For the belated sake of completeness, here's my account of the fourth and final NCT class. This was the session with the breastfeeding counsellor, in the evening of Tuesday 16th October.
We were further depleted this time around - that was the day Alex had her Caesarean, so, of course, neither she nor James were there. Sean (Moira's husband) had also opted out, deciding that the evening's subject matter was more specifically Moira's department. However, on the plus side, Fiona and Rich had returned, complete with five-day-old baby Henry. Sarah, the breastfeeding counsellor, was quite excited to have a real live baby there - apparently it was the first time this had ever happened in a breastfeeding session that she'd taught. Besides, it helped to solve the practical problem of having one fewer practice doll there than we needed.
Breastfeeding is, again, an area where the NCT gets a bad press as being one of the organisations that pressures women excessively. Again, this was not at all my experience with this class. Sarah was at pains to assure us all at the start that what she'd hate most would be to meet one of us after the class and learn that we were breastfeeding despite hating it because we felt we should or that we'd given up breastfeeding but were consumed with guilt about it.
We spent a substantial part of the class discussing ways of getting the latch and positioning right. This is key to successful breastfeeding, and getting it right is often all that's needed to make the difference between a good breastfeeding experience and the terrible painful ones that you hear about in the horror stories. Here's my public health service announcement for the day, and I can't stress this enough - breastfeeding may be uncomfortable at the start, but if it's acutely painful then it's very likely that something's wrong that can and should be put right. Maybe it's the latch, maybe it's thrush, maybe it's tongue tie, maybe something else - but do not be fobbed off by someone taking a brief glance at your positioning and telling you that everything looks OK as though that was that and no more needed to be done or said. I had to work my way through quite a bit of this before, several requests for advice and several days later, I found a midwife who figured out that Jamie's tongue tie was the problem. (Another, very senior, midwife had noticed the tongue tie already while examining him and assured me that because he could still get the tip of his tongue to his lower gum it wouldn't be a problem. Not so.) Not that diagnosing this actually helped that much in practice, since we then ran up against the refusal of the local Trust to fund any local arrangements for getting tongue tie snipped and that is a whole saga in itself, but at least I knew what was wrong and had the option of doing something about it.
We used the dolls to practice positioning, something I was pleased to see came back to me quite easily. Of course, it is fair to say that dolls are quite a bit easier for this sort of thing than newborns - they're a lot lighter and do not have the same annoying tendency to twist their head energetically away from the nipple in a ferociously determined attempt to suck their Babygro cuffs instead. Or maybe that last part was just Jamie.
In the second half of the class, we moved on to discuss other issues - how to recognise mastitis and what to do about it, how to know how often the baby needs feeding, pumping and storing milk to bottle-feed to the baby. Sarah told us that current government guidelines were that pumped milk could only be kept in the fridge for twenty-four hours at most, and milk that needs to be kept longer should be frozen. As a seasoned pumper, I knew this wasn't true - breast milk has a considerably longer life than formula in the fridge or at room temperature, because the antibodies in it actually fight off bacterial contamination. Fresh breast milk will last for up to eight days in the fridge (a figure that will probably be found engraved on my heart when I die. Which will probably surprise the pathologist.). In fact (rather ironically) it's thought that, because freezing destroys some of these antibodies, breast milk that's been frozen and then defrosted may have less of a lifespan than breast milk that's not been frozen - after breast milk has been frozen and defrosted, it's recommended to stick to the twenty-four hour limit in the fridge. So, if milk is to be kept for just a few days before being fed (as is typically the case for a woman pumping each day at work and wanting to keep Friday's milk for Monday), it's probably better not to freeze it. And, of course, not knowing the correct guidelines for storing milk can lead to a lot of good milk getting wasted for no good reason. I pointed some of this out.
"Whatever works for you," Sarah assured us emphatically. As passionately as I'm in favour of that philosophy as a general rule of parenting, I couldn't help feeling that on this occasion it might be a tad misplaced - surely the salient point here is what doesn't work for the bacteria? Given that there's actually some hard evidence on that point, I'd sooner go with that.
