Q. My 3-month-old is constantly crying while at the breast. He's been doing this since he was about 4 or 5 weeks old. We've already seen a lactation consultant, I've tried going off dairy, and the pediatrician prescribed Zantac for my baby's reflux. I think part of the problem could be my fast milk ejection reflex. He chokes while nursing, which leads to the crying. Sometimes he just gives up and refuses to nurse anymore. What can I do?
A. Breastfeeding should be pleasant for both mother and baby, and your baby's distress does not indicate a pleasurable experience. While food allergens in your diet can pass through your milk and affect your baby, it doesn't sound as if that's happening in your case. Infants with food allergies (generally to dairy or wheat products in the mother's diet) have diarrhea, bloating, and abdominal pain after, but not during, feeding.
Gastroesophageal reflux (GER) is also a common cause of pain associated with eating, but, similar to food allergies, the pain from reflux usually occurs immediately or shortly after eating. It sounds as if your suspicions that an overactive milk ejection reflex is responsible for your baby's upset are correct. During breastfeeding, there is usually a balanced supply and demand -- you supply the exact amount of milk that baby needs at a rate he can swallow and digest. Even though some nursing mothers do deliver more milk than a baby can handle at one feeding, by 3 months of age the supply and demand usually clicks in. It sounds as if this balancing has not yet happened for you. You should continue working with your health care provider and pediatrician to find out the exact source of your baby's nursing discomfort. In the meantime, here's how you can help him feed more comfortably:
Pump before feeding. Try manually expressing a few squirts of your milk into a container for 30 to 60 seconds prior to breastfeeding. Expressing just a bit of your milk before breastfeeding may slow down the delivery of milk. You can either pump and dump, or save the expressed milk for situations when your baby will need a bottle.
Burp and switch. As soon as you've finished nursing on one breast, take time to burp your baby before switching him to the second breast. This allows any trapped air bubbles in the stomach to be expelled and gives the milk from the first breast a bit of extra time to digest. Infants have tiny tummies (about the size of their fist), so eating too much too fast can cause discomfort and spitting up.
Feed twice as often, and half as much. This rule of thumb works well for most feeding disturbances, such as ingesting too much milk at one time, milk allergies, and gastroesophageal reflux. Fast feeders will get more milk entering the intestines than they can digest at once. Normally, the intestinal lining secretes enzymes, such as lactase, to digest the lactose or milk sugar. In the early months, if baby gets too much milk at one feeding, there may be more lactose entering the intestines than there is lactase available to digest it. The result: The leftover lactose ferments, causing gas, bloating, and discomfort. Feeding smaller amounts more frequently allows digestion to take place more easily.
Keep baby upright after feeding. Gravity helps keep food down. For twenty to thirty minutes after feeding, let your baby remain upright in your arms at a 30 degree angle. Also, try not to jostle him after a feeding -- otherwise much of the milk is likely to end up on your clothing!
Calm baby before feeding. A baby who is very hungry or upset is likely to feed too fast and too frantically, causing him to swallow too much air and/or milk too quickly. Get in the habit of looking for your baby's early hunger cues -- perhaps he smacks his lips, or roots toward your breast -- and feed him right away before he has a chance to get distressed. Also, be sure your baby has an efficient latch-on. A professional lactation consultant can help you with this. Your baby's lips need to form a reasonably tight seal around your areola. Check out your baby's lower lip: If it's pursed in, flip it out, so it looks like "fish lips." Be sure he opens his mouth wide enough so that he sucks mainly on the areola tissue around your nipples and not on the nipples themselves. The milk glands are located just below your areola (the dark skin that encircles your nipple). You want him to compress these glands during feeding.
Use the above feeding strategies, and you and your baby should ease into a comfortable breastfeeding relationship. Just give it some time: In my experience, most too-fast milk delivery problems subside by 4 months of age, if not earlier.