Miniseries E 2: How to feed a baby

Welcome back to the second instalment of this miniseries where we look at all the things no one tells you about having a baby.

Today's episode is all bout feeding - mostly your newborn baby but we'll also talk about the little known aspects of milk feeds for older babies.

Thought about colostrum harvesting? What about microplastics in bottles? Perhaps your thoughts are currently centred on tongue tie or nipple confusion!

Listen in and let me clear up the confusion and give you some tips to avoid the common pitfalls in milk feeding (breast and formula) your precious little one!

Need more help: www.physiobaby.co.uk

Transcript

Today’s episode forms part of a miniseries entitled, “The Baby Basics: What no one tells you about”, and this instalment is all about feeding your baby - both breastfeeding and bottle-feeding.

As a heads-up, it is quite “breastfeeding-heavy” because there are more areas to trip up with breastfeeding than with bottle-feeding! Also, this instalment is all about my journey as a new mum, rather than my experience as a paediatric physiotherapist, and breastfeeding was an area where I had a lot of difficulty, so there is a lot for me to share on the topic!

I would also like to acknowledge that however you choose to feed your baby, there will always be people expressing (no pun intended) their opinions and passing judgement. I felt a really strong pressure to breastfeed my daughter - from no one person in particular, rather it was the general feeling I came away with whenever feeding was discussed during my pregnancy. So I would like to highlight the following point: I strongly believe we should make the best decision for ourselves and our babies that is not based on the opinions of others, and as such, there is no guilt intended for any of my readers. I made so many feeding mistakes on my journey and my aim with this blog is to share them in the hope that you can learn from my experiences and make your journey a little bit easier.

To begin chronologically, I’d like to talk about colostrum harvesting which takes place in the late stages of pregnancy. Colostrum harvesting is where you express (squeeze out) colostrum that is in your breast, and you freeze it in tiny little syringes to give to your baby when they are born.

You use syringes that are are usually one millilitre in size, so they really are tiny! The idea is that you take these with you to the hospital in case you have difficulty feeding your baby in the first days of life.

Much like breastfeeding, I was quite “heavily encouraged” to do this by my antenatal course instructors and later by myself, once I was hearing that the other mums-to-be in my course were all managing to do it.

I imagined I would have all these little syringes lined up to feed my baby whilst I was busy learning how to breastfeed. In theory it sounds great but the reality is that it is one of the most difficult things to actually do! The technique involves squeezing your breast, particularly your nipple, incredibly hard until a tiny little droplet of yellow fluid appears out of the nipple. You then have to suck it up in a tiny little syringe. Even being one millilitre in size, it takes an extreme effort and time (and squeezing) to fill.

We were told that our partners should help us to do it because it could be rather awkward and uncomfortable, but I found it more difficult for my partner to help me with it. He didn't like to hurt me, and it ended up being easier for me to do it on my own.

After about a month of setting aside time to do this, I ended up with about ten little syringes that I was incredibly proud of. When my daughter was born, we did have a really difficult time establishing feeding and in the first hours of life, I was really grateful to have those syringes there at the hospital. However, they were gone in what felt like an instant! To have really bridged the gap, I would have needed loads more than what I had. Did the benefits outweigh the difficulty and discomfort of getting those syringes? I’ll let you decide!

Another very important point about colostrum harvesting is that you can only do it from about 36 weeks. This is because, firstly, that's when you have the largest amount of colostrum in your breasts, and secondly, it can trigger an early labour. This doesn’t mean that you are less likely to trigger an early labour after 36 weeks, it means that 36 weeks is considered term and if colostrum harvesting does trigger you to go into labour, its is not considered early. Something I had not fully understood prior to my excessive harvesting efforts. 

Later in this blog, I am going to mention microplastics and the containers that we put our milk into, but as a brief first mention of the topic, by expressing your colostrum, you then put it in a plastic syringe and freeze it, exposing your baby to those microplastics from their first feeds.

Finally, there are the logistics to consider as cons - if you are making a pros and cons list! Taking your frozen syringes to the hospital and ensuring they are placed into a hospital freezer before they defrost tops the list. Then there is the fact that you won’t see them thereafter. The nurses will have access to them and bring you your syringes as required. There are multiple opportunities for them to be misplaced, confused, or defrost along the way that you have no control over.

On the pros list is the fact that if you are likely to have feeding difficulties in those early days, for example if you have gestational diabetes or if you know your baby's going to be very large, then it might be a reassuring safety blanket for you to know you have those syringes on hand. 

