Breastfeeding Support

We are confident that we can help with the majority of breastfeeding issues by adjusting fit and hold. During a breastfeeding consultation we will take the time to watch a feed as well as conduct an examination to rule out underlying medical issues that may be affecting feeding. If your breastfeeding is not going as planned, please make the time to come and see us as we would love the opportunity to help you achieve your goals.

We also offer antenatal breastfeeding education for those mothers that wish to get the best start for their breastfeeding journey, or mothers whose previous journey was troublesome. We will take the time to educate you on the Gestalt Breastfeeding Program, write a breastfeeding plan for you to take to the hospital, as well as educate about common breastfeeding problems. This consult is best done in the third trimester, in an hour-long appointment.

Another area of interest is helping non-biological mothers achieve lactation (also known as induced lactation). This may be in the setting of surrogacy, adoption or same-sex couples. It can take 6 months of preparation to get the best results, so we recommend an appointment early in the pregnancy.

Below is more information on specific breastfeeding topics:

The Gestalt Breastfeeding Program 

The Gestalt Breastfeeding Program has been developed by Dr Pamela Douglas and her team. Dr Douglas is an Australian GP, lactation consultant and researcher in the field of mother-baby care. Using the latest research into the biomechanics of infant suck and swallow when breastfeeding, Dr Douglas has developed a style of breastfeeding that is simple, effective and transferrable to almost every mother-baby pair. Her changes to the way fit and hold (or attachment) are assessed and implemented empower women to make small changes themselves to eliminate nipple pain and improve transfer of milk. All of the GPs at the practice have undergone training with Dr Pamela Douglas and are skilled in the techniques of Gestalt Breastfeeding and eager to help women who may be struggling with comfortable, efficient breastfeeding.

Low Milk Supply

It is stressful to feel that you may not be producing enough milk to meet your baby’s needs and perception of low supply is a common reason for mums to decide to stop breastfeeding. We understand it is very difficult to know exactly how much milk your baby is receiving and how worrying this can be!

How do I know that I am making enough milk for my baby?

Signs that supply is adequate include: frequent wet nappies (at least 5 reasonably heavy disposable nappies per 24 hours, with clear, odourless urine); baby is alert enough to demand feeds 2-3 hourly, and is easily able to be settled after a feed; and baby is gaining weight (>20g per day). Very young babies are expected to have at least 3 palm-sized bowel motions a day, and many small ones. Babies over 6-8 weeks may go into an infrequent stooling pattern of 1 stool every 10 days, but the stool should still be soft and weight gain should be normal. 

A “heavy wet nappy” can be hard to tell when you are changing nappies so often. Essentially – it needs to feel heavier than a dry nappy. The blue indicator line  is very sensitive and will change colour with even a drop of urine. The nappy should have some thickness to it as the absorbent material expands with urine. 

What causes low milk supply?

  • Suboptimal fit and hold. We strongly recommend using Gestalt Breastfeeding Technique pioneered by Dr Pamela Dougls. All our GPs are skilled in this technique. 
  • Baby is not being fed often enough (see below)
  • Previous breast surgery, especially breast reduction surgery
  • Recent mastitis
  • Some medications, for example the oral contraceptive pill and over the counter cold and flu medications (pseudoephedrine)
  • Smoking or alcohol
  • Insufficient glandular tissue, a rare condition where a mother is lacking the “milk making” tissue in the breast. 

How can I optimise my supply?

Breastmilk is produced on a “supply and demand” basis and the more a baby is able to empty the breast during a feed, the more milk is produced. Good fit and hold via the Gestalt technique is important to ensure that your baby is draining the breast adequately. Most women find that they need to feed their baby 12 times in 24 hours until supply is established. Breastfed babies require feeding more regularly than formula fed babies as breastmilk tends to be digested much quicker. It is important not to schedule or time feeds, although this may have been proposed to you when in hospital after the baby was born. The baby dictate the feeding pattern: both time at the breast, and time between feeds. 

