Breast advice

The experts answer your most common nursing questions

Sure, it’s natural, normal and best for mother and baby — but that doesn’t mean breastfeeding always goes smoothly. Sore nipples or worries about a fussy baby can make nursing a challenge. But take heart: Most breastfeeding difficulties can be resolved. Here are some of the most common questions mothers have asked me during my 28 years as a La Leche League leader.

My nipples are very sore (or cracked or bleeding). What can I do to make breastfeeding less painful?
“While sore nipples are common, they shouldn’t be accepted as a normal part of breastfeeding,” says Toronto paediatrician Jack Newman, a breastfeeding specialist. Often sore nipples can be improved by adjusting the way the baby latches on. Newman teaches an “asymmetrical latch” — the baby’s head is tipped back slightly, her chin is buried in the breast, the nose is clear of the breast, and more of the breast is covered by baby’s bottom jaw than the top jaw. “When the latch is improved, mothers usually notice the difference immediately,” he says.

Sometimes women experience pain when the baby first latches on, then it subsides after a few seconds. Here’s what’s happening: The baby hasn’t latched well, but his sucking pulls the nipple into a better position. Unfortunately, a lot of pain can be caused in those first few seconds, so it’s better to improve the latch from the beginning.

Newman says that it’s not helpful to keep unlatching and re-latching the baby. Instead, adjust his position while he nurses (by moving his body a bit more toward the middle of your body, letting his head tip back a bit more, and tucking his shoulders in closer).

While latch problems are probably the most common cause of sore nipples, Newman adds that there are other possibilities, such as tongue-tie. That means baby’s frenulum (the tissue that attaches the tongue to the bottom of his mouth) is too tight to allow the tongue to move normally. A doctor can cut the frenulum (it’s a quick office procedure) and the improvement is often quite dramatic.

Another cause: an overgrowth of candida (also called thrush) on the mother’s nipples. Candida pain tends to be described as “burning or shooting” and typically can also be felt between feedings. Consult with your doctor if you think this might be the cause of your nipple pain.

I’m not sure if my baby is getting enough milk. How can I tell?
“Mothers often think their baby isn’t getting enough milk if the baby cries a lot or is nursing frequently,” says lactation consultant Diana West, co-author of Making More Milk: A Nursing Mother’s Guide to Milk Supply. Fussiness, though, doesn’t necessarily mean the baby is not getting enough, and it is normal for new babies to nurse as often as eight to 10 times per day, and some nurse even more.

So how do you know if your baby is getting enough? The best way is to count her bowel movements, as well as monitoring her weight gain.

West gives these guidelines:

• You should see at least three poops every 24 hours for a baby between four days and four weeks old. After that, pooping may be less frequent but should be substantial.

• Expect the baby to gain at least five ounces (142 g) per week for the first three months, slowing to around three to four ounces (85 to 113 g) per week from four to six months, and around two ounces (57 g) a week for the rest of the first year. A slower rate of weight gain should be checked by your doctor.

My baby is gaining too slowly. How can I increase my milk production?
You need to know the cause of the problem before you can solve it, and this may require help from a lactation consultant or other expert. Sometimes the mother has plenty of milk, but the baby isn’t able to get it because of a poor latch or tongue-tie. The mother may have not been breastfeeding often enough, or may have a medical condition limiting milk production.

More frequent feeding, perhaps with some extra pumping or hand-expressing, will often make more milk. (Spending a weekend in bed with the baby and feeding as often as possible can give you a jump-start.) You might want to discuss the option of herbal supplements or domperidone, a prescription medication, with your doctor.

West says that increasing milk production may take time, so until you are making more, you may need to supplement, either with your own expressed milk or formula. Because supplementing may reduce the amount your baby takes at the breast, it’s important to pump or hand-express your milk as well, to maintain your milk production.

I haven’t been able to get my baby to latch on. I’m pumping my milk and feeding it to him, but how can I get him to feed at the breast?
Lactation consultant Sandra Yates of North Vancouver says: “Your baby is more likely to act on his instinct to suck when he is sleepy, so give him lots of skin-to-skin time when he is drifting off to sleep or just beginning to rouse from sleep. Hold him against your chest and he may begin to seek the breast on his own and latch.”

Yates also suggests using a nipple shield during the transition from bottle-feeding to breastfeeding. “It has a similar feel to a bottle nipple, so some babies who are used to taking bottles will take the breast more easily.”

