Establishing Breastfeeding when there are problems during the Corona outbreak (UK bias)

Thu, Apr 30, 2020 21-minute read

Hi, I am Sarah Calvert, I really struggled to get breastfeeding established but got back to exclusive breastfeeding when my baby was 6 weeks old. Now I am super passionate about helping women to breastfeed and I trained as a breastfeeding support peer with St. Mary’s hospital for women in Manchester, UK. I can only imagine how I would feel if I gave birth now in the middle of the corona virus and I was struggling with breastfeeding all over again. It would feel like so much added pressure because the virus would feel like a new threat to my baby and the way I could mitigate that would be with breastfeeding. Also once established breastfeeding is super nice and easy and you don’t have to worry about being able to get to the shops. The usual routes for help and support need to be adapted now as it may not possible to go to local groups with trained support, or even from friends, family or paid help like a post-natal doula. This blog is going to go through getting how I would troubleshoot establishing breastfeeding during the corona virus lockdown.

I have 6 steps to talk through with you in order to keep going with breastfeeding when it is tough at the start and I will go into these in more detail throughout this article.

  1. Lower your expectations
  2. Feed baby
  3. Express milk
  4. Solve any problems
  5. Regain your confidence
  6. Get help

Lower your expectations

Yeah it is great if baby latches on straight away after being born, mum doesn’t get sore, baby seems to be getting enough and they haven’t even lost weight at day 5 after exclusive breastfeeding. This is certainly how I pictured breastfeeding would work for me at the start, but it didn’t go like this (if you are in this camp great keep going, it seems like breastfeeding is working well for you even if it still seems tough). New-born babies are difficult to breastfeed for a number of reasons. A new mum is not alone in facing these problems - I saw many women as a peer supporter each week going through this experience. As a society we don’t see or talk about breastfeeding much so all you do see is women with older babies who have already managed to get breastfeeding established, we don’t see all the women at home or in hospital struggling. In my experience, I wasn’t prepared from the hospital classes I took that breastfeeding can be difficult at the start. Hell, the video of breastfeeding a new-born I had seen showed a baby latching on by itself straight after birth, but my baby was not able to do this. Feeling isolated in this problem and having unrealistic expectation compounded the problem so that I felt like a failure - this was supposed to be something natural I should do, and I couldn’t even do it. With hindsight though my expectations were wrong, it is normal for babies to need extra help at the start and to have trouble latching and loads and loads of women experience this. It is good to aim to do exclusive breastfeeding, but it can be tricky to do this from the start and that is ok too. You are being a really great mum for trying. It is ok to accept that breastfeeding can be hard. Accepting that it is hard will help you to have compassion for yourself and to readjust your expectations.

Feed baby

The best thing for babies is breastmilk from the breast and the first thing to check is the latch. Usually it is good to get a midwife or breastfeeding support peer to come and have a look at a baby’s latch and to offer variations if it isn’t working. But at the moment this may not be possible, so the first thing is to have a look guides online and see if there are things that need tweaking or a different position to try that might be more comfortable. I have selected some videos showing how to do a good latch and different positions to try while breastfeeding:

How to latch your baby:

Different positions to try breastfeeding (note the lying back position at the end)

There are also some good resources out about all sorts of breastfeeding issues:

If impersonalised guides aren’t working there are national helplines and breastfeeding support in local areas:

If mum is completely sore or cannot face trying to get the baby to latch anymore, then have a break. It is ok to do things imperfectly until breastfeeding is established. The second-best thing to give babies is expressed breastmilk so check out the section below about how to get expressed milk out of breasts. This milk can be given in many ways including at the breast feeding with a tube, cup feeding, using a syringe or with a bottle. If possible, ask midwives for guidance when trying any of these feeding strategies. And the final option to give babies is substitute breastmilk formula, make sure preparation instructions are followed carefully and try to come up with a plan about how to use substitute breastmilk formula while establishing breastfeeding It can be useful to formula feed in a way that supports breastfeeding, if breastfeeding is the ultimate goal and there is some good advice here on how to do it https://kellymom.com/bf/pumpingmoms/feeding-tools/bottle-feeding/

