How to protect your breastfeeding journey if your baby is receiving supplemental feeds
Cordelia Uys, March 2021
It’s not uncommon for new parents to be told by a health care professional that their breastfed baby needs supplementing with formula, or for nursing mothers to give formula because they are worried their newborn is not getting enough from the breast. This might sometimes be the case, but unfortunately, it is not uncommon for babies to be given formula supplementation unnecessarily.
How to tell if your baby is getting enough milk
Please see one of the following articles for guidance on how to tell if your baby is genuinely not getting enough milk at the breast:
https://breastfeeding.support/is-my-baby-getting-enough-milk/
https://www.cordeliauys.co.uk/howtotellyourbreastfedbabyisgettingenoughmilk
New mothers are often surprised by how often their newborn wants to nurse, and by how much they want to be held, and misinterpret this as a sign that their baby is not getting sufficient milk. I highly recommend reading the psychologist Sarah Ockwell-Smith’s article The Fourth Trimester, aka why your newborn baby is only happy in your arms, which explains really nicely why babies will often protest when parents try to put them down, for reasons that might have nothing to do with hunger.
Impacts of supplementing with formula
There are short and long-term impacts of supplementing breastfed babies with formula, so it is not a good idea to give formula supplements ‘just in case’. Please see the article Supplementing with formula for more details:
https://breastfeeding.support/supplementing-with-formula/
One of the biggest impacts of supplementing with formula is how much it can undermine a mother’s confidence in her milk supply.
The majority of women are capable of producing all the milk their baby, or babies, need
In a culture like ours that is dominated by formula feeding, it is easy for a new mother to lack confidence in her milk supply. It is therefore important to bear in mind that the vast majority of new mothers are physiologically capable of producing ample milk for twins or even triplets, as long as milk is being removed from both breasts frequently and effectively.
If you have given your baby formula, it is still possible to move to exclusively breastfeeding
If you have given your baby formula, please don’t think this will spell the end of your breastfeeding journey. I have worked with dozens of parents who have supplemented with formula in the early days, sometimes when it was needed, and sometimes when it was not, and who have gone on to breastfeed very successfully.
Contact an IBCLC lactation consultant or breastfeeding counsellor
If you are giving formula top ups, or think you need to, I would urge you to reach out to an IBCLC lactation consultant or breastfeeding counsellor as soon as possible to check if your baby really does need supplementation, and if so, to figure out why.
Find an IBCLC: https://lcgb.org/find-an-ibclc/
Find evidence-based information and properly qualified support
If possible, surround yourself with people who are knowledgeable and positive about breastfeeding. Do some reading and/or join an online group with an admin team who are properly qualified. (Please see below for details of Facebook groups that offer good breastfeeding support).
There is a lot of misinformation and bad advice that can derail your breastfeeding journey, including from people who have the best of intentions, but do not necessarily understand how breastfeeding works. This can include health care professionals, who do not always have the necessary training. Please see this link:
https://lcgb.org/why-ibclc/whos-who-in-breastfeeding-support-and-lactation-in-the-uk/
How milk production works - supply and demand
For the first 2 or 3 days after a baby is born, their mother will be producing colostrum (the first milk). Colostrum production is hormonally driven, meaning it is produced whether a baby is put to the breast or not. However, from around day 3, breastmilk production switches to being locally controlled, meaning it works on a supply and demand basis.
To establish your milk supply, your baby needs to be breastfeeding at least 8 to 12 times in 24 hours
In order for a mother’s milk supply to be established and maintained in the early months, milk needs to be removed from both her breasts a minimum of 8-12 times in 24 hours. In fact, 8 times is the bare minimum and UNICEF talks about an average of 10 to 14 feeds in 24 hours, with many babies needing to feed more often than this.
Programming your breasts
When your baby is born, your breasts have no way of knowing if you have had one, two, or more, babies, or how big your baby is.
It takes 6 weeks for the prolactin receptors in your breasts to work out how much milk your baby, or babies, require. Regular and reliable milk removal from both breasts programmes them to make the right amount of milk for your baby or babies.
