10 things they don’t tell you about breastfeeding

Irish mothers will breastfeed in public en masse in at least 14 different venues around the country this Saturday, as part of the international Quintessence Challenge to see how many babies can be fed simultaneously in one place.

A voluntary group, Friends of Breastfeeding, co-ordinates the event here, in an effort to promote the importance – and normality – of this way of feeding babies. Other events with a similar aim are taking place during National Breastfeeding Week, which starts today.

Despite extensive evidence of health benefits for both baby and mother, Ireland continues to have one of the lowest breastfeeding rates in the world – only 55 per cent of mothers are feeding their babies this way when they leave hospital (47 per cent exclusively) and, by three months, this has dropped to almost 39 per cent (24 per cent exclusively), according to data from 2011.

Among mothers who decide against it from the start, embarrassment and unfamiliarity are cited as the principal factors, according to the HSE's national breastfeeding co-ordinator, Siobhán Hourigan.

Giving up
The main reasons women give for deciding to stop, earlier than perhaps they intended, is exhaustion and feeling overwhelmed.

Hourigan attributes this partly to women not understanding what to expect – particularly if they are not getting support from family, friends and the community.

For instance, it’s perfectly normal for a baby to want to feed between eight to 12 times in 24 hours, as is “cluster feeding”, when the baby keeps coming back looking for more.

It doesn’t mean you can’t produce enough milk; frequent feeding builds up the supply, whereas supplementing with a bottle has the opposite effect.

So what else do they not tell you about breastfeeding in advance – or, at least, you don’t hear because, as a first-time mother, you are so fixated on what is going to happen in the labour ward? Take this list of 10 for starters:

1 It's natural but that doesn't mean it's easy: Visions of maternal bliss as an angelic baby nuzzles into your chest may be shattered by piercing nipple pain when the baby latches on.

Like any new skill, it may take a bit of practice to get it right, says lactation consultant Sue Jameson. But that doesn't mean you should put up with discomfort beyond what she describes as being "a bit got at", without looking for help.

There is a perception that breastfeeding is going to hurt and that’s normal – it’s not, stresses Hourigan.

While in the first fortnight you might feel a pinch when the baby latches on, you should not put up with prolonged pain.

2 You should look for breastfeeding support before you have the baby: While it is near impossible for first-time mothers to think beyond the birth, once you have a baby plonked on your chest, it is going to be a very steep learning curve.

It is a good idea to have met the people whose help you may need – such as your public health nurse and members of your nearest breastfeeding support group.

There are nearly 200 support groups around the country (see breastfeeding.ie for one near you) and counties with particularly low breastfeeding rates, such as Donegal, Sligo and Leitrim, where less than 8 per cent of mothers continue after three months, are being targeted for more support.

Under a new initiative in Kerry, Hourigan reports that public health nurses are now visiting mums before birth.

They find it saves time in the post-natal period because, having met the mother, they can really focus on her needs during the first visit within 48 hours of discharge from hospital.

3 It's really much handier: There are no bottles to sterilise or feeds to prepare and you just need to chuck a nappy or two into a bag when you leave the house. What's more, it is the perfect excuse to sit down and enjoy time with your baby.

4 You are your baby's dummy: Soothers are not recommended in the first few weeks because babies may find it difficult to attach to the breast after using them.

But they don’t need them anyway – you don’t get a better pacifier than the breast.

5 Breastfeeding in public is no big deal: If you haven't done it before, you think everybody is going to stare. In fact, they are unlikely to notice – an artfully draped scarf or specially designed breastfeeding top provides all the cover you need.

6 Dads can make or break breastfeeding: Studies show that the more supportive partners are, the longer the mother is likely to continue.

The father can be doing everything except breastfeeding – bathing, changing nappies, providing meals, suggests Jameson.

“Dad’s relationship with the baby is really important,” she adds, “because it teaches the baby that love and nurture and warmth can also come from the non-food parent.”