My final point to consider is that you will need to get the go-ahead from your midwife or health care professional before you colostrum harvest. It is not advised in some complicated pregnancies, so if it is something you are considering, get the gall clear first and then draw up your own list of pros and cons after doing your own research. Once you decide whether to do it or not, stick with your decision and don’t let the opinion of others play a part in your decision making!

From colostrum harvesting, we move swiftly on to talking about establishing a latch and feeding after your little bundle of joy arrives. I'm quite certain that there can only be a very small percentage of new mums who establish feeding with ease. I think the important thing is to understand this prior to having your baby and to be aware that it may take some time and help to get feeding going. 

I wish someone had told me that not all babies know what to do when they are born, and that many of them need as much practice and assistance with breastfeeding as the mother does!

My experience, as for so many others, was that establishing feeding can be extremely difficult. There was no medical reason for this - for example a tongue tie (more to come on that), it was simply because it was new for me, and new for my baby, and we both had to practice. It's like learning a new dance with a new dance partner. You have to practice it together over and over until a natural flow and rhythm can be established, which can take a really long time.

To complicate the learning process, new mothers are usually exhausted - even after a “straight forward” labour. You may be recovering from a traumatic labour, a Caesarian section, and you may be taking painkillers, so there's a lot to process.

Other compounding factors include your baby’s natural hunger drive, if the baby has fine features and a small mouth, or if the baby is hypermobile. Colloquially known as being double jointed, hypermobility creates laxity of the soft tissues in the body - most commonly the ligaments around the joints. This makes hypermobile people (and babies) able to bend and extend their joints into extreme positions which other people can’t. Hypermobility can also impact the coordination of the muscles, meaning that they need more opportunity to strengthen and practice tasks in order to get those activities finely tuned. My daughter is hypermobile (something I suspected she would be whilst I was pregnant as I am too), and I was well prepared for her to need some help with her gross motor development, but I never really considered the impact it would have on the way her mouth and tongue muscles work.  My daughter also had a very little mouth, so she needed to practice feeding regularly and for much longer before her mouth and tongue muscles became nice and strong and could coordinate properly so that we could establish feeding. Unfortunately, regular practice is rather uncomfortable when your baby isn’t getting their latch correctly, and I had little understanding of how important it is. As a result, I left her for much longer in between feeds than what would have been helpful for us both to get going.

I stayed in hospital for three nights after my cesarean section, so I had nurses helping me to establish feeding. As I mentioned earlier, those colostrum syringes disappeared somewhere around day one or two of life and I still hadn’t managed to get feeding going. 

I'm sure you will already know this, but the baby is weighed pretty regularly if you are in hospital, and once you are discharged, the midwives come to weight them at your home. This is to check that the baby doesn't lose more than ten percent of their birth weight while you're establishing breastfeeding. Somehow, my daughter never lost more than eight or nine percent of her birthweight, so I must have been getting milk into her but still she ended up being given a formula bottle by the midwives on day two of her life. It felt like a very confusing approach as each midwife would tell me a different amount of milk that my daughter should be drinking.

Not only were the conflicting amounts an issue for me, but the fact that when milk or colostrum comes out of the breast, you can not measure it.

Every time someone came and told me how much she should be drinking, it was always in millilitres. One midwife would tell me, “ She's a tiny newborn baby, she just needs a millilitre.” where the next would say, “Oh no, she’s already x many hours old, she needs at least 10 millilitres. I remember the sinking sensation when someone quoted that amount, as it was more than all the little colostrum syringes I had brought into the hospital put together!

Somehow, consensus was reached that I was having difficulty establishing feeding and so not only was she given a formula bottle without actually having lost a significant amount of weight, but I was regularly subjected to having my breasts squeezed by the midwives into tiny cups to measure how much. Worst of all, my milk hadn't come in yet, so it was all still colostrum and incredibly hard to express these huge amounts being recommended.

I'm sure there were clear reasons for all that was being said and done, but I was not in a mental space to understand any of it. It was therefore completely overwhelming.