The Feedback Inhibitor of Lactation (FIL)
Whenever breasts get hard and full, a negative feedback mechanism kicks in, telling them to stop making milk. This means milk production slows down when breasts are full and speeds up when breasts are emptier. The more often a mother feeds her baby, or pumps, the more milk she will make.
In the early weeks, if a mother goes longer than 3 or 4 hours without breastfeeding or pumping, the FIL will kick in, giving her breasts the message to reduce milk production, and she will also be at risk of developing blocked ducts and mastitis.
Why formula top ups impact milk supply
If your baby is having formula top ups, they will not be breastfeeding as often, or for as long, as a baby who is exclusively breastfeeding, meaning your breasts are unlikely to be getting the stimulation they need to establish a full milk supply.
The top up trap
When giving formula top ups, parents often get caught in a vicious cycle, with the baby being full after a bottle and therefore nursing less, meaning the breasts get less stimulation, and therefore make less milk, so the baby needs more and more formula, meaning the breasts are getting less and less stimulation, and consequently make even less milk.
Protecting your milk supply
Therefore, if you are supplementing with formula, you will need to hand express and/or double pump very regularly, otherwise there will inevitably be an impact on your milk supply.
How to eliminate top ups by ‘triple feeding’
If a mother is producing significantly less milk than her baby needs, she is unlikely to be able to substantially increase her milk supply solely by breastfeeding. This is because once the flow of milk in the breast slows down, babies no longer have the incentive to drink deeply, and will either move to non-nutritive sucking (see below) or will simply refuse to stay on the breast. But pumps will suck and stimulate production whether there is milk in the breast or not.
‘Triple feeding’
Therefore, when giving formula top ups, in order to move to exclusive breastfeeding, most women will need to spend some time ‘triple feeding’, which entails:
Breastfeeding
Double pumping shortly after breastfeeds
Giving top ups (which can happen before or after pumping)
As your supply increases thanks to the pumping, there is a good chance you will be able to replace the formula with more and more of your own milk. Once all the milk your baby is drinking via the bottle is your breastmilk, then you can slowly reduce the top ups and pumping and move to exclusive breastfeeding (see Reducing top ups below).
A step-by-step explanation of ‘triple feeding’:
1. When your baby is on the breast
Nutritive versus non-nutritive sucking - Nutritive sucking
In order for milk production to be stimulated, babies need to be doing nutritive sucking, that is to say, they need to be actively and effectively removing milk from the breast.
This a description by my colleague Stacey Zimmels of a baby drinking well at the breast:
https://www.instagram.com/tv/B-98tWxlSJU/?igshid=g6awyu7n83cl
And here is a shorter film of a baby drinking well:
https://www.youtube.com/watch?v=aoWjwm1nMyQ&t=2s
Nutritive versus non-nutritive sucking - Non-nutritive sucking
Sometimes babies will do what is known as non-nutritive sucking, which is comforting for them, but which does not stimulate their mother’s milk production very much, if at all.
Please see this link for an example of a baby who is ‘nibbling’ at the breast:
Offering both breasts
If a mother is only offering one breast per feed, it means her baby is potentially getting half as much milk as they could, and her breasts are potentially getting half as much stimulation. Only offering one breast per feed is a common cause of slow weight gain and reduced milk supply.
Therefore, when breastfeeding is going well, the recommendation is to wait for your baby to come off the first breast of their own accord, wake them up if necessary - nappy changing usually does the trick - and then offer them the second breast.
Whether they don’t take the second breast, take it for just a few minutes, or have a long feed, it is recommended to go back to that second breast for the next feed. By alternating which breast you start with at each nursing session, your breasts will get a good balance of stimulation over a 24-hour period.
Breast compressions and switch feeding encourage babies to drink more actively
However, if babies are not swallowing much, and are spending a lot of time doing non-nutritive sucking, it usually works best to do things a little differently, using breast compressions and switching breasts several times during feeds to encourage the baby to keep drinking.
Breast compressions
When your baby is on the breast, breast compressions will encourage him or her to keep drinking actively, and for longer.
