Breastfeeding problems solved!

Early difficulties can put a damper on a good thing, but not if you know how to fix them!
Photo: iStockphoto

Photo: iStockphoto

The statistics tell the story: While the great majority of new mothers in Canada start out breastfeeding, many have stopped within weeks. For example, the Ontario Maternal and Infant Survey found that about 90 percent of the mothers in that study started out breastfeeding, but about 20 percent had weaned before their babies were a month old. However, early difficulties don’t have to mean the end of breastfeeding! Here are solutions to some of the challenges that can derail your breastfeeding journey.

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Engorgement
It’s two, three, maybe four days after your baby’s birth and your breasts are swollen, rock-hard and painful. Your baby finds it impossible to latch on.

Possible causes Lactation consultant Jill Hicks, who works at Milton Hospital in Milton, Ont., says: “Engorgement results partly because the mature milk has now come in, and also because of extra blood flow to the breasts. IV fluids during labour can make the engorgement worse. If the milk is not removed often enough, inflammation can set in and cause more swelling.”


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Solutions “Frequent feeding helps to keep the milk flowing and reduce inflammation,” says Hicks. “Warm compresses on the breasts before feeding can help the milk to flow, or you can stand in a warm shower for a little while before feeding the baby. After each feeding, try cold compresses or clean cabbage leaves to reduce the swelling.” Pain-relieving medications may help as well. Some mothers find it helps to pump a small amount of milk to relieve the fullness and make it easier for the baby to latch on.

However, if you’ve had IV fluids during labour, pumping may pull more fluid into your breasts and make things worse. Instead, Hicks recommends a technique called “reverse pressure softening.” The mother uses her fingers to press against the tissue in a circle around the nipple. This leaves an indented area where the baby can now latch on. “The baby who could hardly latch at all before is now going gulp, gulp, gulp,” says Hicks. “Mothers say it is such a relief.”

Sore nipples
It hurts! You may feel a painful tug as your baby starts to suckle, or it may feel as though your baby is rubbing your nipples with sandpaper during the feeding. In time, you may see blisters, cracks or bleeding nipples. (If you feel a burning or shooting pain that lasts after you’ve finished feeding, it may be thrush.)

Possible causes Lactation consultant Jacki Glover, of Lethbridge, Alta., says the most common cause of nipple trauma is “not having a deep enough attachment of the baby to the breast.” Yes, she’s talking about latch (see The latch). Sometimes the positioning of the baby is good, but the baby has a tongue-tie — meaning the frenulum, the little membrane under the tongue, is too short. This prevents him from using his tongue effectively, and so the nipple is damaged. Nipple pain that continues after the latch has been improved may be caused by an infection in the cracked or abraded skin.

Solutions “It’s always better to prevent a problem,” says Glover. “Babies kept in skin-to-skin contact with their mothers after birth often have the ability to find the breast and latch spontaneously and comfortably.” If the baby is not doing this on his own, Glover says, “the mother needs to provide stability for the baby’s shoulders, spine and hips with no pressure on the baby’s head, and the baby needs to be facing the mother and not having to turn his head to latch on.” Feeding the baby in response to his cues is also important, and pacifiers and bottles should be avoided. Babies suck on a pacifier or bottle nipple quite differently than at the breast and, for some, this leads to a shallow, pain-inducing latch at the breast.

If your nipples are sore, Glover encourages meeting with a lactation consultant or other breastfeeding expert who can help you assess possible causes. If the baby has a tongue-tie, the consultant may recommend having the baby’s frenulum clipped by a doctor. If the baby’s position at the breast is the issue, you can get help in finding a position that works for you. “Frequent and extended skin-to-skin contact helps relax the baby and mother, and leads to a more effective latch,” Glover adds. “Find a comfortable position and place for feeding. You may want to apply warm, moist compresses to your nipples before and after feeding.” Expressing a little milk onto your nipples and letting it dry there can be soothing and help reduce the risk of infection.

“Many mothers find that clothing brushing on the nipples or sticking to them aggravates the soreness,” Glover adds. “Hard plastic breast shells to cover them can be purchased, or mothers can make ‘doughnuts’ out of strips of cloth.” The doughnuts are worn inside the bra and hold the fabric away from the nipple. Glover finds that using nipple shields while feeding the baby can help some mothers but, in other cases, it makes the soreness worse, and the mother’s milk supply decreases. “I would want to follow the baby closely for weight gain and be sure the mother’s nipples are healing,” says Glover.

Her most important advice: “Early intervention can prevent further trauma. Any mother experiencing nipple soreness should get help before things worsen.”

Baby won’t latch
You’ve followed the instructions about positioning and tried to get your baby to nurse, but she won’t open her mouth or won’t grasp the breast, or she takes the nipple in her mouth, but doesn’t suck. This may have been a problem from birth on, or the baby may have fed well at first, but now won’t.

Possible causes “This does not have a simple answer,” says Glover. “Initial problems with not latching may be caused by medications given to the mother in labour, by suctioning at birth, by forcing the baby to the breast, or by holding the baby’s head for latching.” It may also indicate that the baby has some health problems that need investigation. While many women with inverted nipples have no difficulty with breastfeeding, this is sometimes associated with a baby who won’t latch.

If the baby was nursing well for a while, but then stops, this is called a nursing strike. These strikes can be caused by colds or ear infections, by giving the baby bottle-feedings, even by sudden loud noises while the baby is nursing or a change in the mother’s deodorant.