Use the breast as a tool to soothe or dial down your baby to increase the number of feeds. Offer a “top up” breastfeed if a baby seems unsettled after a feed (this is common with “cluster feeding” in the evening hours). If you have offered the breast many times over a 2+ hour period, and your baby is still unsettled, we would recommend offering a top up of expressed breast milk (EBM) or formula via paced bottle feeding. 

You may find it helpful to switch breasts frequently during a feed to encourage further “let down” or ejection of milk. When your baby is no longer swallowing at the breast, take them off and put them on the other breast. Aim to offer 4-6 breasts in a “feed”. This will transfer more milk than if you had kept them on the one breast for, say, 20 mins, before switching sides. 

The baby is your best pump, and the amount you express does not necessarily give a true indication of your supply. We would encourage you to use your baby as a pump and bring him or her to the breast as often as practical to drive supply.

Some mothers like to offer additional milk at the breast by using a supply line, or supplemental nursing system. This is instead of offering a top up via a bottle. The baby receives milk (or formula) at the breast, delivered by a thin tube that finishes at the end of the nipple. The reservoir of milk is usually held in a container that hangs around mum’s neck, or a syringe attached to the tubing. This set up needs practice and can be facilitated by one of our Doctors. 

In some situations it is worth considering medication to improve your milk supply. Domperidone can be used to increase production of prolactin, the milk making hormone, in order to increase your supply. It is usually well tolerated and has few side effects; however the doctors at Adelaide Mums and Babies Clinic will discuss this with you further if they feel you would benefit.

References and further information:

Functional Lactose Overload (with a generous milk supply)

Breast milk production can be problematic when women have a very generous supply. If the breasts are not emptied well, it can result in engorgement, blocked ducts and even mastitis. Women with a generous supply may find their baby has copious stool production (green and frothy), a bloated stomach, passes wind frequently, is unsettled but with good weight gain. These symptoms are typical of a baby with functional lactose overload – they are getting too much of the sugary milk and not enough cream. There are breastfeeding strategies we can implement to help dial down the milk production to be more in keeping with baby’s needs, while being mindful not to risk mastitis or reducing supply too much. One of our team can help put a plan in place to help you manage this.

Mastitis and Management of Blocked Ducts

Mastitis means “inflammation of the breast tissue”. It occurs in response to an area of breast tissue not being thoroughly drained over several feeds. There is then back-pressure of milk and this causes inflammation of surrounding breast tissue. The number one cause is suboptimal fit and hold. If there is nipple damage/trauma, this can allow bacteria to travel into the breast tissue. Abrupt changes to feeding schedule can also cause milk stasis, and then mastitis. 

Mastitis can occur at any stage of breastfeeding journey, but is most common in the first 8 weeks postpartum. It can affect up to 1 in 5 women. It can be minimized by optimising fit and hold, feeding on demand, offering both breasts each feed and alternating which breast is offered first and avoiding restrictive bras and clothing.

Even at the start of milk stasis, in the inflammatory part of mastitis, you may notice flu-like symptoms, rigors, and body aches. These can come on quite quickly. You may also notice an area of the breast that is  painful, red, swollen or  hot. If it is not managed, it can progress to a bacterial infection needing antibiotics. Further progression in disease may result in a breast abscess. 

It is important to understand that mastitis is a spectrum, and it all starts with milk stasis (ie  areas of the breast that are not well drained over subsequent feeds). To manage mastitis, the aim is to keep the breasts as empty as possible, by emptying often but gently. The ideal way of doing this is for baby to empty to breast by feeding more often and commencing each feed on the affected side in this instance. Baby may be reluctant to feed due to a salty flavour of breast milk. If this is the case, you may need to express. If you choose to use a pump to express, make sure you are using an appropriate size flange. In addition to this it is important to rest, use paracetamol and NSAIDs (ibuprofen) and cold packs. You may find heat prior to a feed helps the milk to flow better, and ice after a feed is best for comfort and inflammation. Avoid restrictive bras or clothing. Any desire to massage the breast should be done gently. Towards the nipple should be no firmer than stroking a cat; and lymphatic drainage is optimised by gentle stroking towards the armpit. If despite this, mastitis does not appear to be resolving in 12-24 hours, antibiotics should be commenced. 

