Some Early Breast Feeding Problems

Almost every woman has some problems or questions with breast-feeding in the first weeks after birth. Some of these are common and predictable and can be handled quite easily. Others are more serious and require more information and assistance. Following are some of the more common breast-feeding problems and suggestions for solutions.

Is the Baby Getting Enough Milk?

A number of signs can tell you if your baby is getting enough milk. A baby who feeds well every two hours or so for twenty to forty minutes with occasional shorter or longer periods between feedings will have six to eight wet diapers each day. After passing his meconium stool, a breast-fed baby may have a loose stool with each feeding, or at least three or more stools a day for the first month. It is common to have a stool after every feeding. Later, as he matures, he may have a bowel movement every other day or even once a week. Your baby’s elimination patterns along with his contentment after being fed are good indications that he has received enough milk. Most importantly, your baby’s doctor will watch his weight gain and growth to determine if he is getting enough milk. If your baby’s weight gain seems to be slow, it could be due to any of the following factors.

Limited sucking time

The let-down may not occur if suckling is limited to a few minutes on a side. This means that the baby will not get the high-calorie hindmilk and will not gain as expected. Your baby needs at least ten to twenty minutes of vigorous suckling at each breast to get the hindmilk.

Gas bubbles

Swallowed air can make the baby feel full. Be sure to burp your baby before changing to the other breast and after the feeding.

Scheduled feedings

A newborn breast-fed baby, especially a slow-gaining baby, needs to be fed more frequently than every three or four hours. Allow your infant to nurse on demand or whenever he seems interested (at least eight to eighteen times in twenty-four hours).

Sleepy baby

If your baby is very drowsy during the feeding, pauses for long intervals, or even falls asleep, he may spend a long time at the breast without getting much milk. To wake up your baby, try stroking the soles of his feet with your fingernail or rubbing his thighs or tummy. Avoid wiggling your breast or rubbing his cheeks which may dislodge a good latch and interrupt the feeding. If these techniques are not enough, make sure he is not overbundled. Then try burping him and switching to the other breast, which can be done several times during one feeding to keep him awake. You may also use breast massage to press milk down toward the nipple and interest him with the flow of milk.

If your baby goes for long stretches without feeding, try waking him every two to three hours during the day and every four hours at night. If the baby was preterm or has had other problems, your doctor may suggest feeding more frequently.

If your baby is sleeping so soundly that you simply cannot rouse him, it is better to wait a half hour and try again than to continue the frustrating and futile effort of waking up a baby who is deeply asleep. If this happens often, record the baby’s feeding and sleeping on an Activity Chart for two or three days and call your baby’s doctor with this information.

Limiting feedings to one breast

Offering only one breast at each feeding may result in inadequate milk production. Switch to the other breast after your baby finishes feeding at the first breast. The baby might nurse very little on the second breast at first, but he will nurse more as he grows.

Nonnutritive sucking

Some infants satisfy their sucking needs without nursing by sucking on their own fists, fingers, tongues, lips, or pacifiers, or by chewing and sucking on the tips of their mother’s nipples. Once their sucking needs are satisfied in this way, they may not appear hungry, leading their mothers to think they do not want to nurse. These babies may have problems gaining weight.

Difficulty with the let-down reflex

Anxiety, fatigue, inadequate nipple stimulation, and excessive amounts of alcohol, caffeine, and smoking all may inhibit the let-down reflex.

Fatigue, insufficient intake of fluids and calories, or poor diet

These may reduce your milk supply but are less common reasons for inadequate milk supply. Spend a day in bed with the baby to replenish a declining milk supply. Pick a day when you have help with meals, household chores, telephone calls, and your other children. Spend the day nursing your baby as often as possible, eating and drinking well, sleeping, nurturing yourself, and letting others nurture you. Besides helping to restore your milk supply and helping you catch up on needed rest, this is a wonderful way to learn more about your baby. Then, over the long term, pay attention to your need for rest, to your food and fluid intake, and to the quality of your diet.

Poor latch

If the baby has not positioned his mouth properly on the nipple, he will not be able to compress the milk sinuses well and will not stimulate a let-down reflex. If the baby’s mouth makes a “clicking” sound during sucking, it may indicate that the suction is breaking with each sucking effort. For the whole feeding, hold the newborn baby tight against your body, close enough that his nose touches your breast. It is possible to start with a good latch and later have the baby’s mouth slip down to the nipple tip as your arm tires. A pillow beneath your arm may prevent this.