My advice to you is to have an understanding of how much and how often you should be attempting to feed your baby in those first days before you have your baby - if you do decide to breastfeed. I wasn't feeding my baby regularly enough and somewhere in my pregnancy I had heard you should establish a routine as soon as possible of feeding every four hours. Looking back, it makes no sense to wait that amount of time to feed a newborn, but I hadn’t thought much about this prior to having her, and it was impossible to start researching and making good decisions when I was feeling so overwhelmed! My daughter was born by cesarean section so she was really sleepy and we had to wake her to feed. This was something I also wasn’t prepared for! It was worrying that she was so sleepy for the first weeks of life, but apparently this is normal for some babies. Sadly, I now know that it wasn’t “normal” for my baby, but rather the result of her being jaundiced, and had I fed her more regularly, the jaundice would have cleared much sooner!My daughter was quite happy to sleep for four hours straight (sometimes even longer) without a feed! It was up to me to recognise that she actually needed more regular feeding. Also, had I known to wake her, rather than wait for her to show hunger cues, I would have been practicing the art of feeding far more regularly, and perhaps established successful feeding much sooner.This all continued for the first weeks of life, and it was a stress that could have been avoided had I known better. Fortunately, I had a very good friend who had had a baby about a year before me. She had a large, hungry boy and had breastfed him roughly two hourly. (She had felt very judged for this, and tried to hide the fact that her baby was such a regular feeder! Parents just can’t win, can we?!) 

It was after a very gentle prompt from my friend to feed my baby more regularly that made the difference. As soon as I started to do so, the actual feeding process became much easier for all of us and her jaundice resolved really quickly!

To conclude this point, I recommend feeding more regularly than you think, and secondly 

do some research before having your baby so that you have a more informed idea of the amounts you want your baby to be having in those early days. Also, have a vague idea of your threshold to introducing formula top-ups and getting help from a professional.

So why is it that feeding can be so difficult for newborns?

Firstly, there are those who have little mouths and are hypermobile as I have explained that will need growth and strengthening of the oral and tongue muscles to become efficient at it.

Secondly, I’ve mentioned the exceptionally sleepy babies who don't have those strong hunger cues that can make establishing feeding quite tricky. 

Finally, there are the babies born with tongue ties which is where there is a piece of soft tissue underneath the tongue that is a little bit too short and tight and so it restricts the movement of the tongue.

In order for a baby to drink effectively from the breast, they have to be active participants in the process. Putting it simply, the baby needs to draw the milk out of the breast which requires a rather sophisticated tongue movement. When the baby has a tongue tie with restricted tongue movements, it can interfere with their ability to effectively draw the milk out the breast. It can also  reduce the baby’s ability to latch on. All of this can of course cause you pain, blocked ducts, and even mastitis.

Tongue ties can also affect bottle-feeding, particularly if the baby is battling to latch on to the teat. You might see that your baby battles to create a good seal around the teat, or they have milk leaking down the side. They may end up swallowing a lot of air and the feeds may take a lot longer than what you would expect. 

It is important to clarify here though that not all tongue ties do cause problems. If you are not having a lot of pain and your baby is picking up weight, then their tongue tie may not even need to be treated.

However, if you do experience any of these difficulties, it is worth getting help from a professional and worth remembering to keep that threshold for getting help low. Don't battle it out, ask for help sooner rather than later.

There are fantastic lactation consultants out there who come to your home and can quickly identify the problem, and give you strategies to resolve the issues. There are tongue ties that are significant enough to require a frenotomy, a small surgical procedure to release that tight bit of tissue under the tongue.

Some babies have an instant improvement in their feeding after this procedure, whilst others take longer as they need to learn how to use their tongue that now has more freedom. You may also need to do specific stretches in your baby’s mouth after the procedure, but your professional will give you this information should your baby require that. You should also bear in mind that your baby may have other unrelated feeding difficulties that also need to be addressed as well as the tongue tie.

The take-home is always to get help, and it doesn’t have to be at a great cost. In the UK, lactation consultants are part of the NHS care. You may have to wait a bit to see someone, but the service is there. I had a brilliant NHS lactation consultant who was amazing in her knowledge and experience.

There are also many online resources that can assist, but if your baby isn't putting on weight or you are in pain, its a good indication that you need a professional to come and see you and assess the situation.

I was in hospital for three nights to establish feeding and there the nurses helped me to express milk and they gave me a teeny tiny little bottle which we brought home for our first bottle-feed. As a result, we settled into a pattern from really early on of giving her bottle-feeds as well as breastfeeding.

If your baby may needs formula top-ups, or you need the rest or you would like to express milk and give them bottle-feeds, you may be feeling resistant to the idea because you have heard of “nipple confusion”. Whilst this is a real concept, I do think parents need to be as worried about it as they usually are, as it is not a guaranteed phenomenon (if you introduce a bottle whilst you're breastfeeding it will lead to the baby refusing the breast from then on).

