• Babies
• Building a Family
• Children
• General Parenting
• Newborns
• Teenagers
• Toddlers
• Pregnancy

Common Concerns During the Early Weeks of Breastfeeding

Page 1

Common Concerns During the Early Weeks of Breastfeeding

My Baby Won't Latch On
During your hospital stay, the nurses probably assisted you in latching your baby on to your breast. Without such expert guidance, you may be having difficulty getting your baby to attach correctly now that you are home. Even infants who once nursed well may have difficulty latching on if the mother's breasts become swollen and firm when her milk comes in abundantly. In addition to the extreme frustration a latch-on problem causes, both your baby's well-being and your milk supply can be placed in jeopardy if your infant is unable to nurse correctly.

More: The Ultimate Guide to Cluster Feeding: What Is it, How Long Does it Last, and Why Does it Happen?

Try the strategies outlined in this article. If you are not having success getting your baby to nurse well within a few hours, you need to call your baby's doctor and make a plan for assuring your infant receives adequate milk. I strongly advise you to seek assistance promptly from a lactation consultant or to call the nursery at the hospital where you delivered. Ask a neonatal nurse if you can return right away for assistance in getting your baby to breastfeed. The hospital probably has an efficient electric breast pump that you can use while you are there. If your breasts are engorged, expressing some milk will soften your nipple and areola and make it easier for your baby to grasp your breast. Any milk you express can be fed to your baby. Even if you have to pump and feed your expressed milk for a day or so, with patience and practice, your baby can learn to latch on and nurse correctly.

Some babies have overcome latch-on problems with the use of a silicone nipple shield placed over the mother's nipple. The shield is stiffer and more protuberant than the mother's own nipple, and most babies accept it readily. Your nipple is drawn into the shield as your baby breastfeeds. After nursing with the nipple shield for a while, you should try to remove it and attach your baby to your breast. A nipple shield should be used only with the direct supervision of a lactation consultant or other breastfeeding specialist who can assure that your infant obtains adequate milk nursing with the shield and closely monitor your baby's weight gain. I also recommend pumping your residual milk after you breastfeed using a nipple shield, since nursing with the shield is not as effective as direct breastfeeding. Your baby's doctor needs to know that your infant is having difficulty breastfeeding.

How Do I Arouse My Sleepy Baby?
While some newborns awaken on schedule and act hungry, others fail to demand feedings as expected and must be coaxed to nurse. The parents of such infants often mistakenly conclude that they have "such a good baby." At a time when new parents are exhausted and overwhelmed, an apparently contented, nondemanding infant can seem like a blessing. Uninformed health professionals often reinforce this misperception by telling new parents how fortunate they are to have a newborn who sleeps through the night.

But a nondemanding infant is not a blessing. Such a baby can create a false sense of success at first because the infant seems so satisfied. Before long, however, ineffective and infrequent nursing can result in an underweight infant and an inadequate milk supply. If your newborn is not demanding at least every three and a half hours, you need to try to awaken the infant to nurse. Try the following measures to arouse your baby from light sleep (look for rapid eye movements, arm and leg movements, facial twitches, or mouthing motions) and entice her to nurse:

• Dim the lights. Babies are more likely to open their eyes in subdued room lighting and will close their eyes in the presence of bright lights.

   

• Unswaddle the baby. Babies get drowsy when they are overly warm and swaddled. You may need to undress your baby down to her diaper to make her less cozy and stimulate her interest in feeding.

   

• Position your infant upright, either sitting on your lap with your hand under her chin or placing her over your shoulder as if you were going to burp her. When positioned upright, most babies will reflexively open their eyes.

   

• Perform "passive" sit-ups with your baby. While supporting your baby on your lap in the sitting position with one hand behind her head, gently lean her backward until she is fully supine (lying on her back). Slowly rock her back and forth at the hips, going from sitting to reclining, about four to six times. This usually will cause her eyes to open.

