Podcast: How to stop the top-ups (Season 1 Episode 9)

Information for mothers who want to exclusively breastfeed or reduce top-ups

Have you been advised to give extra milk besides breastfeeds? This is known as giving a top-up feed and it is often only needed as a temporary measure. Unfortunately, many mums find that they have been caught in a cycle of topping-up and they don’t know how to stop. In this episode, Jessica and Simone chat about some of the things you can do to breastfeed more and stop, or at least reduce, the top-ups.

Information discussed in this episode:

• How to wean from formula supplements 
• Mixed feeding 
• How to tell if your baby getting enough milk 
• Baby weight gains 
• Breastmilk supply 
• Expressing and storing breastmilk 
• Purchase our booklet, Breastfeeding: and your supply 
• Purchase our booklet, Breastfeeding: expressing and storing breastmilk 

Credits:

This episode is presented by Jessica Leonard and Simone Casey.

Show notes by Emma Pennell. Transcription by Madina Hajher. Produced by Belinda Chambers, Sky Mykyta, Jessica Leonard and Eleanor Kippen.

JESSICA: Imagine you’re a new mum. You knew all the way through your pregnancy you wanted to breastfeed, but things have gotten off to a rough start. You’ve had to give your baby some extra milk along the way, maybe expressed breastmilk, maybe infant formula. But, expressing is time consuming and exhausting. Every time you give your baby a bottle, they seem to want more and more extra milk. Either way, you want things to change. What do you do?

JESSICA: Welcome to Breastfeeding … with ABA. Today we’re talking about top-ups.

SIMONE: I’m Simone. I’m an International Board-Certified Lactation Consultant and a breastfeeding counsellor with the Australian Breastfeeding Association.

JESSICA: And I’m Jessica Leonard. I’m a breastfeeding counsellor with the Australian Breastfeeding Association.

SKY: We are recording this podcast in different parts of Australia. We acknowledge the traditional custodians of the land on which we are recording and on which you are listening to this podcast. We pay our respects to elders, past, present and emerging and to any Aboriginal people who are listening today. We also acknowledge Aboriginal women who have breastfed their babies and raised their families up on this country for thousands of years.

JESSICA: Simone and I have known each other for around 8 years. We’ve worked together on a lot of projects, but I always remember the first time Simone came to my house. We were inside working and our toddlers were playing in my backyard. Right up until Simone’s little one ran inside bleeding. One of my backyard chickens had pecked him so badly on the finger that it drew blood. A lot of blood. I remember feeling mildly traumatised by the experience, but thankfully Simone remembers the day more positively.

SIMONE: I just remember them both being little blonde boys, so cute.

JESSICA: In Simone’s work as a lactation consultant, she sees lots of mums who have gotten off to a rough start with breastfeeding. Sometimes that means that they’re giving top-ups of extra milk. What do you think that we mean when we talk about ‘top-ups’?

SIMONE: Mostly I think women come to me and wanting to reduce top-ups or they just tell me they’re giving top-ups. It usually means they’re giving some extra milk whether it’s expressed breastmilk or formula in a bottle after a breastfeed. And you know there are lots of reasons why someone might be starting to do that. It could be to do with the baby’s not sucking effectively for some reason and for some reason they’re not getting the amount from the breast that they need to have so milk is given to them in a bottle which usually is an easier way of consuming a higher volume of milk so that’s usually why they need to give a top-up.

JESSICA: Lots of mums say they feel stuck in a cycle of top-ups, but because breastfeeding works on supply and demand the amount of milk that’s removed from the breast either by breastfeeding or expressing kind of puts a baby’s order in for the next day. If a baby isn’t feeding well at the breast, they’re often not able to get milk out efficiently and the supply and demand system goes a bit wonky. Simone’s seen lots of different scenarios that lead mums to top-ups.

SIMONE: They’re started very young like when they’re first born it could be something like the baby was jaundiced and very, very sleepy and not getting enough on the breast and sometimes they’ll go on the breast for, you know, one minute and fall asleep and they don’t seem to be stimulating the supply enough and so the mum might start expressing and topping up with what they’ve got. Another common scenario would be in the early days that maybe baby’s lost too much weight after the birth, and they all lose weight, but if they lose say more than 10% of their birth weight then sometimes the health professionals will say, ‘right we need to top-up’, and sometimes that may be when formula might start. The expressed milk that they’re giving or the milk’s not quite in enough and then they can’t keep up with the expressed milk. So, that could be two reasons in the early days. A little bit later on it might be that the babies aren’t meeting the weight requirements and they’re not quite putting on enough weight, or maybe it’s behavioural and the baby’s crying a lot and very, very unsettled and then they might say, ‘okay, this baby needs to be topped up’.