There are in fact many babies who switch between the two without any issues. My daughter was one of those babies and quite happily took a bottle of expressed milk and then came back to the breast. If you are keen to introduce a bottle whilst continuing with breastfeeding, then there are guidelines that will help you to reduce the risk of nipple confusion:

Most consultants would advise you to first get feeding established so that the baby knows how to breastfeed effectively before introducing a bottle. This is because the bottle is so much easier for a baby to get milk out of as they don't need to be quite so active in the process. If you have established breastfeeding to the point where your baby already really enjoys breastfeeding and you then introduce the bottle, the baby will have motivation to come back to the breast when it is offered later, despite the increased effort required. If you are battling with establishing breastfeeding, you really don’t want to complicate the process by adding in new variables - if you have the luxury of delaying!! If your baby is losing weight and you are advised to top-up, you won’t have the choice of delaying. I certainly didn’t have the choice - I was advised at the hospital and I just went along with it as I was not in a state to make decisions for myself.

I honestly didn't even think about nipple confusion! The nurses used a hospital expressing machine and on day three of life I was discharged home with 35ml of breast milk in a teeny tiny bottle. We continued with this throughout the early infancy - one bottle of expressed milk per day, fed to my daughter by my husband. I found it incredibly helpful and would encourage you to consider this after doing some of your own research. (Not only fear of nipple confusion, but again micro plastics come into play here!)

Once you have made a decision to introduce a bottle, the current recommendations are to do “Paced bottle-feeding" to reduce the nipple confusion risk.

Paced feeding basically mimics breastfeeding so that the baby doesn’t notice how much easier it is to take a bottle. Firstly, you make sure you are using a slow flow teat so that the milk comes out slowly. 

Secondly, you hold the baby in a more upright position (rather than lying flat) as this ensures that you don’t end up holding the bottle upside down, enabling gravity to make the milk flow out of the bottle very quickly and easily. In paced bottle-feeding, you want to hold the bottle at a horizontal angle, something that is easier if your baby is more upright.

This way they can't rely on gravity to get the milk out, rather they have to actively draw it out as they would on the breast. 

Thirdly, you need to have regular pauses. When a baby breastfeeds, they tend to suckle for 20 to 30 second bursts and then they rest briefly before they continue sucking. To mimic that, one would hold the bottle horizontally for 20 to 30 seconds, and then tip it downwards so that the teat is on top, preventing the baby from getting the milk and giving them a natural rest. You then return the bottle to the horizontal and continue in cycles to mimic the normal breastfeeding pattern. 

Another thing to do is to make the baby latch onto the bottle actively. Latching on is a big part of breastfeeding and something that can be one of the hardest things to establish. The baby has to open their mouth and then close it onto your breast with enough accuracy. In paced feeding, you replicate this by holding the teat to your baby’s lips and waiting until they open their mouth and latch onto it, rather than putting it straight into their mouth and allowing them to passively receive it.

Finally, if you tend to breastfeed from both sides at each feed, you’ll do the same with the bottle. Halfway through the feed, stop and switch sides before continuing. Obviously, if you're someone who always feeds from the same side (or if you breastfeed from one breast and then pump out the other), it's not necessary to do this.

As with all bottle-feeding, with paced feeding it is important to look for fullness cues, that is, your baby’s signs that they have had enough. Breastfeeding mothers often learn these quicker as there is no way to tell how much the baby has had- and they therefore have to stop when they believe the baby is showing them they have had enough. With bottle-feeding, we so often keep getting the baby to drink until a certain amount has been taken. It is really important not to make the baby dislike bottle feeding because they are being forced to take too much because we feel it is necessary to have x millilitres before we can stop. Rather, apply the same understanding of fullness cues that you do when you breastfeed to decide your baby has had enough: If your baby turns their head away from the bottle, pushes the teat out their mouth, or even falls asleep on the bottle. Don’t be tempted to keep going until they have had the full bottle if they are displaying these cues - unless you have had other advice from your health care professional as there is a reason your baby is needing that strict feed amount.

In summary, if you want to reduce nipple confusion, mimic whatever you do whilst breastfeeding so that your baby doesn’t come to the conclusion that bottle-feeding is a much easier, smoother process! 