Other ways to manage mastitis are currently being investigated. These include probiotics, lecithin and ultrasound from a physiotherapist. You may find some benefit from these strategies however they are not backed up by evidence at this stage.

The Academy of Breastfeeding Medicine released a new protocol on mastitis management in 2022. Some of the advice in this protocol contradicts our advice. We do not agree with some of their theoretical framework. American women are less likely to direct breast feed, and more likely to express and offer milk in a bottle. Therefore, they are at much greater risk of hyperlactation than women in Australia. Their advice to not empty or feed/pump from the affected breast may work for women who are hyper -actating, but is likely to not be applicable to women that are breastfeeding and not over-supplied.

RESOURCES:

 

Nipple Pain

Nipple pain during breastfeeding can, unfortunately, be quite a common experience. But that doesn’t mean you have to put up with it! And it’s definitely NOT normal to have pain with breastfeeding.

By far and away the most common cause of nipple pain is poor fit and hold. If you have been told that your “latch looks good” but you are still experiencing uncomfortable breastfeeds, then your latch is not good.

Our GPs are skilled in improving fit and hold for pain-free feeding. During a breastfeeding consult we will talk you through the principles of achieving a good fit and hold, then watch a breastfeed and help you adjust your style, empowering you to make the necessary changes.

An assessment of your nipples will also take place. We will assess for trauma, infection, dermatitis and nipple vasospasm to make sure we are not missing any underlying medical diagnoses. A treatment plan will be tailored to your unique situation to help heal your nipples and treat any medical problems.

There are some important medical conditions that can cause nipple pain. Our GPs are in the best position to assess this for you.

Click here for more information on these specific conditions

Breast Refusal

Breast Refusal can be an incredibly upsetting element of a breastfeeding journey. It can occur at any age and for a variety of reasons. The Australian Breastfeeding Association has a wonderful handout which offers some helpful suggestions about how to manage this difficult situation. We find that by implementing the Gestalt Breastfeeding approach, we can improve breast refusal. Positional instability is a really common cause of babies fussing at the breast. This can increase as babies get older. Reclining and tucking their legs into our body can help. Our doctors would be more than happy to discuss your concerns and perform a breastfeeding assessment to determine if fit and hold can be optimised to ensure that this is not contributing to any breast refusal.

Using a Supplemental Nursing System

A supplemental nursing system (SNS), allows your baby to receive extra milk whilst attached to the breast rather than via bottle. Medela is the only brand that is available in Australia. The design involves a small vessel which can be worn around Mum’s neck, with tubing attached. The tubing ends at the nipple, so when baby is attached to the breast, its sucking draws milk from the vessel, as well as milk from the breast. The milk in the container may be expressed breast milk (EBM), donated breast milk or formula.

The benefits of a SNS is that baby receives extra time at the breast which can help stimulate further milk production. Additionally, if baby is tiring easily at the breast, they are likely to receive more milk for less effort with a SNS.

A SNS may be useful for you and your baby if:

  • You have had previous breast surgery
  • Your baby was premature or unwell and tires at the breast easily
  • You have insufficient glandular tissue
  • You are wanting to relactate or re-introduce breastfeeding
  • You have a very low supply and are wanting to increase this

Further information on how to access a SNS can be found on the Medela website.