   

• Talk to or sing to your baby. Use a high-pitched voice and exaggerate your intonation and accentuate each syllable. "You're a h-u-u-u-n-g-r-y b-a-a-a-a-b-y."

   

• Massage your infant. Gently rub her arms and legs, stroke her head, wipe her face with a warm wet cloth, or massage the soles of her feet. Gently run your finger along her upper lip. Start in the midline and move toward the outer edge, one side at a time.

   

• Change her diaper or perform cord care. The stimulation involved in changing your baby's diaper and washing her bottom may suffice to arouse her. If that doesn't work, applying alcohol to the base of the umbilical cord is a pretty surefire way to awaken a sleepy baby. The cold alcohol against the baby's abdomen almost always gets a response.

   

• Offer a little expressed milk to your baby by spoon, cup, or dropper. Hand express or pump as much colostrum or early milk as you can. You can dribble a little milk onto your nipple to entice your baby to nurse. Some drowsy babies who appear disinterested in feeding actually have borderline low blood sugar. Giving them a little nourishment can perk the baby up and bring her to an alert state in which she can nurse effectively.

   

• Stimulate sucking activity using your clean little finger. After washing your hands, place the nail side of your little finger against the baby's tongue and stimulate her palate with the fleshy part of your finger. After your baby starts sucking, remove your finger and offer your breast.

Page 2Many nondemanding, sleepy babies do better with a few simple breastfeeding modifications. If the infant does not sustain suckling very long, it is preferable to restrict her nursing to only five minutes per breast. Babies generally take more milk nursing for a shorter duration at both breasts than nursing a little longer on one side only. An exception to this recommendation is the sleepy infant who cannot be enticed to take the second breast after being removed from the first side. In this case, letting the baby nurse longer on the first breast is preferable to interrupting nursing on the first side and then having the baby refuse the second side altogether.

If your baby sucks vigorously for only a few minutes and then stops, try arousing her and switching her to the other breast. You can keep her on the first breast as long as she swallows after every couple of sucks. When her swallowing slows down or she starts to doze off, remove her from the breast, try to bring her to a more wakeful state, and switch her to the other side. This "switch nursing" method will provide her with more milk than allowing her to drift off at the first breast.

Is My Baby Getting Enough Milk?
Even though you can't see exactly how much milk your baby takes while nursing, observant parents usually can tell whether breastfeeding is off to a good start. If your baby can latch on to both breasts well, nurses often with frequent audible swallowing, seems contented after feedings, wets six or more diapers, and has at least four yellow bowel movements each day, she is probably thriving. The following questionnaire developed at the Lactation Program in Denver has proved useful in distinguishing whether breastfeeding is off to a successful start or whether additional help is necessary. If you have any concerns, call your baby's doctor and arrange to have your infant weighed. Remember, if a problem is caught early, it is easier to solve.

Early Breastfeeding Screening Form
Please complete this screening form when your baby is four to six days old. If you circle any answers in the right-hand column, call your baby's doctor to arrange for further evaluation. The earlier problems are identified, the easier they are to correct. Ask your doctor to refer you to a lactation consultant who can observe your nursing technique and provide one-on-one assistance.

Do you feel breastfeeding is going well for you so far? Yes No Has your milk come in yet? (That is, did your breastsget firm and full between the second and fourth post-partum days?) Yes No Is your baby able to latch on to your breast withoutdifficulty? Yes No Is your baby able to sustain rhythmic sucking for atleast ten minutes total per feeding? Yes No Does your baby usually demand to feed? (Answer "No"if you have a sleepy baby who needs to be awakenedfor most feedings.) Yes No Does your baby usually nurse at both breasts at eachfeeding? Yes No Does your baby nurse approximately every two tothree hours, with no more than one longer interval ofup to five hours at night? (at least eight nursings eachtwenty-four hours?) Yes No Do your breasts feel full before feedings? Yes No Do your breasts feel softer after feedings? Yes No Are your nipples extremely sore? (for example, causingyou to dread feedings?) No Yes Is your baby having yellow, seedy bowel movementsthat look like cottage cheese and mustard? Yes No Is your baby having at least four good-size bowelmovements each day? (that is, more than a "stain" onthe diaper?) Yes No Is your baby wetting his/her diaper at least six timeseach day? Yes No Does your baby appear hungry after most feedings?(that is, crying, sucking hands, rooting, often needinga pacifier?) No Yes Do you hear rhythmic suckling and swallowing whileyour baby nurses? Yes No

Copyright © Lactation Program, Denver, CO. Used with permission.