Here is a good explanation of breast compressions by my colleague Kathryn Stagg:
Switch feeding
When your baby is no longer swallowing actively on the first breast, even with breast compressions, switch him or her to the second breast, and repeat the breast compressions. Once they are no longer swallowing on that side, switch them back to the first breast. Switching back and forth between breasts several times at each feed is called switch feeding and is a very effective way of increasing milk supply. This is because it is active sucking that stimulates milk production, not the length of time spent on the breast.
Limit your baby’s time at the breast when you’re going to pump after a feed
When breastfeeding is going well, mothers are encouraged to let their baby feed for as long as they want on each breast. However, if you need to pump after a breastfeed, the recommendation is to limit your baby's time on the breast, so you have enough time to fit in a pumping session.
It is up to you how long you spend doing breast compressions and switch feeding; some mothers only do 5 minutes; others spend as long as 20 minutes. Of course, it is a good idea to keep compressing and switching breasts for as long as your baby is actively drinking. The amount of nutritive sucking your baby is doing will likely increase as your supply increases.
2. Expressing, and pumping, after feeds, to increase milk supply
While you are producing colostrum: hand expressing after breastfeeds
At first, while you are still producing colostrum (usually, until around day 3 or 4) the recommendation is to hand express shortly after a breastfeed. Colostrum comes in volumes that are too small to be collected in a pump. It is hard to say how long to hand express for, but I would suggest aiming for at least 5 to 10 minutes on each breast after each breastfeed.
(N.B. Please note that a recent study https://pubmed.ncbi.nlm.nih.gov/34529518/ found that the volumes of colostrum new mothers are able to hand express increases in the first six hours after the baby’s birth, and after that, the volumes of colostrum decrease. The lowest volumes of colostrum occur between 12-15 hours, and volumes stay low until a sudden increase in volume at 30-33 hours postpartum.)
You can collect the drops of colostrum directly from your nipples with a syringe and feed them to your baby. Alternatively, you can hand express on to a sterilised spoon, or into a small sterilised cup, and then suck up the colostrum with the syringe.
Colostrum comes in very small quantities, but that’s fine because babies’ tummies are very small in the first few days.
Have a look at this film from Stanford Medical School which explains how to hand express:
Hand Expressing Milk | Newborn Nursery | Stanford Medicine
Once your mature milk comes in: double pumping after some, or all, breastfeeds
Hiring a hospital grade double pump
If your baby needs supplementation, with your own milk or with formula, it is a good idea to hire a hospital grade double pump as soon as possible, so you can begin double pumping after breastfeeds as soon as your mature milk starts coming in, which normally happens on day 3 or 4.
It is imperative to use a hospital grade pump because regular pumps are not powerful or gentle enough to increase milk supply. Double pumping (removing milk from both breasts simultaneously) provides much more stimulation than single pumping and saves precious time.
You can hire a hospital grade double pump from:
Ardo Breast Pumps: https://www.ardobreastpumps.co.uk/shop/products/rent-a-breastpump/?gclid=EAIaIQobChMIuZvixpeZ7gIV2ZTVCh3PgwfaEAAYASAAEgJiEfD_BwE
Medela: https://www.medela-rental.co.uk/?gclid=EAIaIQobChMIjciF7ZeZ7gIVibTtCh1tzAhrEAAYASAAEgLAlPD_BwE
Alternatively, the Spectra S1 is a Korean-made hospital grade double pump that can be bought online, and which gets excellent feedback from experienced pumpers.
Make sure the breast shields (flanges) fit you properly
Please note that a correct breast shield fit is fundamental; when breast shields don’t fit, women can experience pain and damage, and pumping will be less productive. Pumping should never hurt; if it does, it is either because the breast shields don’t fit, or because the suction/vacuum is too high.
How to tell a correct breast shield fit
During a very interesting talk for the Gold Lactation conference in May 2022, Jeanette Mesite Frem stated that many people should actually be using a flange size a lot smaller than the standard sizes provided by pump manufacturers. If used with a little lubrication from some coconut oil, apparently a smaller flange size will increase milk yield quite substantially. Jeanette said lanolin or vaseline are too sticky.
