About breastfeeding

This should have been written almost 2 years ago when I completely weaned the littlest member of our family from breast milk. Before my knowledge of what is involved in breastfeeding fades into oblivion, I had better write it down. I am no lactation expert but I thought it might be helpful to put down what I have learnt from my own experience of breastfeeding each of my two boys for 1.5 years and that of other mums into writing… just so I don’t have to re-tell or re-type on the phone every time a new mum approaches me with breastfeeding issues 😛

To breastfeed or not to breastfeed?

Hospitals in Singapore generally encourage mums to breastfeed because of the numerous health benefits for mums and babes, and get new mums started on breastfeeding while they are still in hospital. However, the support given is often insufficient to help mummy continue to breastfeed or be equipped to know how to deal with breastfeeding difficulties when they return home. You may have heard that breastfeeding a baby is the most beautiful and natural thing. But believe me, to most new mums, it’s a real pain and something difficult to master. So painful (more painful than labor for some) and difficult that some mums, who were determined to breastfeed their babies for at least the first 6 months, decided to give up much earlier. Therefore I always tell mums-to-be, “Just try your best to breastfeed but don’t feel bad about giving up early or deciding not to breastfeed at all. Most of us grew up on infant formula and survived. What’s more important is the upbringing of the child and if it means feeding the baby formula so that you can be more sane and patient, so be it.”

Getting the right support from lactation consultants (LC) is crucial for successful breastfeeding. Most mums who give up early do so mainly because they didn’t get help early enough. So I always advise mums to learn how to breastfeed using different positions and how to prepare their breasts for feeding (yes you do need to prepare and not just pop nipple into baby’s mouth!) before leaving the hospital, and contact a LC if they run into any problems when they return home. An additional day of stay in the hospital just to learn how to breastfeed well is a good idea as the consultations are free and you get nurses to help you to take care of the baby for one more day. A good free lance LC whom I always recommend is Doris Fok. She’s one of the most experienced LCs in Singapore who can help you in the comfort of your home.

What breastfeeding products should I get?

What you need to get depends on your budget and circumstances.

Breast pump. If you are going to be the baby’s primary caregiver, a manual pump will suffice as electric pumps (especially dual pumps) can cost up to several hundred dollars and you will probably be latching the baby most of the time anyway. If you intend to return to work, a dual electric pump may be better for you. In order to save some money, you can try borrowing, renting or buying second-hand pumps. Avent and Medela are the most common brands that mothers and hospitals use in Singapore. Whichever brand you choose, it is more important to get funnels with the right size. Mums with large nipples may find that their nipples get sore from pumping when using standard sized funnels as the sides of the nipples rub against the funnel. Check with your LC if you need a larger funnel if you suspect this to be the case and she should be able to help you to find the right size. Whether you decide to use the pump your milk or latch your baby, it is important to learn how to hand express your milk. This helps to ensure that there are no blocked ducts and it’s very handy for expressing small amounts (no need to wash and sterilize pump), for instance, when teaching baby to drink from straw/sippy cups.

Nursing pillow. This is useful only for the first month or two when the baby is still very small and you are not familiar with handling a newborn. Having said that, most mums including myself, find this really useful in the early days. Nursing pillows are also not cheap but definitely more affordable than an electric pump. Here’s a link for the nursing pillow I used. You may choose to borrow or do without it (use a pillow or cushion) if you are on a tight budget.

Nipple cream. Mums usually get sore nipples when they haven’t learnt how to latch the baby well or during the first couple of weeks when the body is still trying to get used to breastfeeding. Therefore, it is not necessary to buy a tube of nipple cream before the baby comes. You can get a tube of it from the hospital before you are discharged and that should be more than enough for the whole length of time you are breastfeeding.

Nursing bras. This is a necessity and here is a useful link on how to choose nursing bras.

Nursing pads.You may or may not need nursing pads as part of your breastfeeding apparel. However, it is wise to purchase at least one package of nursing pads until you know what your needs will be. Here’s a useful link about nursing pads.

Nursing tops and bibs. I lump these two items together as they are good to have but may only be necessities if you intend to nurse out in the open often. If you intend to nurse at home and in shopping malls, these items are not necessities. Most shopping malls in Singapore have nursing rooms with individual cubicles for privacy. So if you are worried about not being able to nurse properly without exposing yourself, this will not be a concern :). I used to carry a shawl in the diaper bag just in case the nursing room has to be shared with other mums.

How often should I breastfeed my baby?

