Breastfed babies feed frequently, particularly in the newborn period, and this is normal and to be expected baby behaviour. Support for the new mother is essential as she establishes breastfeeding – empowering support that promotes confidence and self-belief. Attending a dedicated breastfeeding education session or a breastfeeding group in the community during pregnancy can make a big difference as mum-to-mum peer support can be very helpful. It’s also useful to observe other mothers breastfeeding at these sessions and listen to them talk about their experiences. Midwives talk about what helps to get breastfeeding off to a good start with their pregnant clients, and they include partners and whānau whenever possible so everyone knows what to expect and how to be supportive too. The Baby Friendly Hospital Ten Steps to Successful Breastfeeding supports evidence-based breastfeeding friendly practices after birth in maternity facilities. One of the Ten Steps is about supporting skin-to-skin contact between mother and baby after birth and this is a very important part of initiating breastfeeding. The Ten Steps are about supporting all women and babies, so skin-to-skin is encouraged for women who plan to bottle-feed too. You can ask to see the breastfeeding/infant feeding policies and the full Ten Steps at all maternity facilities in New Zealand.

Most of the research evidence shows that it is better to establish breastfeeding first even if women are planning to mixed feed. For healthy infants, unnecessary supplementation can interrupt the supply-demand physiology of breastfeeding, and ultimately reduce milk supply. Most women say it can take up to six weeks before they feel confident that breastfeeding has established well. It’s a new skill for first time mothers, or mothers with other children who are breastfeeding a new baby for the first time. Breastfeeding can be a steep learning curve and practice, time and support are needed. Midwives support mothers for up to the first six weeks in their own homes and can provide information about all aspects of infant feeding, whether exclusive breastfeeding, mixed feeding or formula feeding. This includes those few situations when a mother plans to continue breastfeeding but there may be a short or long term issue with milk supply. If supplementation of breastfeeding is necessary – then this is discussed, and mothers are supported, as the most important concern is always to make sure the baby’s input is satisfactory and the mother has all the information she needs to support whatever decision she has made about her baby’s feeding.

Midwives work in partnership with women and provide evidence-based information as a foundation on which women can make their own informed decisions. Breastfeeding is considered to be a public health intervention so supporting breastfeeding is a key component of health promotion activities for midwives. This does not ever mean that women who make a decision to not breastfeed, or to stop breastfeeding are not supported as much as possible. Breastfeeding, mixed feeding, formula feeding and bottle feeding women are provided with the information and support they need on an individual basis.  This includes how to use formula and bottle-feed if needed. It is also important to provide compassionate support for women who plan to breastfeed but stop breastfeeding for whatever reason. A recent study found that for mothers who were not depressed during pregnancy, the lowest risk of postnatal depression (PND) was found among women who had planned to breastfeed, and who had actually breastfed their babies, while the highest risk of PND was found among women who had planned to breastfeed and had not gone on to breastfeed. In NZ we have between 94-96% of women who plan to breastfeed. Supporting women who plan to breastfeed is important, but we also recognise that some women will mixed-feed or stop breastfeeding for a range of reasons. Providing information so that women feel supported with their decision making is something midwives do during pregnancy and right through until the end of the postnatal home visits.

Midwives and other staff members working at maternity facilities explain to parents about the signs of an effective breastfeed, and they observe breastfeeds. Then Lead Maternity Carer midwives follow up on breastfeeding, when mother and baby are at home. Signs of effective breastfeeding that parents are told to look out for are; soft sounds of swallowing; a change in the baby’s sucking pattern from fast suckles at the beginning of a feed to slower ones as the milk starts to flow; what’s in the nappies is important – looking at baby output, poos and wees; sometimes mums see visible milk at the end of a feed, or if the baby comes off the breast in the middle of a milk let-down, or if the baby spills a little bit of milk with a burp (which is normal); plus keeping an eye on weight gain is important. Breastfeeding mothers often feel the difference in their breasts when the milk ‘comes in’ – often around sixty hours after birth but this can be later. Before the milk amount increase (milk ‘coming in’) the baby gets small amounts of colostrum which is physiologically normal and most often all that is needed. The average amount of colostrum taken in the first 24 hours by the baby is 30mls or one ounce. Once the milk ‘comes in’ mothers breasts can feel full and then may feel softer after a breastfeed. Some mothers feel their let-down reflexes when the milk starts to flow – but not all women. There is a wide range of normal in terms of sensations experienced.

Babies are monitored for wakefulness in terms of feeding. Most babies wake frequently for feeds. Babies born before full term do not always wake for all feeds, and this may also happen for babies who have been exposed to labour medication, so parents will be informed about when and how to wake a sleepy baby for a feed. This in itself would not always be considered a serious issue – it’s one that would be monitored by midwives and other staff members. If women have delayed lactation for any reason they are supported to express breast milk to stimulate milk supply, and so that expressed colostrum can be given to the baby. This is monitored by staff as well. Mothers with complicated medical histories, or those with previous breastfeeding issues, or those who have had complicated births, or caesarean sections, may also be seen by a hospital-based lactation consultant, as clinical lactation issues can sometimes be complex. If at any point, in the first 24-48 hours, the delay in lactation is an issue then there is a conversation with the mother about supplementation. The bottom line is always – feed the baby. Some women use donor breast milk and some use formula for supplements. If there is concern about a baby, baby blood sugar levels are monitored as well. Any mother and baby who have not initiated breastfeeding effectively before they go home, have a comprehensive feeding plan put into place. This could include expressing milk, continuing work on supporting the baby to breastfeed, and feeding the baby via bottles of donor milk from another woman, or infant formula. Babies’ weight gain is also monitored and feeds continue to be observed.

• Sleepiness
• Irritability
• Less elasticity in the skin
• Eyes and fontanelle appear sunken
• Dry mouth
• Decreased number of wet nappies or not as many wet nappies as expected

If you have any concerns let the Midwife in the maternity unit and /or your Lead Maternity Carer Midwife know.

A 5-7% weight loss during the first 3-4 days after birth is normal. Any loss above this is a sign that breastfeeding needs to be evaluated. A weight check at five days (baby should be gaining rather than losing weight by day five) is a good idea so if there are feeding issues these can be sorted early.

Babies should regain their birth weight by around two weeks. If the baby has been unwell or is premature, it may take longer to regain birth weight. If a baby does not regain birth weight by two weeks after birth, feeding will need to be re-evaluated.