She suggested measuring the diameter of the nipple and then trying sizes of that diameter, 2mm bigger and 2mm smaller and seeing what happens. This is totally different to what is suggested currently which is to measure the nipple and add 2-5mm.
(This is what pump manufacturers currently suggest: https://www.verywellfamily.com/ways-to-tell-if-your-breast-pump-flanges-fit-2758354 )
Many pump manufacturers have 21mm as their smallest size, but the following inserts can be used with Spectra and Medela pumps and come in smaller sizes:
https://www.amazon.co.uk/s?k=maymom&crid=2YUWQJ1DVODQI&sprefix=maymom%2Caps%2C89&ref=nb_sb_noss_1
Please make sure you don’t cause any damage or hurt yourself; if it doesn't feel right, stop and try another size.
Pumping technique: maximising your milk production with hands on double pumping
Have a look at this video on double pumping from Stanford Medical School; massaging your breasts while you are pumping will make a difference to the volumes you are able to produce:
The four minutes of hand expressing on each breast, at the end of a pumping session (as described in the film) are really good at encouraging milk production.
You might also find some helpful suggestions in my article on the let-down reflex:
https://www.cordeliauys.co.uk/the-letdown-reflex-1
Pumping bra for hands-on-pumping
You can create a pumping bra using an old exercise bra that you don’t mind sacrificing. This will allow you to have your hands free to massage your breasts while double pumping. It is also possible to buy a pumping bra online, but these are often too tight, with less ‘give’ than a regular bra, and can therefore cause blocked ducts.
Here is a photo of a client wearing a sports bra she turned into a pumping bra:
It’s a good idea to keep track of the volumes you are pumping, and pumping times.
There are some excellent Apps that can help you stay on track with pumping; many are free, for example:
https://apps.apple.com/gb/app/the-best-baby-tracker/id985523028
When to pump?
The best time to double pump is shortly after a breastfeed. This will probably mean that you collect less than if you pump before you feed your baby, but please bear in mind that removing milk when your breasts are relatively empty is very good for stimulating supply. It is like sending in the order for the next feed.
Also, your baby will be less keen to feed if you have recently pumped.
Time of day and milk volumes
Please be aware there will be times of the day when you make less milk. Most women produce greater volumes of milk in the morning; volumes tend to be lower later in the day. This is a clever evolutionary design, because when volumes are lower, babies tend to want to feed more often, and a period of several hours a day of frequent feeding (known as ‘cluster feeding’), albeit exhausting, is great for stimulating milk supply. (In the first couple of months, it is normal for babies to be fussy, and to cluster feed, in the evenings.)
N.B. It is not unusual for one breast to produce more milk than the other
Contact a lactation consultant or breastfeeding counsellor
Ideally, you want to work with an IBCLC lactation consultant or breastfeeding counsellor who can guide you on how often to double pump, and how long to spend pumping at each session. The following suggestions are only a rough guide.
How long to pump at each pumping session?
You will need to work out how long to pump for; it depends a lot on a mother’s milk supply, and on how much top up her baby is taking. Usually, the recommendation is to double pump for between 15 and 30 minutes. But even 5 minutes of pumping will help to increase your supply.
It is not a good idea to pump for longer than 30 minutes non-stop as this can cause nipple soreness.
If possible, continue pumping for several minutes after your milk has stopped flowing, as this tells breasts to make more milk. If you stop as soon as the flow stops, your breasts will not get the message to make more milk.
How often to pump?
As a rule of thumb, the recommendation would be to double pump after breastfeeds, at least as often as you need to top up, whether that is with your own milk or with formula.
Power pumping
Sometimes, instead of, or as well as, double pumping after feeds, a mother will choose a time of day when she can spend an hour ‘power pumping’. It is usually only possible to do this when there is someone else around to care for your baby, or in the evening, when your baby has gone down for their first big stretch of sleep.
The idea of ‘power pumping’ is to mimic a baby who is nursing frequently to stimulate a mother’s supply, as is common during a cluster feeding session, or during a growth spurt.
