't have any antibodies anyway", said a mum during a phone call yesterday.  She went to continue but I had to interject - sorry, wait, what?

Turns out mum had seen some photos on Facebook. One showing white milk and the other showing a rich golden yellow - with the claim because baby was sick, the yellow colour was all the antibodies, just like colostrum....

Oh my days.

YOU CAN'T SEE ANTIBODIES with the naked eye!  Any more than you can see vitamin D or harmful bacteria, antibodies do not colour breastmilk.

Colostrum is not coloured by antibodies. The fact is colotrum can vary from mother to mother - it can be clear, pale and golden or bright orange like cordial!  What's more, colostrum can vary in colour hour to hour, day to day from the same mother. The colour variation and orange tinge is because of carotenoids in the fat, NOT antibodies.

Eat enough beta-carotene rich carrots, squash, sweet potatoes etc and you can turn your whole self orange too, in a condition called "carotenemia" (I kid you not).

Breastmilk is shown to be a dynamic fluid that changes moment to moment, hour to hour, day to day - to best meet the needs of that individual baby.  This means the time of day she expresses, how long ago it was since her baby fed/she last expressed, how full her breasts were at the time - all can make a massive difference to how milk looks when milk is removed.

We can best see this difference if a mum who has full breasts expresses until they feel softer and a "full feed" volume of milk has been removed (or more if mum has oversupply/engorgement):

As this post discusses - when mum is full, the first milk is higher in lactose (to fuel brain growth and provide a "drink").  As the breast drains, we see the fat content increase. If mum was to express milk right at the end of a feed, when her breasts felt much less full and softer, we'd see a picture more like the right. However unless mum was extremely full and then got a superb expression with a pump, she'd be unlikely to notice such a distinct difference as above - it's a gradual transition, not a flipping switch. If stood in the frige, it typically looks much more like this.

What's even more ridiculous about the whole "visible antibodies theory", is it seems people can't even decide what colour they are!

Vaccines DID NOT turn her breastmilk green, or blue, depending on your point of view (maybe it's like that dress where people saw different colours?). The claim is her body thought it was sick from the vaccines, sent this signal to mother who made coloured milk!

What's far more likely is mum ate some green foods, drank some Gatorade, took a Spirulina supplement or something else that tinged her breastmilk.

Mums are often worried their breastmilk doesn't look "right", or "nourishing" or that there isn't enough fat. This is purely because cow's milk proteins result in a yellowy/creamy hue (and typically the more cream the more golden/yellow). Yet human breastmilk as the norm has more of a white/bluey tinge unless the fat is separated out.  What's more, even expressing with hands on techniques, you're unlikely to remove as much milk (and thus fat) as a baby feeding well.  If you just put the pump on and go without breast compressions, you typically remove less still. 

Rest assured your milk is perfect for your baby.

When The Breastfeeding Baby Keeps Falling Asleep Before They're Full

AKA "The Power nap"

We all know it's totally normal for breastfeeding babies to fall asleep when they've finished their dinner.  We know that in the first few days after birth it's also not unusual for baby to "forget" what they're were doing and take a quick snooze mid-feed, particularly if they're a little jaundiced or have had a more tiring delivery.

But what about when baby is consistently falling asleep before they're full?

It tends to go like this - baby drinks the first milk ejection or letdown, a nice suck/swallow ratio can be seen and this tends to be the part of the feed everyone watches.

As this naturally slows down, instead of pausing and then starting to drink with a regular swallow pattern again - baby adds more and more sucks for each swallow, becoming slower and slower until they're asleep. 

Except they're not. 

This article has been updated 2026 and can be read in full here

A Gain is Not a Gain. Faltering Growth in Breast & Formula Fed Babies.

We've been running our weekly infant feeding clinic in Yorkshire for years now, and during that time it's been fascinating to note the changing trends when it comes to feeding babies. 

Book your infant feeding assessment with AA at Milk Matters Infant Feeding Solutions: ifs.as.me

When we first started, a common problem was parents were advised their baby needed additional milk when they didn't.  This happened because their growth was plotted on charts based on the growth patterns of formula fed babies, resulting in the breastfed babies older than a few months, appearing not to grow adequately.  We spent so much time reassuring parents that their babies were growing perfectly well for a breastfed baby and didn't need coaxing to take additional milk.

Many believe formula fed babies gain weight more rapidly than their breastfed peers; however initially the reverse is actually true.   The  non-breastfed baby typically gains weight more slowly in the first four months, it's after this the shift occurs and they start to gain weight more rapidly compared to those who are breastfed.

Thus historically on the old charts, many breastfed babies appeared to have suboptimal gain and as a result the UK growth charts were updated to reflect the typical growth patterns of those exclusively breastfeeding.

In our clinic in the last couple of years, things have definitely shifted.  Now it's rare we see an over-supplemented baby, instead we've observed a steep increase in actual cases of "faltering growth" - that is babies who aren't a little underweight, but chronically so.

What's perhaps most surprising is both these babies above were under the care of and regularly seen by healthcare professionals.

In the case of the first baby, they were eventually referred to a paediatrician.  I completed a new growth chart for them to take, so weight trend was clearly visible.  Baby had a tongue tie and we can see when the supplement plan was initiated at 7 weeks.  Mum however was reluctant to give extra milk as her group online had warned her it would impact her supply (untrue, a baby not transferring milk will do that) and that anyone suggesting formula wasn't truly supportive of breastfeeding.  This meant additional milk was given (provoking gain), withdrawn (resulting in the same amount gained lost again) and re-introduced again - creating the static pattern at the end.

Note the growth trend - how far away from that bottom curve are the dots (the minimum typically expected weight) and we can see there's a consistent pattern of faltering growth resulting in a 38% deficit based on expected weight.

It was a cold winter's day when they attended their paediatric review and baby was dressed in a fleece snowsuit.  The paediatrician didn't feel it necessary to undress the baby, instead they unzipped the suit enough to listen to baby's chest with a stethoscope.  They asked if  he was peeing and pooping and said they weren't concerned about weight as we had plotted the chart wrong....

