by Alissa Pemberton – Midwife, International Board Certified Lactation Consultant & Holistic Sleep Coach| www.motherandmilk.co.uk
Many parents are advised to 'top their babies up' in the first weeks or months of life (see our separate post here for a much more in depth look at top ups). Often this comes in the form of giving a bottle - but there are a number of other alternatives which will help support you breastfeeding journey, rather than hinder it. Firstly - lets look at why bottles might cause an issue.... The mechanics of breastfeeding involve baby taking a deep mouthful of breast, drawing the breast right back to the soft palate at the rear of their mouth. They need a good seal with their lips to create suction and rhythmic motion of jaw and chin to get milk flowing. Without suction and sucking, there isn't adequate milk flow. Baby's tongue holds the breast against the roof of their mouth, whilst the movement of their jaw puts pressure on milk sinuses within the areola to control the flow of milk. Rapid sucking when they begin feeding stimulates a release of oxytocin which contracts muscle fibres around the milk ducts and causes a 'let down' of milk. When baby ceases sucking or breaks that nice seal/vacuum the milk flow stops. This allows baby's to very effectively regulate their milk intake and slow down when they are getting full, this also helps prevent them overfeeding at the breast. At a bottle (with the majority of bottle teats) milk will flow on it's own, without the suction and rhythmic jaw movement needed at the breast. Because the teat holds it's shape, baby doesn't need to open a wide mouth, or use the muscles of their tongue to hold the breast deeply in their mouth. If the milk is flowing too quickly, a baby may thrust their tongue forward against the teat of the bottle to try to stop the flow. It's also very easy for baby's to use small, gentle sucks to obtain milk, as it flows so easily. For a baby who is having difficulties with breastfeeding (and if there's issues with weight gain, causing the need for top ups - then we know something isn't quite right) using a bottle regularly may only make these issues worse. There are some situations where using a bottle may be recommended or even preferable, and advice from a breastfeeding specialist will be invaluable, but for the most part we know that bottles can hinder the breastfeeding relationship - but can other means of supplementation actually help it? So - what's the alternative? In this blog we'll explore three different methods of feed which you can use to supplement (top up) your baby where required. Once again if you've been advised to top up, without any specialist support to explore the underlying feeding issues I'd encourage you to contact an IBCLC/Breastfeeding Specialist and also to view our blog on newborn weight loss. Cup Feeding
Many parents will come across this method during their hospital stay/the first few days after birth if it's recommended that their baby receive formula for any reason. Cup feeding involves placing expressed breast milk or formula into a small plastic cup (about the size of a shot glass) and allowing the baby to lap at the milk. How does it work? - start by placing a small amount of expressed breast milk (or formula) into a clean sterilised small cup. There are speciality cups available for cup feeding but in general these aren't necessary. A small plastic cup (like the kind which are often available for measuring liquid medications, or disposable plastic shot glasses are all good options). - for young babies it may be beneficial to swaddle your baby so they don't knock the cup over with flailing arms! - place your baby in front of you, facing towards you with their bottom resting on your lap and one ahnd supporting behind their head. - always sit your baby upright (about a 45 degree angle) when cup feeding, never lay them down and pour the milk in. - rest the cup on baby's bottom lip, and tilt it slightly so that milk comes to the edge of the cup (remember we are not aiming to pour the milk in, but keep a small amount of milk close to the edge of the cup to entice baby to extend their tongue and lap at the milk).
- you should be able to observe baby extending the tip of their tongue and lapping at the milk like a cat. When would cup feeding be the best option? - cup feeding is definitely preferable to bottle feeding in most instances. This will work well for parents who need to provide small amounts of supplementation to a baby (perhaps mum and baby are separated for a period of time after birth, or mum is unwell and is only able to express and not to physically be with baby). - it is also a great alternative to giving bottles if mum needs to spend some time away
from baby during the first six months, and wishes to leave the baby with another carer. For older babies (4 months +) an alternative like the Doidy cup is a great option for cup feeding. Older babies need never have a bottle for milk feeds as they can be cup fed (using correct technique) from a very young age. When should I avoid cup feeding? - cup feeding may not be the best choice for supplementing a baby who is having significant difficulties with breastfeeding or where there is suspicion of a tongue tie. - babies with tongue restriction may find the action of cup feeding difficult (as tongue tie will often result in restrictions in tongue extension beyond lower gum). - babies who are premature, or have neurological conditions resulting in poor muscle tone may not be suitable for cup feeding.
Finger feeding can be done via two methods - using a syringe, or using a feeding tube. Both provide a very helpful method for supplementing a breastfed baby, and one which actually supports a baby to develop skills for breastfeeding and return to the breast sooner. As the name suggests this technique is achieved by parent/caregiver placing a finger into baby's mouth, allowing them to suck on the finger whilst they either take supplement via a syringe or feeding tube. By allowing baby to take a supplemental feed whilst sucking on a finger mimics (about as closely as we can) the action baby needs at the breast - a good seal, deep latch, rhythmic suck/swallow patterns.
