PREGNANCY

Soon after her pregnancy test proved positive, Joanne Elder began thinking about improving her odds for breastfeeding success. Three years before, when her twins, Annika and Gabriel, were born, Elder had experienced some difficulties breastfeeding. "I expected that it would be easier with just one baby this time," Elder says, "but I was still concerned about possible problems. So I started planning early."

If you are a first-time mother, or have encountered breastfeeding challenges with an earlier baby, remember that a little planning can often prevent difficulties and get you and your baby off to a good start. Here are ten tips to keep in mind:

Before the Birth

1. Choose a doctor or midwife who is knowledgeable about breastfeeding.

Breastmilk is recognized as the best food for babies by the medical profession, but not all doctors have the specialized knowledge necessary to help mothers learn how to breastfeed.

A supportive caregiver can provide information on breastfeeding, help you find a breastfeeding group in your community, suggest accurate books or videos, and will let you know that you have made a good decision for both you and your baby. Your caregiver should also discuss any concerns you have - such as how you can continue breastfeeding when you go back to work - and suggest ways for you to get additional support.

In contrast, paediatrician Jack Newman cautions that comments such as "Breastfeeding and formula feeding are essentially the same," or "Breastfeeding right after birth is not important" reveal a lack of knowledge; you may want to look for good breastfeeding support elsewhere. Be wary as well if your caregiver offers free formula samples or information booklets from formula companies during your pregnancy.

2. Enlist your partner's support.

Elder recalls how encouraging her husband, Carlos, was when she was nursing their twins. "I'm not a very assertive person," she says, "so it was important to me that Carlos was supportive and ready to do what he could to help me."

Elder found that attending an information meeting for couples (sponsored by the local La Leche League) gave Carlos lots of practical ideas about how fathers can help with breastfeeding. If your partner or family are lukewarm about breastfeeding, you might want to share some information about the benefits of breastfeeding for mothers and babies, watch a video, attend a class or information session together, or check out some of the Web sites that provide good breastfeeding information (see Resources).

3. Know your breasts.

Lactation consultant Leslie Ayre-Jaschke says, "Your health-care provider should examine your breasts and nipples, especially if you have had breast surgery, such as a breast reduction." For most women, this checkup provides the reassuring news that their breasts are normal and preparing to produce milk for their baby.

Heather McBriarty, a nurse with the Saint John Breastfeeding Alliance, explains, "Some women have inverted nipples, which retract into the breast rather than protruding and can make it more difficult for a baby to latch on properly. Breast shields, available from La Leche League or a lactation consultant, worn in the few weeks before and after birth, can help the nipples to 'come out from hiding.'"

Previous breast surgery or inverted nipples do not mean that breastfeeding is impossible, but it may be helpful to talk with a lactation consultant before the baby is born for some tips and extra support.

4. Learn from the experience of others.

McBriarty suggests: "Attend La Leche League or other support group meetings long before the baby is due. Although the La Leche League philosophy may not suit everyone, they have well-trained leaders who have lots of good information and there will be other mothers with experiences to share." In addition, if you do run into problems later, it's easier to call someone you've already met to ask questions or get help.

Ayre-Jaschke adds: "I see a difference in the breastfeeding experience of women who attend La Leche League meetings and those who don't. Those who go learn that babies come in a wide variety of shapes, sizes and personalities, and that even if they have some initial difficulties they can still breastfeed. This 'I can do it' attitude is very important."

If you can't find a group to attend, McBriarty suggests searching out other mothers who have succeeded in breastfeeding. If you can find even one person who is supportive and knowledgeable, it will make a big difference. Up-to-date books and videos about breastfeeding can also be very helpful (see Resources ).

When You Start Breastfeeding

5. Breastfeed early and often.

Breastfeeding as soon after birth as the baby is ready seems to help breastfeeding get off to a good start. Elder recalls, "I asked to have Naomi laid on my abdomen as soon as she was born, without being wiped or washed, and that's exactly what they did. After a while, when she started to move around and look for the nipple, I helped her to my breast. She latched on and nursed for a good long time, then went into a deep, relaxed sleep in my arms. It was a wonderful feeling."

Even after an unexpected complication, such as a Caesarean birth, you can ask to be helped to breastfeed as soon as possible. Doula Lenore Kilmartin recalls helping a new mother who had a Caesarean section after a long and tiring labour. "She was flat on her back because of the epidural, and so tired she barely looked at her newborn son. But I knew she really wanted to breastfeed, so I laid the baby across her abdomen and helped him to latch on while she was lying there. It worked! He nursed right away, and we're both convinced it helped."

Sometimes the baby may not be ready to nurse immediately, but may need some time to recover from the birth. If you can keep the baby with you - preferably skin-to-skin - you will be ready to respond when he does move towards the nipple or begin to root.

Frequent nursing in the early days helps mother and baby get comfortable with breastfeeding (practice makes perfect!) and helps establish mom's milk supply. Another bonus: Offering the breast often can prevent or minimize engorgement - hard, uncomfortably overfull breasts that may make feeding difficult when the mother's milk comes in.

6. If your baby is unable to nurse, pump to keep up your milk supply.

Sometimes a baby is too premature or too ill to be put to the breast at first. For some premature babies, it may be weeks before they develop the physical strength and sucking reflexes that make nursing possible. When that is the case, it is most helpful if you can pump to develop a good milk supply.

In most cases, your baby will be given the milk you pump. Even if that is not possible, continuing to pump on a regular basis (every three to four hours) will mean that when your baby does begin to breastfeed, you will have plenty of milk. Your hospital may have a high-quality electric pump available for you to use or may be able to suggest places where you can rent one.