They said that although baby was 38 weeks when born and a typical weight of over 7lb, they felt a premature chart should be used (designed for babies born before 37 weeks and of a lower weight), and so adjusted the baby's chart in his red book notes to reflect this:

The bold dot and arrow indicate where the consultant felt the dot should be with this adjustment. Baby was a couple of days shy of 8 weeks at the last weigh in, (as you can see from the original dot now marked with the arrow), yet the new mark is plotted at 5 weeks.  This results in an almost 3 week adjustment...

I can still recall the exact words the mother said to me when I expressed surprise at the consultant's nonchalance and checked additional milk was going to be continued :  "You're the only one who is concerned about my baby's weight, everyone else thinks he's fine".  A relative expressed she felt I was causing the mum unnecessary concern and worry, when clearly "those in the know" were happy with his gain.

If parents find their baby is struggling to gain weight, they can soon find themselves on the receiving end of contradictory recommendations and conflicting advice.  They may be told by some just to "feed, feed, feed" or take baby to bed and "baby-moon" (both of which of course assume effective milk transfer when baby is feeding, rather than just burning yet more calories), whilst others are expressing concern and suggesting additional milk is needed alongside identifying the original issue that has led to growth faltering.

A further problem is  many don't really understand the charts, sometimes the graph isn't even completed by healthcare providers.  This means at a glance nobody can even see the growth pattern, let alone know if the baby is tracking an appropriate curve.

First we need to understand they're based on averages.  If we take a huge group of healthy, term, breastfeeding infants - we can identify the typical maximum and minimum rate of growth they undertake.  That's not to say every baby outside this range absolutely has an issue, only that its atypical enough (when compared to the masses) to warrant further investigation.

If we use this data of healthy babies to create a chart - the heaviest infants will of course sit around the top and the lightest infants will sit near the bottom.  We can also calculate the "average" - which would be the 50th percentile line (so half the babies will sit above this line and half below).  This range allows for genetics, stature, build and so on.

It isn't desirable to sit on a particular place on the charts - in fact that's really quite illogical.  We wouldn't take a group of adult females and identify their average weight is 7-13 stone, then tell everyone their optimal weight was 10 stone.  We'd expect the weight of someone who was 5ft and of petite stature, to be less than someone who was 6ft and of broader stature?

The same is true for babies.

Once on the chart, we can similarly expect different levels of gain from those at the top and bottom too - and we know that typical healthy young babies gain roughly 5-8 ounces per week (140-225g), after the first few days and doing so will result in them returning to birthweight by around day 10 and tracking a curve on the chart.

Babies may sometimes plot slightly above or below a line, it doesn't have to be an exact track of a centile but should be thereabouts.

Below we can see the growth chart of a twin baby girl born at 38 weeks, weighing 5lb (2.27kg) and with a tongue tie. Baby was readmitted at a week old with significant weight loss and you can see on the chart where the hospital implemented a "top up" plan.  The next jump up the charts is when the tie was released:

If babies don't gain the expected amount as outlined above, instead if following a curve we see a flatter line appearing as they slide down the charts.  Crossing two centiles triggers referral to a paediatrician to rule out underlying and potentially significant causes.  Thus the saying "a gain is a gain" is ridiculous; I've heard this said when babies have gained 30g per week, the amount expected per day - that somehow as they haven't lost all is well.  Considering nobody seems to check intake before this referral - it also seems a costly exercise too.

When babies are underweight not only can they lack the energy to take a full feed, but they become disorganised and less effective - creating a catch 22 situation.  If this continues week after week, the energy and weight deficit often simply continues to get bigger, rather like you trying to run a marathon when you've just spent a month with Bear Grylls on a desert island.

What evidence are people working from that they feel a very underweight baby is better than one who is supplemented?

The first choice of course would always be mum's own breastmilk, however if baby feeds very frequently due to not transferring enough per feed, finding time to express may be difficult.  If baby has been taking less than they needed for weeks, mum's body similarly may have reduced production and supply may need additional stimulation.

Donated milk may be an option depending on accessibility and more mums are using and sharing donor milk, both informally and via their local milk bank; but for many it will mean considering infant formula.  The concern is that formula disturbs the microbiome, which is of course true - but we surely have to ask whether we believe there are no risks to inadequate food at a time of rapid growth when energy demands are high. 

Not enough calories also means potentially not enough vitamins and minerals either.  This could be a whole new discussion in itself, but let's pick one we know is important for the immune system, zinc:

"Infants and toddlers are vulnerable to zinc deficiency due to their rapid growth rate and high demand for tissue synthesis, neurological development; immune function and tissue growth (Aggett 2000; Friel 1994; Krebs 2014). Cells with rapid turnover demand the highest concentrations of zinc, notably skin, gastrointestinal, immunological, neurological, and, in the developing infant, skeletal cells.

"Mild to moderate zinc deficiency is characterised by stunted growth, deficits in immune function, and altered integrity and function of the gastrointestinal tract (Krebs 2014). Zinc deficiency may be associated with deficits in attention, and motor and cognitive development in children (Black 1998" here

We International Board Certified Lactation Consultants, often the only ones trained in infant feeding - can frequently find ourselves undermined by a whole range of people.

The twin baby above as an example was on a feeding plan - as she had a tie, combined with the fact mum hadn't received adequate advice on protecting her milk supply prior to our visit, this meant at the point we saw them baby couldn't physically transfer enough and the increased demand now exceeded supply.

Despite this a consultant in a different unrelated field (who works with multiples), saw fit to advise the parents to drop all the supplements and just feed her babies.  Thankfully the mother contacted us confirming this wasn't correct, but I do wish people would consider the implications of their lack of specialist knowledge and how parents feel when they receive this conflicting advice, from someone absolutely not in a position to be giving it.

We hear sometimes of underweight babies who seem  happy and settled - they sleep long periods, yet surely if they were hungry they'd wake and cry?  The reality is that hungry babies cry, very hungry babies who've experienced consistently reduced intake don't have the energy to expend crying.  On the contrary, they often sleep longer spells to conserve calories and don't signal too much (which again burns energy) if the feed intake is less than they'd like.   Some will feed very frequently yet never really seem "milk drunk" or full and that's without considering that persistent weight gain concerns can be a huge cause of maternal anxiety.