7 It's not just cows who develop mastitis: About one in 10 breastfeeding mothers will be affected by this condition. Symptoms include a painful swollen breast and possibly flu-like symptoms.

“Heat, rest and empty breast” is the recommendation for the first 24 hours and then, if there is no improvement, a visit to the GP for a course of antibiotics is recommended. Make sure medication that allows you to continue breastfeeding is prescribed.

8 It's invaluable when your baby is ill: Expressed breast milk – whether the mother's own or a supply from the island's only human milk bank, in Co Fermanagh – is vital for premature babies.

But any baby feeling poorly craves the comfort of the breast, so is less likely to stop suckling a real teat, as opposed to a plastic one.

Dublin mother Lisa Finnegan was very glad she was still breastfeeding her one-year-old baby when he became very sick during a trip to Tenerife. “He wouldn’t eat or drink, he was vomiting – the only thing he would do is breastfeed.”

Hospital staff wanted to keep him in and put him on a drip, until they saw her put him to the breast. Instantly their attitude changed, she says, and they told her she could take him home, that he should be fine.

“It was one time it really hit home to me that I was doing the right thing,” she adds.

9 You're not a failure if you stop early: Some mothers feel very guilty when they don't reach the targets they had set themselves for breastfeeding.

It’s one of the reasons the HSE is promoting the slogan, “Every Breastfeed Makes a Difference.”

It is also intended to encourage women to take it a day at a time, which can seem less daunting than the six months of exclusive breastfeeding recommended, and then up to two years in combination with solids.

10 You might not want to stop: The pure pleasure of breastfeeding, never mind the health benefits and the added bonus of it being a slimming aid, means it can be a hard habit to kick.

However, telling everybody how wonderful breastfeeding can be, may cause you to be branded a member of the “Breastapo” or, at least, regarded as a bit odd. So it’s a discussion rarely heard outside breastfeeding groups – which does first-time mothers no favours.

For more information on National Breastfeeding Week, see breastfeeding.ie and friendsofbreastfeeding.ie. An HSE information leaflet on what to expect when breastfeeding is available on healthpromotion.ie.

swayman@irishtimes.com

The Irish maternity system needs to provide a 'pathway' to treatment for tongue tie

If breastfeeding continues to be difficult and painful for more than a couple of weeks, “tongue tie” in the baby may be the issue.

When the small bit of tissue (frenulum) under the tongue is unusually thick, tight or short, it restricts movement of the tongue. This can hamper the baby’s latching and sucking, resulting in persistent pain for the mother and sometimes the failure of the baby to get enough milk.

Research has found that 4-10 per cent of babies are born with this condition – the estimated incidence varies from study to study – of whom nearly half are likely to have feeding problems, particularly those who are breastfed.

However, the medical establishment here is yet to be convinced of a need for treatment.

“It is a big block. We don’t seem to be able to get it into paediatricians’ heads that this is a problem,” says lactation consultant Nicola O’Byrne, who thinks they regard it as a “fad”.

She believes tongue tie (known medically as ankyloglossia) is not being taken seriously by the maternity hospitals.

“It causes huge anger among the mothers who have gone through a couple of weeks of very difficult breastfeeding and really want to do it and then find out that this has been the problem all along.”

A pathway to treatment
If the Irish maternity system is trying to promote breastfeeding, it needs to provide a “pathway” to treatment for tongue tie, says paediatrician Dr Justin Roche, one of the few professionals in the Republic offering to do this procedure – known as a frenotomy – on young babies.

It involves the snipping of the frenulum that is restricting movement of the tongue and, when done in the early weeks, can be carried out without any anaesthetic.

“From an intervention perspective, it is comparable to having a blood test or a vaccination,” says Roche, consultant paediatrician at South Tipperary General Hospital in Clonmel.

Most babies get a little bit of bleeding; for one in 300 cases it will be up to a teaspoon in volume. They will be upset by the procedure for 30 seconds to a minute and then settle down, he says.

Roche has treated more than 1,000 babies for tongue tie and had to start a weekly private clinic to meet the demand, as more and more were referred to him from all over the country.