Treatment

If you wonder if the baby is getting enough milk, try the following:

• Feed frequently and for at least ten minutes from each breast.
• Avoid pacifiers, at least in the beginning.
• Feed the baby whenever he indicates an interest in feeding (awake, alert, sucking fingers or fists), and try not to postpone feedings.
• Massage your breasts during feedings to increase the milk flow.
• Nurture yourself. Rest or sleep when the baby sleeps. Get adequate fluids and eat well.
• Get help from a lactation specialist, your childbirth educator, your doctor, or an experienced breast-feeding mother. A poor newborn weight gain (an indicator of insufficient milk) can be improved if an experienced person can help you figure out the cause of the problem and develop a plan for treating the weight gain problem.

Engorgement

Engorgement is an inflammation of the breast with swelling in the tissue surrounding the milk-producing glands. It is accompanied by an accumulation of milk in the ducts. It occurs when the “milk comes in,” usually the second or third postpartum day. Your breasts swell, become firm and warm to the touch, and painful. Keep in mind that engorgement may be prevented or at least reduced by allowing the baby to nurse early and frequently for an adequate time and with a proper latch. Engorgement usually subsides after a few days. Pumping to remove the milk your baby does not take will relieve, you will also get some relief from very cold washcloths or wrapped ice-cubes laid on the breasts. A simple over-the-counter pain-reliever will help, too.

Treatment

• Let the baby nurse frequently for as long as he wishes. You can feed him whenever he is awake and interested in feeding.
• Use warm packs or a warm shower before a feeding to help the milk flow.
• Express milk right before feeding to soften a hard, swollen areola and to make it easier for the baby to grasp.
• While feeding or pumping, massage your breasts to enhance milk flow.
• Use an electric or mechanical breast pump after the feeding if nursing does not reduce the fullness.
• After feeding or pumping, apply cold packs to reduce blood flow to your breasts and to provide comfort.

Sore Nipples

Soreness from unaccustomed use is much rarer than people used to think. Unless you are red-headed or very blonde, with pale skin and very pink nipples, you should be able to avoid soreness without limiting your baby’s luxurious sucking time.

Avoid washing nipples with soap in late pregnancy or while breast-feeding.

They have built-in lubrication from tiny glands around the areola (“Montgomery’s tubercles”) which you don’t want to remove. It is more effective than any cream you might use to replace it, and more hygienic, too.

Don’t massage and scrub nipples to harden them.

They are made for the job of breast-feeding and you don’t want them though, you want them flexible and elastic.

Try to let them air-dry after feedings,

speeding up the process with warm air from a hair dryer if you are rushed.

Keep plastic-backed breast pads for special occasions.

Once they are damp they will keep your nipples damp and soggy. Ordinary pads are better; frequently changed bras are better still. You can often stop leakage by pressing the center of the nipple firmly in with the end of your finger.

Never pull a sucking baby off the nipple.

Wait until he pauses for breath or break the suction by inserting a gentle finger in the corner of his mouth.

Make sure your baby never sucks on the nipple;

his jaws must squeeze the areola with the nipple itself drawn right to the back of his mouth.

At the first sign of soreness, adjust your position

so that a different part of the nipple takes the main stress.

Sore nipples may occur at any time but are most common during the first weeks of breast-feeding. Soreness may range from discomfort only when the infant first grasps the nipple to continuing pain throughout and between feedings. Sore nipples can almost always be treated successfully. In severe cases, the nipples may crack and bleed, but even these cases can be successfully treated without stopping breast-feeding.

Sore nipples are usually caused by improper positioning of the baby’s mouth on the areola (improper latch). Flat or inverted nipples are more prone to soreness. Less commonly, sore nipples are due to overvigorous pumping or hand expression, a very vigorous baby whose gums clamp hard on the areola and whose suckling may scrape the tissue of the areola, or an infection of the areola. They are not prevented by prenatal nipple “toughening” exercises (rubbing or pulling the nipples), as was once believed. The common belief that limited suckling reduces or prevents nipple soreness has also been shown to be a myth. Frequent unlimited suckling with a good latch is not associated with an increased incidence of sore nipples.