It's really difficult for parents who are with babies to accurately gauge gain in their newborns based on visual appearance.  Babies change a lot in the early weeks and when with someone a lot it's harder to notice subtle or gradual changes - which is precisely why we weigh newborns.  It's what we do with this information that counts, the earlier a problem is spotted - the more rapidly it can be resolved. Reassuring people things are ok when they're not, in the longterm doesn't help anyone.

Book your infant feeding assessment with AA at Milk Matters Infant Feeding Solutions: ifs.as.me

Daily Mirror Claims Baby Nearly Starved After Milk Dried Up Overnight!

The British Media are at it again today, with the Daily Mirror running a spectacularly inaccurate, scaremongering piece claiming breastmilk suddenly dried up overnight, leaving a baby starving because his mum didn't realise.

It's a rather bizarre piece they claim is an "exclusive interview" with a mother in America and whilst articles that appear to try and scare parents into formula feeding aren't new,  they are increasing in frequency.  This is because as an "opinion piece" there's little restriction in what can and can't be said legally, with no need to provide accurate or evidence based information.  Thus we should all be extremely suspicious before we even start reading.

Of course the Mirror could choose to accurately convey the story of what supposedly happened, as ethically this piece is questionable at best.  But then there'd be no click bait headline, reduced readership and that doesn't make money does it?

Au contraire it's so dramatic, it's hard at times not to laugh - except the fact mothers may read this and panic, means it's actually far from funny funny.

"Before being allowed home with their son, Andrea was taught how to breastfeed, but admits in hindsight that this was the start of her problems."

Being taught how to breastfeed was the start of her problems? Yet as we'll discover, after the first few days breastfeeding was comfortable and according to mum and health records going well for the first FOUR months.

Kara O'Neill either seems a bit confused about what she's actually reporting, or is just particularly bad at explaining:

"It was only when he reached four months old and his weight dropped and Jogie began to look thinner that Andrea switched to formula milk and realised she had been starving her baby for eight weeks."

This infers that he reached 4 months old and was underweight, giving formula mum realised she'd been "starving" her baby for 8 weeks (ie since 2 months of age); yet as we read further into the piece this isn't what happened.

In fact at 4 months Jogie was thriving, perhaps those breastfeeding lessons helped after all ;)

"Doctors said her child was growing well, and he was gaining weight appropriately for his age. At four-months-old he weighed 14lbs 6oz."

If we plot Jogie's birth-weight on the growth charts, we can see he was born just under the 50th centile.  When he was weighed at 4 months, he again plots on the 50th and has doubled his birthweight - suggesting optimal growth, you couldn't get a more typical growth pattern.

The next bit is super important:

"But it was at this point that things started to take a turn for the worse.
Andrea said: "Jogie had a lot of trouble sleeping at night. I googled what the possible cause could be, and I saw many posts about the four-month-old sleep regression. So I sleep trained him, and after a couple of weeks, he was back to waking up only once or twice in the middle of the night."

"Sleep trained him" - another, perhaps nicer way of saying "so I withheld feeds he was signalling for".

Baby woke frequently and instead of exploring why - his cues were ignored as "undesirable behaviour", no doubt the words "self-soothe" also appeared in there.

Whereas previously he'd been getting calories at night, now he was limited to twice - and for whatever reason that clearly wasn't enough for this baby.

Thus it would seem to me that "sleep training" was in fact the start of her problems.  In fact a more accurate headline would be:

"Mum 'can't forgive herself' for not realising sleep training could cause breastfeeding problems".

The next section is a mish-mash of parent-misleading advice - whereas her breasts had previously felt full and engorged, now they didn't.  Whereas she could at first pump 4 ounces now she couldn't; she googled this was normal and so didn't worry.

Indeed this IS normal - mum shouldn't feel uncomfortably full at 4/5/6 months, mums who don't regularly express wouldn't expect to pull 4 ounces unexpectedly at this age (breasts regulate to provide what baby needs) - but I can now imagine mums all over the country worrying their totally normal supply is in fact dwindling because of comments such as this.   It feels really insidious...

Mum noted she felt "empty" and perhaps more importantly that:

"Jogie's nursing sessions reduced in time dramatically. When he was born, Jogie would be latched to her breast for 10 minutes each time he was fed."But his time feeding continued to get shorter and shorter, falling from eight minutes down to six, and eventually just three minutes in total.Then, in early July,  Jogie refused to feed from Andrea's breast completely"

The timeline is a little confusing as if he was born December, his 6 month check would have been due in June.  However Andrea says they didn't see a doctor at this time as they didn't have insurance (remember no NHS there) - thus July would make him 7 months and it can't have been only 8 weeks since last weigh in as the Mirror report.

Andrea recalled: "The doctor didn't seem too concerned, but she also did not know how much he weighed before, so she didn't want to make any judgements. Her children were also very small and light, so she didn't want to say anything"

Switching doctors usually means transferring of notes so why did this doctor not have a prior weight recording? In the UK this doesn't happen as the baby has their "red book" which parents hold and is taken to different healthcare professionals.

If mum noted the baby looked thin at this time, why didn't the doctor?  I'm also not entirely sure what is meant by "she didn't want to say anything", is the mum implying the doctor was medically negligent based on her own personal situation?  If so this surely needs investigating?

Did the mum tell the doctor her baby had reduced his feeds down to only a minute or two?  Clearly not enough time for a baby of that age and size to take a full feed?

Something else confusing is Americans don't see a "GP" for baby checks, they see a paediatrician, so it's confusing why the Mirror chose to use this terminology.

"On July 4, after Jogie had refused to feed entirely, Andrea made a decision that would ultimately save his life and decided to switch to formula milk."

In the timeline of the piece it reads as though Jogie saw the doctor for his 6 (now 7) month check PRIOR to the switch to formula - because according to mum from the first feed it clicked he had become underweight because he'd been hungry and his gain soared to 50g per day as she immediately abandoned breastfeeding in favour of the bottle.