Solutions “Think of this as a detour,” says Glover. “The road back includes plenty of skin-to-skin contact, which often leads to the baby spontaneously latching on; expressing the breasts regularly to establish and maintain milk production; and feeding the baby by cup or bottle until feeding at the breast is established or re-established.” The baby should also be assessed for possible problems that might be affecting her ability to breastfeed. If the baby is still not latching after a few days, Glover will sometimes suggest a nipple shield.

The latch An effective latch means that the baby is able to get the milk he needs and the mother is comfortable. Many mothers and babies find their own best position, but here’s a technique that works for many: Position your baby tummy to tummy, supporting his body with your right arm, with your right hand behind his shoulders and his neck against the webbing between your thumb and first finger. Your hand should not be touching his head. Use your left hand to support your left breast, while keeping your fingers well back from the nipple. Aim the nipple at baby’s nose, and bring him in close so that his chin is touching your breast. As he opens his mouth wide, tuck his body close to yours and let him take the nipple deeply into his mouth. His nose should be clear of your breast and his chin pressed against it, and you should hear his initial fast sucks change to slower, rhythmic sucks and swallows, as feeding continues.

Thrush
“The symptom that makes most mothers reach for the phone to call for help is a burning, stinging or shooting pain that is impossible to ignore,” says lactation consultant Helen Bratzel of Windsor, Ont. The pain may start after weeks of pain-free breastfeeding, or right from the beginning. Pain often continues after the feeding. Your nipple or breast may feel itchy and may look pink and shiny. Your baby might have symptoms of thrush as well (usually white patches inside his mouth or a pimply red rash on his bottom that won’t go away).

Possible causes Thrush is an overgrowth of Candida albicans, an organism that normally lives on our skin and in our bodies. Antibiotics, corticosteroids, estrogen-containing medications (such as some birth control pills) and other medications can be factors, as can nipple damage from a poor latch. Warm, humid weather makes it easier for the Candida albicans to grow, and diets high in sugar and dairy also encourage thrush.

Solutions “If a mother thinks she has thrush, she should call her doctor or midwife as soon as possible,” says Bratzel. “Diagnosis is important before treatment begins, as the pain could be from other causes. Thrush can be very stubborn and the sooner it’s treated, the sooner the pain will stop. Both mother and baby should be treated.” Usually, an antifungal cream is prescribed for the mother’s nipples and an oral antifungal medicine for the baby. “There is also an ointment [see below], developed by paediatrician Jack Newman, that contains antifungal, antibacterial and anti-inflammatory medications which deal with several causes of nipple pain at once,” Bratzel adds. “It’s so popular in my area that a number of pharmacies keep the ingredients stocked.”

To clear up thrush, the mother needs to keep up the treatment for both herself and the baby for the full duration of the prescription, even if her symptoms are gone. She may also need to try more than one medication as some strains of the Candida albicans are resistant to some medications.

Dr. Newman’s thrush ointment The ointment has to be prescribed, but the components are:
• Mupirocin 2% ointment – 15 grams
• Betamethasone 0.1% ointment – 15 grams
• Miconazole powder to make a final concentration of 2% miconazole (or clotrimazole powder if miconazole not available)

The pharmacist mixes this together, and the mother applies it sparingly to her nipples after each feeding. Details are in Dr. Jack Newman’s Guide to Breastfeeding (rev.) by Dr. Jack Newman and Teresa Pitman, HarperCollins 2003.

Not enough ,ilk
Your baby’s weight gain is lower than expected (average is about four to seven ounces per week, after the drop in the first week), and you’re seeing few wet or poopy diapers. Mothers sometimes worry that a baby who is fussy, cries a lot and wants to nurse frequently is not getting enough milk, but these could also be signs of a baby who is colicky, sensitive to something in mom’s diet, or dealing with too much milk rather than not enough

Possible causes Postpartum doula Robyn Berman of Halifax says: “Many new mothers aren’t aware that frequent feedings, especially in the early days, are important to signal the body to produce enough milk to meet baby’s needs.” Trying to schedule or delay feedings can lead to lower milk production. An ineffective latch may have the same effect—even though baby may be at the breast frequently, she’s not able to take much milk each time.

Some women’s breasts haven’t developed normally and don’t produce a full milk supply. Mothers who have had breast surgery may also have difficulty producing enough milk. Another possible cause: taking hormonal birth control or certain other medications, including some decongestants.

Solutions “First, I want to make sure that the mother has a really deep, good latch and that the baby is drinking at the breast, not nibbling,” says Berman. “I would encourage the mother to use breast compression (which means squeezing the breast between thumb and all four fingers as though she’s hand-expressing into the baby’s mouth as he nurses) with each feeding to maximize the baby’s efficiency.” Berman often suggests that mom and baby spend a few days in bed together, if possible, to just focus on nursing at every opportunity, explaining that “sometimes this can turn things around very quickly.”

Pumping after feedings may also help. When these steps aren’t enough, Berman says the mother might want to consult with a breastfeeding expert to discuss taking herbal supplements or prescription medications to boost her milk supply.

If you find that, despite all efforts, you aren’t able to produce all that your baby needs, remember that your baby benefits from even a small amount of your milk. You can supplement while continuing to breastfeed as much as possible.

Other issues

Your breastfeeding challenges may be different: You may have an oversupply of milk, plugged ducts or mastitis. Don’t be discouraged! There is help out there. Your doctor, midwife or public health nurse should be able to help you find a lactation consultant, breastfeeding clinic or La Leche League leader. These resources can help you and your baby discover the happy breastfeeding relationship you deserve.

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