JESSICA: Sometimes there’s something else going on that causes problems with breastfeeding.

SIMONE: Tongue-tie’s certainly a reason that means that a baby might not be as efficient at the breast as they could be and that could be a reason that they might do a top-up. I usually find it’s just that mums are off to a bad start for some reason, you know, and it could just be like I said the jaundice or it could just be that the baby was really sleepy or sometimes they’re born like you know like a little 37 or 38 week old and they’re considered term but they actually just don’t do a good job yet and they probably weren’t supposed to be out for another 2 weeks and they’re just not quite as good as a term baby at removing that milk and so then because they haven’t removed enough then they haven’t stimulated enough and the supply seems to be a little bit low as a result. Or sometimes the mum actually does have the milk there, but the baby can’t remove it and that’s when the pump can do a better job than a baby because they baby’s still not quite efficient enough.

JESSICA: Mm, yeah I guess there’s a lot of other kind of biological reasons as well is that it will often be mums who have had a difficult birth and that their baby might have a sore neck or something from being stuck in a certain position or if there’s been an assisted delivery and that is something that can impact and like you were saying with the really little babies that they can just take a little bit of time to grow out of that.

SIMONE: Yeah, I’ve seen mums who have just had a really traumatic time for the first couple of times and they’re just out of it and they really haven’t even been putting much focus into the breastfeeding and almost you know the babies have been going to the breast maybe and just sort of lying there and the mum is not really very focussed on what’s happening because they’re still recovering.

JESSICA: It might not seem like a lot of extra work to add in some top-ups and get extra milk into your baby but for new parents a little bit of extra work can become overwhelming pretty quickly.

SIMONE: Even just the thought of having to prepare the bottles afterwards, even if it is, you know, if it’s expressed milk is probably slightly easier because you just pour the milk in the bottle, but if it’s formula they have to boil the kettle they have to measure out the formula and quite often when they’ve got a young baby and they’re using formula they might be sterilising bottles as well as washing them which they have to as well.

JESSICA: Feeding your baby is really personal and for every family there’s a different way that parents feel about what’s happening with top-ups.

SIMONE: Well, it’s funny I just had someone this week say to me that she told her health nurse that she was topping up and the health nurse was so focussed on reassuring her that that was okay but she still wasn’t giving her the information on how to stop that if she wanted to, she goes, ‘it’s alright you know, people do mix feed it’s okay’ and then the mum’s like, ‘well, I know that’s okay I don’t feel shame but I still want to stop it. I prefer to give all my own breastmilk, if I can’ or ‘I prefer to give just the breast and not the bottle as well’. So, I think you know that they feel like they’re double handling and it’s much more time consuming and they prefer to do one thing if they can. And you know, usually they’re hoping it’s just going to be breastfeeding.

JESSICA: We mentioned earlier the cycle of top-ups where parents get stuck giving more and more extra milk as breastfeeding adjusts to supply and demand.

SIMONE: I guess what starts to happen is that the mums start to give a small top-up so they might even start out giving 10 mL or 20 mL or something like that after a feed. Sometimes they only do it when they’re (the babies) unsettled or they might only do it a couple of times a day but what they start to notice is the babies are more and more demanding as they get older or as the weeks go on and suddenly they feel like these small amounts don’t seem enough so they feel they need to increase them and then instead of every second feed it might turn into every feed and then it might turn into you know 20 mL becomes 40 becomes 60 and then they might be topping up quite a lot each feed because they don’t seem to be keeping up with either the expressing or the baby’s needs seem to be higher than what they’re able to give them.

JESSICA: So, what should people watch out for if they want to prevent falling into the cycle?

