Using a lactation aid to supplement

Supplementing breastfeeding with a lactation aid at the breast

Many mothers feel, rightly or wrongly, that they do not produce enough milk for their babies and end up supplementing their babies with donated breastmilk or formula. Their belief usually starts immediately after birth because in too many hospitals “rules” result in unnecessary supplementation which begins a downward spiral to more and more supplementation.  And in many cases, if the baby is supplemented with a bottle, the baby may sooner or later completely reject the breast and continue only with bottles.  The way to avoid the use of bottles is to use a lactation aid at the breast to supplement.  Photo 1. below shows a baby being supplemented at the breast with a lactation aid.  The photo is arranged to show the container we use to hold the supplement.  With a long tube (91 cm or 36 inches) as we usually use, the container can be put on a beside table, or held in place in the mother’s clothing.

Why is supplementing with a lactation aid at the breast better?

• babies learn to breastfeed by breastfeeding: Is this such a radical notion?
• mothers learn to breastfeed by breastfeeding: Is this such a radical notion also?
• the baby continues to get milk from the breast even while being supplemented: This is important because this helps increase the mother’s milk supply
• if the lactation aid is used properly, the baby will not reject the breast. Breast rejection is very possible if supplements are given frequently away from the breast
• there is much more to breastfeeding than the milk. Breastfeeding is a close, intimate, physical and emotional relationship between two people who usually love each other very much.

 

But the lactation aid is difficult to use

This is not really true, or rather, perhaps we should say, that this should not be true, because we do know that many women have found it difficult.  I will return to this question later in this discussion.

Why do so many women start giving bottles in the first few days, often on the baby’s day of birth?

In most cases, the mothers do not want to give bottles or formula, but are under pressure from hospital staff to do so.  Why?

1. There is concern that the baby has low blood sugar. Too often blood sugars are measured for no good reason and too often supplementation is started because too many physicians/nurses don’t understand that it is normal for the baby’s blood sugar to decrease immediately after birth. For those babies at high risk for low blood sugar, there are options to formula.

2. Another reason for early supplementation is that the baby has higher than average levels of jaundice.

3. Yet another reason, perhaps the most common, is that the baby has lost 10% or more of his birth weight. This approach is not only useless, it leads to unnecessary supplementation, while, at the same time, often convincing the mother that she will not produce enough milk even when the milk “comes in”.

4. Another common reason is that the mother has sore nipples, so bad that she cannot put the baby to the breast. The answer to sore nipples is prevention and help the mother to achieve the best latch possible. If the mother already has sore nipples, the approach is to improve the baby’s latch. Sore nipples are almost always due to a less than adequate latch by the baby. There is a better way to latch babies on than what they are usually doing.  A better latch can make a huge difference in preventing and treating the mother’s sore nipples.  Helping the baby get more milk in the first few days, with a better latch, as well as breast compression can decrease time on the breast and faster flow from the breast improves the baby’s latch.  It is my belief, based on what mothers tell us, that the mother’s having severe pain from the very first time they put the baby to the breast, the baby has a tongue tie,

So how to deal with a baby not getting enough from the breast and mothers’ sore nipples?

1. Get the best latch possible.  This will deal with the vast majority of problems for which babies are supplemented, even after the first few days.  Including the mother’s sore nipples.

2. Watch for the baby drinking at the breast. The pause in the baby’s chin is the best way of knowing if the baby is receiving milk. The longer the pause, the more milk the baby is receiving. This baby is mostly nibbling and thus not getting a lot of milk.  Many mothers are advised to feed the baby on just one breast at a feeding so the baby gets the high fat “hindmilk”, but this makes no sense, since if the baby is not drinking, the baby is not getting any milk, never mind “high fat milk”.

3. Once the baby is not drinking very much, before the baby starts getting sleepy, the mother should use breast compression to keep the baby drinking. Babies tend to fall asleep at the breast when the flow of milk is slow, especially when they are younger than 2 or so months of age, and tend to pull away from the breast when the flow of milk slows when older, though many babies do both at different times and some very young babies will pull away and some older babies will fall asleep.

4. Once breast compressions are no longer working, the mother should switch sides and repeat the steps in points 1 to 3.  But the baby should not fall deeply asleep on the breast.  When flow of milk is slow, babies tend to fall asleep at the breast, not because they are tired, but because babies respond to milk flow.  If flow is slow, they tend to fall asleep.  Older babies tend to pull away from the breast when the flow slows.  But let us, for example, assume that the baby received 80% of his milk on the first side.  If he has fallen deeply asleep on the first side, he may be “almost full”, and not wake up to take the other side.  Switch sides before the baby is asleep, when even compressions are no longer getting the baby significant amounts of breastmilk.

