Engorgement or full? Combination feeding issues.

[user1490025201]

Hello, would welcome some advice on my feeding and what I am doing wrong.

Due to various breastfeeding issues (have seen dozen of midwives, lactation experts etc on latch) - I am doing combination feeding. This equates to breastfeeding through a shield, bottle feeding expressed milk, and bottle feeding formula milk.

My baby is 8 weeks old now, however I think my breasts are borderline engorged a lot of the time / or is this fullness normal? Especially last thing at night, first thing in the morning, and before my late afternoon (5pm) feed my breast are hard and stretched on the nipples. They are not AS engorged as when my milk came in at 3 days post birth (which were when they were super painful and HUGE). But they do get hard and stretched. Whilst not uber painful they are uncomfortable. I already find breastfeeding fairly stressful and I'm concerned that this hardness/stretching hing is not normal and I'm doing something wrong. I am also concerned what this is going to do to my breasts (sorry don't shout, but this is a selfish thought of what daily regular engorgement is going to do long-term aesthetically to my breasts).

I do seem to have a lot of milk that comes out initially in breastfeeding feeds - however the baby usually falls asleep on the breast after a few minutes - though I wake him up, but does make breastfeeding quite a long process. Also not sure how successful we are at completely emptying the breast when breastfeeding (though they do definitely soften and feel more empty - but I reckon I could still get a decent amount more out if I were to express at this point). I almost always give some sort of top up feed after breastfeeding (on baby's demand).

I also always do a big express at 10pm before I go to bed (to completely empty the breasts (producing approx 90ml in total, which takes me approx 30 mins).

Re the shield - the pain and blood is too much without the shield. Also now the baby won't except breastfeeding without the shield (I could try and wean him off, which I have tried a few times, but the pain issue would still be outstanding).

My rough feeding plan is.

Feed One : 7am - Bre astfeed with shield (usually up to one hour). Then top up feed (of expressed milk) at approx 8.30 of 80-90 ml

Feed Two : 10am - breastfeed with shield (up to 40-45 mins). Then top up feed of formula milk at approx 11-12iish).

Feed Three : 2pm - Formula feed

Feed Four : 5pm Breastfeed (up to 30-45 mins) then top up expressed milk

Feed Five : 6.30pm Formula milk

Feed Six : 10pm ish- Formula milk

(If I have to skip a feed for whatever reason, I always try and express additionally instead - so have enough express milk in stock).

Any advice of whether the hardness of my breast is normal / or what i should be changing in what i am doing to have a a less stressful and more successful breastfeeding / combination experience would be much appreciated.

My baby is 9 weeks and ebf. The only time my breasts get hard now really is overnight or if I skip a feed. Am I right in reading that as you go from 10pm to 7am without feeding or expressing? I would be in quite a lot of pain and leaking everywhere if I did that.

It sounds to me like what is happening is that your breasts are trying to make more milk than you need. You might have an oversupply?

I notice that your feeding plan is quite lopsided in that you have Breast, Breast, Formula, Breast, Formula, Formula. It might be best to swap the middle four or the first/last around so that you're alternating Breast, Formula, Breast, Formula. Or cut to two feeds a day so it's Breast, Formula, Formula, Breast, Formula, Formula.

I think I would cut out the top ups and keep it as separate, this feed is breast, this feed is bottle. If baby is asking for more you can swap sides. It might be an idea not to express when baby doesn't want to feed, because this just seems to be encouraging your supply. Remember that emptying the breast sends the signal to make more milk, whereas leaving it full/engorged sends the signal to produce less. If you've had engorgement for a long time with no change then it can be oversupply.

Anecdotally oversupply sometimes seems to correlate with tongue tie, but there's no research on this. However this could be a reason baby falls asleep on the breast as feeding can be hard work for them.

