10 Apr

Guest post: Breastfeeding through pregnancy and beyond

Emma Pickett is the chair of the Association of Breastfeeding Mothers, and also works as a lactation consultant. Here we share her article on breastfeeding through pregnancy, and potentially continuing to breastfeed two (or more!) children, known as tandem nursing.

Let’s imagine you are breastfeeding your toddler and you discover you’re pregnant. It’s a much wanted pregnancy but perhaps you weren’t expecting that positive test quite so quickly. And now here you are, pregnancy test still drying, teeny tiny new person inside you and less teeny person on the outside, very much still in love with breastfeeding.

By still feeding your toddler, you’ve already been up against it in terms of what most modern cultures find comfortable and acceptable. Now you’re ticking the box for another misunderstood area of breastfeeding: one full of myths and nonsense and one lots of uneducated people claim to be experts about.

A useful starting point is finding a group online of mothers who have breastfed through pregnancy and beyond. That can be reassuring and immensely helpful but it’s worth remembering that every woman’s experience is different and it’s very hard to make predictions about how things will go for you.

I’m going to guess that when many people are looking at the drying pregnancy test, their thoughts shift to the consequences for their current nursling. Then soon, you wonder about the baby-to-be. Is breastfeeding during pregnancy ‘safe’?

What does the research say?

Let’s look at this study from 2012: A comparative study of breastfeeding during pregnancy: impact on maternal and newborn outcomes. Madarshahian F, Hassanabadi M. The study looked at 320 women in Iran, some breastfed during pregnancy and some did not. It showed that, “Results found no significant difference in full-term or non-full-term births rates and mean newborn birth weight between the two groups. We further found no significant difference between full-term or non-full-term births and mean newborn birth weight for those who continued and discontinued breastfeeding during pregnancy in the overlap group.”

So, breastfeeding during pregnancy didn’t ‘take nutrition away from the baby’ and it did not cause prematurity.

Another study of 57 Californian women from 1993: Breastfeeding during pregnancy. Moscone SR, Moore MJ. Just under half continued to breastfeed through pregnancy and after the new baby arrived. The new babies were healthy and appropriately sized.

However, it’s not all clearly positive. Another research study on 133 women in Peru found a link between breastfeeding through pregnancy and 125g on average less weight gain for the new baby in the first month. (Postpartum consequences of an overlap of breastfeeding and pregnancy: reduced breast milk intake and growth during early infancy. Marquis GS, Penny ME, Diaz JM, Marín RM. 2002)

Another study looked at 540 women in Egypt with sub-standard nutrition. Effect of pregnancy-lactation overlap on the current pregnancy outcome in women with substandard nutrition: a prospective cohort study. Shaaban OM, Abbas AM, Abdel Hafiz HA, Abdelrahman AS, Rashwan M, Othman ER (2015). This was not all positive news with increased risk of maternal anaemia and issues with infant growth. BUT there was NOT an increase in miscarriage risk when women breastfed through pregnancy.

How’s your nutrition and how are your iron levels? If you are a mother with access to good nutrition, it appears you have less reason to be concerned.

Does breastfeeding trigger early labour? Even for those women who were struggling with other issues, it doesn’t appear so.

Hilary Flower is the go-to person on the subject of breastfeeding during pregnancy. Her book, “Adventures in Tandem Nursing” is considered the bible on this subject. It was first written in 2003 and is now out-of-print but a second edition is currently being worked on. Her focus was on bringing the facts to pregnant mothers and she looked at this idea of triggering contractions or early labour in detail. She reminds us that we need oxytocin to trigger a milk ejection reflex (the letdown reflex) and this is also the hormone that can trigger uterine contractions. However, this doesn’t mean that breastfeeding in pregnancy triggers risky contractions and there are several safeguards in place. We need hormone receptor sites to exist before hormones get acted on by the uterus and they remain small in number until around 38 weeks of pregnancy. And even the hormone receptors that are in place can’t really do their job of causing contractions as there are oxytocin blockers in place like progesterone (made by the placenta) and proteins missing which would act as special agents to help the oxytocin do their job. Triple protection! So, oxytocin can carry on doing its breastfeeding jobs while baby remains protected in the uterus.

I think we can say science is on our side. Which makes sense when you think that throughout history women have been breastfeeding older babies and having sex and getting pregnant.

Do you know anything about the history of pregnancy testing? Today, we might know we are pregnant days after conception. For generations, it was based on guess work, someone examining your urine’s appearance and something about rabbits (early 20th century pregnancy tests involved injecting urine into a rabbit and observing a change in their ovaries). A lot of breastfeeding women couldn’t rely on whether they had missed a period as periods may only just be settling in or may not have even appeared yet. Some breastfeeding mums get pregnant without yet having a period. They ‘catch the first egg’. Then they go and see their doctor and the doctor brings out the chart that predicts due date based on last menstrual period, “errr…2015?”

Nature isn’t daft. If breastfeeding during pregnancy was hazardous, I doubt you nor I would be here. Hilary Flower mentions that if you have a high-risk pregnancy, you should talk to your health care providers about your specific situation but if you are safe to continue sexual intercourse, breastfeeding is very very likely to be fine too.

Science might say that breastfeeding during pregnancy is safe but that doesn’t mean you have to do it, or that it’s super easy for everyone. There is a wide range of experience and you need to reflect on what feels right for you.

The age of your current nursling might be a factor in your decision. If they are 7 months, you might feel differently than if they were 4 years old and you were getting a bit tired of breastfeeding a plastic truck several times a day.