To ‘power pump’, hook-up as you would for a normal pumping session, double pump for 10-20 minutes, rest 10 minutes, then double pump another 10 minutes, then rest for 10 minutes, then double pump again for 10 minutes. You do this for about an hour, once per day.
Sterilising
If your baby is full-term and healthy, you only need to sterilise the pumping equipment once in 24 hours. After each usage, wash equipment carefully with hot water and washing up liquid, then rinse well and put to dry on some clean kitchen paper.
Bottles used to give formula need to be sterilised after each usage.
Storing breastmilk:
Breastmilk is safe at room temperature for approximately 6 hours.
Here is info on storing breastmilk:
You can add newly pumped milk to milk already stored in the fridge on the same day, but only after it has cooled down in the fridge for at least 30 minutes. Never add warm milk to cold milk, as this encourages the growth of bacteria.
Timing of breastfeeds/pumping sessions – make sure both your breasts are having milk removed a minimum of 8 times in 24 hours
It is not necessary to breastfeed and/or pump at set times. It is normal for the gaps between breast feeds to be irregular, and it is fine for the gaps between pumping sessions to be irregular.
Try not to go longer than 3 hours without breastfeeding and/or double pumping during the day
When a mother is working on increasing her milk supply, it is best not to go longer than 3 hours without breastfeeding and/or pumping.
How long can you go without breastfeeding/pumping at night?
At night, it is probably okay to have one 4-hour gap between the end of one breastfeeding or pumping session and the beginning of the next, as long as you are stimulating your breasts more often at other times. You need to be able to fit in a minimum of 8 double pumping sessions and/or breastfeeds in 24 hours for your milk supply to be established and maintained.
Don’t let your breasts get uncomfortably full
If your breasts get uncomfortably full, the Feedback Inhibitor of Lactation (FIL) will kick in, telling them to reduce milk production. You will also be at risk of getting blocked ducts and mastitis. If you are experiencing uncomfortable fullness and cannot breastfeed or pump, it is a good idea to hand express enough to stop that ‘bursting’ feeling.
Night feeds - prolactin
Prolactin is the hormone that makes milk; your prolactin levels are highest at night so it is important that your breasts are being stimulated at night.
At night, you might want to either solely pump or solely breastfeed
Because breastfeeding and then pumping at night-time is extremely hard work and exhausting, many women choose either just to breastfeed, or just to double pump.
Your partner’s support at night
While you are working on increasing your milk supply, if you choose not to breastfeed at night, you could ask your partner to take charge of feeding and settling your baby, so you can wake up, double pump and then immediately go back to sleep. You could put the expressed milk in a cool bag by your bed rather than taking it to the fridge.
This is a personal decision: some women get upset at the idea of being separated from their baby at night, whereas others find that a night or two of solely pumping gives them a chance to catch up on some much-needed sleep. Getting a bit more sleep tends to help with milk production.
If you decide to solely breastfeed, your partner could be in charge of topping up your baby, if that is necessary, and even more helpfully, of settling your baby after feeds.
Galactagogues:
Please see this article for suggestions of herbs and medications that can be taken to help increase milk supply: https://breastfeeding.support/what-is-a-galactagogue/
3. Supplementing your baby
Please remember to read the article Is My Baby Getting Enough Milk? (link below) to help you work out if your baby really does need supplementing.
The first 48 hours
It is rare for a healthy, full-term baby to require supplementing in the first 48 hours of their life; as a midwife friend puts it: ‘babies are born with a full tank’.
Milk options
Your own breastmilk: if you are worried that your baby is not getting enough at the breast, the first step is to supplement with your own colostrum, and then, once it comes in, with your mature breast milk. This might be all that is needed to get a bit more into your baby, and to kick start your breastfeeding journey.
Donor milk: as a next step, the World Health Organisation recommends pasteurised donor milk for babies whose mothers are not immediately able to breastfeed or express enough milk to satisfy their baby’s needs.
For more information on obtaining donor milk, please contact the Hearts Milk Bank:
Formula milk: if you are not able to hand express or pump all the milk your baby needs, and donor milk is not available, the recommendation is to supplement with first infant formula (whey-based). Please see this First Steps Nutrition link on formula milks: https://www.firststepsnutrition.org/parents-carers
Feeding methods
Finger feeding colostrum
Colostrum comes in volumes too small to put in a bottle. The easiest way to get expressed colostrum into your baby is by finger feeding them with a syringe.