Treatment of Sore Nipples Due to Problems with Latch

• Check for proper latch and make adjustments if necessary.
• Check your grasp of your breast. Your fingers should be below your breast and behind your areola. Your thumb is above and behind your areola. Using a “scissor-hold” (holding your nipple between two fingers) sometimes interferes with your baby’s ability to latch if your fingers slip down over the nipple area.
• Vary the feeding position. Feed your baby in a cradle hold, football hold, or lying down. The different positions change the placement of your baby’s mouth on your nipple so that the pressure from your baby’s suckling will not be in the same place all the time.
• Feed your baby frequently, and begin on the less sore side. Try to nurse for at least ten minutes on each breast, but avoid frequent “marathon” nursing sessions lasting longer than an hour.
• Soak a tea bag (black tea) in a small amount of hot water, making a very dark solution. Apply the tea solution to your areloae and dry with a hair dryer at low or medium heat held at arm’s length. The tannic acid in the tea is thought to help the skin be more resistant to soreness. Sometimes applying warm, moist, tea bags to the sore area for ten to fifteen minutes after several daytime feedings is helpful. To protect your clothing, cover the tea bags with plastic wrap and pull up your bra flaps. Dry the breasts well after removing the bags.
• Dry both areolae well after each feeding by leaving bra flaps down and using a hair dryer or exposing them to sunshine briefly until dry. To keep the nipples dry, change nursing pads frequently if you are leaking milk during or between feedings.
• Express a small amount of breast milk and rub it over the sore area. The anti-infective properties of breast milk and other substances in the milk help the tissue to heal. Breast creams and ointments are sometimes recommended. While they may help in some instances, they may also cause irritation of the breast (for example if you are allergic to wool, lanolin may create a rash), or they may clog the Montgomery glands. If you use creams, apply the cream sparingly just over the sore area. Vitamin E oil should be used sparingly if at all as it can raise the baby’s blood level of vitamin E to toxic levels. And it has been found that creams containing lanolin may also contain insecticides used to treat sheep from which the lanolin comes.
• Use perforated breast shells or cups between feedings to keep anything from touching your sore nipples and to keep them dry. Sometimes these breast shells increase leaking.
• Apply a small ice pack (a zip-lock bag with frozen peas or corn works well) to the sore area for five minutes before feeding to provide some relief of pain as the baby latches on. Apply an ice pack again for twenty minutes following feedings. This relieves pain and aids healing by taking advantage of an increase in circulation that occurs after application of ice.
• Avoid using nipple shields. They are never a solution for a poor latch. They may be used in rare instances when sore nipples have been a long-standing problem. They offer only temporary relief and, because they prevent stimulation of the areola, they cause a decline in milk production.

Treatment of Sore Nipples Due to Overvigorous Pumping or Milk Expression

• Be sure to center your nipple in the breast pump cup. When the nipple is not centered, friction to the areola is unevenly applied and your nipples become sore.
• Use only enough suction to cause milk to flow well. Too much suction stretches the areola too deep into the pump cup and may injure the tissue.
• When expressing by hand, use breast massage first. Express milk gently. Except when expressing from an engorged breast, hand expression should not hurt. Carefully and patiently express milk from your milk sinuses and avoid bruising the tissue.
• Use the measures previously suggested if your areola or nipple is sore, cracked, or bleeding.

Thrush (Yeast) Infection

If your nipple pain continues even between feedings; is sharp, deep, or searing; and persists even when you have a good latch, you might have a thrush infection. The areolae or nipples may appear slightly pink but are usually unremarkable in appearance.

If you or your baby have taken antibiotics, if you have had a vaginal yeast infection, or if your baby has or has had thrush, an areolae thrush infection is possible.

Treatment of Sore Nipples Due to Thrush

• Consult your doctor. Thrush infections are most effectively treated by applying a prescription medication to your areola and to the baby’s mouth and by treating any vaginal yeast infection.

Breast Pains on “Let Down” Reflex

Some women experience a sharp, deep pain behind the areola at the beginning of each feeding. The pain, which subsides when the milk is flowing, does not indicate a problem and will usually go away in time without treatment. Your baby is helped to get the milk from your breasts by the draft or “let down” reflex. Sucking, hunger cries, or the baby’s mere presence when your breasts are full, release the hormone oxytocin into your blood. Oxytocin shortens and widens the ductules and ducts (this makes the muscle fibers around your milk glands contract) and facilitates the flow of milk through them (forcing their milk down into the milk ducts). Oxytocin also makes the muscles of your womb contract and some women feel the contractions as mild colicky pains. They stop being noticeable after two or three days.

Sometimes the draft reflex makes the second breast leak milk while the baby sucks from the first, or it makes both breasts leak when they are overfull or when the sight or sound of any young baby reminds your body of your own

Cracked Nipples

If a sudden, thin, sharp pain darts through your nipple as the baby latches on, and continues as long as he sucks, there may be a tiny crack in the nipple. A cracked nipple must be rested and reported to your doctor who will probably give you some cream to put on it to aid healing and prevent infection. Healing will only take a day or two, but during this time the baby must be fed only from the other breast. You can gently express the milk from the affected side

Leaking

Milk often leaks from the breasts in the first few weeks or months of nursing. This subsides as your breasts become more finely tuned and they “learn” how much milk to make and when to let it down. Leaking usually occurs when your breasts are very full, when you are feeding from the other breast, when you hear a baby cry, or when you are sexually aroused.

Treatment

• When you feel the milk starting to let down, press your hands or forearms firmly against your nipples to slow the flow of milk.
• Compress your nipple between your thumb and forefinger to stop the flow of milk.
• To prevent soaking your clothes, wear cotton or disposable breast pads and discard them when they become damp. Avoid breast pads with plastic liners.
• Wear plastic breast cups or shells, such as the ones used to make flat nipples protrude, for short periods of time when you want to keep your clothing dry. Because these cups actually stimulate milk production, avoid using them for long periods. Discard any milk collecting in the cups and allow the nipples to dry well between wearings.

