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The Top Up Trap

March 14, 2019

The Top Up Trap

top up trap diagram
The top up trap has been responsible for sabotaging many a breastfeeding mums milk supply. But don't stress, knowledge is power and when you understand how it happens and how to transition out of the top up trap, there is light at the end of the tunnel!
There are many reasons why a mum feels like she has top her baby up, most of them are unnecessary and not reliable indicators of her actual milk supply, however they seem very very real when you are sleep deprived and have a screaming baby!
And of course, there are situations when a baby most definitely does need to be topped up. For this article though, we are talking about normal physiological breastfeeding in a mother baby dyad. More information on assessing if baby is getting enough can be found in the blog post How Do I Know My Baby is Getting Enough Milk
Some of the most common reasons mums feel baby needs to be topped up include:
  • Baby fussing at the breast
  • Baby wanting to frequently feed (also known as cluster feeding and is perfectly normal)
  • Seeming never satisfied and constantly crying
  • Baby doesn't sleep for long periods 
  • Baby wants to feed frequently over night
  • Breasts not feeling full
  • Not feeling letdowns 
  • Not getting a lot out when mum pumps

As discussed in other blog articles, these aren't reliable indicators of milk supply, they can be, but they are also normal baby behaviour when baby's output of wet and dirty nappies, regular weight gain and meeting milestones are being satisfied.

Once a mum doubts her supply to the point that she thinks she isn't making enough milk for her baby, she then tops up with a bottle of formula. Formula takes longer for a baby to digest and they drink more from a bottle in a shorter period of time than at the breast (regardless of it is is formula or EBM/expressed breast milk the bottle delivers large volumes quickly and baby's are clever!).

After having the formula, they then calm down, sleep longer (or for the first time in what feels like days) and mum thinks her suspicions are confirmed that she doesn't have enough milk. The cycle then continues. 

At the next feed, mum will try to attach at the breast, bub might latch, pull off, latch, scream, appear like they are refusing the breast, and mum feeling awful like she is starving her baby (you aren't!) then gives another bottle of formula. Bub settles down and then this cycle keeps happening.  The top up trap can very, very quickly end up replacing multiple feeds.

When a baby goes for longer periods not suckling at the breast, the body then gets the message that not as much milk needs to be made and subsequently can decrease the amount of milk mum makes, especially when the length of time between feeds keeps getting longer. Breastfeeding and milk supply is supply and demand. Frequent and efficient breast feeds and milk supply tells our body to keep making milk. Shortened, inefficient feeds or no stimulating and on milk removal tells our body to stop making as much milk, it isn't needed.

Another element that can occur after a baby is introduced to the bottle is breast refusal/bottle preference, which a mum then further believes shows evidence of her breasts/milk not being good enough. This is not the case, babies are clever and a bottle delivers a large amount of milk, quickly, with no effort. They have to work on the breast.

This cycle can continue and more feeds can end up being formula.

Please note, there is nothing wrong with supplementing if that is your decision, this is being written from the perspective to educate the breastfeeding mum who wants to cut out supplemental feeds she may have very easily slipped into. The downward spiral can happen very quickly. And if you have fallen into the top up trap and you want to get out, you can! There are solutions!

We all make calls in those first weeks and months that sometimes we wish we hadn't have made. Unfortunately, there is no rule book that comes with motherhood. Just don't beat yourself up about it, many mums fall into the top up trap, even experienced mums with multiple children. Nothing tugs at our heart strings more as mums than our crying baby! Take a big breath, you are doing a wonderful job and read on.

If you are stuck in the trap and want to get out, get in contact with a international board certified lactation consultant and they can help you come up with a plan. But there are things you can do before you get to see a IBCLC.

Offer the breast at every opportunity

Keep offering the breast as much as possible and I do mean as much as possible. And don't wait for baby to be hungry, get bub before those hunger cues start, you will have more chance of a calm baby interested in exploring and working with you. Offer the breast at every opportunity whenever you can. Hand express some milk out prior to getting bub to latch so they can smell your milk. And do lots and lots of skin to skin.

Never underestimate the value in skin to skin. It is warm, comfortable and offers a familiar heartbeat and the perfect body temperature which is beneficial for both you and bub, it really is a lovely 'reset' and great way to get the oxytocin flowing. A 'nurse in' is an extended skin to skin session. When you block out all jobs and task for the day and stay at home with bub on your chest allowing unrestricted access to the breast. Just you and bub, warm, comfortable, safe and secure connecting and exploring and learning more about each other. Something we often don't afford ourselves the luxury of doing in our busy lifestyles.

Pumping to replace a breastfeed

If bub won't latch you are going to have to make sure you are pumping in place of a feed.You have to keep stimulating the breast and removing milk so your supply keeps up. If you give baby a bottle of milk and don't pump you are stretching out the time between your breasts being stimulated and milk being removed, that is when your body will 'learn' that not as much milk is needed. You can hire or purchase a hospital grade electric pump, use a manual pump or hand pump if you are super keen!

Supplemental Nursing System

You can also look at using a supplemental nursing system which is a small line of tubing that attaches to the breast as bub feeds. They still breast feed and get milk from mum, but their supplemental feed (formula or ebm) is delivered via the small tube and mum still receives the much needed stimulation. These are often used to help mums get out of the top up trap because your baby will be happy to stay and suckle at the breast because the supply line is providing the instant and faster gratification they are used to from the bottle, so they are often happier to stay on the breast for longer when using a supply line. Make sure you are working with a breastfeeding professional when you are using this though, as although bub might be happy to attach and stay on the breast, they might not be working as hard as they would without the supply line, so you might still need to pump after feeding to remove milk and keep your supply up. Medela is a popular brand for the SNS.

Nipple Shield

The same goes for a nipple shield. A nipple shield might get bub happy to attach, because the more tactile feel of the shield is closer to a bottle teat and it can be a good way to transition them back to the breast, but again, because the shield is a piece of silicone between baby and the nipple, milk might not be being removed as efficiently as it needs to be to maintain supply so you might need to pump if using a shield as well. 

And yes, I am not going to lie, that routine of latching, attempting to latch, using a shield or supply line, then pumping and feeding bub by a bottle if the attempt wasn't successful, is exhausting. Is it worth it? Absolutely it is, because the satisfaction of transitioning back to breastfeeding and the benefits of breastmilk to your baby and you most definitely out weigh this period. 

When you are sleep deprived and totally cast into the new foreign world of breastfeeding and motherhood, it can be extremely daunting and overwhelming. Because it is overwhelming and daunting! 

However, just remember, thousands of other women have been in your position, you are not alone in your struggles and feelings and help is available. You can get out of the top up trap!

If you have fallen into the top up trap and want to get out, get in contact with a local IBCLC in your area, your midwife, child health nurse, the ABA or your GP. Make it very well known your intentions and what you would like to do so a plan can be devised.

Breastfeeding like motherhood, has it challenges, but with the right support and information, you can succeed and have long term, beautiful feeding relationships (whatever that looks like for you).

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