Tips for Slow Weight Gain/Inefficient Breastfeeders
The below information aims to help you improve latch and latch pain, whilst increasing feed efficiency & effectiveness and improving milk supply. Further, moderating bottle feeding aims to improve breastfeeding skills, reduce the reliance on formula/expressed milk and increase confidence in breastfeeding.
The information here is written for a generic audience, and all information may not be appropriate for you - please refer to your personalised plan and contact Heidi Hembry IBCLC if further clarification is needed.
Getting a Deep Effective Painfree Latch
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Cross cradle: Use your opposite arm to breast to support baby when you are latching across your body. Tuck baby’s bottom in securely between your elbow and your body, and use your forearm to support along the spine. The more secure s/he feels, the easier latching will be. Watch out for any fingers on the back of baby’s head - s/he won’t be able to tip her/his head back, so try to ensure support is to the back of the neck/base of the skull, and around the shoulders.
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Underarm/rugby hold: This can be a great alternative, particularly for woman with larger breasts, or post c-section. Remember to sit forwards on the sofa/bed with support behind you so that you can get baby far enough back to keep the bottom lip far away from your nipple. C-shaped cushions at your side can be helpful here.
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Cradle hold: Uses the same arm as breast. A great hold for babies older than 6 weeks who are already skilled at latching. For younger babies it is particularly important to ensure that their head is nearer to your wrist to allow them to lift their chin from their chest to root. Having their head supported near your elbow can lead to them curling in, tucking chin to chest, to seek your nipple, making it very uncomfortable to latch and drink.
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Laid-back positions can work well too. Use the same arm as breast to support both the breast and baby down the side. Ideally, s/he should be low on your tummy, reaching up for the breast from slightly below it. You can use your other hand to gently shape the breast if helpful. Like any new skill, the ease of getting this position improves with practice.
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You can use a 'half swaddle’ to keep fretful hands out of the way. Place a muslin folded into a triangle under baby, long edge level with ears, point aiming down to toes. One at a time bring each wing over the shoulder and on top of the arm, holding baby’s hand down by their hips. Lift their legs like you are doing a nappy change and tuck the material under their bottom. Repeat on the other side.
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Before latching in any position aim to have baby's chin touching your breast, with the bottom lip about an inch away from your nipple, nipple tickling the end of baby’s nose. This will mean that baby’s tongue is working on your areola, which is much more comfortable.
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You can also try 'sandwiching' your breast a little - this is where you gently squash your breast in line with corner to corner of baby’s mouth (think eating a giant sandwich or burger, and how we squash it a little and lead with our chin/bottom lip). With baby lying across your tummy, or on their side for rugby, this means shaping your hand in a U shape, under your breast, rather than a C shape at the side of your breast.
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An exaggerated latch uses your thumb or fingers to aim your nipple up to baby’s nose, and away from the top lip, encouraging even more breast tissue into the mouth by the tongue. This is often a temporary technique, used for just a couple of weeks.
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Tease baby a little to encourage a wide mouth and when you see this wide gape, push her/him fast and firmly onto your breast. You may need to repeat this a few times before s/he latches well.
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Always break a painful latch by using a finger or thumb to push in through the corner of baby's mouth and onto the tongue. By re-latching, you are doing several things. Baby is learning that s/he doesn't get to feed 'this way' and her/his skills improve. A better latch means easier and more milk for baby, and less pain for you. You can re-latch during a feed too if s/he suddenly changes the latch.
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Remember - if baby’s chin is too close to her/his chest, s/he can find it very uncomfortable to drink. Try this by sitting up against a flat wall, with your hips, shoulder and back of your head touching the wall - you really need to tip your head back further to drink comfortably! You can try tucking baby’s bottom much closer into your body, pulling her/him gently towards their feet. Or relatch, moving baby just a cm or so further away from your nipple.
VIDEO - deep effective latch
https://youtu.be/lkpMobnxyHE?si=BaxOnuLnFPYdD6JG
VIDEO - exaggerated latch
Maximising Milk Intake
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Use compressions (squeeze 2, 3, 4 relax 2, 3, 4) when you see the suck swallow pattern slowing or the breaks become longer than the sucking bursts. Blowing, tickling, fake-removing can work for some babies.