The switch to formula was the 4th July and the 1st and 2nd were a Saturday and a Sunday -  which only leaves July 3rd as the day he must have seen the doctor, ONE DAY before this "lifesaving" decision.

Are we seriously to believe his life was at risk?  The moment he refused the breast entirely, his mum gave another milk - he wasn't at death's door.

But yey for formula milk, the saviour for mothers worldwide who receive sub-optimal, substandard, crappy internet advice!  No mention that mum could have taken steps to increase her supply, that she could have continued to breastfeed alongside formula whilst someone helped to establish why - that wouldn't fit the narrative at all would it?

I begin the lose the will to live at this point:

"My message to other mothers is that their milk supply can dry out suddenly and without any explanation. Breastfeeding was great for the first four months of Jogie's life. Everything went well.
"He was happy. Then things took a turn for the worse, and I kept blaming it on something else because my internet searches kept reassuring me that the baby can get the milk he needs from you via supply and demand."

 My message to Andrea would be no, milk supply can't and didn't in this case dry up "suddenly and without explanation".

Breastfeeding was going "great" until his night-feeds were restricted, perhaps at a time he was feeding more frequently to naturally increase supply to meet his growing needs.  As you say it's all about supply and demand, yet when he "demanded", he was sleep trained.  As supply fell in response, his feeds became shorter yet having being trained his cues are ignored, there was little point expending energy to rouse more frequently.

As feed duration reduced (IE demand reduces), supply would fall further in response - compounding the problem.  Indeed his feeds gradually became shorter - highlighting it was as the opposite of "suddenly and without explanation".

My first rule is always to feed the baby, and I do get so sick of internet groups, where clearly starving, drastically underweight babies are told repeatedly everything is fine.  Yet again this mum was failed by the system, failed by those around her and left blaming herself.  Now THAT is what we should all be up in arms about.

Upper Lip Tie, Fall Guy...

doctorspiller.com ©

Or the "maxillary labial frenum" if you want to be technically correct.

Before I get started I want to stress now that some babies absolutely do have a restrictive  upper labial frenum.  Some babies and children need it releasing to have appropriate function.  This blog isn't intended to try and deny a problem exists, but we have gone beyond that to the point it seems every baby has lip tie, tongue tie or both!

Recently "I think my baby has upper lip tie and it's causing feeding problems", is the most common phone call I receive. Whilst I've often blogged about tongue tie, I've avoided lips until now. I wanted to research, discuss with those treating, and experience working with parents who have decided to get treatment, and those that didn't.

To be fair I can see why it seems the obvious answer.  Mum experiences feeding problems, pushes back the top lip, sees a frenulum and bingo - it's clearly the cause.  If things were only so simple...

So let's start at the beginning.

What is a lip tie?

Firstly we need to recognise that the adult and infant mouth are different.

I think many people are looking for adult dentition in a baby's mouth.  In adults the frenum is typically high up the gumline, well away from teeth.  This is because for the vast majority of people, the frenum regresses during the early years of life:

"In little children, the maxillary labial frenum is often attached between the two central teeth. In most cases, this attachment migrates away from the teeth as the child approaches the age of 8 or 9.

Children generally have a large space between their central incisors during the "ugly duckling" years, but by the time the adult canine teeth are fully erupted, between the ages of 11 and 12, the space should close." (1)

and

"The attachment of the frenum to the gingiva moves progressively upwards and thins out as the alveolar process enlarges and maxillary incisors and canines erupt" (2)

and

"Labial frenal attachments are thin folds of mucous membrane with enclosed muscle fibers originating from orbicularis oris muscle of upper lip that attach at the lips to the alveolar mucosa and underlying periosteum. It extends over the alveolar process in infants and forms a raphe that reaches the palatal papilla. Through the growth of alveolar process as the teeth erupt, this attachment generally changes to assume the adult configuration." (3)

and

"For most children, the medial erupting path of the maxillary lateral incisors and maxillary canines, as described by Broadbent 3, results in normal closure of this space. For some individuals, however, the diastema does not close spontaneously" (4)

 So what are we expecting to see when we push back the lip of a baby?

 Those who are members of our Facebook Group will know I have shared this study a lot over the last few years, as we absolutely need to establish what is normal, to identify what isn't...

"Oral examinations were performed of 1021 newborn Swedish children
The upper labial frenum was attached to the crest of the alveolar ridge in 76.7% of the children, palatally in 16.7% and buccally in 6.7%." (1)

Which means, should you go and push the lips of many babies back, over 3/4 will have a frenum attaching on the gum-line, with another chunk going through to the palate. This clearly highlights it is the physiological norm for a baby.

This means that for a baby, the frenum attaching close to, or on the gum or palate - does not confirm a lip tie. Let's say that twice.  Seeing your baby's frenum attached to the gum or palate, does not automatically mean they have a lip tie.

It simply means they have an upper frenum, which the vast majority of people do. In fact absence of an
upper frenum can indicate it is worth ruling out other genetic abnormalities.(3)

I decided to ask for photos online, from parents who had not experienced problems.  So babies who had always breastfed wonderfully since birth, gained weight well, slept well day and night, no reflux, colic or wind ie the definition of a typical "easy baby" that Gina Ford and co would be proud of - can you please flip their lip and take a picture?

Here are the first six I received, the rest were no different:

So photographs aren't a reliable way of assessing the function of the lip. What else?

Lip Tie Myths:

• If baby's lip does not flange when feeding, stays straight or even curls inwards - it suggests lip tie.

A baby transfers milk effectively by making a seal with the lips and tongue.  This seal allows them to create a negative pressure, as the tongue lifts and drops.   If a baby has tongue tie, the tongue may not be reliably playing its part in this process, and so in my experience the baby will very often attempt to compensate by gripping extra hard with their lips.

If they didn't/can't compensate enough they can constantly slip off the breast.  I have seen babies do this who have no upper frenum as it has already been removed.  You can often spot babies doing this as the mum tends to hold her breast, baby's head and sit holding the two together. 