SIMONE: When I do get some people to come in to see me, they’re usually quite upset that it’s got to that and they don’t know how to stop this cycle. Usually, the thing I do the most with these mums is actually watch them feed and watch their baby feed and see if we can encourage the baby to be more efficient on the breast. Most of the time we can, in the very early days, I reckon the first week if they’re really jaundiced and sleepy sometimes, they just have to grow out of that. But further down the track you get your 4-week olds, your 6-week olds, by then they’re usually pretty strong and they actually can do more work on the breast so some of the techniques that I help them with is things like learning to give your breast breast-compressions where you actually give your breast a bit of a squeeze so that some milk comes out and it reminds the baby to keep going. The other thing that I get them to do is to switch feed which means that they’re swapping sides more often. That doesn’t mean, you know some people say, ‘do I do 5 minutes, 5 minutes, 5 minutes, 5 minutes?’ It’s not even a timing thing it’s just like watching the baby suck listening for the swallow and then using compressions and things like that to encourage as much of that as possible and then if the baby’s not responding anymore that might be a time you take them off, give them a bit of a burp or wake them up a bit and switch them over. I quite often suggest even up to four times so back forth, back forth, so at least they’re getting a little bit more action I guess on the breast.

And even with the switch feeding the way I describe it to the mums as to why that works is that when we’re breastfeeding just say you’re on the left side and you get that let down which is the milk ejection reflex, when you’re getting the letdown which is the hormone that is released actually ejecting the milk as the baby’s sucking they’re actually getting the let down on the other side at the same time and I often ask them mums you know, ‘have you noticed with your pumping or feeding on one side that your other side actually drips. And even women who I think that their supply is quite low will say, ‘oh yeah I actually usually get a drip when I’m pumping or when I’m feeding’ so that’s your let down happening on both sides at the same time. If you’re able to take advantage of that extra milk that’s starting to be created, we can switch over and then suddenly the baby gets quite a good little serving of milk on the other side and then that’s why switching back and forth can actually increase the volume of what they get because they’re having these extra let downs and taking advantage of them. I call it the ‘free milk’, the free milk on the other side that they’ve already created with the letdown.

JESSICA: they’ve put in their order.

SIMONE: Yeah, that’s right, put in their order so they can ask to have some for the next time and then we switch again and there’s more there and then we switch again and there’s more there so it’s a really good way you know for sleepy babies or inefficient babies to get a bit more volume into them.

JESSICA: You’re listening to Breastfeeding … with ABA. I’m Jessica Leonard, a presenter and one of the producers of Breastfeeding … with ABA. Today I’d like to thank you, the listener, for supporting this podcast. Everyone who’s listened to episodes, rated and reviewed the podcast and joined the conversation on social media, we thank you for your support. We all make the world a better place when families support each other. The Breastfeeding … with ABA podcast will return soon with season 2. Remember to join the Facebook group to continue the conversations and support other families. Search for Breastfeeding with ABA and answer the joining questions to be added.

So, if someone is stuck in a cycle with topping up with extra milk what’s the first thing you suggest they do?

SIMONE: Well usually the first thing I say is I usually ask the mums, ‘do you think you have the most milk in the mornings’, for instance, and most people say yes so I would say most women do have the most milk in the morning they feel the fullest. Usually the end of the day is when they’re complaining that they don’t have so much left. So, I usually think the best time to drop a top-up would be in the morning. If they’re doing a whole express, top-up, express, top-up cycle I would suggest not expressing for the last feed of the middle of the night which most people are really happy with so that might be at 4 or 5 in the morning. And I’ll say, ‘don’t express after that feed’ and they’ll say, ‘oh thank goodness!’ and then the feed after that your breasts should be really nice and full because you haven’t pumped and you’ve got that 6 or 7 am feed, that’s the feed you concentrate really heavily on doing the switch feeding and then you don’t top-up after that feed. And I always warn the mums that maybe their baby might want to feed again in 2 hours instead of 3 but that’s the way we start the process of dropping the top-ups and I always think that if you drop a pump and a top-up at the same time is a good idea. A lot of mums try to drop the top-ups without dropping any pumping and I don’t think it works as well because then the breast isn’t as full for that next feed and hopefully, they would have got everything that they might not have pumped the time before. So that’s sort of how I start the process is usually that first one in the morning. I say if they do really well try another one, you know, if the first one’s okay and then they feed and they do really well they’re not complaining they go to sleep then the baby wakes for the next feed, try to do that one without a top-up and you might get all the way through to lunch time without doing any top-ups by doing it like that. Then by lunch time they might be a bit empty for a top-up. Sure give them a top-up then. But that’s sort of how we inch away, we might even do for a week or two weeks until we actually might be ready to drop another one. Mostly if they’re using formula, I try to encourage the mums to push the formula towards the end of the day rather than give lots of little top-ups all the time. If they need to they might need to give a larger top-up before bed you know like at 7 or 8 or 9 or 10 at night and then try to breastfeed more often during the day. So that’s another little strategy where we just still use the same volume of formula maybe but over a larger amount but less frequent bottles.