I have already mentioned this in my sleep training post but I will just post it here for easy reference. Tracy Hogg came up with a guideline on how often to feed babies during the first 3 months based on baby’s weight*:

– For babies weighing 2.25 – 2.95 kg, feed every 2 hourly during the day and at most go for 4 hours without a feed at night.

– For babies weighing 2.95 – 3.6kg, feed every 2.5-3 hourly during the day. These babies are capable of lasting for 4-5 hours without a feed at night.

– For babies weighing more than 3.6kg, feed every 3 hourly during the day. These babies are capable of lasting for 5-6 hours without a feed at night.

Both my boys managed to last for 7-8 hours without a feed at night when they weighed between 5 – 5.5 kg.

Babies should only be fed on demand if they are breastfed for the length of time needed for the mother to establish her milk supply. Beyond that, it would be best for baby to be fed on routine. From 4-6 months onwards, babies should be fed 4 hourly during the day with one late night feed between 10pm – 12am, which can be eliminated once he/ she starts eating 3 solid meals a day.

I have to stress that this is a guideline and not a strict schedule that you have to follow. Every baby is different so you have to adapt accordingly. E.g. my preemie who had a very low birth weight needed one extra milk feed until he started having 3 solid meals a day. As long as the baby is fed at roughly the same time everyday and does not need to be fed in the middle of the night or wee hours of the morning by the time he reaches 5.5-6kg, you are doing fine.

How long should each feeding session take?

The length of feeding time depends on the age of the baby and if he is going through a growth spurt. Newborns may take 30-45 minutes whereas older babies and toddlers may take only 5-10 minutes. During growth spurts, the feeds may take up to an hour or more (my record time was 1h 20min!) with baby repeatedly draining each breast until he’s satisfied. When your milk supply has caught up with the increase in demand (usually a few days to a week), the feeds should get shorter again.

How do I know if baby had enough milk?

You read from the internet or learn from prenatal classes that the baby will release his latch when he’s full and root around for nipple and cry when he’s hungry. That may not always be the case. The baby may have used you as a pacifier to help him to fall asleep and released his latch before he’s full. Sometimes, baby just can’t get enough of the comfort he needs from sucking on your nipple and roots around and cries 1-2h after a feed. You mistakenly think that he’s still hungry and latch him. But he feeds only for a few minutes before spitting up a lot of milk, indicating that he’s been overfed.

Unfortunately in order to answer this question, you need to observe your baby and by trial and error over time, figure out for yourself if baby had enough. My boys felt significantly heavier after some feeds so I was sure they were full :D. A full baby should be able to last for an interval of time between feeds that is appropriate for his weight and age, and have at least 6 wet heavy diapers within 24 hours. Bowel movements are not indicative of whether or not a breastfed baby is fed enough as it can be as frequent as after every feed and as infrequent as once in 2 weeks

Should I pump exclusively?

Some mums find it too difficult or painful to latch their babies and their babies seem to feed better with the bottle. They decided to feed their babies on expressed breast milk and not latch at all. While this may work for some mums, it may cause a gradual decrease in milk supply as latching the baby still extracts more milk than the breast pump. Mums who pump exclusively may be more prone to blocked ducts as well. Having to sterilize breast pump and milk bottle, pump milk out, feed the baby (or store, reheat then feed the baby), and then wash bottles and pump, is a very time consuming affair. As one mum puts it, she spent the whole day feeding the baby and doing nothing much else. I had to exclusively pump while my preemie was in the NICU as he was unable to latch. That was the time I had lots of blocked ducts that resulted in a fever and my milk supply reduced by half for a few days.

Breastfeeding positions

You can get this information easily from the hospital and online resources so I shall not describe the standard positions that are often used, i.e. cradle hold, transverse cradle hold, football hold and reclining position. As a new mum, I found it tiring to carry my heavy firstborn using the standard positions and he had a tendency to fall asleep and spit up when held in a lying down position. I found a position that was pretty comfortable that I used from the time the baby was about a month old all the way to toddlerhood.

You can try sitting up the baby with his body facing you and with legs spread apart (works for swaddled baby too). Seat the baby on a pillow or cushion on your lap if he’s too short. Support the baby’s head and neck while you guide your nipple into his mouth. It was so easy and comfortable that I was wondering why it was not recommended :P. However, if the standard positions work for you, you can stick to it.