Furthermore if a baby is reliant on the grip from their lips, they will frequently be so tight mum is unable to flick the lip to a more comfortable position, or if they can it may gradually pull back under.

Post feed both lips can look blanched, swollen or "shiny" from the pressure.  Baby can also develop a red stripe above the top lip and below the bottom (this tends to happen more when using a bottle)

Photo courtesy of theleakyboob.com

There is also a misunderstanding in the "non breastfeeding world" as to what the top lip actually should be doing during feeding.  

It is now common to hear "both lips should flange like a duck".  This actually isn't true, and as lactation consultants many have commented we often see this "duck positioning" when baby is shallow.

When a deep latch is achieved, the top lip typically sits in a neutral position - as can be seen on this animated latch clip here and the photo on the right.

In contrast lets look at the lips of a baby with a shallow attachment:

Catherine Watson Genna, author of the fantastic "Supporting Sucking Skills in Breastfed Infants", agrees and touches on this in her book:

Whilst Catherine often writes about tongue tie, I was interested to hear whether she felt lip ties were a significant cause of breastfeeding issues. She replied:

"I think the upper lip frenulum is infrequently an issue when breastfeeding.  I am concerned that the term "lip tie" causes parents to be overly concerned about this issue and could increase doctors' skepticism of frenotomy."

• Sucking blister on the top lip

So we have a baby gripping hard with its lips, if the tongue is thrusting, rather than undulating (as we frequently see with a tongue tie), it can cause the baby to move back and forth like a piston.  This can often be more easily seen when baby is sucking a finger or bottle, ie it physically moves in and out of their mouth, like Maggie sucking her pacifier in the Simpsons...

Add together tight grip of the lips + moving = friction blister on upper lip/babies slipping off the breast as their own suck pushes them backwards.

• Clicking when feeding

We discussed baby needing to make a seal above.  A tied tongue or shallow attachment can provoke "snap back",  breaking this seal and a loud clicking is often heard. As the tongue moves forward it briefly creates a seal, and as it slides back for the swallow it breaks.  Because it is linked with a shallow attachment, babies without tongue tie can click too.  

• Small gape

It's easy to assume a smaller than typical gape is because the lips are preventing adequate movement, however tongue tie is king of the small gape.

Take a look at this picture:

The gape is wider than it is tall.  If a baby opens their mouth to cry, the tongue naturally lifts which in turn (if tightly anchored to the floor of the mouth), pulls the bottom jaw up = small gape.

Now let's consider feeding.

Baby comes to breast, if he gapes wide and the bottom jaw drops, in the case of tongue tie - so does the tongue.  However baby needs to bring their tongue forward to latch, if not they will need the breast/bottle placing right into their mouth, rather than latching on effectively.  Some babies develop a great "spaghetti style suck" - where the nipple is drawn in with a suck like a child with a long string of spaghetti :)

However if they lift the tongue, it pulls their mouth closed again.

We see many many babies who post tongue tie treatment open with a giant mouth compared to pre division.

Here is a before and after pic:

Again things other than tongue tie are linked with small gape.  A tight or stiff jaw, neck or base of the skull from delivery may also cause baby to be uncomfortable with a wide mouth.

• The lip wont flange when pushed easily.

Now I'm half with this one.

If a baby has had their tongue tie released, isn't stiff or has any other obvious causes for increased oral tension such as say a forceps delivery, very rapid labour or suchlike - that's when we typically reassess the upper lip, if tightness is identified at the initial assessment.  IF mum continues to experience problems.

I don't believe it's often accurate to assess with a tongue tie in place, or within the first few weeks after birth for many babies.

Take a look at this picture:

The oral tension is significant throughout the whole mouth.  Sometimes this can be so significant in my experience it can be hard to even get in the mouth to assess - and the babies are often declared to have tiny mouths with a short tongue.

The bottom lip looks equally as pinched, as do the corners and even the area around the mouth looks tight.  Once the tongue is released a significant number of babies have "pop out lips" ie they suddenly have full, flexible function.

• Toddler teeth

Again, it is common for people to expect to see adult dentition in young children, nice teeth neatly sitting together, without gaps.  

According to orthodontist, Glenn Carty:

"Did you know that Adult front teeth are 2-3 mm wider than baby front teeth? Adult front teeth therefore occupy more space than baby front teeth. 

A young child's smile should appear very different to that of an adult's. The smile should resemble a picket fence. The baby front teeth should be spaced. While this might not look pretty, the extra space is needed for proper alignment of the adult front teeth".

Furthermore, it's well recognised they may have a gap:

"The permanent maxillary central incisors are flared laterally at this time because the unerupted lateral incisors constrain the roots of the centrals. The median diastema, which results from this flaring is normal and often is called the "ugly duckling stage" of the developing dentition. As the permanent maxillary lateral incisors and canines erupt, pressure is exerted medially, causing the space to close and the frenum to atrophy." (4)

"In some cases the series of events just described does not occur." (4)

In the UK it is common to treat an upper frenum around the ages of 10 or 11 if it has not regressed and is impacting on alignment of the upper teeth, a brace may also be used at this time to assist with closure.  And I think this reflects healthcare typically in the UK, and why treating upper lip frenums is much less popular here.  As a tax funded system, we treat something if and when it's a problem.

My understanding of US medicine is that it more heavily focusses on potential prevention.  Lip attachment appears to be removed at times because they might cause a problem later, or they might be causing a problem now, and the parents travelled across 8 states for four days to get here, and as we understand it we don't "need" an upper frenum, so lets remove them just in case; it's only a frenum!  And I'm sure there are both pros and cons to this approach too.

I also collected photographs from people kind enough to share of untreated upper lips and the normal regression that occurs:

The baby in the bottom image, is the sibling of the child on the right

Despite treatment 2 1/2 years ago for the child on the right, the gap remains and looks remarkably similar to his sibling's pictured bottom left.

This isn't surprising.  To give you a potted history of the information I've gleaned about upper ties and diastema, and then a link to where you can read the full caboodle if you fancy.