As the breastfeeding seems quite hard work for you both, what would your feelings be about expressing for bottle feeds rather than bothering with the direct breastfeeding at all? It seems that you could then do it more often which should reduce the engorgement, but baby would get more breastmilk overall without the faff of tricky feeds and you can still top up with formula if you need to.

Thanks both!

BertieBotts - you're right, the feeds are lopsided. I had always done that as I had thought more milk is produced in the morning naturally, so better to do breastfeeding them, but perhaps better to space out.

Silly question (Sorry finding this combination feeding a bit of a trial and error), but I'm now gathering milk production doesn't follow a 24 hr schedule clock? e.g. if I breastfeed more at a certain time (e.g. morning, late morning, late afternoon etc) more milk is produced for these points then the following the days. If it doesn't, then presumably it's better to just make sure my breastfeeds are always spaced out an equal amount apart - e.g. every 6 hours, and my milk supply will adjust to that?

Ps baby did get diagnosed as having tongue tie, but when we went to hospital for it to be sorted then said they could barely see it, and was unlikely to make much difference - so we didn't get the procedure in the end.

Re suggestion of expressing all feeds. That is actually how we started out (well expressing and formula feeds), when breastfeeding was proving too difficult in the first two weeks. However once my partner went back to work I found it impossible to make the time to keep up with regular expresses ( as found I could only do it when the baby was asleep, so were minimum windows to do this. Also meant had literally no time to do anything else).

I am only expressing at 10pm ish (when my partner gives the late feed). I am emptying both breasts at this point, so they can get me to the next morning (though am waking with engorged breasts). Is emptying the breasts at this point a mistake? Is emptying the breasts at night leading to worse engorgment in the morning?

Thanks so much in advance. Boobs so sore.

You should get the tongue tie thing followed up because no matter what they say it clearly is causing issues! I think this needs addressing with some urgency. Saying oh this shouldn't cause issues, when something is clearly causing massive issues often correlated with tt, is silly.

Milk production can do the 24h thing but much much later than what you're dealing with now. This happens once milk supply has regulated and been regulated for some time, like post six months. At the moment your body is still trying to work out how much you need so of course it's going to throw tons of milk at you while it does that. The problem is that eventually even an oversupply will regulate and I'm afraid I don't think three feeds plus one expressing session a day is likely to be enough to keep things going long term.

I reckon you can either try breastfeeding/expressing more often, which should reduce engorgement in the short term while pushing for the tt to be resolved urgently, or take steps to reduce the engorgement like cutting down on feeds completely with the attitude of whatever he gets is a bonus and if my supply runs out it's okay.

Sorry this is so frustrating :(

Agree with Bertie about the tongue tie. If necessary there are lots of private practitioners who are almost always far more experienced than NHS in terms of tongue tie. It does come with a coat unfortunately but could help with your bleeding and pain - which is an absolute red flag that the tongue tie is causing issues.
Posterior tongue tie is generally felt and not seen anyway so I would be wary of any doctor saying "I can't see it so it isn't a problem".
By the way, I fed with shields for eight weeks and managed to ditch them thereafter - no tongue tie in our case but my son was poorly at birth and couldn't latch well initially. My breasts only really "settled" after then.
You're in an interesting situation as it seems that oversupply might be a problem but shields can often cause the supply to drop as milk transfer generally isn't as efficient. Some women do breastfeed long term using shields with no issues (and using them certainly saved breastfeeding for my son and I) but I would urge you to seek further help with the tongue tie x

*cost not coat!

I would also look at the tongue tie again. I was told by a paediatrician in a&e after being admitted for loss in body weight that there was a small tongue tie but 'we over medicalise these things' and therefore I should persevere.
A week later at a breastfeeding group the Nct peer support worker (also a neonatal nurse) told me it was one of the worst ties she'd ever seen and sent me to a private practitioner to get it snipped who echoed those sentiments. Baby took to Feeding without nipple shields almost instantly although I had to work hard to build my supply back up.
Good luck! I understand the relentlessness of feeding/ expressing/ formula top ups. The one silver lining was that my baby got used to a bottle and by choice my husband did one feed each evening which allowed me to have a bit of time to myself which was lovely.