 

Common problems experienced

Here’s a useful link for breastfeeding support. My list here is not exhaustive so you may need to do more research, call your LC or drop me a message/ call to ask me 🙂

Blocked ducts

This is perhaps the most common problem that breastfeeding mums experience. Almost every breastfeeding mum I know, including myself, suffer from painful blocked ducts at some point during the whole course of breastfeeding. Blocked ducts usually make their painful appearance when the milk first comes in at around day 3-5 after delivering the baby, for mums who have an over supply of milk (like me!) and weaning too quickly. The technique of clearing milk ducts blocked by plugs of breast milk is not an easy one to master. It took my second child to get me to master the technique and only after a bout of fever caused by badly blocked ducts that I couldn’t clear after a few days. Improper techniques of massaging the breast can worsen the problem as the breast is stimulated to produce more milk but the site of blockage has not been cleared. This results in more pain and a bigger hard lump in the breast. You should seek help from a LC if the hard lumps are not cleared within 24 hours as you may develop a fever with reduction in milk supply or mastitis from it.

Knowing the anatomy of the breast is helpful in learning how to clear blocked ducts. Blockages have to be cleared from the nipple radially out towards the areola, and then the breast surrounding the areola. Be aware that some nurses who have not been properly trained may perfunctorily massage the breast instead of carefully checking for blocked ducts and working their way from nipple outwards, causing blocked ducts to become more blocked. I have also heard complaints from mums that Malay massages caused their blocked ducts to become more blocked although it has been claimed that such massages help to alleviate engorgement and soreness. In order to avoid blocked ducts, it is advisable to prepare the breast before feeding baby/ pumping breast milk by doing the following:

1. Roll nipple between thumb and forefinger

2. Roll areola between thumb and forefinger first at the 12-6 o’clock position, followed by the 1-7,  3-9 and 4-10 o’clock positions. Observe the milk coming out from the pores. After a while, you will become familiar with the distribution of the pores on your nipples and therefore be alert to any blockages when you don’t see milk coming out from certain pore/pores.

3. Massage the area of breast surrounding the areola with thumb and forefinger at 12-6, 1-7, 3-9, 4-10 o’clock positions to ensure that there are no hard lumps. Hand express a bit of breast milk if you are very engorged (especially overnight) so that the baby can latch well.

If you are trying to clear blocked ducts, follow steps 1-3 and then continue working radially outwards from the nipple at the various o’clock positions, especially around the blockage. Be prepared to press really hard and use both thumbs instead of thumb and forefinger if you have to in order to press hard. I find it helpful to clear blocked ducts under a hot shower (as hot as you can bear) as the heat helps to dilate the ducts and I don’t have to worry about catching any loose milk sprays. Try for 15 minutes. If you are still unable to clear, try again later in the day. LC cautioned that taking too long to clear blockages may end up making it worse as the breast is stimulated to produce more milk during the massages.

You can follow the above steps or watch an online demonstration on how to clear blocked ducts. But nothing beats having your LC around to show you how to do it because this is something that requires hands-on experience to learn. Watching a demo on the screen or reading about it can’t teach you exactly how much pressure to apply or where and how you should massage.

Application of cold cabbage leaves is often recommended to soothe engorged, painful breasts. LC cautioned that too much use of it may lower milk supply. Alternatively, a damp towel soaked in ice water placed over the breast helps to soothe the hot, swollen and painful feeling you get after attempting to clear blocked ducts.

Milk high in fat content (due to eating lots of fish or taking fish oil supplements) may cause ducts to get blocked more easily, as my LC said. If you have blocked ducts that are hard to clear, it may be advisable to temporarily eat less fatty fish or stop taking fish oil supplements.

Sore nipples

The nurses and LC in the hospital should have educated you regarding how to avoid or treat sore nipples before you leave the hospital. You can ask for a tube of nipple cream before you are discharged from the hospital or use a bit of expressed breast milk to coat the nipple after each feed and let your breasts air for 5 minutes. When latching the baby, make sure that he takes in as much of the areola as possible. In the beginning, you may be latching the baby correctly but still get sore nipples. This is very common and you should feel better after the first 2 weeks with continued proper latch.

How to tell if baby is really hungry or using me as a pacifier?