In 1907 it was first suggested that a thick labial frenum was the cause of diastema.  By the middle 1900s, the it was believed to be correlation rather than a cause.  They found gaps without frenums, frenums without gaps, and several studies found no associations between the size of the gap and the frenum.  They also discovered that in some cases, the bone had not formed correctly - and that in such cases an abnormal frenulum was the result.  Ie potentialy the gap caused or correlated with an abnormal frenum rather than the reverse.

"A V-shaped bony cleft develops between two central incisors, and an "abnormal" frenum attachment usually results.16.  Transseptal fibers fail to proliferate across the midline cleft, and the space may never close.1 ' 18"" (4)

In short during conception, a tiny cleft forms in the bone, holding the teeth apart.

They even studied the effect of frenectomy on diastemas, and found "that although closure progressed more rapidly in the frenectomized group than in the unoperated group, there was no difference in the final results after 10 years. These results intimate that frena may exert passive resisting mesial pressure, but are not an important etiologic factor in midline diastemas.22" (4)

Thus we absolutely cannot say that ties cause gaps, or treating a tie will resolve or prevent one.

The next question logically therefore is does potential early closure of a gap affect placement of other teeth, and if so in a negative or positive way? 

This image on the left was sent to me by a dentist who got it third hand, so I'm not sure who it belongs to in terms of crediting/using here, there was no copyright notice displayed - therefore if it's yours please get in touch!  (I have tried reverse image searches etc to no avail)

You can see the gap quickly closes post revision.

The UK dentists I've spoken to all seem unsure and say they would rather wait until clear and obvious reasons for immediate intervention.  But then very few here regularly perform frenectomies on babies, and so have little experience.

Presumably the American dentists treating upper frenums don't notice an increase in problems?  But I haven't seen any written material addressing this, if you have please share :)

The issue of decay to infant teeth also arises in the case of a tight frenulum, which again seems to split dentists (even those who treat).  As one pointed out, if you know there's a frenum, simply wipe up each side instead of over the top as it's stray food particles than cause the problem - so make sure you remove them.  Others don't feel that is sufficient to prevent problems.  Reducing bottle use can also reduce the impact of milk plus food together, which is a known risk in terms of decay; brushing teeth after the last feed if using formula is also advised.

Any other risks?
Without studies, how can we know?  An ENT here in the UK who would treat upper frenum with a "half snip" only if the tongue tie didn't improve things, and only if a midwife or lactation consultant confirmed they believed it to be the cause (I speak past tense as he's now emigrated), used to ask parents to sign a document stating that there may be potential unforseen consequences, without research we cannot be sure.

He also theorised a risk of removing the upper frenum, may be that without the "anchor", the lip would then lift too high exposing gum.  I was assured by two different providers this absolutely wasn't the case, and in fact the opposite was true - a tight frenum pulled the lip.

As soon as I published this blog today, someone got in touch to say this is exactly what both she and her dentist felt happened to her, and she sent me the photo you can see on the left hand side.  Her upper frenum which extended onto the palate was removed at 10 years of age due to a huge gap.  As you can see this closed, but she states that whilst she does have long gums, her lip didn't lift to reveal them to this degree before surgery.  She has promised to dig me out some childhood pictures, and so I will update then.

I also believe there are increased risks to treating both areas at the same time.  For a baby with tongue tie, compensating with the lips as discussed, to make both the tongue and lip sore can be a step too far. Remember they have likely already found feeding difficult for sometimes months.

Helen Marshall IBCLC said:

"I am seeing a high incidence of breast refusal. Usually just for 24-48 hours but that is significant to the mother who was exclusively breastfeeding and is now having to bottle or cup etc"

Discussion:

In the UK we tend to like regulations, guidance and studies.  We have that in the form of NICE guidelines for tongue tie treatment, which confirms anaesthesia is not required, and has evaluate the risks benefits involved.  We don't have this for frenectomy, we don't even have any studies confirming if and when it helps feeding.

The other problem appears to be that both upper lips and tongue ties are treated at the same time - so how on earth do we establish which intervention helped?  At suggestion they could potentially study this I was advised it was unethical to do so, as it would mean leaving a baby with a known tongue/lip tie to test the theory.  Can't say I'm entirely convinced by that logic.

Undoubtedly as I said in the introduction to this article, there are times the attachment is restrictive.  I've seen several so thick and tight the lip is unable to function properly - and who wants to spend their life with their top lip stuck down?  But these, in terms of feeding problems, appear to be a small percentage of babies.

What's more, if we're not quite right with the diagnostic criteria, could we potentially miss those that are restrictive?  My son (8) for example has a thin upper frenum, well away from his teeth and with apparently normal "flangability".  However he has for several years intermittently told me it's "too tight", asked if they can "cut it off", struggled to clean a spoon for a long time, and I think has reduced movement when talking.

If you feel up inside his lip when it's relaxed - that's the point at which the frenum feels tight.  (I should add he does have a posterior tongue tie that wasn't diagnosed during infancy)

In short we know some, we are still learning, but there's a lot left to learn.  In my opinion anyone who talks in certainties about lip ties can only be speaking anecdotally, because there are no controlled studies.  Whereas tongue tie and the impact on infant feeding has been explored over decades, we have a hole where the lip tie studies need to be.

Yes it's a relatively minor intervention in the scheme of things, if there are clear issues the preservation of feeding is of course paramount, due to the health implications of early cessation of breastfeeding.  But if we are talking "every baby with a tongue tie has a lip tie" (as some webgroups claim), don't we need guidance?

Does the area need numbing?  What is appropriate pain relief? If you're into complementary medicine, an

acupuncturist once tol me the upper lip frenum is a key point as it apparently sits on a junction of two significant channels. This might mean more to you than me, but there's a little more information here.

It's a minefield for parents at the moment, in an age of trying to seek out answers via the internet, and simply wanting to resolve their baby's issues - they're vulnerable to the next quick fix or magic wand.  I get calls three days after a tongue tie treatment saying "it hasn't worked and should we now treat the upper lip?".  The reality is that there are no instant solutions for many babies, even once the tongue is free - being a muscle it often needs to develop strength to consistently perform well, particularly with posterior ties.  You wouldn't get a cast removed from your leg and expect to run a marathon 24 hours later.  Similarly there is no benefit to patiently waiting weeks if baby has another reason they're not feeding better, such as a supply dip, a stiff neck or reattachment.