Thanks all! Appreciate all the advice here.

Maybe all the nipple stimulation (via long but not efficient shield feeding is leading to the oversupply? As often baby is so sucking but after initial few mins of swallowing I hear a lot less / no swallowing? I don't think it's just a hind milk thing. I should perhaps take baby off breast once swallowing stops/and is tired - and put him on again when more awake? I am also trying breast compressions.

Re the tongue tie - I'm not sure if it is that. The leader of my breastfeeding group referred me to the lounge tie clinic after she saw the shape of baby's tongue and the state of my nipples (the damage and how the tips were white due to baby chomping) whereas she thought our latch was fine. When we got into the tongue tie clinic in hospital the very lovely nurse said she couldn't see any tongue tie. She then got her colleague to look - who seemed quite experienced. She said that it was hardly there, very posterior sub-mucosal - and that having the snip was unlikely to do anything, and suggested I didn't do it (though said she would do it if we wanted). As I had had quite a tough birth and got stuck in hospital, I just didn't want anyone to prod/hurt baby unnecessarily again so we decided not to do it. Maybe we should have...The tongue tie experienced lady also thought that what I might have is Raynard's syndrome instead of Tongue Tie (she put this down to the pain I described (sandpapering of my nipples) and the look of them (the tips are white) - which there is no great remedy for (from what she said).

Fyi Randomly the tips of my nipples are no longer white (now that I am breastfeeding through shields).

I've just moved areas, so am going to go to the breastfeeding group near here and see if they have any tongue tie / Raynard's thoughts. (Annoyingly group is held today, but can't make it as have conflicting hospital appointment to discuss broken stitches , so will need to leave it till next week). Everything (apart from my gorgeous little one) is so frustrating after birth!

I'm going to drop a feed, to help with engorgement in the meantime (so oversupply eventually goes down) and try and stop overstimulation of nipples when baby is not properly feeding. Plus will cut down of different sources of feeding during a feed.

So rough schedule of

7am / Breast
10am Formula
2pm Breast
5pm Breast portion and mostly expressed milk bottle

6.15pm Formula (prefer to do formula here, as put baby down for a big nap after this)
10pm Partner to do formula feed whilst I express

Overnight I'll just do breast, but baby has suddenly become a good sleeper over last few days, so usually wakes 5.30-6.30am ish - which is when I will give him enough breast until he goes back to sleep).

Wish this whole post birth stuff was easier. I'll get through it. So achey. Ugh.

Reynauds is a thing but I don't know much about it. But you could certainly do a search here as I've seen people post about it before.

So having read through again (sorry to be confusing!) I'm not so sure about the oversupply any more. I think it's possible but it's also not jumping out at me so much, I think perhaps it's the age of your baby (under 3 months) combined with big gaps between feeds which is probably causing the engorgement, and I don't know that you'll successfully get overall supply to reduce to the levels you want without compromising it entirely.

I understand your reluctance to get the TT cut in that situation. I can't say whether it would make a difference. Sometimes it doesn't. Sometimes mothers are able to achieve a deeper latch by trying baby in the biological nurturing position (AKA laid back nursing).

Kellymom is a website with good information:
kellymom.com/bf/concerns/mother/nipple-blanching/

kellymom.com/bf/concerns/mother/engorgement/

Sorry this isn't really any answers! I suppose you just have to do what feels like the best fit for now, and see how it goes moving forward. Good luck with it.

Just to add, I wouldn't worry too much about not hearing swallowing. I fed my son for over 2 years and he was a very quiet feeder - can count on one hand the number of times I actually heard him gulping/swallowing.

I agree that your baby is feeding rather infrequently for age . I would be highly tempted to put to the breast more often ... your supply will settle but at the moment you are expecting a lot of your system