JESSICA: So, what would it look like if a mum is at home with her bub and trying to drop more top-ups by encouraging more feeds at the breast?

SIMONE: So, it might be a bit more of a frequent cycle for them when they are topping-up and a lot of mums when I explain the end result are happy to do that in the daytime. Usually at night they’re not as happy so then they usually say, ‘well let’s just leave that one until later and we’ll still do the top-ups at night, but why don’t we in the day really push it a bit further. We’ll try and feed a little bit more often if the baby needs to, but if it’s still sleeping fine we don’t have to wake the baby up or anything, but if the baby wants to feed every 2 to 3 hourly instead of 3 to 4 and maybe even 1.5 hours or something like that just to sort of feed a bit more often. If they just feel like they can’t take the baby off at all like they’re just on and on and on and on and every half an hour they’re you know, I would say yes give a top-up. We don’t want the baby just continually attached to the breast from 9 till 5. We do want some breaks and the baby does need to sleep as well.

JESSICA: So, how do parents know that their baby’s still vetting enough milk if they’re reducing the amounts of top-ups?

SIMONE: That’s one of the things I really make sure the mums understand before they go off and trial these things on their own because the whole point of it isn’t to starve the baby. The point of it is to try and help the baby to get more milk from the breast, to reduce the amount of milk we’re giving in a bottle or condense those bottles so that we’re not giving as many bottles, and to really look out for those wet nappies and making sure we’ve got those 5 heavy wet nappies in 24 hours and that’s super important because again, we’re not starving the baby we don’t want them to lose weight or we don’t want them to gain very minuscule amounts. We do want them to gain the normal amount of weight and to thrive normally. It’s just that we have to look at that overall picture I guess. And look, getting baby’s weight is a good way of understanding how much milk they’re getting as well. We don’t want to do it all the time but especially babies who are getting formula and they’re increasing their supply I get mums come back to me going, ‘oh I don’t think my supply has increased that much’ and when we weigh them after a fortnight and they’ve put on way more and they haven’t added any formula at all in fact they’ve decreased slightly and all their supply increasing techniques have worked well so we can see the baby’s put on actually 100g more this week than they did the week before and that’s a really good measurement for the mum to look at to say oh, ‘okay yes I can drop some more formula that’s okay’. So, weight gain is a good indicator as well it’s just not the only one.

JESSICA: Things like the amount of poo your baby’s doing, how much weight they’re gaining, and their behaviour are good signs to look at to make sure they’re getting enough milk. These ones depend on how old your baby is, so have a look at our website breastfeeding.asn.au for more info on that. If your baby’s having at least 5 very wet disposable nappies over 24 hours though, this is a really good sign that they’re getting enough milk.

SIMONE: And I think what really makes sure the mums understand what a heavy wet nappy feels like and I think during our ABA antenatal classes we do a little demo where we pour the water, I think it’s 60 mL of water into a disposable nappy, and get all the parents to feel it because I have had mums that think they’re doing really well and they say, ‘oh yeah heaps and heaps of wet nappies’ but when I look at those nappies, yes they’re wet but they’re not heavily wet. And then we look at the weight gain and it’s not so good or they’ve maybe lost a little bit so they’re pushing really hard to drop the top-ups but they’re actually not really looking at those nappies. So I think it’s important to make sure they really are heavily wet.

JESSICA: in the end what we do as people who support families to breastfeed is to help them get to where they want to be.