Express milk

Expressing milk serves two purposed: it can be given to baby and it will build up mum’s milk supply. Breasts respond individually to how much milk is taken out of them and the more that comes out the more will be made in future. To protect mum’s milk supply it is important for some milk to come out of the breast, this can be via baby feeding, hand expression or pump expressing. It can be worth trying hand expressing as some women get really good at it and find it quicker and more comfortable than a hand or electric pump, but it is especially useful in the first 3 days. Here are some good guides for hand expressing:

https://www.laleche.org.uk/hand-expression-of-breastmilk/

Unicef hand expression:

Apart from that feel free to try hand pumps or electric pumps if available. Please note in the early days of expressing it is normal for very little quantity to come out, this will improve as supply builds up and expressing technique gets better. Also being relaxed will help. In the early days of expressing don’t worry about the amount of milk that comes out, just see whether it increases over the following days. Any amount of milk will help maintain mum’s supply and help to ramp up production later. It is normal for the amount to vary throughout the day to get less expressing milk in the evening than in the morning. Also, it is really helpful to release some milk overnight (between 11-5am) as this is when milk producing hormones are highest. But nothing is utterly crucial so even if overnight sessions are missed it is possible to make it up in the daytime instead.

Solve any problems

So, the basics are covered, but it feels like hard work and it would be better for baby to have a good latch. Getting a good latch can be a tricky issue, some people will find the latch naturally improves when the baby develops just a bit more whereas others may need help from experts and possibly further interventions. In this blog I will briefly cover the 8 topics I think are most likely to come up while getting breastfeeding established - this is not an exclusive list there are plenty of resources online or in books for example: https://www.laleche.org.uk/get-support/#bfinfo La Leche League’s “The Womanly art of breastfeeding” Gill Rapley & Tracey Murkett’s “Baby-led breastfeeding” However, do not worry if you can’t quite decide from a book or online what issue is happening, these will undoubtedly help some women but not every woman. My own experience was that I got a bit obsessed, read everything, convinced myself I had everything going wrong and didn’t have confidence in my knowledge in order to be able to put a remedy plan in place. I was only able to apply my knowledge with assistance from a trained supporter. Just because it bears repeating here is a good list of free places to contact for breastfeeding support https://www.nhs.uk/conditions/pregnancy-and-baby/breastfeeding-help-support/ . Below is a list of common issue, but this is not exhaustive or intended as medical advice, if you are worried about your symptoms please seek medical attention:

Poor latch

Symptoms

Sore nipples, baby fussing at breast and not seeming satisfied, low nappy output and poor weight gain in baby and low milk production.

Cause

If baby does not have enough breast tissue in mouth and is nipple feeding they will cause rubbing on the nipple that causes soreness and will not be able to stimulate enough milk release from the breast so they don’t have enough milk to make wees and poos and will limit mother’s milk supply by not taking enough out.

How to solve

Get help on latch. Ideally if you can see a person with specialist breastfeeding knowledge face-to-face or via video call do that, otherwise go back and review the latch video or mother’s and others guide to see how to improve it. Breastfeeding should feel comfortable and baby should suck and swallow (followed by pauses and possible fluttering pattern at the end). If no amount of tweaking seems to keep baby happy at breast then get help and see section on tongue tie.

Sleepy baby or jaundice

Symptoms

Baby is not waking for feeds, has difficulty latching and falls asleep quickly before a satisfying feed.

Cause

Babies are often especially sleepy for the first few days after birth. If they do not feed properly in this time it can exacerbate issues with jaundice leading to even more sleepiness.