Further information about using a SNS is available from the Royal Women’s Hospital

 

Paced Bottle Feeding

Paced bottle feeding is a style of bottle feeding that is useful for all bottle fed babies, but particularly those who are also breastfeeding. It slows down the bottle feed, allowing the baby to take what it needs and not any more (which will reduce spilling and allow titration of a top-up according to baby’s appetite). It means the baby still has to “suck” the milk out, rather than just drink it, which is more like a breast feed. It should reduce the chance of “flow confusion” which is usually the underlying cause of a baby starting to prefer the bottle over the breast.

See our blog post on Formula Feeding

Hand Expressing

Hand expressing is a valuable skill to learn. It may come in handy antenatally to collect a supply of colostrum; in the early days to encourage your milk supply; when you are separated from your baby; or when you are separated from your pump. Some women find this to be an easy way to express once this skill is mastered.

To see a video for explanation about how to hand express, click here. 

Expressing and Storing Breastmilk

The Australian Breastfeeding Association has lovely summary of how to safely express and store your breastmilk. It also covers how long you can keep milk for once it is defrosted. Breastmilk in the freezer won’t “go off” it just loses its nutritional value over time.

Click here to go to the ABA webpage on “Expressing and Storing Breastmilk”

FUN FACT:
Did you know that when you leave freshly expressed breastmilk at room temperature, it will contain LESS bacteria over time. This is because breastmilk has living anti-bacterial cells that continue to destroy bacteria.

Click here to see our Blog post on “Expressing 101”

Click here to see our Blog post on “Double Pumping Made Easy”

Breastfeeding and Returning to Work

When it is time for you to return to work, you may have many questions about how to maintain your breastmilk supply, when and how to express at work, how to store the milk and how to encourage baby to take a bottle. We are more than happy to help you navigate this road as we have both been there before!

Breastfeeding and Anaesthesia

Are you breastfeeding and about to go to hospital for surgery? Unfortunately, many women are given out-dated advice about the safety of breastfeeding after an anaesthetic. Almost all anaesthetic agents currently used are compatible with breastfeeding. As soon as you are awake, you are safe to breastfeed your baby.

It is important you tell your surgeon and anaesthetist prior to your surgery date that you are breastfeeding and will continue to breastfeed after your operation. This may impact some aspects of your care and it is best to have arranged these prior to the day.

On the day of your operation, you will need to stay hydrated with intravenous fluids – something that is not always done for those that are fasting pre-op. You may need to ask for this.

You may have to negotiate someone bringing in your baby so you can feed up until your operation, and when you are in recovery, or back on the ward. If this is not possible, you will need to bring a breast pump with you (or borrow one from the hospital if they have one), so you can express to maintain your supply.

The Academy of Breastfeeding Medicine has an excellent protocol with evidence-based advice about breastfeeding after an anaesthetic or when using strong analgesia. This may be handy to print off and show to your anaesthetist if they are concerned about you breastfeeding after an anaesthetic. Click here to go to their website.

Medications and Breastfeeding

Most medication is safe when breastfeeding. This is quite different from when you are pregnant.

One notable exception is Panadeine Forte. Codeine is best avoided while breastfeeding.

If you would like to get good, evidence-based information about the medication you would like to take while breastfeeding, we suggest the 2 online resources that are linked below:

  1. Lactmed
  2. E-Lactation

Simply put your medication into the search function and have a read. Both of the above resources are significantly more reliable than your local pharmacist, or even many health care professionals!

They also cover over-the-counter medications and recreational drugs.

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Adelaide Mums and Babies Clinic acknowledge the traditional owners of this land and pay our respects to their elders both past, present and emerging. We acknowledge and uphold their continuing relationship to this land, the land of the Kaurna and Peramangk people.

Adelaide Mums and Babies Clinic is committed to providing an inclusive service, and environment where individuals feel accepted, safe, affirmed and celebrated. Adelaide Mums and Babies Clinic is committed to equity irrespective of cultural or linguistic background, sexual orientation, gender identity (LGBTQIA+), intersex status, religion or spiritual beliefs, socio-economic status, age, or abilities.