Breastfeeding Support

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.

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), good skin colour and tone, baby is alert and reasonably settled and baby is gaining weight and growing. Very young babies are expected to have at least 3 bowel motions a day, although this does tend to slow down after a few weeks and some breastfed babies may go several days without having their bowels open.

What causes low milk supply? 

• Suboptimal fit and hold (see below)
• Baby is not being fed often enough (see below)
• Previous breast surgery affecting the nerve supply in the breast, for example in breast reduction surgery
• Recent mastitis
• Some medications, for example the oral contraceptive pill and over the counter cold and flu medications
• 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 (see Gestalt breastfeeding information) 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. Breast fed 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. Use the breast as a tool to soothe or dial down your baby to increase the number of feeds or offer a “top up” breastfeed if a baby seems unsettled after a feed (this is common with “cluster feeding” in the evening hours). It is very tempting to offer your baby “top ups” of expressed breast milk (EBM) or formula if you are concerned about your supply, however this may in fact tell your body that your baby doesn’t need the extra milk and your body may reduce the amount of milk it makes. Of course, there are situations where supplementation is recommended and this should be discussed with your doctor. If this is required, you may like to try a SNS (a supplemental nursing system) to increase the amount of time the baby spends at the breast.

You may find it helpful to switch breasts frequently during a feed to encourage further “let down” or ejection of milk. 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.

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 our doctors will discuss this with you further if they feel you would benefit.

References and further information:

• Australian Breastfeeding Association: Increasing Supply
• Kellymom Parenting and Breastfeeding
• The Royal Women’s Hospital: Low Milk Supply
• Domperidone
• Gestalt Breastfeeding
• Supplementary Nursing System
• Blog post – Expressing 101
• Blog post – Double Pumping Made Easy
• Blog post – Donor Breast Milk

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 is caused by breastmilk blocking milk ducts and being then forced into nearby tissue resulting in inflammation of the breast. This is often the result of suboptimal fit and hold, nipple damage, blocked ducts or fast/abrupt weaning.

Mastitis can occur at any stage of breast feeding journey, but is most common in first 8 weeks post partum. 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

You may notice flu like symptoms, rigors, aches of reasonably sudden onset, as well as painful, red, swollen, hot areas of the breast. It can progress quickly and a breast abscess may develop if not adequately treated.

To manage mastitis, the aim is to keep the breasts as empty as possibly 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. Feeding position should be changed, for example trying side lying feeding. Baby may be reluctant to feed due to a salty flavour to breast milk. If this is the case, you may need to hand express. If you choose to use a pump to express, make sure you are using an appropriate size flange. In addition to this: rest, use paracetamol and NSAIDs and cold packs (and warmth prior to a feed). Avoid restrictive bras or clothing. 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.

RESOURCES:

• Australian Breastfeeding Association: Mastitis (Good resource for patients)
• Royal Women’s Hospital: Mastitis (Good resource for patients)
• ABM Clinical Protocol #4 – Mastitis (Good resource for Health Professionals)
• Lecithin treatment for Recurrent Blocked Ducts – Kellymom.com
• Amir, L et al., Probiotics and mastitis: Evidence based marketing? Int Breastfeed J 2016 11:19
• Arroyo et al., “Treatment of infectious mastitis during lactation: antibiotics vs oral administration of Lactobacilli isolated from breast milk” Clin Infect Dis 2010 Jun 15; 50(12) 1551-8 

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 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. 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.

• ABA information on breast refusal
• Gestalt Breastfeeding

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, it’s 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 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 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. 

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”

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!

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.