How to solve

Feed baby on demand where possible, try waking baby every 2 hours during the day for feeds and 3 hours overnight. Go over basics of latch to ensure it is as smooth as possible. Sometimes you just need to get some food into baby at the start even if baby is not breastfeeding yet. Try hand expressing some milk into a syringe, cup or straight into baby’s mouth to see if that will wake them enough to feed or give expressed or formula milk via a bottle, cup or tube. When baby starts to wake more try to reintroduce breast feeding from the breast. Babies have instincts in the first 3 months of life to more easily be able to learn breastfeeding and even after this point it is never too late to switch to breastfeeding baby.

Low milk supply

Symptoms

A mother’s milk supply works on a demand = supply basis, so when a baby cluster feeds they are boosting their mother’s milk supply. Low supply in the mother is often caused by not enough milk being taken out of breast to stimulate more production of breastmilk but can also be caused by some issues in the mother that limit total milk producing ability. (Please note cluster feeding is not necessarily a symptom of low milk supply).

Cause

Issues that reduce milk being taken out of the breast include a poor latch, a sleepy baby or feeding to a schedule or not feeding baby on demand. Issues with the mother that can cause low milk supply include previous surgery to the breast and polycystic ovarian syndrome or other syndromes that disrupt hormones.

How to solve

To redress not enough milk being taken from the breast try to ensure there is a good latch, expressing milk temporarily if needed and feed baby on demand and not to a schedule. Feed from both sides at each feed and feed as much as possible. Especially the first few days of “on demand” feeding can feel intense and take confidence to keep going. It is heartening to note that once any problems are solved it is impossible for a breast to empty of milk and breasts will quickly respond to new demand for more milk production so mums can get back to exclusive breastfeeding within a couple of days. Also once problems are removed it is fairly easy to build up mum’s milk supply in the first 3 months after baby has been born and it is definitely possible to do it after this time as well by following the milk out = milk made rule. If the mother has some conditions that may lead to low milk supply it can be useful to get extra help, lots of women will be able to exclusively breastfeed with these conditions, but some may need to mix feed to supplement the breast milk with artificial feeding or do just artificial feeding. It is especially a good idea to monitor babies wee and poo output and weight gain in these situations for peace of mind. Remember any breastmilk given will benefit baby.

High milk supply

Symptoms

Baby may cough and splurt and come off breast while feeding and have green poos. Mother’s breast may leak a lot and be uncomfortable and be at an increased risk of engorgement or mastitis.

Cause

Most mother’s breasts naturally overproduce milk a few days after a baby is born and then overtime regulate themselves to produce just what the baby needs but this can be especially prominent in some women, and as breast tissue increases with each pregnancy it can also increase each time a child is born.

How to solve

This one will resolve itself over time. It can be worth trying laid-back breastfeeding as working against gravity will slow the flow help baby to stay latched. Also try feeding from just one side each feed. If mum gets uncomfortably full or baby has trouble latching mum can express a little to make breast softer (try to express the least amount of milk possible). Extra milk can be expressed and stored for future use (label with date clearly and fridge or freeze) and it may be possible to donate extra milk to a milk bank.

Engorgement

Symptoms

Overfull breasts that are uncomfortable to touch and may be hard and shiny.

Cause

Engorgement is cause by not enough milk coming out of the breasts and will happen if women are not breastfeeding, produce too much milk, if there are long periods of time in between breastfeeds or baby is not breastfeeding effectively.

How to solve

Engorgement is treated by getting some milk out of the breasts so feed baby when breasts are becoming full, rather than already full, or express some milk to be more comfortable. With engorgement the fullness of breasts can make it tricky to express milk or feed baby, so don’t be surprised if it takes a few minutes before milk starts to come out or if a little milk expression is needed at the start in order to help baby to latch effectively. Check that baby is latching effectively. Painkillers can be taken. Some women find cooling to be effective (hence the fabled cabbage leaves from the fridge to the bra) - but be careful and limit cooling time avoiding feeds if you want to keep breastfeeding. Cooling is particularly effective for women who do not want to breastfeed or express and want to stop or limit their milk supply.