Apparently, government guidelines also now say that bottles shouldn't be introduced until six weeks - which, again, contradicts what I've previously heard. When I was looking into this while pregnant with Jamie, everything I read (and I read up on the subject assiduously) advised me that bottle introduction at four to six weeks was the optimum window for getting a baby to transition back and forth easily between bottle and breast. Too early, and you risk confusing a baby who's still learning to nurse by giving them a different technique to grasp before they've got the hang of the first one, or (if the teat is fast-flowing) leading a baby to decide that since getting milk from a bottle is so much easier to learn how to do they're not going to bother with learning how to suckle from a breast; too late, and you risk the opposite problem of a baby who is now very happy on the breast thankyouverymuch and has no intention of bothering to learn another way of getting milk.
Of course, the four-to-six-week rule isn't set in stone - there is enormous variation between babies, and there are plenty of babies who will transition back and forth happily no matter what age you choose for introducing the bottle. However, anecdotally, I've almost never heard of someone having problems with bottle introduction at that stage, while I've heard lots of stories of problems with later introduction. My concern is that, by advising women to leave it until six weeks or later, the government may be increasing the chances of many babies refusing bottles. And, while this may not be too much of a problem for a woman who's with the baby full-time (though, even then, it can be a pain never getting a chance to leave the baby with anyone and things can get tricky in an emergency), it can be an absolute horror story for a woman who has the deadline of an early return to work hanging over her. Nearly all babies will accept the bottle eventually and there are always alternative ways of feeding for a baby who really won't, but bottle refusal is something a mum can do without.
The problem with evidence-based guidelines is that between the evidence base and the guidelines, you have the opinions and values of the person who has to turn the former into the latter. Unfortunately, it's all too easy for those to end up woven indistinguishably into the guidelines, presented as solid fact. In this case, I strongly suspect that what's happened is that whoever wrote these guidelines decided that the overriding priority was to decrease the chance of breastfeeding problems, and didn't see an increased risk of bottle refusal as something they needed to weigh into the equation. This is conjecture on my part; Sarah (who I'll bet was just loving me by then) promised to look out the evidence on which the guidelines were based and send it to me, but I never received it. But I'd much rather see the advice leaflets discuss the pros and cons of different approaches in such a way that different parents have the information they need to make the choice that works best for them in their circumstances, rather than handing us a single rule as though that would automatically fit everybody.
Overall, I did feel that although the general advice on breastfeeding was good, there was something of a general theme of the information being a lot poorer when it came to what a woman would ideally need to know in order to combine breastfeeding and work. Sarah told us that if we wanted to go back to work, we should start thinking about how to manage things the week before. Well, you could leave it that late - but, given the time it took me to read up on different types of pumps and pumping brassieres and order what I needed (the information's out there on the 'Net, but it takes a while to find and if you want to pump regularly at work you'll probably need the kind of high-quality pump that isn't available in Mothercare's and needs to be ordered specially), and build up a freezer stash (something to feed the baby on your first day away from him, plus some spare to cover shortfall in what you pump day-to-day), and discuss a timetable for pumping breaks with your boss, and, of course, make sure your baby is taking milk from some source that doesn't involve you actually being present, I'd really hate to be trying to sort all that out in only a week. Especially if that was going to be my last week at home with my baby and I wanted to enjoy spending that time with him without a lot of hassle and distraction. I ordered my pump before Jamie was born and was pumping regularly in the months before I went back, saving milk. I started to say all of this and then realised that nobody in the class apart from me was going back to work early enough to make it an issue, so everyone was spared my loud mouth on that issue at least. But, if that class was a sample of the information available for women looking to combine work with breastfeeding, then there's a hell of a lot of room for improvement. Apart from that, I thought it was good.
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I do wonder how breastfeeding will be second time around. Hopefully having previous experience will help - if nothing else, at least I know exactly what to do about tongue tie now (GET IT SNIPPED, regardless of what your local health authority try to tell you or whether it means a bit of a trek to get it done - oh, and check out this list of people who'll snip it, because, whatever anyone tells you, you may well not need to go as far as Southampton). But there are a whole load of potential problems that I could run into that have nothing to do with tongue tie.