This is why working closely with your lactation consultant or breastfeeding counsellor who specialises in tongue tie is key for some.  One look at the internet chatter tells us that removing a piece of skin before pushing parents out the door 10 minutes later simply isn't enough for many.  Babies and their barriers to feeding are more than bits of skin, but that's a blog for another day....

Note:  I got 3/4 of the way through this blog, when Dr Ghaheri posted this great article.  Worth a read as although there is some crossover, it's great to get another perspective.

References:

1.  http://doctorspiller.com/Childrens_Dentistry/Childrens_Dentistry.htm#adult_eruption_schedule

2. Tethered Labial Frenum With Midline Diastema, SANJEEV TULI, MD, DEEPA SUNKARI, MD, DALLAS McKAY, MD, MARIA KELLY, MD, and SONAL TULI, MD, University of Florida, Gainesville

2. Department of Pedodontics, University of Umeå, Sweden.International Journal of Paediatric Dentistry (Impact Factor: 0.92). 07/1994; 4(2):67-73. DOI: 10.1111/j.1365-263X.1994.tb00107.x

3. An overview of frenal attachments, M Priyanka, R Sruthi, T Ramakrishnan, Pamela Emmadi, N Ambalavanan, Department of Periodontology, Meenakshi Ammal Dental College, Chennai, Tamil Nadu, India, Year : 2013 | Volume : 17 | Issue : 1 | Page : 12-15

4. The midline diastema: a review of its etiology and treatment Wen-Jeng Huang, DDS Curtis J. Creath, DMD, MS, American Academy of Paediatrics, Pediatric Dentistry - 17:3, 199 

When To Introduce a Bottle To a Breastfed Baby?

A few months ago I received a call from a confused mum; her baby was 3 months old, breastfed, and that night he had refused his daily bottle.  Mum couldn't understand why, after all they had given a bottle once per day since week 2 as advised to "get him used to it".  He had always taken it without a problem why now should he refuse?

I get asked when should parents introduce a bottle a lot, and like the mum above many are told early introduction equals success, and conversely if the bottle isn't introduced early then baby is likely to refuse or struggle with technique.

What's the deal?

Firstly expressing:

In the early days of breastfeeding (once milk has "come in") your body is trying to establish how much milk your baby needs and thus how much to produce.  It does this based on what is removed, so if you feed baby and then express, your breasts will replace a feed plus more to replace the amount expressed.

Mums often plan to express so dad can give a feed and allow a longer stretch of sleep, but in the early days this often proves rather impractical as missing a feed results in overfull, painful breasts - meaning mum ends up pumping again whilst dad gives the bottle.

Some mums deliberately choose to cultivate an oversupply early on, usually if they want to build a stockpile for some reason ie they want to feed baby now, plus add a regular amount to the freezer.  Otherwise an oversupply can be problematic, leading to engorged painful breasts between feeds, faster flowing milk and increased leaking (as an example at the extreme end of the scale, one mum I worked with had to sleep with a super absorbent nappy taped over each breast at night).

Bottles:

I've spoken to so many mums over the years who have diligently given a bottle every day, or every week from a young age to ensure baby would be used to taking it.

This doesn't however account for the fact babies have personalities. 

Some will take that daily/weekly bottle fine until one day they decide out of the blue that they don't want it thanks; others will continue to take a bottle just fine.  Some will refuse a bottle in the early days, then one day decide actually OK they will drink from it.  Others that aren't offered a bottle when young will take it just fine when offered at any age.   The same can also happen to a baby fed exclusively from the bottle.  I've worked with mums struggling to get the necessary amount of formula or expressed milk into baby because they fuss or refuse the bottle, take hours to consume small amounts or leak, splutter and gulp.

Introducing a bottle and finding baby takes it, really only tells you they will do so at that point in time.  It is no indicator of how baby will respond at any point in the future.

It seems a standard expectation (particularly with first babies) that mum will of course express and bottle feed at some point, imagine not being able to leave baby!  Some mums have no alternative but to do so if they need to work or be separated.  On the flipside if you don't need to, it's also OK if you don't want to, mums often tell us that the expectation she will want time away, is greater than her desire to actually do so.

Babies naturally settle into a more predictable pattern of feeding, and so some mums find it's easier to work things in and around this rather than expressing.  From around 4 months some soft spouted cups are suitable if you don't need bottles on a regular basis, and things like a doidy cup can be used even earlier.

Nipple confusion, real or not?

This really depends on who you ask!  In my experience the biggest risk in terms of bottles is if a baby hasn't completely mastered the breast and/or has reduced milk transfer, the flow from a bottle can cause some to quickly show preference to the easiest milk source, causing them to fuss earlier and earlier into breastfeeds (although as the breast isn't just food, they will often be happy to return to it afterwards).  Others in this situation will refuse a bottle outright too, but ultimately the key is resolving the initial problem, the bottle is a symptom.

Although more and more bottles are claiming to be "like the breast", realistically to baby they are still poles apart.  No bottle can deliver the smell, sounds and scents of mum (think Heston Blumenthal style dining). None are made of the same substance as nipples or let down in milk ejections as the breast does.

This can cause some to become impatient waiting for the breast to "letdown", which is why mums are often advised to use the slowest flow teat and encourage sucking without milk beforehand, with regular pauses during the feed.

For an infant refining his breastfeeding technique, I like an analogy Lisa at Everyday Miracle uses.  Imagine you are just learning to use a knife and fork, but at some feeds these are swapped for chopsticks - something that requires a totally different action and technique.

The added difference however is that the bottle requires far less effort than the breast, and the baby may try out techniques that work on the bottle when at the breast:

"When bottle feeding occurs, only the buccinator muscles and the orbicular muscle(s) of the mouth are exerted without stimulating other muscles. They concluded sucking only during breastfeeding promotes correct muscle activity, and thus proper development of the oral motor structures" (1) 

It's important to note however....