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Some families find compressing at the start of a suckling burst works well, others compressing when there is no sucking happening to reinvigorate activity. The most important aspect to consider ensuring that the compressions are working to give you more swallows, more regularly
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Squeeze and hold your breast firmly (not painfully) as if squeezing a sponge, no need to slide your fingers down towards your nipple. You may need to repeat it a couple of times to encourage good swallows.
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Repeat compressions every time baby becomes inactive/ineffective.
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When compressions are no longer working, unlatch. According to your personalised plan, if your breast still feels firm and full with plenty of milk, consider Rouse & Return to the same breast. If it feels well softened, or baby is particularly inefficient, it’s time to switch breasts.
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Repeat compressions as necessary.
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Rouse and return and/or Switch back and forth as often as needed in 30-45mins, using undressing/redressing to rouse baby for multiple courses to make up a full meal until s/he begins to feed better without help
VIDEO - recognising swallowing vs sucking
Understanding Feed Frequency
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Babies are little humans and will feed and nourish as we do: Meals, snacks and drinks. So some feeds will be long 3-course meals with extra cheese and coffee, using both breasts or sometimes 3, 4 or more breasts. Others will be snacks, and others short drinks.
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Just because a baby sometimes wants to 'feed' again within half an hour it doesn't mean that s/he didn't get enough, or you don't have enough. In the early days, these frequent feeds are essential to building a growing milk supply for your growing baby. It could just mean s/he wants a drink after a big meal, or a cuddle and nurse to settle to sleep.
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If baby is gaining weight well, feeds are generally between 5-45mins, and range between 30mins - 3hrs apart (from start to start) then this is all good and healthy.
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When baby is consistently gaining weight well on breastfeeds, then allowing longer periods of sleep is absolutely fine... especially if they happen at night.
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Offering a second or third breast will depend on your personalised plan. For most mums it's usually a good idea to offer the second breast, especially as your milk supply is growing in the early weeks, and definitely if your supply is low. Sometimes baby will take it. Sometimes s/he won't. Aim to alternate the breast you start a feed on, regardless of whether s/he takes one or more breasts, but if you forget, be guided by which breast is fullest. If we have identified an abundant supply as part of your consultation, then remaining on one breast for a dull feed may be indicated.
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Growth spurts usually last 24-48 hrs - just when you think you see a pattern, baby will change it, feed seemingly constantly for a day or so, then settle again. This is her/his way of giving your milk supply a super boost. Growth spurt days typically occur during days 3-5, days 7-10, week 3 and week 6.
Responsive/Paced Bottle Feeding
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Aim to use Responsive Bottle Feeding techniques to minimise the risk of bottle preference.
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One of the key points is to always tap the teat to baby’s upper lip and encourage rooting and a wide gape. S/he doesn't need it for bottle feeding, but s/he will need to retain or re-learn this skill to latch well at a naked breast.
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Encourage with speech eg "Big mouth baby, aaaaaaaahhhhh" as s/he will love to copy you. You can recreate this at the breast too so it becomes an association with feeding. Keep milk out of the teat during the initial latch to encourage active suckling, just like s/he would need to do at the breast to stimulate a letdown. After a couple rounds of “suckle, pause, suckle pause, suckle”, tilt the bottle up to allow some milk flow.
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If the teat is fully empty, babies do not take in excess air this way, just like you will not swallow air into your stomach if you suck on a straw in an empty cup.
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When raising for milk flow, use the bottle near to horizontal. You want the teat holes to be covered (to avoid air intake), but not have the whole teat full. Aim to see the milk lapping at baby’s top lip - this slows the flow down to better mimic breast milk flow, and ensures that the holes in the teat are well covered at all times when suckling and swallowing.
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Every so often, eg 5-10 swallows, or when s/he naturally takes a break, drop the bottle down and allow baby to suck a little on the empty teat, pause and begin suckling again and perhaps even pause then suckle again, before raising and giving milk again. This better replicates a natural letdown, reduced flow followed by another letdown, whilst encouraging baby to continue sucking even when your milk slows down at the breast too!
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After about 50-70% of the bottle, remove the bottle entirely. Baby will indicate if s/he is still hungry.
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Repeat a good 'latch' by tickling the upper lip again with 'aaaah' noises. Remove again after another 50%, etc etc.