Here is a film showing how to finger feed:
Paced bottle feeding: when a baby is held in the traditional, reclined bottle feeding position, a combination of gravity and the baby’s sucking reflex means it is easy to persuade them to drink more milk than their tummy can comfortably fit. This puts them at risk of overfeeding, and gets them used to a fast flow, which in turn means they are likely, sooner or later, to reject the breast, which usually has a much slower flow.
Whether you are giving breastmilk or formula in a bottle, it is crucially important to use the paced bottle feeding method, as this will protect your breastfeeding journey.
This film explains paced bottle feeding: https://www.youtube.com/watch?v=OGPm5SpLxXY
Responsive feeding - be guided by your baby: the beauty of paced bottle feeding is that your baby will be able to indicate when they are full much more easily. It is very important not to try to coax your baby to drink more than they can comfortably fit, or their ability to self-regulate might be impacted, putting them at risk of future overweight and obesity.
Please bear in mind that between 4 weeks and 6 months, your baby’s maximum stomach capacity is around 120ml - 150ml.
What type of bottle?
The type of bottle and teat you use is not as important as making sure that whoever is feeding your baby always practises paced bottle feeding.
It is easier to practise paced bottle feeding with a bottle that is not too big or too fat. Look for a bottle that has around a 150ml maximum capacity, and one that resembles Kate Moss in shape, rather than Beyoncé.
https://breastfeeding.support/best-bottle-breastfed-baby/
Using a nursing supplementer instead of a bottle
If you need to supplement your baby for longer than a week or two, you might want to consider using a nursing supplementer, also known as a supplemental nursing system (SNS)
https://breastfeeding.support/supplementing-at-the-breast/
Although learning how to use a nursing supplementer can be tricky, it allows the baby to get their supplement at the breast, so that they are stimulating the breast at the same time.
Using a nursing supplementer also eliminates the need to give a bottle, saving time, and meaning the baby will not be at risk of developing a bottle preference.
When to give your baby the supplement
Usually, parents will give supplemental feeds shortly after the baby has been on the breast. However, if your baby is sleepy and hard to rouse, giving them a relatively small amount of milk before offering the breast can wake them and whet their appetite. Obviously, you do not want to give them too much, or they will not be interested in nursing.
If your partner is around to help, they could give your baby a bottle while you pump. Otherwise, you could give the bottle either before or after you have double pumped.
Volumes
In the first week
In the first week, the volumes a baby needs will increase day by day. To give you a rough idea, on day 1, a baby’s maximum stomach capacity is circa 5ml per feed, on day 2 it is circa 10ml per feed, on day 3 it is circa 20ml to 30ml per feed, and it increases by 10ml per day until plateauing at around 60-80ml by day 7.
The volumes your baby takes will often vary from feed to feed, and will depend on many things, such as how often they are feeding, and also how much they are getting from the breast. Since it is impossible to see how much a baby is taking while nursing, you will need to be guided by your baby’s feeding cues and signs of satiety.
Baby feeding cues: https://metronorth.health.qld.gov.au/rbwh/wp-content/uploads/sites/2/2017/07/feeding-cues-term.pdf
After the first week
Here’s a link giving a rough idea of how much milk your baby might need after the first week:
How much expressed milk will my baby need?
Please bear in mind that the volumes in this link are for a ‘full’ feed, that is to say for babies who are not nursing shortly before being given a bottle. Your baby might need less than this if they are being given a supplement after a breastfeed.
Feeding frequency
Watch out for your baby’s feeding cues. It is fine for your baby to feed more than 12 times in 24 hours, but you want to make sure that he or she is not feeding fewer than 8 times in 24 hours.
Wake your newborn baby if they are sleeping longer than (roughly) 3 hours
Until your baby has overtaken their birth weight, and is producing at least 6 heavy wet nappies, and two good-sized poos in 24 hours, the recommendation is to wake them if they are sleeping longer than roughly 3 hours, although one 4-hour stretch at night should be fine as long as your baby is feeding more frequently at other times.