SIMONE: Not every mum is aiming for exclusive breastfeeding so sometimes they want to get rid of the top-ups because they’re sick of this ‘feed, top-up, feed, express, top-up, feed, express, top-up’ sort of cycle, but some of them don’t mind if they’re using a bit of formula or they’re using a bit of expressed milk. In those situations, I say it’s good to do it in a smart way and to me a smart way is a way that’s going to help the breastfeeding to continue as long as possible and to make sure that the baby’s not the one that decides, I know I don’t like this breast anymore because it’s too hard. I’m going to go for the bottle and the mum can get quite upset when that happens so to do it in a smart way, often if we’re going to continue some mix feeding, if we can do limited bottles but larger volumes it usually works better so you know you might have a mum that’s 80% breastfeeding and she’s got all the convenience of being able to go around and breastfeed in a café or out and about but they still are giving maybe 120 mL of formula at night before bed and the baby’s weight gains are steady and normal but every time they try and drop that formula the baby’s upset or they don’t actually settle at night and their weight isn’t as good so they seem to need that extra milk at night, and if we can do it once or twice a day, often that’s much more sustainable than 8 times a day and that’s much more of a danger of the baby getting that nipple confusion and getting that feeling of the bottle is easier and not wanting to try on the breast anymore.

JESSICA: When I’ve spoken to mums who have been doing the expressing and then topping up what they say is ‘Well I’m feeding my baby at the breast, and then I go and get my breast pump and put it together and then express milk and then I have to get the bottle and feed the baby the expressed milk …’ and they just find this really long process of so much extra time that it’s just incredibly frustrating when the breastmilk is there, and if we can just get the baby onto the breast for those feeds then they’re a lot happier that they’re not double handling with milk all of the time.

SIMONE: And I say to a lot of mums it’s not a life for you to always have to have the pump out all the time. You don’t just go to a BBQ and bring your pump and bring it out in front of everybody whereas you could just feed at the table with your baby. Usually, the aim is with most mums that they prefer not to be pumping all the time.

JESSICA: I guess it’s such an important point that we always have to discuss with mums when we’re counselling them about breastfeeding is, what are your goals? What do you want to get the end result to be? And for me it’s always about helping mums to achieve their goals. It’s not about what I would do, it’s about where do you want to be with this and what do you want to achieve and then helping her find a way to do that.

SIMONE: And sometimes that is a mix feeding situation and sometimes it is that they do really want to exclusively breastfeed so yeah you’ve just got to find out the end goal before you sort of launch into a big plan, but most of the time people aren’t wanting to do all those things at once. There’s usually one sort of plan to get to whether it’s mostly breastfeeding or certainly not as much pumping as some mums are needing to do, especially if they’re doing it every feed.

JESSICA: And what else do you think is important?

SIMONE: I guess just having a support person that’s really encouraging of you to drop the top-ups. Sometimes a mum might have a partner or a mum or a sister or someone whose going to help them along because they might hit some times where they feel like it isn’t worth pursuing or they put the bottle in the baby’s mouth and it’s so much easier for the baby to get that bottle that they just go, ‘Oh, gosh, I can’t be bothered with this breastfeeding’ but if they have someone that’s there and keeps saying to them, ‘it gets better, it gets better!’ then at least you’re pushing through those parts and in the end you do get there and then it’s worth it but you need that support person as well which ABA can help with that with Helpline, but also if you can find someone in your life that’s supportive that’s really, really helpful for them to know what your goals are and even with a partner just to explain why you’re doing it because sometimes some of the partners aren’t quite understanding of why, especially if the partner can help give the bottles or the top-ups. They feel like oh well they’re helping but they don’t realise the end goal is that they don’t want to be doing it this way forever.

JESSICA: Sometimes that really practical support can help as well. I will often encourage mum if they’re trying to get their baby onto the breast more often to just ignore some of the housework and things like that for a little while and just lay in bed and relax with your baby. You know don’t do it when they’re screaming and upset. Have a nice little cuddle, skin to skin with your baby and just having someone there who is going to just go and wash the dishes or organise dinner, that’s actually a really important type of support as well.

SIMONE: Yeah, yep.

JESSICA: For more information and links please check the episode notes. For breastfeeding information or to access LiveChat with a qualified volunteer, visit breastfeeding.asn.au. You can speak to a breastfeeding counsellor on the National Breastfeeding Helpline on 1800 MUM2MUM or 1800 686 268. The Australian Breastfeeding Association receives funding from the Australian Government. Search for ‘Breastfeeding…with ABA’ on Facebook to continue the conversation. Make sure you answer the joining questions so we can add you quickly. Please rate, review and subscribe to Breastfeeding…with ABA.

Thank you for supporting the Australian Breastfeeding Association.

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