If the baby does latch on, Yates suggests squeezing the breast in time with the baby’s sucking (breast compressions). When he sucks but does not swallow, squeeze the breast and he’ll start to swallow and drink. When he stops swallowing, release the compressions, and when he sucks again (but does not swallow), squeeze again, and so on. She adds that some babies may make the transition to breastfeeding quickly, while for others it takes longer, but if the mother keeps up her milk production, most babies will eventually learn to nurse.

What is this tender, hard spot in my breast, and what can I do about it?
It’s likely a plugged duct, says Yates. She suggests having a warm shower or applying a warm compress to the area. Then massage the breast from behind the lump, along the duct and toward the nipple. Immediately feed the baby on that breast. You might have to repeat this for a day or two. If the duct hasn’t cleared within three days, consult your doctor.

Yates adds that if a fever or flu-like symptoms develop, you may have an inflammation of the breast called mastitis. This should be checked out by a doctor, as antibiotics may be needed.

How should I pump and store my milk?
There’s no one answer to that question, says lactation consultant Melisande Neal of Millbrook, Ont. If you are storing milk because you want a night out, your needs will be different than if you have a premature baby in the hospital, or if you are returning to work. In any case, you might need to experiment a bit to find what approach works for you, Neal explains. “For some mothers, hand-expressing works well, others may use a small hand pump and others need the higher-grade electric pump.” Pumps that include compression as well as suction seem to work best, she says. See below for information on storing milk.

Safely storing milk

Lactation consultant Melisande Neal gives these guidelines based on The Breastfeeding Answer Book:

Colostrum

  27–32ºC (81–90ºF)

12 hours

Mature milk

  Room temperature 19–22ºC (66–72ºF)

12 hours

 Fridge

8 days

Freezer above fridge

4 months

Chest freezer

6 months or longer

My baby is fussy and has almost explosive bowel movements. I think it could be related to something I’ve eaten. Can she be sensitive to foods in my diet?
“The most common sensitivities seem to be to cow’s milk and wheat,” says Neal. “Unfortunately, those are in many foods, and are often hidden. Mothers really have to pay attention to the labels.” Be cautious, though, about replacing cow’s milk with soy milk, since soy often causes symptoms in babies as well. Caffeine is another common culprit. Neal suggests mothers keep a food diary to see if they can find a connection between what they’ve eaten and the baby’s reactions.

“You often need to eliminate dairy for three weeks before you see a really significant improvement,” Neal adds. You may also want to talk to a dietitian to be sure you are getting the nutrients you need.

It’s important to note that these symptoms can also be due to an oversupply of milk. Some mothers with abundant, fast-flowing milk find that their babies get more of the lower-fat foremilk, which seems to move too quickly through their digestive systems, causing gas and explosive bowel movements. Strategies to reduce this problem include giving the baby just one breast at each feeding.

My doctor has recommended I take medication. Do I have to stop breastfeeding?
“With only a few exceptions, such as some anti-cancer drugs, the amount of medication that gets into your milk is very low and has no effect on the baby,” says Newman. Discuss the impact of your medications with your doctor. You can also contact Motherisk (motherisk.org), which provides guidance on the effect of substances on fetuses and infants.

Some medications can reduce milk production. These include hormonal birth control and some decongestants and antihistamines.

In the past, mothers who needed to supplement their breastmilk were usually advised to breastfeed first, then give the baby any supplement that was needed from a bottle, says lactation consultant Diana West. This often led to the baby taking less and less at the breast and eventually weaning. She suggests giving the baby a bit less than the usual amount of supplement before breastfeeding. “The baby then has more patience to nurse longer and takes more milk. When the baby ends the feed, she learns to associate the feelings of pleasure and satisfaction with breastfeeding, so she is more motivated to feed longer and better at the breast,” West explains.

Getting help

Thanks to recent research, we now understand more about how breastfeeding works, and the experts are finding new strategies to help overcome the challenges. If you have concerns related to breastfeeding, here are some places to look for up-to-date help:

clca-accl.ca Canadian Lactation Consultants Association
lllc.ca La Leche League Canada
drjacknewman.com Jack Newman’s website

You can also contact your local public health unit, as many have lactation consultants on staff.

Sometimes you have to try more than one strategy (or consult with more than one person) before breastfeeding becomes the easy and enjoyable experience it should be.

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