A newborn baby who is not getting enough milk can lack the energy to wake up and ask for feeds.
(N.B. You can pour 45ml of water into a clean disposable nappy to feel what is meant by a ‘heavy’ wet nappy).
How to tell if your baby is getting enough milk
Nappies:
Please keep close track of your baby’s pees and poos as they will indicate whether your baby is drinking enough milk:
https://www.justonenorfolk.nhs.uk/media/2447/p2p-nct-whats-in-a-nappy.pdf
In the first week, it can be helpful to take photos of your baby’s poos to show to your midwife.
N.B. After 6 weeks, some breastfed babies no longer poo on a daily basis. As long as poos are soft and plentiful when they arrive, and your baby is producing plenty of wet nappies and gaining weight as expected, this is not a cause for concern.
Weight loss in the first few days is normal
Your baby's weight will of course also be a good indication of whether they are getting enough.
When they’re weighed by the midwife on Day 5, it is normal for babies to have lost up to 7% of their birth weight if they were born vaginally, and up to 10% if it was a caesarean birth. It can then take 2 to 3 weeks for babies to regain their birth weight.
Weight gain for breastfed babies: https://kellymom.com/bf/normal/weight-gain/
If your baby isn’t producing the expected amount of wet and dirty nappies, or their weight gain is not as expected, please contact your GP or health visitor.
Moving to exclusive breastfeeding
Once your baby is drinking more actively, you can stop switch feeding
As your supply increases, you will probably find that your baby is drinking more actively when they are nursing. At that point, you can start allowing your baby to spend as long as they want on each breast, rather than switch feeding. We usually expect babies to spend anywhere between 5 and 45 minutes on each breast.
Make sure you always offer both breasts at each feed.
Your baby might sometimes no longer want a top up
You might find that your baby does not always want a top up – this is a good sign.
If they are still taking a top up, you could try putting your baby back on the breast after the top up, for ‘dessert’.
Reducing top ups
Once you are producing all the milk your baby is drinking, it is usually safe to start reducing top ups
Once all the milk your baby is consuming is your breastmilk, you can gradually start to reduce top ups.
Changes need to be made slowly. The recommendation is to reduce the amount of supplement you are giving your baby at each feed gradually. If their weight gain and nappy output remain satisfactory, you can then slowly stop offering a top up after every feed, following your baby’s lead.
Keep a close eye on your baby’s nappy output and their weight gain
Nappies
The whole time, you will need to keep a close eye on your baby’s pees and poos. If you see their nappy output reducing, you will need to go back to giving bigger volumes of top up, and/or topping up more frequently.
Weigh your baby before reducing top ups
It is a good idea to weigh your baby before you start reducing top ups, and then again a week later, to make sure they have gained enough weight. Once they have regained their birth weight, up until 4 months, you want your baby to be gaining a minimum of 180g per week:
https://kellymom.com/bf/normal/weight-gain/
Phasing out pumping
As your baby reduces the amount of top up they are taking, you can start to phase out the pumping. Obviously, you have to go at their pace, making sure you are still pumping enough for the top ups they need.
Don’t phase out pumping too quickly or you risk developing blocked ducts and mastitis. Here are two different suggestions for how to safely decrease, and then stop, pumping:
a) Drop one pumping session at a time: try dropping one pumping session every 3-7 days. For example, drop the first session on day 1 (while pumping regularly at other sessions), the second session on day 4, the third session on day 7, etc.
b) Gradually decrease pumping time for every pumping session at once: try decreasing all the pumping sessions you are dropping by two minutes every other day.
Whichever way you phase out pumping, always let comfort be your guide; you don’t ever want to let your breasts to get uncomfortably full.
In conclusion
‘Triple feeding’, that is to say breastfeeding, topping up and pumping, requires a tremendous amount of hard work and dedication, and the prospect can be daunting, to say the least. It is important to bear in mind that in the vast majority of cases, this will just be a temporary measure. Most mothers don’t need to ‘triple feed’ for more than a week or two. It can be very helpful to take one day at a time.