Page 3When Is Poor Feeding a Sign of Infant Illness?
One of the most important clues to infant well-being is the frequency and quality of feedings. Parents, especially mothers, quickly become attuned to their baby's usual feeding pattern and readily notice any changes in feeding frequency, duration, or vigor. Young infants have few ways to communicate illness. Poor feeding is one of the strongest indicators of a medical problem, and it must not be ignored. Sleeping through feeding times, showing less interest in feedings, suckling for a shorter period of time, or nursing with less stamina all could indicate some type of medical problem, such as an infection or a heart condition. You should promptly report any change in your baby's feeding pattern to your infant's doctor.

What Does Infant Jaundice Have to Do with Breastfeeding?
Many newborn babies develop a yellowish color to the whites of their eyes and their skin, a condition known as jaundice. Parents often wonder about the significance of newborn jaundice. In adults, jaundice rarely occurs and represents an important sign of illness, such as hepatitis. Jaundice in adults must never be ignored; its cause always must be investigated. Unlike adults, some degree of jaundice is evident in nearly half of all newborns, usually by the third day of life. Most cases of newborn jaundice are mild and require no treatment. The yellow color results from a substance known as bilirubin, a breakdown product of hemoglobin, which is present in red blood cells. Normally, the liver metabolizes bilirubin and excretes it in a modified form into the intestines where it gets passed from the body in bowel movements.

Many factors contribute to higher bilirubin levels in newborns during the first week of life. First, babies are born with more red blood cells than adults and these cells have a shorter life span than that of adult blood cells. In addition, many babies experience bruising during the birth process, and the red blood cells trapped in a bruise quickly add to the bilirubin load. Thus, newborns must handle proportionately more bilirubin than normal adults. Ironically, the immature newborn liver is less effective in metabolizing bilirubin. Furthermore, even when the liver does its job and excretes bilirubin into the gut, bilirubin can be reabsorbed from the infant's intestines into the bloodstream, especially if the baby stools infrequently. Since breastfed babies often obtain less milk compared to formula-fed babies during the first few days of life, breastfed babies may stool less often and develop higher levels of bilirubin. In fact, many studies have confirmed that breastfed babies, on average, have higher bilirubin levels than bottle-fed babies.

Now you can appreciate why so many healthy newborns develop some visible jaundice. Numerous medical disorders can further exaggerate the bilirubin level, such as blood type mismatches between mother and baby that cause the baby's red blood cells to break down faster than normal; liver disease that impairs the metabolism of bilirubin; infection; heart disease; or a low level of thyroid hormone. Thus, whenever jaundice is present, it is important not only to monitor the level of bilirubin but to identify the cause of its elevation as well. Normal, or physiologic, jaundice must be distinguished from serious underlying causes of jaundice that require treatment.

Another reason we worry about jaundice is that high levels (usually over 25 milligrams percent) are toxic to the newborn brain and can cause brain damage and/or hearing loss. Permanent damage can be prevented by monitoring bilirubin levels carefully with blood tests, searching for and treating any identified causes, and using phototherapy (in the form of bilirubin lights or phototherapy blankets) to bring the level down. (Rarely, the bilirubin level rises so high that an exchange transfusion becomes necessary to lower the level rapidly.) Proper treatment of jaundice involves more than just "making the yellow go away." It should include finding and treating any underlying medical conditions contributing to the problem. Inadequate breastfeeding is a common cause of newborn jaundice that needs to be recognized and treated.

