Sunday, 8 November 2015

The importance of skilled breastfeeding support



I've been thinking a lot about the importance of thorough breastfeeding support and how so many mums don't get the support they need.  Putting our baby to the breast to feed is a beautiful and simple act, but like so many things in nature, the deeper you look the more complexity you see.  Breastfeeding is actually a very complex interplay of a mother and baby, and if problems arise, having someone ask the right questions can make all the difference to helping you ease into an enjoyable breastfeeding experience.  A good breastfeeding assessment/consultation is not a "latch check".  It involves looking at the full picture of mum and baby to tease out exactly what is happening.  Without a wide view it is easy to misdiagnose an issue or to medicalise something which is actually normal or easy to resolve.

To illustrate this I did some googling to see what internet sites list as symptoms for common issues which may arise in the early weeks.  This is what I found:


Reflux Fast Letdown Tongue Tie Low Supply
  • Spitting Up
  • Slow Weight Gain OR
  • Fast Weight Gain
  • Fussy at the breast (back arching, bobbing on and off)
  • Frequent hiccups
  • Crying
  • Poor Sleep
  • Refusing the breast OR
  • Frequent feeding / comfort feeding
  • drawing legs up to tummy after feeds
  • coughing / wheezing
  • Frequent hiccups
  • Spitting Up
  • Slow Weight Gain OR
  • Fast Weight Gain
  • Fussy at the breast (back arching, bobbing on and off)
  • Noisy feeding (loud swallows / clicking)
  • Gagging 
  • Crying
  • Poor Sleep
  • Gassy
  • Green Stools
  • Refusing the breast OR
  • Frequent feeding / comfort feeding
  • Drawing legs up to tummy after feeds
  • Clamping down on the nipple
  • Spitting Up
  • Slow weight gain OR
  • Fast weight gain
  • Frequent feeding
  • Fussy at the breast (back arching, bobbing on and off)
  • Noisy feeding (loud swallows / clicking)
  • Gagging
  • Frequent hiccups
  • Crying
  • Poor Sleep
  • Gassy
  • Green stools
  • Opens mouth to attach but doesn’t, shakes head or bobs on and off before becoming frustrated
  • Clamping down on the breast to maintain latch
  • Slow weight gain
  • Frequent Feeding
  • Fussy at the breast (back arching, bobbing on and off)
  •  Crying


These are by no means definitive lists, they are simply the most common symptoms I found listed for these conditions when I googled.  Pretty similar symptoms arent they?  A few differences, but in general they are the same symptoms.

So what is a mum to think if her baby is arching at the breast?  She feels something is wrong and she searches the web and reflux pops up.  It fits her symptoms, she sees her Dr, and they diagnose reflux, with the medication that comes with that.  The problem is that the website didn't take a case history.  It didn't know that due to poor advice the mum had been feeding on one side for too long which had resulted in poor milk supply and baby was arching due to hunger and frustration.  Worse still, perhaps that mother found the fast letdown page and began block feeding to correct her "oversupply" and so reduced her supply further.

Perhaps another mum searching for arching at the breast finds a tongue tie page, looks in her baby's mouth and sees a frenulum and goes to a provider to get it snipped.  That provider should be doing a functional assessment, but often that doesn't happen, so lets say the provider diagnoses on appearance and snips the frenulum.  Mum goes home but the problem doesnt resolve - becuase the problem never was tongue tie.  Maybe the problem actually was that the mum has been expressing every day on top of exclusive feeding and has a fast letdown due to the large supply, or maybe the problem was that her difficult forceps birth meant that her baby had some muscle restrictions which made it difficult for him to cope with a letdown.

Each of the symptoms above has mutliple possible causes.  Fussy feeding / back arching can be fast flow / slow flow / uncomfortable positioning / wanting to swap sides more frequently / bottle preference / needing to burp / needing to pee (you'd be surprised how peeing can affect breastfeeding behaviour).  Breastfeeding mums who practice EC (Elimination Communication) often use bobbing on and off the breast as a sign that baby is asking to be pottied!   Colicky crying can be due to a growth spurt week as much as any of the other things above, and crying when laid down may simply be that the baby isn't in arms.  Babies need to be in your arms.  Spitting up also has multiple causes.

The issue with these lists on websites is that they only focus on symptoms and only on one side of the equation.  As The saying goes:  "There is no baby.  there is a baby and someone".  A breastfeeding issue cannot address only the baby.  An assessment must also consider the mum.  A mother's supply is only as good as the stimulation she gets from her baby (or from expressing), and likewise a baby's latch can be dependent on the mother's positioning.  Whether mum is cue feeding, feeding on a schedule or using a dummy can change baby's intake.  Age of baby, feeding from one side or both, experience during pregnancy and birth all can play a role.  

A good breastfeeding assessment is not a latch check.  Checking a latch is like taking a photo.  It gives you a snapshot into what it looks like right at that moment.  Observing a feed, by contrast is a video.  Latches can change throughout a feed.  A baby may not be latching well to a full breast, but be comfortable on an emptier breast or vice versa.  A baby may change the latch at letdown.  They may latch well initially but change to a shallower latch within a few sucks.

A breastfeeding assessment should involve listening to your story, your history of breastfeeding, how the birth went, how your baby has fed from birth till now, and how your experience has been (including any pain and trauma - the latch is not fine if you have trauma!).   It should look at the pattern of weight gain.  The IBCLC (board certified lactation consultant) or breastfeeding counsellor should observe a feed.  This doesn't just mean looking at the mouth, nose and chin at the breast.  It takes into account the entire positioning of mum and baby: is the mother comfortable and relaxed or are her shoulders tense and hunched (this affects shape of breast)?  Is she bringing baby to her breast or bring her breast to the baby?  Is the baby nicely aligned along head, back and hips?  Is the baby's head tilted back and his body in contact with mum?  If you see an IBCLC, a consultation may involve an oral assessment of baby to check any signs of tongue restriction.  It may involve a structure and function assessment to check for muscle tension in the body.
A full assessment/consultation should address your concerns and help you to create a plan to meet what you want to achieve.  It should involve follow up as you work through your plan.

Too many mothers who are in pain, or are concerned with some aspect of feeding simply have their latch checked and are told it is fine.  A snapshot photo in a world of 3D IMAX film.  A latch check cannot distinguish the reason for fussy feeding.  Skilled breastfeeding support is so much more.  If you are concerned about any aspect of feeding and are being told your latch is fine, please look elsewhere.  Look for an IBCLC or an accredited breastfeeding counsellor who will look at the whole picture of you and your baby.  Simply being told your latch is fine is not enough.  You should be listened to, feel cared for and be taken seriously.  Your breastfeeding supporter should inform and empower you with the information that you need.  Seek out skilled support that truely explores your concerns and meets you and your baby's needs.