Mastitis

Symptoms

Mastitis is marked by a tender area that often feels like a bruise, this area will be red and hot and often forms a cone shape with the tip towards the nipple and then pain and redness spreading back from there. It is usually accompanied by flu like symptoms.

Cause

Mastitis is caused by a milk duct being blocked and then the area behind that becoming inflamed. It can happen due to bacterial infection or restrictive clothing or bags putting pressure on the breast tissue. Please note mastitis can cause further problems if it is left untreated so even if you do not want to breastfeed it is important to express milk to treat mastitis and then try to reduce milk production after.

How to solve

With mastitis it is especially important to keep milk coming out of the affected breast. It is usually advisable to seek further medical attention as antibiotics is sometimes needed as well. Applying heat (using warm towels or have a warm shower) and massage the sore site (as much as it bearable) will help to clear the blockage. Try feeding baby on the sore site first at each feed, placing babies chin on the sore area is particularly helpful at clearing any blockages and get milk flowing out of the inflamed area, as is dangle feeding. Expressing milk from the not inflamed side might be needed to stay comfortable. (For treating mastitis, I would say it is worth getting as much milk out the sore side as possible - including expressing milk that can be frozen or disposed of. After the mastitis has cleared you can reduce expressing by one session a day as needed so you are just producing the milk baby needs). To reduce discomfort painkillers can be taken. Please note mum’s milk is still the best thing for baby to drink when she has mastitis

Tongue tie

Symptoms

Baby has difficulty latching onto breast (they may not latch at all; they may be on and off or they may start feeding then be there for hours). They may have high weight loss at the first few days and slow weight gain afterwards and they are producing a low number of wees and poos coming out. Also, babies may swallow a lot of air with each feed making them gassy and colicky. These babies may only be getting early milk from the breast so may have green poos (after they used to be yellow). Baby may be unputdownable. Mother is likely to have sore nipples and may have low milk production.

Cause

The frenulum underneath the tongue is too short, inelastic or comes too far forward to allow full movement of the tongue in the baby. As full tongue movement is needed for effective breastfeeding this means the baby is unable to latch effectively to the breast and then to keep breastfeeding going. Essentially this is the same issue as a poor latch except baby may not be able to correct their latch.

How to solve

If tongue tie interferes with feeding it is essential to feed baby however possible and to express milk. Some babies tongue ties correct themselves as they get a little older, so keep trying at different stages. It is usually worth trying different tips and tricks to help baby latch as well as possible as some mum’s find a new technique will make all the difference for them. Try using a nipple shield to reduce nipple damage and pain https://kellymom.com/ages/newborn/nb-challenges/wean-shield/ . Try using the exaggerated latch to encourage baby to latch as effectively as possible:

Also, as much support as possible for the interim time. Some women and babies will find this is enough for them, and some will want further assistance in the form of an operation called an frenulotomy. A frenulotomy is where the tight frenulum under the tongue is cut allowing the tongue to be able to work effectively. This operation does not hurt the baby and can be done easily with local anaesthetic. The first thing is to get referred to a tongue tie specialist either through the NHS through your GP or health visitors (https://www.nhs.uk/conditions/tongue-tie/) or privately (an estimated cost around Manchester is about £200 for the assessment and operation) https://www.tongue-tie.org.uk/find-a-practitioner/ . During lockdown this is likely to be harder and may involve travelling further or waiting longer, so during this time it is important to keep perspective and do your best. It is also worth remembering that mum and baby will have strong instincts to restart breastfeeding easily in the first 12 weeks, but this can be extended after this point as well.

Nipple confusion

Symptoms

Baby fusses at breast but seems to feed more readily from a bottle.

Cause

Babies can develop a preference for how their milk is delivered if they are sometimes given milk one-way and sometimes given milk another way (although some other babies will happily switch back and forth). As bottle feeding requires less work from a baby than breastfeeding they can sometimes prefer that (if you turn a bottle upside down it drips milk but that does not happen with a breast).