This is a really tricky one and every new mum has difficulty figuring it out. It takes a bit of trial and error and careful monitoring of baby to tell the difference. Tracy Hogg suggested using a pacifier to test if baby is hungry. If it has been 2 hours or less since the last feed (for newborns), you can try giving baby a pacifier. If he is contented to suck on it he’s probably not hungry and just needed to soothe himself. However, sometimes babies can be picky and can only be soothed to sleep by mummy’s breast. If you find that baby falls asleep within 5-10 minutes into the feed or is sucking with shallow, rapid sucks without swallowing, he’s probably using you as a pacifier. A hungry baby takes deep sucks and swallows.Try your best to keep baby awake during feeds to ensure that he’s getting a full feed, won’t cry within an hour for milk and not using you as a comfort item to get to sleep. (Babies should be taught to sleep on their own and not nursed to sleep. Check out my post on sleep training.)

How to keep sleepy baby awake during feeds

You can find various suggestions on how to keep baby awake from the internet but as mums will tell you, they don’t really work. It took an ice cube wrapped in damp cloth on the ear, cheeks, feet or arm to shock my sleepy babies awake to continue feeding (damp washcloths didn’t work!). But even then, only for a few seconds before they fall into deep sleep again. All the hand and feet massaging, tickling, arms flapping, chin chucking etc didn’t work for my badly jaundiced elder boy and preemie younger boy (both types of babies are notoriously sleepy during feeds). If you have tried your best and baby still can’t wake up, just let him sleep and try to stick to the feeding times for the next round. Take heart that babies will get more wakeful as they grow older and this problem shouldn’t last longer than a few months.

Low milk supply

Mums often wonder if baby is getting enough breast milk. One way to check is from the diaper output. If you suspect that baby is not getting enough, you can try pumping out breast milk just in time for the feed (i.e. 2.5-3h after last pumping session or feed) to check the amount.

In order to increase supply, you can feed on demand or more frequently (every 2 hours instead of every 3 hours) for 3-5 days, or pump for 5 minutes after each feed/ pumping session to stimulate the breast more. Try not to supplement with formula for these few days as your aim is to tell your body that demand for milk is up and your body will naturally respond by increasing supply. Feeding on demand shouldn’t last longer than a few days as it disrupts the baby’s sleeping pattern and the body usually responds by increasing supply. Ensure that there are no blocked ducts as many new mums think that they have low supply when they actually have blocked ducts that prevent more milk from coming out. Have a well-balanced diet, plenty of fluids and as much rest as you can (I know… taking care of a newborn means you are sleep deprived but take every chance to lie down even if you can’t sleep). I find that eating fatty fish makes the breast milk higher in fat content and baby tends to be more satisfied with less milk or shorter latching times. In the event that you have tried everything, including taking medication or herbal supplements to increase supply, and your supply is still not enough, don’t feel bad about supplementing with formula.

For those of you who engaged a confinement nanny, do let her know of your intention to breastfeed successfully, and not to feed the baby with formula without your permission. Some of these ladies are more pro-formula and anti-baby crying, so they may feed the baby with formula at the slightest hint of hunger. This will not be helpful if you are trying to increase your milk supply as baby will not be hungry by the time you latch him.

How to wean without too much pain

Some mums are able to drop a feed or wean completely by going cold turkey. But most mums will get painful engorged breasts or even mastitis if they wean too fast. The trick to wean comfortably is to do it gradually. As the baby grows, you will naturally drop one feed at a time. A 3 month old takes 6 feeds a day, a 6 month old takes 5 feeds a day, a 7-8 month old who is eating solids 3 times a day will take 3-4 milk feeds a day and by the first birthday, baby should only be taking 3 milk feeds a day. When I was sure that my boys were able to take whole milk at a year old, I dropped their midday feed at around 13 months and continued breastfeeding them twice a day until I was ready to wean them completely. I would feed them increasing amounts of whole milk (starting from 30ml and increasing by 20ml each day) just before latching them so that the demand for my milk slowly decreased over time. I took 2 weeks to wean completely and even then, took the time to hand express some milk when I showered if I still felt too full or if there were blocked ducts. If you feel you need to use cabbage leaves to soothe engorged breasts, this is the time to do so. You can store hand expressed or pumped milk if you would like baby to have as much breast milk as he can after you have stopped latching him. Some mums who have an over supply of milk may find it hard to wean naturally and need medication to help them to reduce their milk supply.

 Forceful letdown

Some mums who tend to be over suppliers have forceful letdowns, like myself. Here’s a useful link about a mother’s experience and helpful tips on what can be done. Like this mum, I had to feed my newborns from only one breast at each feed in order for them to have more hind milk.

 

*Baby Whisperer Solves All Your Problems: Sleeping, Feeding, and Behavior – Beyond the Basics from Infancy Through Toddlerhood