That giving a bottle doesn't mean baby wont be able to breastfeed effectively again.  I get asked quite frequently whether its worth persisting with breastfeeding if baby has had a bottle, could learning this incorrect action permanently hinder skills at the breast and be the cause of their problems?

Dig a little deeper however and a lot of mums experiencing problems now, who introduced a bottle in the early weeks when trying to establish feeding, did so because they were experiencing a problem; pain, baby that wouldn't leave the breast and settle, slow weight gain - whatever.  So we always have to question what came first, the chicken or the egg?

Even after a bottle baby can still refine, improve and develop their technique at the breast. Conversely some mums never need or want to use one and that's fine too :) 

1) The relationship of bottle feeding and other sucking behaviors with speech disorder in Patagonian preschoolers BMC Pediatrics 2009, 9:66 doi:10.1186/1471-2431-9-66

Starting Formula Doesn't Have To Mean Stopping Breastfeeding...

We hear lots of different reasons mums choose to introduce formula when breastfeeding; pain, a very unsettled, hungry (or perceived to be) baby, feeling overwhelmed at being the sole person responsible for nourishing their new bundle (who perhaps may be growing slower than health professionals are happy with), returning to work or fear over feeding in public are a few of the common ones.

Society has researched, surveyed and tried to explore these reasons, in the hope barriers to success can be broken down.  But something I don't see examined with such scrutiny, is why mums so often "switch to" formula.

What I mean is why does it have to be a straight swap from 100% of one to 100% of another?   Why does it have to be all or nothing? 

Of course if a mum has damaged/sore nipples wanting to rest them is natural, but if we consider all the other reasons mothers change to exclusive formula feeding, why is it so often assumed once formula is regularly used one might as well switch 100%?

If we think of the breast purely as food, it perhaps seems logical.  If baby is getting adequate nutrition from another source, why continue any feeds at the breast?

But it's not.

Breastfeeding is about so much more!  Hormones, antibodies, bonding and comfort, often a "go to sleep" switch for all involved, to name just a few from a long list.

The problem is how often does a new mum know all this?

Whilst mums often hear oodles of tales about cracked nipples and mastitis, how often does someone who has breastfed successfully for longer than a few months, sit at a baby group regaling others with tales of all the upsides?  Er no, that's the definition of smug, judgy breastfeeding mum is it not?

For women who have never breastfed, have no family or friends that can share their insight into what lays beyond the early days, the sad thing is most don't even know what they're missing.

Of course the norm should be that all mothers get fast, effective help to resolve their problems; that all should be supported to exclusively breastfeed for as long as they wish.  But at the moment this isn't the reality.   For those who haven't managed to resolve problems and are about to switch 100%, don't they deserve to know they have other options?

To be supported to even share one breastfeed per day?  To know they can put the baby to the breast before or after the bottle (a baby causing lots of nipple damage may be more patient in adjustments and suck less strongly when he's not as hungry) at every feed, at some feeds or even for just one if that's all mum feels she can manage.

Once nipples have healed, mum may then choose to increase this if desired.  If we remember babies who  (for whatever reason) are not able to transfer milk as effectively as they need, may consistently feed for very long stretches or very frequently, and that baby is most likely not transferring well because of shallow attachment - the combination of the two can quickly cause cracking or bruising to the nipple.  Once this has healed mum may find combination feeding doesn't permit frequent enough feeding for trauma to reoccur.

I think mums also deserve to know that even if baby's main source of nutrition is formula, that doesn't mean they must also switch to an artificial pacifier; mum can continue to use the inbuilt original aka her breast should she wish to do so.  I've known babies suckle at breasts with barely any milk supply, which surely only confirms that to them, it's definitely not always just about feeling full.

Using some formula doesn't mean mum has to also miss the special little moments; baby pulling from the breast smiling, milk running down his chin.  The instant soothing of a teething pain, learning to sit bump, or 3am fussies with a simple lift of her shirt?

Some mums who feel baby just wasn't getting enough at the breast might choose to supplement feeds during the day and breastfeed only overnight.  If we think calories over a 24 hour period, if low intake was the issue (and increasing supply isn't an option) the extra milk can be given during waking hours, giving the ease and convenience of being able to roll over and feed baby instantly without either party fully waking.

For mums returning to work with younger babies and not wanting to express, you can continue to breastfeed your baby when you're with them.  Yes supply may drop compared to exclusive feeding, but if the alternative is a complete swap, then any feeds are a bonus right?  If baby drains the breast well when you do feed, and this happens with any regularity, supply is unlikely to dwindle altogether.

Even if baby isn't drinking lots of milk when at the breast and supply does reduce, it is likely to happen more gradually; this reduces the chance of mum suffering blockages or mastitis.  As supply reduces the breast begins a process called "involution", and milk gradually reverts to a more colostrum like substance to give the weaning nursling a boost of antibodies.

We could go through lots of scenarios to show how breastfeeding can work in different situations, and it is worth noting there is the potential for a baby finding breastfeeding difficult to become increasingly fussy or refuse the breast once nutritional needs are met elsewhere.  But if the alternative is no breastmilk anyway, some may feel they want to give it a try.

Lastly, and perhaps a key reason to not jump feet first, is that it leaves a window open for a change of heart.  Mums often choose to stop breastfeeding when emotionally at their lowest; tiredness may be overwhelming and she's aching for the situation to stop, never wanting to breastfeed again!  But a few days down the line feelings can change, if partners go back to work the realisation of just how much of a faff formula is (not to mention the ongoing cost) can hit. If not, mix feeding may feel more doable, but if mum does want to stop entirely that option is still there.  At least then the decision has been made rationally and not because things are so unbearable mum feels she has no choice.

I think we have to recognise that whilst there are such gaping holes in the support mothers receive, and a culture still so pro alternatives, any continued breastfeeding should be celebrated as one small step for mothers.  Perhaps instead of focusing on what we can't or don't do, we need to look more closely at what we can.  Celebrating every single feed as one more than might have been; after all every day matters.