If, on the other hand, your baby doesn't want a bottle, the advice would be to keep persisting with it! This usually happens when trying to introduce a bottle later on, because you've made breastfeeding an enjoyable, comforting and bonding process (for both of you!) and so your baby needs loads of persuasion at this stage try something else. It’s really helpful if your baby is refusing a bottle to get somebody else to give them the bottle - if you have someone else who can do that for you. When a breastfeeder attempts to give a baby the bottle, the baby can smell, feel and see the person who usually offers them the breast. It therefore makes sense that they will refuse the bottle as they can smell the original and be aware the breast is within their reach. This will be distracting for the baby! If you don’t have someone else to assist you, you could always try feeding your baby a bottle in an unfamiliar environment, in a different position and perhaps with a perfume on to disguise your natural scent that your baby knows so well.

The last thing I want to make new parents aware of is microplastics. As I said earlier, this is one of my areas of a real regret, because I didn't know anything about them when my daughter was a baby. I expressed my breastmilk and then kept it in plastic bags or bottles in the fridge or freezer. I would then put them in a jug of boiling water to defrost and warm to the correct temperature. When we did move to formula bottles, I would pour boiling water into the plastic bottle, shake this up and wait until it cooled to the right temperature. (I wasn’t avoiding the microwave - we just didn’t have one!)

I am now aware of the fact that when you heat plastic, particularly in the microwave the microplastics leach out of the plastic container and into the milk which your baby then consumes.

When you put a formula powder in and then the boiling water, the agitation of shaking it up to mix them together can make the microplastics leach out into the bottle contents even more.

Many bottles are “BPA free” now, however, there are a number of other chemicals, toxins and non-BPA microplastics that are in plastic bottles that would ideally be avoided. 

If possible, don’t heat milk inside your plastic bottle. Rather do this in a glass or ceramic container and then transfer it to the bottle once it has cooled to the drinking temperature. This will reduce the amount of microplastics that are leaching into it. 

Unfortunately, in the early days, we need to sterilise our babies’ bottles at a really high temperature. This is unavoidable but there are now far more products on the market that you could use instead of plastic. 

There are glass bottles that are suitable for tiny babies that are thick and solid. Of course they aren’t indestructible, but they do take quite a pounding before breaking! My daughter made use of a glass bottle once I discovered microplastics, but by this stage, she was already about three years old. It was no problem for her to manage a glass bottle at that age, but a smaller baby may battle with the heavier weight of these bottles.

There are also stainless steel bottles on the market now that are light weight. It is really important to do your research when looking into bottles and teats (try go for medical-grade or food-grade silicon teats) and try to make whatever small adjustments you can to risk your baby’s exposure to those microplastics wherever possible.

Be kind to yourself - you will never get it 100% right, so just do what you can. My daughter drank Rooibos (Redbush) tea out of a plastic bottle until she was three years old. This is a South African tea that does not contain caffeine and is full of anti oxidants so I thought I was doing something wonderful for her. I would pour boiling water into the bottle over the tea bag and let it steep there before adding the milk. I have also since heard that teabags too contain microplastics so there is a lot of regret for me in this! As an aside, if you do fancy getting your child to drink Rooibos, the Tick Tock brand does not contain microplastics (I have no affiliation with Tick Tock!) so this is a nice sugar-free, healthy and comforting drink for a young child.

In summary:

1. Do your research on all these aspects of feeding before you have your baby rather than after when you are likely to feel too overwhelmed and exhausted to make good decisions.
2. Have a very basic idea of what you will be expecting your baby to be drinking in the early days and what your threshold is for giving formula, trialling expressed bottle feeds and getting a lactation consultant.
3. If you are keen to breastfeed, do it more frequently in the beginning to give you and your baby a chance to practice and for your baby’s muscles to strengthen up. This is especially so if you have a sleepy baby who never seems hungry!
4. Know that breastfeeding can take a really long time to become easy and comfortable. You may need to top-up or express feed sooner than you wanted to. If that is the case, use paced bottle-feeding.
5. Avoid microplastics wherever you can.
6. Get help sooner rather than later when you need it!
7. Don’t allow anyone’s opinion to make you feel ashamed. Someone can judge you for something, but guaranteed, if you chose to do the opposite, someone else would shame you for that! Decide based on what is best for you and best for your baby!

Even though this pod is from my experience, more as a mum than as a physiotherapist, if you do need help for anything baby-related you can find me at www.physiobaby.co.uk

There are loads of free resources, tutorials and courses for you to have a look at.

Wishing you all the very best, and most of all, all the best for your baby xx