How does it work?
- start by washing your hands and preparing your supplemental feed either in a syringe (particularly for colostrum) or in a bottle/supplemental nursing system (if using feeding tube).
- place baby on your lap, on a diagonal with head towards one of your knees, and feet towards your opposite hip.
- place a clean finger upside down in your baby's mouth (fingernail side down) and encourage to suck on your finger (a little wiggle or pulling your finger slightly out of their mouth and then back in will entice baby).
To finger feed with syringe - place the tip of the syringe into the corner of baby's mouth - as they suck on your finger slowly depress the plunger of the syringe a small amount at a time - you should feel the liquid against your finger and see/hear your baby begin to swallow - continue until syringe is empty. - this method works best when giving small amounts of less than about 10ml (such as when giving hand expressed colostrum) To finger feed with feeding tube - using a sterile nasogastric tube, place the 'cap' end of the tube, with cap open, into a bottle of expressed milk or formula - slide the other end of the tube either into the corner of baby's mouth (next to your finger, once they have begun sucking) or prior to placing finger in baby's mouth, place the tube along the underside of your finger (pad side, not nail side) with the tip of the tube near to the end of your finger.
- Place a small piece of tape on the tube to secure, then slide finger and tube into baby's mouth - as your baby begins to suck on your finger you should see milk begin to flow into the tube, and feel the liquid in baby's mouth. - if baby is struggling to get milk flowing, lift the bottle of milk higher than baby to allow gravity to increase the flow. Inversely if baby is gulping quickly, spilling milk from the corners of the mouth or struggling with fast flow, place the bottle down lower than your baby.
When would finger feeding be the best option? - for giving expressed colostrum at any stage of life, this is the most effective method - for a baby with tongue tie or abnormalities with suck, or a poor suck/low muscle tone this method works very well. This will help build strength in baby's tongue and can help to improve their suck at the breast. - use finger feeding with a feeding tube for larger volumes of milk (more than 10-20ml). - this is also a useful method for baby's requiring supplementation after a tongue tie release as the exercise of sucking on a finger will help to improve strength in tongue and aid recovery post tongue tie release. When should I avoid finger feeding? - babies who are very low birth weight, extremely premature or taking long periods to feed and/or where there are significant weight gain issues may find finger feeding (just as breastfeeding) very exhausting. Whilst this would be a good technique to use with them on occasion, this may also be a circumstance to be giving some top ups via bottle for efficiency. At Breast Supplementation
also referred to as a supply line or supplemental nursing system. Many mums I work with are surprised to hear that supplementing baby can actually be done at the breast. What? I hear you ask - well...babies who require supplementing generally do so because there are concerns about their weight gain. This usually stems from one of two things - either baby has an oral/structural abnormality preventing them from feeding effectively at the breast and removing the milk which is available, or mum has a low milk supply and not enough milk is available. We know that babies respond best to adequate milk flower - the faster the flow rate of milk the more effective the feeding/sucking patterns - even in babies with structural abnormalities. So whilst we would always look to diagnose and deal with these issues as quickly as possible, for both these categories of baby, we can improve their feeding by improving the milk flow.
How does it work?
At breast supplementation can be done either using a device such as the Medela Supplemental Nursing System or by using a sterile nasogastric tube.
There are two main techniques used for at breast supplementation
Prepare your SNS/supply line device with some expressed milk or formula.
Bring your baby to the breast and allow them to latch on as normal.
Once they are latched, slide the feeding tube in through the corner of their mouth. The tube will probably go into their mouth about 2-3cm.
Before latch baby, position the tube at the breast, so it will enter babies mouth either in the corner of their mouth, or in the centre of their upper lip. If feeding baby in cradle/cross cradle hold this will mean positioning the tube either a) on the outside of your breast (as in the first picture above) or b) on the top of your breast (as in the second picture above).
When would at breast supplementation be the best option?
- this is definitely the best option for mums with any sort of decreased milk supply or mums with insufficient glandular tissue (IGT)
- also beneficial for babies who are needing assistance/returning to breastfeed. This might include relactation, premature babies, babies who have had a tongue tie division etc.
Supplementation should always be undertaken after a thorough breastfeeding assessment. Particularly in situations of concerns over weight gain, simply introducing supplements will not fix the original problem which has impacted milk transfer and therefore led to slow weight gain.
If you have been advised to supplement, it's worth getting in touch with your local breastfeeding specialist or IBCLC for a full review to assess the root cause and formulate an individual plan.
In the UK you can access a full list of IBCLCs at www.lcgb.org/find-an-ibclc
Mums in Suffolk/Essex can access support from Alissa Pemberton, Midwife, IBCLC & Gentle Sleep Coach via the link below.