If you observe any yellowish color to your baby's skin or the whites of her eyes, notify your baby's doctor, who will decide whether to order a bilirubin level. Ask to have your infant weighed. Many doctors don't appreciate that inadequate breastfeeding can contribute to jaundice in a breastfed infant. When breastfeeding is going poorly for any reason, the result can be insufficient caloric intake by the infant, excessive weight loss from birth, inadequate weight gain, infrequent stooling, and an elevated bilirubin level. If your baby has jaundice, your doctor can help you determine whether the level is high enough to pose any danger and whether inadequate breastfeeding might be contributing to the problem.

Review the expected normal patterns for breastfed infants described earlier. Is your baby latching on correctly and feeding on an appropriate schedule? Is she wetting and stooling normally? Has your milk come in? Is she emptying your breasts well? Has she lost excessive weight or started to gain consistently?

Bilirubin levels usually peak around three to five days of age, just when your milk is coming in abundantly and your breasts are maximally engorged. At the point when your breasts need to be drained well, your sleepy, jaundiced baby may not be the most effective candidate for the job. I usually recommend a hospital-grade rental electric breast pump for mothers whose jaundiced infants are not nursing vigorously. By pumping after nursing, you can stimulate a generous supply, improve milk flow, and obtain expressed milk to be used to supplement your baby if necessary.

Unfortunately, many doctors mistakenly believe that it is necessary to discontinue breastfeeding temporarily when a baby's bilirubin level gets high. In fact, this is almost never necessary. Most often, exaggerated jaundice in a breastfed baby is due to inadequate breastfeeding. What's needed are measures to improve the baby's intake of milk, not a temporary switch to formula (which often turns out to be permanent).

Why Do I Get Cramps When I Breastfeed?
The hormone oxytocin that plays a role in breastfeeding is the same hormone that causes your uterus to contract during labor. In the first days after delivery, oxytocin released during breastfeeding causes the still-enlarged uterus to contract. The resulting cramps, known as afterpains, help the uterus shrink to its prepregnant size. The discomfort usually is worse for women who have given birth previously than for first-time mothers. While afterpains can be quite uncomfortable, they are short-lived, usually lasting only seven to ten days. These uterine cramps not only help you recover from childbirth, but they are a good sign that your milk ejection reflex is working well.

Page 4My Breasts Are Swollen and Painful
One of the most frequent early difficulties encountered by breastfeeding women occurs when their milk comes in abundantly and their breasts get larger, firmer, and tender. These breast changes that coincide with the beginning of copious milk production are known as postpartum breast engorgement. Engorgement results from hormone fluctuations after delivery that cause a sudden increase in milk volume. Tissue swelling, lymph drainage, and increased blood flow to the breasts also contribute to the dramatic breast changes.

It is generally believed that frequent, unrestricted nursing during the first days postpartum will relieve milk congestion and prevent severe engorgement. In my experience, however, the severity of engorgement cannot always be explained by a woman's early feeding practices. Some women begin nursing right away and feed often, yet still experience excessive engorgement, while others don't start breastfeeding for a day or so without getting severely engorged. Most experts agree that engorgement is more remarkable in first-time mothers than those having subsequent babies. In addition, I have observed that engorgement is often greater in women whose breast size increased dramatically during pregnancy.

Fortunately, postpartum breast engorgement is a temporary condition, usually lasting only a few days until your body adjusts to the process of making and releasing milk. By the end of the first week after delivery, milk flow is usually well established and breast engorgement has subsided. In the meantime, it is very important that your baby be helped to latch on correctly and to nurse often (at least every two to three hours) while your breasts are engorged. You may need to express some milk to soften your nipple and areola and make it easier for your baby to latch on. Frequent milk emptying will make you more comfortable, keep your baby well fed, and assure continued generous milk production.

For specific strategies to help your baby nurse well when your breasts are swollen, to relieve uncomfortable engorgement, and to improve milk flow, see this article.