On an average week, he treats between 10 and 13 babies – with a waiting list of two to three weeks for private patients and up to six weeks for public patients.

“It undoubtedly works,” he says, although not for absolutely everybody. An early audit he did of 150 cases, some 95 per cent reported an improvement in the baby’s feeding – and for more than two-thirds it was a “marked” improvement.

Personal experience
It was personal experience as a father of six children – three of whom were born with tongue tie – which led to him providing a frenotomy service.

He had been sceptical about the procedure until not only his eldest daughter had it done in the UK but then it was also recommended by a lactation consultant for his youngest daughter who was born here.

He ended up doing that one himself – the first time he carried out a frenotomy, although he has since gone to the UK for training to ensure he was following best practice.

The UK’s National Institute for Health and Clinical Excellence (NICE) provided guidelines for the tongue-tie procedure back in 2005, concluding that dividing the frenulum was safe and “worked well enough” for use in the NHS.

There it is mostly lactation consultants who are doing it, although availability is still patchy.

Here in Ireland, the National Breastfeeding Strategy is looking for the introduction of guidance around diagnosis, referral and treatment of tongue tie, according to the HSE's national breastfeeding co-ordinator Siobhán Hourigan. It is, she adds, a "work in progress" with the national clinical programme.

Treatment is generally not available in maternity hospitals. For instance, a spokesperson for the Coombe Women and Infants University Hospital tells The Irish Times: “We believe tongue tie rarely complicates feeding. In the small number of cases where it does, the Coombe Women and Infants University Hospital believes that the procedure to release the tongue, a frenulectomy, [another name for frenotomy] is best carried out by an experienced surgeon/plastic surgeon.

“For that reason, any case identified in this hospital is referred onwards to Our Lady’s Children’s Hospital in Crumlin.”

Lisa Finnegan is one mother whose baby was diagnosed with tongue tie by O’Byrne and referred to Roche, after weeks of struggling with breastfeeding.

“I was in so much pain, I was crying at each feed,” recalls Finnegan.

She hadn’t been able to get baby Rory to latch on properly after he was born at the National Maternity Hospital in Dublin in 2011.

But she and the midwives put this down to him being “lazy” after having bottles while she was in recovery following delivery by Caesarean section.

“He would latch on but he just wouldn’t suck,” she says. He was checked by midwives, the public health nurse and a paediatrician, but all suggested his feeding would soon settle.

After weeks of excruciating pain, and supplementing with a bottle, it was her husband, Mark, who finally said this couldn’t be right and she should seek help again – which led her to O’Byrne.

After a four-week wait the couple brought Rory down to Roche in Clonmel.

"He talked us through everything and then did the procedure, which took two seconds compared with the 20 minutes he took making sure we were happy," she says. Rory bled a little and she was advised to feed him.

"The first feed afterwards was completely different. I was still sore but it was a different kind of pain. It was pain that was already there, rather than injury being done. We haven't looked back since," she adds.

Kellie Sweeney, a nurse living in Tallaght, Dublin, found her baby daughter Madison kept “bobbing on and off” the breast after birth in the Coombe hospital eight months ago. She knew this wasn’t right and, when O’Byrne saw Madison at just five days old, she identified tongue tie.

Ongoing problems
Sweeney gave it a few weeks to see if it was going to cause ongoing problems. When the pain persisted, she had Madison’s tongue tie snipped at six weeks by a GP in Maynooth, Co Kildare.

He has since had to stop offering the procedure as his insurers deemed it should be done only in hospital which, according to Roche, is "horse manure".

The lack of a frenotomy service in Ireland is partly, Roche believes, because his generation of paediatricians were trained using text books which advised against it.

Yet, up to the 1950s, any baby with a tongue tie was likely to have it divided, he points out.

“The pendulum probably swung too far – some of them probably didn’t need doing, then we went to where nobody was having it done.”

He’s hoping his medical colleagues here will eventually be convinced that we need something in between.