5. Based on how well the baby drinks, or not, supplementation may or may not be necessary. Some babies are drinking well enough not to get into immediate problems, but not drinking well enough to be sure they will gain weight well. In such cases it is worth giving the baby some time to turn around and start gaining weight before advising supplementation.

6. If after points 1 to 5, it is felt the baby should be supplemented, supplementation should be done at the breast with a lactation aid. See video below.

 

Admittedly, some mothers have real problems using the lactation aid at the breast

Some mothers do have difficulty using it, whether it is the manufactured version (Supplemental Nursing System or SNS) or our improvised version. I think that the improvised version works better than the SNS much of the time, however.

Basically, the lactation aid works very well, and the whole process takes less time than feeding at both breasts and then giving a bottle.  But in order for the lactation aid to work well, the baby must have a good latch and the tube needs to be in the right place.  See the video above.  Note, however, that a baby with a tongue tie does not have a good latch no matter how it looks from the outside.

Some mothers have difficulty getting the tube in the right place, especially when they are already having difficulty latching the baby on and/or they do not have help using it. Help from another person at least the first few times, can make all the difference. With time, it becomes easy as the mother “gets the hang of it”. So what do mothers complain about with regard to the lactation aid beside difficulty making it work?

1. It takes too long. This is a variation of the mother’s not being able to make it work at all. The tube is in the baby’s mouth and the baby is on the breast yet the mother says that the baby takes an hour to get the baby 30 ml (1 oz) of supplement. This makes for a very long feed and I agree that something is not working as it should. Incidentally, using a 15 inch (38 cm) tube, as is frequently done, instead of a 36 inch (91 cm) tube also makes this whole operation awkward and it should not be. So why is it taking too long?

The mother tries to use the tube only after the baby has completely “emptied” the breast. Though I can understand her reasons for trying to squeeze the last drop out of the breast before inserting the tube, the problem is that the baby will often be fast asleep and slipping off the breast if the mother waits too long to insert the tube or, in the case of the SNS, to open the valve that lets the supplement flow. It is not necessary to try to get every last drop out of the breast before using the lactation aid. Indeed, I would recommend the mother use it sooner rather than later, though not from the very beginning of the feeding, except in exceptional situations (for example, the baby will latch on only with the tube in place or unless the baby pulls away from the breast very soon after being latched on). The mother feeds the baby on the first breast until the baby is drinking only occasionally even with compression and then changes sides.

When the baby is drinking only occasionally on the second side even with compression, the mother inserts the tube. If the baby pulls off the breast the mother can try latching the baby on with the tube in place and thus, onto the breast and the tube at the same time. The baby, if latched on well, will continue to get her milk from the breast even if being supplemented at the same time. A baby who breastfeeds really well will not need a lactation aid at all. If the baby being supplemented drinks well only for a short while on both sides, he may need to be supplemented after trying the various methods of getting him more milk as listed above. The whole feeding should not take more than 30 to 45 minutes, maybe an hour, but certainly not two hours.

2. Mothers often shy away from using the lactation aid at the breast when they are out in public. Nobody is surprised if a baby is fed a bottle while the parents are at a restaurant or at the mall, say, and rarely is a mother ever asked why she is bottle feeding her baby. It’s normal to feed a baby with a bottle, right? But if a mother is using a lactation aid, she worries about being a spectacle and being asked why she is doing that and why isn’t she just giving a bottle? Many mothers who manage the lactation aid at home very well have refused to use it in public. But I think this is a very good way to educate others about the importance of breastfeeding and keeping the baby at the breast. Mothers can tell anyone who asks: “I need to supplement him and because bottle feeding is not what I wanted to do, I am supplementing him this way in order to keep up the breastfeeding and preventing him from refusing to latch on.”

3. The lactation aid is preventing the mother’s milk from increasing. I must say I don’t understand this idea. The baby is still latched on the breast and thus the baby is still drinking the mother’s milk even if there are only small amounts and this has the potential of increasing the milk supply. The baby now may nurse less often, true, but this may not be a bad thing – it may be because he is getting more milk now. This mistaken idea reflects the teaching that has always been given with regard to breastfeeding that “the more the baby sucks, the more milk there will be”. This is not true. The true statement is that the more milk the baby drinks from the breast, the more milk there will be.

Do you need help for breastfeeding? Make an appointment at the International Breastfeeding Centre.

 

Copyright: Jack Newman, MD, FRCPC, Andrea Polokova, 2017, 2018