My Nipples Hurt
Sore nipples are one of the most frequent complaints of breastfeeding women. Early, mild nipple tenderness, beginning on the second day, is so common as to be considered normal. Usually the first minute after your baby latches on is the most uncomfortable. Try your Lamaze breathing techniques to help you relax prior to nursings, so you won't tense up in anticipation of pain.

First and foremost, pay attention to proper nursing position and the infant's attachment to the breast. Early sore nipples are usually due to improper infant latch-on. Another helpful strategy is to begin feedings on the least sore side, since your baby suckles more vigorously at the beginning of a feeding until the milk ejection reflex has been triggered. Once your milk begins to flow and nursing is more comfortable, you can move your infant to the more painful side. However, try to assure that both breasts get equal stimulation and emptying. Frequent, shorter feedings are preferable to long nursings at wider intervals. Most mothers find that a soothing emollient applied to their nipples promotes healing. I recommend USP Modified Lanolin (medical grade), such as Lansinoh for Breastfeeding Mothers or PureLan. These products can be obtained from breast pump manufacturers, La Leche League, lactation consultants, maternity shops, and other locations. Pat your nipples dry and apply a thin coating of lanolin after each nursing. You do not have to remove medical grade lanolin before feeding your infant.

Because the volume of colostrum is low, some babies create a strong vacuum when sucking during the first few days and cause nipple soreness. Once abundant milk production begins, the baby generates less negative pressure during nursing, and nipple pain usually starts to subside. By the end of the first week, you should have little, if any, discomfort with feedings.

Severe or persistent nipple pain is not normal. If your nipples are so painful that you dread feedings, if discomfort persists throughout a nursing, if you have open cracks or fissues, or if your pain does not improve after your milk comes in, you need to seek assistance. Notify your own and your baby's doctor and request to be referred to a lactation consultant.

Can I Feed My Baby on Schedule Instead of by Demand?
The vast majority of breastfeeding proponents strongly attest to the importance of round-the-clock demand feedings for young breastfed infants. However, some parent educators emphasize the value of creating structure and order in a young baby's life by the early establishment of predictable patterns of feeding and sleeping. Other parenting experts consider this philosophy of ordering a baby's life to be somewhat controversial. In my opinion, parents should make every effort to meet their infant's needs promptly in order to help their baby feel loved, safe, and secure and to build trust in the world. Meeting your baby's individual needs as quickly and effectively as possible forms the basis for a strong love bond with your infant. A baby's emotional development can be harmed when her needs go unmet because her parents adhere to an arbitrary feeding schedule. Those who advocate the desirability of regular routines in infant care make attractive claims of successfully feeding babies on predictable schedules and getting them to sleep through the night at an early age.

Obviously, a wide range of parenting styles can be effective in raising healthy, happy children. However, some babies develop regularity in their feeding and sleeping patterns more easily than others. I strongly believe that the unique needs of an infant take priority over parents' desires for predictability and order. While some breastfed babies can thrive well with a regular schedule, it is my impression that the great majority do best on a demand schedule. Breastfeeding is most successful when infants remain in close contact with their mothers and are allowed to nurse in an unrestricted fashion. In some instances, rigid scheduling of feedings has resulted in an infant's failure to thrive.

Page 5How Can I Express Some of My Breast Milk?
Many new lactating mothers will need to express some milk in the early weeks of nursing, for example, to relieve uncomfortable engorgement if the baby doesn't empty her breasts adequately. I believe all breastfeeding women should be taught hand expression. In this way, even if they have no pump or can't use their pump effectively, they can still express some milk. After all, you always have your hand with you!