Hard, Sore Lumps in the Breast

Very occasionally one of the tiny tubes which carry the milk from glands to nipple gets blocked. Milk gathers above the blockage and cannot escape. You will be able to feel a small, hard, painful lump.

Bathe the breast repeatedly with hot water and massage it gently, then feed the baby. If the lumpiness and pain subside, you have helped the milk duct to clear itself. If they do not, see your doctor the same day. The lump could be due to an abscess forming rather than to a simple blockage.

Clogged Ducts

Redness, pain, swelling, or a lump in the breast can mean either a clogged duct or mastitis (an infection). If these symptoms occur in an area in one breast and you do not have a fever or other flu-like symptoms, you may have a caked, clogged, or plugged duct. If untreated, this could lead to mastitis. Any lump that does not respond readily and go away with the following treatment should be evaluated by your doctor.

Treatment

• Apply a warm, moist pack to the sore area and leave it on for ten minutes. Repeat three to four times a day.
• Massage the area toward the nipple during feedings.
• Avoid tucking clothing up under your arm during feedings; it may hinder milk flow.
• Avoid poorly fitting bras; they may obstruct milk ducts.
• Nurse frequently.
• Express milk after the baby has nursed if fullness remains. You may massage the full area to promote milk flow.

Breast Abscesses

These are usually the result of infection getting into the breast through an untreated crack in the nipple. One area of the breast will be hard, red and painfully throbbing. You may have some fever and feel unwell. It is important to see your doctor on that same day, although you can safely continue to feed the baby from the affected breast while you wait.

If a breast abscess is treated in the early stages (usually with antibiotics), you will be able to go on feeding the baby normally throughout the treatment period and you need have little pain. If the abscess is neglected you may have to confine the baby to the other breast for many days and it may be memorably painful.

Mastitis

Mastitis is an infection of the breast, which can occur at any time while you are nursing. Presence of bacteria and lowered maternal defenses associated with such conditions as cracked nipples, fatigue, or stress may cause mastitis.

The breast may have a tender, reddened area or the whole breast may be involved. Symptoms include fever, chills, fatigue, headache, and sometimes nausea and vomiting. Many women feel as though they have a severe flu. If you have these symptoms, suspect mastitis and call your doctor.

Treatment

• Continue to nurse from both breasts. The milk is not harmful.
• Rest and stay in bed until you feel better.
• Take antibiotics, if prescribed, for the full course of the prescription.
• Apply a warm, wet towel over the painful area to help increase circulation to the breast.
• Apply cold compress after feeding to reduce congestion and pain in your breast.
• Drink ample water, juice, and other fluids.
• Avoid constricting bras and clothing so milk may flow easily. During feedings, breast massage may help.
• If mastitis occurs frequently during the course of breast-feeding, more prolonged low dose antibiotics may be helpful.

Physiologic Jaundice in the Newborn

Physiologic jaundice usually begins on the second or third day after birth. It is not a reason to discontinue breast-feeding or to give water or formula. Physiologic jaundice in breast-fed babies is often the result of insufficient breast-feeding. In fact, it has been called “lack of breast milk” jaundice. The most effective way to prevent jaundice in the breast-fed infant is to feed frequently and to not limit feedings. This will help the baby to have bowel movements, which is his way of excreting bilirubin. Since very little bilirubin is excreted in urine, water bottles are not helpful in preventing or treating jaundice.

Breast Milk Jaundice

Breast milk jaundice, a rare condition, does not occur until the baby is five to seven days old and is thought to be caused by a substance sometimes found in breast milk that interferes with the normal metabolism of bilirubin. The bilirubin accumulates, causing the jaundice. To slow the rise in bilirubin or reverse a high bilirubin level, you may be asked to stop breast-feeding and feed with formula for twelve to twenty-four hours. This is usually enough to lower the bilirubin levels and is diagnostic for breast milk jaundice. If there is another rise, interrupting feedings once again may be suggested. Eventually the bilirubin levels fall or stay down and no other treatment is necessary. You should pump your breasts during the periods you are not nursing to maintain your milk supply.

Interrupting breast-feeding in this way is very stressful when you are trying to establish your milk supply. You should be reassured that your milk is not “bad”; your baby is simply not able to handle it yet. Your baby is not likely to be harmed by this rise in bilirubin level.

Treatment

• Continue nursing your baby unless your baby’s bilirubin levels are too high and continue to rise. Your doctor can help you decide if they are too high.
• If you are asked to interrupt breast-feeding, feed with formula and pump your breasts to maintain your milk supply. (You can save the milk to be used later.)