By following the suggestions above, there is a good chance you will be able to transition to exclusively breastfeeding your baby. Many mothers say how glad they are that they made the effort.
Good luck!
Kerryann describes her experience of ‘triple feeding’:
My breastfeeding journey with my daughter did not go to my plan. For several reasons (c-section, delayed skin to skin, poor support for first feeds, and tongue tie) by one week postpartum my milk supply was at risk and my baby’s weight would prove to be a concern. If I had been left in my own ignorance, I would have believed giving up breastfeeding was the best, if not only, solution. Thankfully, with the right guidance on triple feeding, we were given a chance find our way back to exclusive breastfeeding. It was tough going for several weeks, but at each stage I would remind myself of the vision - to be able to feed my baby from source (breast) and for her to thrive in every way.
The strategy of triple feeding gave me a way to protect everything that was most important to me - my baby’s wellbeing, my milk supply, and the breastfeeding relationship between me and my so-longed-for baby. I won’t lie or sugar coat the experience - it was hard work, and it took emotional resilience and unwavering (well, most of the time) commitment. But gradually we were able to reduce the ‘scaffolding’ around breastfeeding and make it back to the heart of exclusive breastfeeding. Was it worth the effort?... Absolutely! For all the reasons I wanted to breastfeed in the first place - convenient, fuss-free, relational, intimate, emotional, and spiritual. I was also surprised to learn how deep I could dig into my might and power when something so important to me was at stake. Now, looking back on all the iterations of feeding patterns we moved through, it feels surreal. It felt endless while in it, but like a blink of an eye now it has passed, and we are feeding like a dream!
Articles:
What to do if your newborn isn’t latching: https://www.cordeliauys.co.uk/what-to-do-if-your-newborn-isnt-latching
Is My Baby Getting Enough Milk?: https://breastfeeding.support/is-my-baby-getting-enough-milk/
The Fourth Trimester: https://sarahockwell-smith.com/2012/11/04/the-fourth-trimester-aka-why-your-newborn-baby-is-only-happy-in-your-arms/
Supplementing with formula: https://breastfeeding.support/supplementing-with-formula/
Feeding cues: https://metronorth.health.qld.gov.au/rbwh/wp-content/uploads/sites/2/2017/07/feeding-cues-term.pdf
What’s in a nappy: https://www.justonenorfolk.nhs.uk/media/2447/p2p-nct-whats-in-a-nappy.pdf
Galactagogues: https://breastfeeding.support/what-is-a-galactagogue/
First Steps Nutrition information on formula milks: https://www.firststepsnutrition.org/parents-carers
The relationship of milk expression pattern and lactation outcomes after very premature birth: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0307522
Reading:
Amy Brown: The Positive Breastfeeding Book
Amy Brown: Let’s talk about the first year of parenting
Emma Pickett: You’ve Got It In You: a positive guide to breastfeeding
Getting support:
Who’s who in the world of lactation: https://lcgb.org/why-ibclc/whos-who-in-breastfeeding-support-and-lactation-in-the-uk/
Finding a lactation consultant: https://lcgb.org/find-an-ibclc/
Facebook groups for breastfeeding mums:
Can I Breastfeed In It: https://www.facebook.com/canibreastfeedinit/
Can I Breastfeed In It Off Topic discussion group: https://www.facebook.com/groups/canibreastfeedinitOT/
Breastfeeding Yummy Mummies: https://www.facebook.com/groups/BFYummyMummy/
Boob or Bust: https://www.facebook.com/groups/BoobOrBust/
Breastfeeding Support and Information UK: https://www.facebook.com/breastfeedingsupportandinfouk/
Breastfeeding Twins and Triplets UK: https://www.facebook.com/groups/460888727398997/
Breastfeeding lines:
National Breastfeeding Helpline: 0300 100 0212
NCT feeding line: 0300 330 0700 (option 1). The line is open from 8am to midnight, including bank holidays.
Association of Breastfeeding Mothers: 0300 330 5453
La Leche League: 0345 120 2918