7. Trust your baby's signals rather than follow the clock.

Instead of following a feeding schedule, watch for your baby's unique signals that she wants to nurse. She might squirm around and move her head back and forth, make smacking noises with her lips, try to get her hand in her mouth or suck on a corner of her blanket.

That's the policy Joanne Elder has been following since Naomi was born four days ago. "If I feed her and she starts to fuss 15 minutes later, I just nurse her again. I don't worry about how long it's been, I'm just paying attention to her. And it's working. My milk came in much earlier this time, and she's really filling her diapers."

Ayre-Jaschke observes, "Schedules aren't good for breastfed babies, particularly in the early days and weeks."

8. Learn to get a good latch.

McBriarty says that getting the baby latched on well is important, but reassures new mothers that they shouldn't worry if they don't get it perfect the very first time. "It does take practice! So relax. And try nursing before your baby gets really hungry, when you'll both have a little more patience."

McBriarty describes good breastfeeding technique this way: "Sit with pillows supporting you, your arm and the baby. Make sure the baby's face, chest and hips are all facing directly towards you. Cup your breast with your free hand, fingers below and thumb above and tickle the baby's lips with your nipple. He should open his mouth really wide. Then pull him straight in to your breast, getting as much of the areola in his mouth as possible. Don't let him slide down so that he's just sucking on the nipple. You will see his jaw working and hear him swallowing. Try again if he doesn't seem to be sucking well or if you are experiencing pain."

In the first two or three days, your breasts produce colostrum, a special milk which is rich in antibodies. Since the volume of colostrum is small, you may not see much swallowing. You want to be sure that your baby has a good mouthful of breast, and you should see a sucking pattern that changes from rapid, almost fluttering sucks to slower, rhythmic sucking as he gets a few mouthfuls of colostrum.

Ayre-Jaschke adds: "It's important to let the baby decide when she is finished." How will you know? "The baby will just come off the breast, usually looking content or perhaps falling asleep," says Ayre-Jaschke. "Then you can change baby's diapers, and offer the second breast - but she may be full enough from the first side. Just be sure to offer the other breast first next time."

9. Avoid pacifiers and bottles in the early days.

Another technique tip from McBriarty: "Nipple confusion can be a problem if newborns are offered pacifiers or bottles in the first few weeks. Babies must learn a complex tongue movement to squeeze milk from the breast. Bottles require a very different mouth action, and have a faster flow of milk. While some babies manage to feed from both, others quickly run into problems with nursing - and this can lead to sore, cracked nipples for the mother and a frustrated baby who isn't getting enough milk from the breast. While you and baby are learning, avoid using bottles or pacifiers - even though they can be very tempting."

10. Catch problems early and don't hesitate to ask for help.

This sounds like common-sense advice, but how does a brand-new mother know if things are going well or not?

Ayre-Jaschke suggests: "By day three or four, your baby should be nursing at least eight to ten times in 24 hours, breastfeeding should be comfortable - you may feel some tenderness or discomfort as baby latches on but not any toe-curling pain - and you should hear the baby swallowing for a good portion of the feeding."

Painful nipples may also be the result of thrush - a yeast infection - and the risk of this is increased if you have been given antibiotics during labour or in the postpartum period. If antibiotics are needed, ask your doctor for an anti-fungal cream at the same time, to be used at the first signs of burning nipple pain that continues between feedings.

You can also look for signs of good feeding at your baby's other end. In the first few days, look for a steady increase in wet diapers - perhaps one the first day, two the second, and four on the third day. By the latter part of the first week, when your milk has "come in," your baby should have six to eight very wet diapers (four to six if you are using disposables) and at least two or three bowel movements in 24 hours. The baby's bowel movements should gradually change from tarry and black on the first day to yellow and loose by day four or five.

McBriarty adds: "Babies tend to lose about ten percent of their birth weight in the first couple of days. Don't get too worried about this. Count the wet and poopy diapers. As long as your baby starts to regain that lost weight at a rate of four to seven ounces per week, he's doing OK."

If your baby isn't meeting these guidelines, or if you have painful, cracked or bleeding nipples, pain in your breast or are concerned for other reasons, don't hesitate to call your doctor, public health nurse, La Leche League leader or lactation consultant for advice. The sooner you begin working on a problem, the more quickly it can be resolved.

Resources

To find a La Leche League leader or group near you, call LLL Canada at 1-800-665-4324. There is also a listing on their Web site.

To find a lactation consultant, contact the International Lactation Consultants Association. Phone (919) 787-5181 or e-mail ilca@erols.com

Your local hospital or public health unit may also offer a breastfeeding clinic or other breastfeeding help.

Breast Is Best is an informative and enjoyable video available from the Infant Feeding Action Coalition (INFACT Canada). To order, e-mail infact@ftn.net or phone (416) 595-9819.

Good general breastfeeding books:

The Womanly Art of Breastfeeding (sixth edition) , La Leche League International, 1997. Available from local LLL groups or from LLL Canada (see above).

So That's What They're For! Breastfeeding Basics, by Janet Tamara, Adams Media Corporation, 1998. Good practical advice with a lighthearted approach.

Bestfeeding: Getting Breastfeeding Right for You, by Mary Renfrew, Chloe Fisher and Suzanne Arms, Celestial Arts, 1990. Well illustrated, with lots of detail about positioning and latch.

Books that deal with specific situations:

Nursing Mother, Working Mother: The Essential Guide for Breastfeeding and Staying Close to Your Baby After You Return to Work, by Gale Pryor, Harvard Common Press, 1997.

Breastfeeding Your Premature Baby, by Gwen Gotsch, La Leche League International, 1999.

Mothering Multiples: Breastfeeding and Caring for Twins, Triplets and More!, by Karen Gromada, revised edition, La Leche League International, 1999.

Originally published in Today's Parent, Pregnancy & Birth, Autumn 1999