However, most of those problems have got solutions. Not all, but most. During the break, Sarah and the others asked me about my experience with Jamie. I ranted to them a bit about the tongue tie saga, and then I told them that I thought that the most important factor that enabled me to keep breastfeeding was that I went into it prepared for difficulties and believing that it would be worth trying to keep going even if things weren't easy. Breastfeeding problems in the early weeks are very common - what's almost as common is for things to settle down a great deal as the weeks go by, to the point where, a few weeks further down the line, it's far easier than using formula. The sad thing is the number of women who either don't know this or don't have the support they need in the early weeks, and who thus never get far enough to find out.
When I've read stories of women who didn't manage to breastfeed, two opposite themes kept coming up frequently - either women would assume it was all going to be easy and be so poleaxed when it wasn't that they'd just give up, or they'd assume it was all going to be insurmountably difficult and not even try. I certainly do not mean to imply that this covers all women who couldn't breastfeed, but those two reasons seemed to come up often enough that I went into it braced for difficulties and determined to treat them as challenges and persevere if humanly possible. That was what worked. Obviously, it can also come in very useful to know something in advance about what specific problems might happen and how they might be dealt with, especially if you end up in a situation where you're struggling in the middle of the night and don't know who you should be calling for help. But, for me, the most important thing was just being prepared to hang in there even though the going got tough and to believe that it would get better.
The other crucial factor, I found, was support. And, more accurately, being willing to go out looking for support, because I'd read enough to know I couldn't count on it coming to me. I found an internet breastfeeding forum while I was still pregnant, and spent a lot of time on there, so I knew I could go there for help. And I was very proactive about asking midwives for advice when I needed it, and asking again when the first advice didn't seem to be helpful. It made a huge difference having the back-up.
I don't want to make it sound as though my breastfeeding story was some sort of success story of triumph against the odds, because that's not really the way I feel about it. We never really did seem to get to the easy stage that I mentioned above. The initial mismanagement of the tongue tie just screwed things up too badly for us ever fully to recover, and then there were the practical difficulties of me returning to work and having to pump. But, although there were a lot of mistakes I made and things I'd do differently if I had it to do over, one thing I'm proud of is that I kept going even in the face of all the difficulties. In the end, I breastfed until Jamie was sixteen months old. He may never have got as much breast milk as I'd ideally have liked him to, but, in spite of everything, I did manage to keep going with breastfeeding until the time was right for us to stop. And that part of it was a triumph.
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Anyway, that completes the story of the long-awaited NCT classes. Just as hoped, I had a good time, and met people I liked, and, so far, we've stayed in touch. I'm pleased I spent the money.
Before I close, though, there's one final thing I want to say. Remember how the woman who arranged the bookings for the class in the first place told me I shouldn't even bother going if my husband couldn't make it? Because, supposedly, I wouldn't be able to take part in all the exercises without him and so it would just be a complete waste of time and money?
Baloney. There were no exercises for which my husband was expected to be present. None. Well, unless you count the getting-to-know-you exercises in the first class when the men were asked to stand in order of the distance they'd had to travel and give their name and their partner's name. For that I was advised to give the classes a miss in their entirety? If anyone ever tries handing you that line when you want to book in for a National Childbirth Trust class, just bloody ignore them.
I actually know several people who had trouble introducing the bottle at 4-6 weeks, and I also know some people whose baby took the bottle then and then refused it later, usually right before the mom planned to go back to work. So my impression was that it didn't much matter -- babies change so much in the first months that a baby who refuses the bottle at 4 weeks may take it happily at 12 weeks (and vice versa). I knew one mom who wanted to give up nursing because her baby wouldn't take a bottle by six weeks and she thought this meant she was doomed unless she took drastic measures.
No data, though, just anecdotes that differ. I wonder if there is real data?
Anyway, thanks for writing it up, and good luck in the next weeks. Just wanted you to know that people are reading your stuff.
Posted by: beth | Sunday, November 18, 2007 at 19:25