How to solve

Get babies breastfeeding instincts to kick in again, by keeping things calm with lots of skin-to-skin and try some laid-back or physiological breastfeeding to let baby have control. Baby may sleep for a bit, or head-bob or lick mothers nipples before trying to latch properly but all of that is ok. Try to just use breastfeeding if possible so that baby learns that is the way to get milk or if not possible try getting another person to do bottle feeds and just breastfeeds from mum. If baby is very hungry and irate try calming them with shushing and rocking or by expressing some milk into their mouth or starting with a bottle feed and once calm continuing with breastfeeding. It may take time to re-establish breast feeding but once baby is latching on well it is worth trying to do exclusive breastfeeding as much as possible so that baby learns how to breastfeed effectively. You never know in a few weeks baby may prefer breastfeeding to bottle feeding because it brings them nice and close with mum.

Regain your confidence

Acknowledge that confidence might be low after a rocky start to breastfeeding, but also that it is incredibly good to keep the breastfeeding relationship going at all. To increase mum’s confidence in her ability to exclusively breastfeed look for signs that baby is content (at least most of the time). Trust your instincts. Does baby have periods of being awake and alert and seem content and is baby weeing and pooing enough? Here is a good resource to check if your baby is getting enough https://www.laleche.org.uk/is-my-baby-getting-enough-milk/ . Finally, over time you will see baby growing, you will see their body change and their weight will go up. Try not to weigh baby more than once a week (unless advised otherwise by health care professional). To weigh a baby in lock down - speak to a health visitors about using their scales, buy baby weighing scales or it might be possible to use kitchen scales (be careful of baby falling - potentially put the scales on the floor). While you regain confidence take your breastfeeding journey week by week. Try exclusive breastfeeding if that is what you want to do - so long as your baby is weeing and pooing a reasonable amount they will be fine. If your baby stops weeing or pooing or doesn’t gain weight in this time get advice it may just take a little longer to solve any issues but speaking to a health professional will mean you don’t have to do that on your own. When baby starts putting on weight just take it week by week again and after enough weeks of the scale going up you will have more confidence in feeding your baby and get bored of contacting the health visitors.

Get help

Ok so part of this is getting help from people with specialist breastfeeding knowledge again if you are struggling with breastfeeding loads of people want to help you here: NHS - https://www.nhs.uk/conditions/pregnancy-and-baby/breastfeeding-help-support/ blossom antenatal - https://www.blossomantenatal.com/ & https://www.eventbrite.co.uk/o/blossom-antenatal-30028089478 for a fee - lactation consultants https://www.lcgb.org/find-an-ibclc/ and post-natal doulas with breastfeeding experience https://doula.org.uk/ The other half of this is acknowledging that looking after a baby is tough, getting breastfeeding established can be tough even when it goes well. So, get other people to help out as much as possible, they can cook food, do any basic cleaning, bring drinks and snacks, hold baby during the day so mum can nap or change nappies. Get them to look after you while you learn how to look after the baby. If mum lives by herself, she can still make a comfy cosy nest and do the absolute minimum needed while getting to know baby. In lots of cultures after the birth of the baby the mother has a 40-day period of doing nothing except getting to know the baby and getting breastfeeding established. While this may not work for you it is worth remembering that it is ok if it is hard and to take it as easy as possible.

In summary

So overall, breastfeeding is not always the easy natural experience that a lot of women expect but that doesn’t have to be the end of the road if it is important to you. Even if you don’t get the start to your breastfeeding journey that you wanted, if you keep going you are doing your baby good. You also keep the option open to do exclusive feeding once the problem is solved. Have faith that breastfeeding is resilient, and you will be able to get to a point where you have the breastfeeding relationship you want with your baby. And once you get there enjoy that quiet, bonding time with your new tiny baby safe in the knowledge that you can achieve the parenting journey that you want.