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When baby slows down and also most stops suckling on the empty teat, starts to fall asleep, or appears settled and keeps her/his mouth closed when offering the teat, this is a sign s/he has had enough.
VIDEO: https://youtu.be/JgEVn4ershA
(The above video is helpful if you are introducing bottles and baby is breastfeeding well. When baby isn’t breastfeeding effectively or becomes very frustrated at the breast, then slowing it down even more is helpful. For this, when you sit baby up/tip bottle down, you wait for baby to stop suckling, let them start again, and watch them pause again… on the 2nd or third time of starting suckling again then you tilt baby back/raise the bottle and allow them to drink once more. This will help them to understand that sometimes they need to work a little harder to get the flow of milk going again, and this is what is needed sometimes when breastfeeding is very slow! Repeat this every 5-10 swallows)
Expressing to Increase Milk Production or Provide Bottle Top-up/Starter
Having a well fitting flange/flange adapter can make a huge difference to your expressing comfort, volume expressed, and efficiency. Though fit seems to be the most important aspect, there is some early research that suggests hard flanges are more effective than soft inserts. Soft inserts are often easier and cheaper to purchase in a set of sizes. Once you have found your best fit, you can purchase the correct hard flange if desired.
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Finding a few minutes to express after feeds is a great way to increase your milk production
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You won't expect to get a large volume, but what you do get will be fatty high high-calorie milk and make an excellent top-up.
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In addition, the better drained your breasts, the more milk they will want to make to refill again.
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Just like with feeding at the breast, you can switch back and forth when expressing if you are working to increase a low supply.
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Warmth, massage, leaning forwards and jiggling can all help get higher yields.
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Hand expressing (which gets easier with practice) can also be effective when pumps struggle to get fatty milk out.
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Different expressions can be added together to make a top-up or full feed as needed.
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Aim to use Responsive Bottle Feeding techniques to minimise the risk of bottle preference https://www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2019/04/Infant-formula-and-responsive-bottle-feeding.pdf
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There is no need to sterilise kit that is only used for breastmilk. You can wash in hot soapy water and rinse in fresh water and leave to dry. Many mums expressing often keep their expressing kit in a clean Tupperware box in the fridge and only wash or sterilise once a day to reduce time.
BFN - expressing and storing
http://www.breastfeedingnetwork.org.uk/wp-content/pdfs/BFN%20Expressing%20Leaflet%202019.pdf
https://www.breastfeedingnetwork.org.uk/breastfeeding-help/expressing-storing/
VIDEOS - hand expressing
Easing Digestive Discomfort for Babies
Our babies are designed to be held upright often, if not all the time. It is a small distance from the top of a full tummy to the back of the throat. Some babies really struggle with their milk feeds pushing back up their oesophagus when they are laid down flat after a feed. This can result in grunting, writhing, crying and other signs of discomfort. You can try some of the following tips:
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Hold baby upright for 20+mins after a feed, allowing digestion to start and milk to thicken. The milk is then less likely to regurgitate and cause discomfort.
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Wear baby in a sling - research shows babies that are carried often cry up to 50% less and suffer less with colic and reflux symptoms.
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Place something under mattresses/cots to raise the bed at an angle. This can help gravity keep milk feeds in the tummy better. Play with the angle - too little and it is ineffective, too much and baby will slip down the bed. You should always be in the room with your baby if they are inclined so you can observe and adjust for any risk factors (rolling, slipping etc)
All babies are windy. Wind can be taken in during feeds and during crying. Wind taken in this way usually comes up as a burp. Wind from the bottom is almost always created as a normal part of digestion, it is not because you haven’t effectively winded your baby. If you are concerned about wind, try some of these tips:
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Hold baby upright on your shoulder or lap after a feed. Wind usually comes up within a couple of minutes.
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Rocking baby gently back and forth, side to side in a sitting position can help release trapped wind.
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If your baby is struggling with passing stools or gas, getting into the habit of gently cycling their legs at nappy changes can ease motion through the digestive system and prevent discomfort from building up in the first place.
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Baby massage can be fantastic for easing discomfort, as well as bonding and aiding baby’s overall development - many courses are available from 6 weeks of age or sooner
VIDEO: https://youtu.be/Fcn6gVX5y4I