If your baby is 7 months, or at any age where milk is still a significant proportion of their nutrition, you’ll need to do some thinking. It’s likely they will need an alternative source of milk (still doesn’t mean breastfeeding needs to end). Most women who are breastfeeding when they are pregnant do notice a decrease in milk supply – often a very significant one. This can start as early as the first few weeks after that positive pregnancy test. Whatever you do, your body will be resetting in its lactation story and you will go back to making colostrum during your pregnancy. It happens at different times and some mums might go through a period of feeling like they have virtually nothing and their child is ‘dry nursing’ before colostrum then appears and quantities seem to increase again.
Nurslings behave differently during the changes of pregnancy. Some self-wean as the quantities drop. Some self-wean when things seem to taste a bit different. Some care not a jot that changes are happening and would carry on breastfeeding whatever was coming out or if nothing was.  Word of warning: colostrum has a laxative effect. That’s one of the reasons it’s so great for newborns as it helps them to pass meconium. Potty training a toddler? Brace yourself.

What else can you expect? For some women, not much else. Pregnant and breastfeeding felt a lot like not pregnant and breastfeeding. You’ve just got to worry about the bump being in the way towards the end. (This was my experience).

Other women struggle with sore nipples from increased sensitivity that probably has something to do with hormonal changes and sometimes aversion to breastfeeding can be a problem.

The reduction in milk supply can also be upsetting for some. It can come at a time when we might already have mixed feelings about giving birth to another child. We know what positives a new sibling can bring for your toddler but there’s sometimes a feeling of loss or even guilt as we’re concerned how their life is going to change – especially in the first few months. And when milk seems to be going too – that can feel doubly hard. Unfortunately, there isn’t much you can do to increase milk supply in pregnancy when changes are starting. All the usual stuff doesn’t work: pumping, herbs, just feeding more frequently. Many herbs that we might consider when we want to increase production are not thought to be safe in pregnancy. It appears that milk storage is affected for almost all women (only a small minority don’t feel their supply has diminished). You might want to consider using a supplementary feeding system at the breast, so baby can remain attached and get other milk through a lightweight tube.

It’s important to remember though (and this is engraved on the heart of many of us in breastfeeding support) that BREASTFEEDING IS NOT JUST ABOUT MILK. Your little bloke with the plastic truck might not care a jot if supply diminished and milk tastes different because this is only partially about milk. It’s also about connecting to you, relaxation, safety and contentment. That big world out there is only getting bigger and breastfeeding is home.

If you are happy to continue with that, breastfeeding is still working.

You might also be wondering what life is going to be like when the new baby arrives. How does breastfeeding work when there is a newborn and a toddler? Pretty much like it did the last time there was a newborn – nature gets on with it. While breastfeeding during pregnancy doesn’t ‘use up’ colostrum, during in the first few days after the birth, it’s sensible to let the newborn do their thing first before the older nursling gets a turn. And once your mature milk transitions, you can make decisions based on how your newborn’s nappies and weight gain are getting on. Sometimes there is talk of restricting a baby to one breast and a toddler to another. Most lactation consultants agree that’s not sensible. Ideally you want the newborn to have the option of both and continue to have the option of both fully lactating as their breastfeeding experience continues. Toddlers feeding after newborns are very effective at helping a milk supply to develop and tipping into oversupply is more of a worry than running out of milk. A toddler is also fabulous at relieving engorgement in the early days post-partum. Flashback to my 3-year-old son announcing proudly to his grandmother (not entirely on board with natural term breastfeeding) that he ‘helped mummy because her milkies were really full’!

Does the toddler feel jealous of the baby having ‘their milk’? I have yet to meet a mother who feels that’s been a problem. In fact, many feel that it can help in the arrival of a new member of the family. Toddlers are likely to need some extra support, but breastfeeding is still there for them. The thing that has always provided comfort and reassurance. And good news! It’s changing back to regular milk and there’s lots more of it! What might not be sensible is weaning a toddler in the last few weeks of pregnancy so if you are thinking tandem breastfeeding really isn’t for you, it might be wiser to wean sooner rather than just prior to baby arriving. If that’s you, I wrote an article on weaning an older child which you might find helpful:
http://www.emmapickettbreastfeedingsupport.com/twitter-and-blog/weaning-toddler-bob-and-pre-schooler-billie-how-do-you-stop-breastfeeding-an-older-child

It sometimes happens that an older child who hasn’t breastfed for a while asks to do so again when a new baby is on the scene. That might be because they weren’t a fan of the colostrum. Or there might be some other things going on in their head. Are they ‘testing’ whether they still get to be your baby? Are they just curious? Some resume breastfeeding at this point. Some are happy to have a taste of expressed milk in a cup. Some ask and run away giggling and don’t mention it again. There’s no right or wrong answer on how to deal with this but ideally, we’re looking for ways to minimise rejection and any refusal is done so as gently as possible.

Still think it’s a bit hippy and ‘risky’? This is the American Academy of Family Physicians (folks on the opposite end of the spectrum from hippy and risky):
“Breastfeeding during a subsequent pregnancy is not unusual. If the pregnancy is normal and the mother is healthy, breastfeeding during pregnancy is the woman’s personal decision. If the child is younger than two years, the child is at increased risk of illness if weaned.
Breastfeeding the nursing child during pregnancy and after delivery of the next child (tandem nursing) may help provide a smooth transition psychologically for the older child.”

We can’t guarantee it’s all smooth but breastfeeding through pregnancy and beyond is something mothers have been doing for millennia and there’s very little to fear and lots to embrace. Those of us who do it are often those who have taken the path of child-led weaning and it instinctively feels right to let the nursling make the call. But you’ll make the decision that’s right for you.