Hand Expression
Hand expression takes practice, so be patient with yourself. Always wash your hands before handling your breasts or collecting expressed milk. For best results expressing milk, first gently massage your breasts, going from the outer areas toward the nipple. A good time to practice learning how to express is when your milk is letting-down. Warm compresses or a warm shower are useful in starting milk flow. Place your thumb above your nipple and your first two fingers below, positioning them about one to one and a half inches behind the base of your nipple. Your fingers should be situated over the milk sinuses, or dilated milk ducts, beneath your areola. Next, press your thumb and fingers back toward your chest wall. Then gently roll your thumb and fingers together (as if you were simultaneously making thumb and fingerprints). The rolling motion will extract the milk pooled in the dilated ducts beneath your areola. Lean forward slightly and collect your dripping milk in a clean cup or other widemouthed container. Try to avoid letting your milk roll over your fingers as you collect it. Repeat the push and roll motions until milk stops flowing. At first you might obtain only a few drops with each compression, but soon you should be getting sprays from several duct openings. Rotate your thumb and finger positions around your nipple to empty milk from all the lactiferous sinuses.

Manual Breast Pumps, Battery-Operated Pumps, and Small Electric Breast Pumps
Many breastfeeding women purchase a breast pump to remove some milk when their breasts get engorged, to occasionally express milk when they must miss a feeding, or to collect extra milk to leave for their baby if they must be absent. A dizzying variety of breast pumps are available for purchase, including simple hand pumps, battery-operated types, and small electric options. Each has its own unique features and price range. Women have varying success using different types of breast pumps, making it difficult to generalize about which is the most effective, comfortable, or convenient in each category. Thus, I suggest you review several pump options with a lactation consultant who can help guide your decision. Before purchasing one of the smaller breast pumps, however, consider whether a hospital-grade rental electric pump would better suit your needs.

Hospital-Grade Rental Electric Breast Pumps
It is generally agreed that the most effective, efficient, and comfortable breast pumps available are the hospital-grade rental electric pumps equipped with a double collection system that empties both breasts at once. In addition to being fast and comfortable, these pumps are remarkably effective in maintaining and even increasing your milk supply. Many of them offer fully automatic cycling and feature a control mechanism to allow you to regulate both the speed at which the pump cycles and the amount of vacuum it generates. A hospital-grade electric breast pump can be extremely helpful in many situations, including the following: to relieve severe engorgement; to maintain your milk supply when you work outside the home or when your baby cannot nurse due to prematurity or illness; to increase a low milk supply; or to pump after ineffective nursings (for example, if your baby has a sucking problem). You must purchase your own set of collection containers, in addition to paying the pump-rental fee. The rate is more cost effective when you rent the pump for longer periods than at a daily rate. Most women agree that the effectiveness, convenience, and comfort of these pumps make them well worth the expense. In many instances, such as premature birth, the cost of the pump rental is covered by insurance when your health care provider documents that breast milk is medically necessary for your baby's health. Hospitals, lactation consultants, La Leche League, Nursing Mothers Counsel, WIC clinics, and physicians' offices also can refer you to a pump-rental outlet.

What If My Baby Needs Supplemental Milk?
Despite all the admonitions you will hear about not giving a breastfed baby any supplemental milk, the fact is that some newborns do not obtain sufficient milk by breastfeeding. If your baby has lost excessive weight after birth or has not started to gain an adequate amount of weight, your baby's doctor might prescribe extra milk feedings. Your baby's welfare must be your top priority. Meeting your baby's nutritional needs will indirectly help your breastfeeding, as a well-nourished baby will nurse better than an underweight infant.

My first preference is to pump the mother's breasts after nursings and try to obtain high-fat residual hindmilk for the baby's supplement. If the volume of breastmilk is inadequate, then some quantity of infant formula (or screened, processed donor breast milk where it is available) might be necessary to correct your baby's underweight condition.

If bottle-feedings are not desired, other options exist for feed-ing supplemental milk to babies, including the SNS device, cup, spoon, or dropper. I certainly don't recommend giving supplemental milk without a valid medical indication. On the other hand, I cannot condone withholding essential nutrition from a baby who is being underfed. Obviously, whenever supplemental milk is prescribed, ongoing efforts should be made to keep the baby breastfeeding as effectively as possible, to increase the mother's milk supply, and to ultimately return to full breastfeeding.