Jenny wants to transition her baby (born at 31 weeks gestation, corrected age one week) away from formula supplementation to exclusive breastfeeding
Baby Harper fusses a lot at the breast, or drowses off to sleep without swallowing much
Jenny first saw me when her prematurely-born baby Harper was nine weeks in this world, just one-day-old by corrected age. Jenny had been pumping every three hours with a double pump since she gave birth, and was also taking domperidone.
Feeds consisted of an offer of the breast, which typically did not go well, with her baby fussing and pulling off the breast, or not swallowing much but drowsing off to sleep. After that, Jenny pumped, and then offered Harper the expressed breast milk in a bottle. This was usually about 20 mls in total.
She and her husband were also offering a top-up of formula in order to maintain Olivia's weight gain, and the baby was taking anywhere from 20 to 40 mls of formula each feed. Each feeding experience took perhaps one and a half hours, which was very disruptive in the nights, and Jenny rarely left the house. She burped Harper regularly during feeds, either at the breast or bottle, and held him upright for 30 minutes afterwards. This gave her an hour of free time if her husband was out of the house at paid work, before it all needed to start again.
Jenny looked me straight in the eyes when she first sat down in my consulting room and announced: "I'm here because I want to get to the situation where I'm exclusively breastfeeding."
Baby Harper has positional instability due to both their fit and hold and the nasal prongs delivering oxygen
When I assessed Jenny and Harper, I found a baby with adequate weight gain, who wore nasal prongs on a clear plastic tube attached to an oxygen cylinder. Harper's saturations had been borderline unremarkable last time the doctors checked, but the advice they gave was to continue with the oxygen for another fortnight.
When I assessed breastfeeding, I could see that Harper fussed at the breast due to positional instability. Jenny fitted Harper into her body in a way that meant baby was too high at the breast and too far 'around the corner', too far towards her upper arm on the side she was feeding from, resulting in breast tissue drag. But as we worked together, I also felt that the nasal prongs and tube running across Harper's upper lip were interfering with his capacity to comfortably bury his face and upper lip into his mother's breast.
"We won't be able to change things all at once, because he is still a newborn by his corrected age," I ventured cautiously. "But his intra-oral vacuums are strengthening now that he has reached his birth date, and we want Harper to become your best pump, so that even if we need some formula supplementation, you are able to stop that exhausting step of taking milk out of your breast and then feeding it into Harper by bottle."
In that first consultation, we focussed on the gestalt method. Harper still fussed at times and pulled back from a face-breast bury, which I attributed to the oxygen prongs. I wasn't sure, but I wondered if there was also some conditioned dialling up occurring, and explained what this was to Jenny.
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You can find out about the gestalt method starting here.
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You can find out about conditioned dialling up at the breast and what to do about it here.
Jenny began to use fewer bottles even as we maintained safety for Harper
After another fortnight had passed, Jenny made some effort to pump less, and to offer Harper the breast frequently and flexibly.
After a week of trying this out, Jenny came in and reported back that Harper often fussed and refused to take the breast now, even though I could see that he had increasingly good positional stability when they fed. unfortunately, he had only gained 20 gm in weight that previous week.
Jenny was very upset, and I was worried too. I could see that Harper had now developed a serious conditioned dialling up, even though the nasal prongs had been removed.
Had I suggested that Jenny transition from the pump too early, before positional stability was ensured? I regreted not asking her to come back 48 hours after the previous consultation, to weigh the baby given the changes that we were making with the pumping and expressed breast milk. Sometimes it can help to offer to weigh the baby even just 48 hours after the parents begin a transition off the pump, letting appetite drive the baby to the breast in the context of very rich and changing sensory nourishment. This gives a back-up so the parents don't need to worry, until that consultation when the situation is reviewed.
Then, Jenny confided that she often breastfed standing up with a hand holding Harper's head to her breast, and I could better make sense of what had been happening. Holding a baby on the back of the head might seem to work at that moment, but could severely worsen a conditioned dialling up at the breast, because the baby couldn't move her head and neck freely. This switched off the baby's breastfeeding reflexes, and meant that the baby felt under pressure or physical coercion at the breast.
We worked together on the fit and hold again, and on strategies to deal with the conditioned dialling up. His weight gains improved even as Jenny stopped pumping and just offered the breast frequently and flexibly.
Harper never did exclusively breastfeed, but perhaps three-quarters of his milk came directly from his mother's breast and the rest from formula, without any pumping, until he transitioned onto solids. Jenny weaned him at 18 months of age. In the end, she was very proud of how well her breastfeeding relationship with Harper went, given just how challenging the start to little Harper's life had been.
Recommended resources
When does pumping of your breasts help with breastfeeding?
What timings work best if you're pumping your breast milk?
How to protect your nipples and breasts from injury during pumping
When might pumping get in the way of direct breastfeeding your baby?
Why triple feeding andthe top-up concept can get in the way of successful breastfeeding
How to transition from formula use to exclusively or predominantly direct breastfeeding
You can find out about expressing and storing your breast milk on the Australian Breastfeeding Association's website, here.
Selected references
Gridneva Z, Warden AH, McEachran JL, Perrella SL, Lai CT, Geddes DT. Maternal and infant characteristics and pumping profiles of women that rpedominantly pump milk for their infants. nutrients. 2025;17:366.
Rosenbaum K, McAlister B. An integrative review of exclusive breast milk expression. Journal of MIdwifery and Women's Health. 2024:doi:10.1111/jmwh.13713.