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Breastfeeding Problems and Solutions

Michael Brian

Breastfeeding even under the best of circumstances can present challenges, as both mother and baby are learning what to do. Yet, breastfeeding is well worth the effort it takes to overcome hurdles you encounter. Your baby receives important nutritional, immunological, and developmental benefits, and both of you get to enjoy the special closeness of a nursing mother and baby. Here are some common breastfeeding problems mothers experience, and the solutions our personal and professional experience has taught us.

How can I get my baby to latch on properly?

In our experience, the most common breastfeeding obstacle is improper latch-on. A baby who does not take the breast correctly will not get as much milk and will probably give his mother sore nipples. Here's what we tell mothers:

First, position yourself correctly. Milk flows better from a relaxed mother, and it's easier to breastfeed your baby if your arms, back, and shoulders are well-supported. Prepare a nursing station in your favorite room with a comfortable chair, plenty of pillows for support, and peace and quiet or soothing music. After you've prepared your body to breastfeed, prepare your mind. Take a few relaxing breaths and imagine your nourishing milk flowing from your breasts into your baby. Help your infant to relax, too. If she's crying, rock and sing to her until she quiets down. If she's sleepy, gently bring her body into a sitting position while saying her name. Babies latch on best when they are in a quiet, yet alert, state.

Next, position your baby correctly. Whether you use the cradle hold (baby cradled in your arms lying on a pillow on your lap), the clutch or football hold (baby's body tucked to the side, under your arm, near your breast, neck supported by your cupped hand), or the side-lying position (nursing in bed), be sure that Baby's head and body are turned to face your breast with her mouth at the level of your nipple. Pull her in close -- she should not have to turn her head or strain her neck to reach your nipple.

Cup your breast in your hand, with your fingers and palm underneath and thumb on top, well behind the areola. Avoid the "cigarette hold" (when the nipple is between your two fingers) because your fingers would be right where baby needs to latch on. Express a few drops of milk. Using your milk-moistened nipple, gently massage your baby's lips, encouraging her to open her mouth wide, like yawning. As she opens wide, direct your nipple slightly upward and toward the center of her mouth, and with a rapid arm movement, pull her close to you, so that her mouth will close down over your areola. We call this technique "RAM," an abbreviation of "rapid arm movement." It may sound startling at first to say "RAM Baby on," but it really helps mothers remember two important components of latching on: that they need to move their arm to draw their infant in closer (rather than leaning forward, which can make their backs sore), and that they must move quickly before the baby's mouth closes again.

Make sure your baby feeds from the areola, not just the nipple. To prevent painful breastfeeding, her gums should take in a one-inch radius around the nipple as she latches on. Compressing this area allows your baby to get more milk, since the milk sinuses are located under the areola.

Contributing editors Martha Sears, R.N., and William Sears, M.D., are coauthors of The Breastfeeding Book.

Pinching, Cracked Nipples, and How Much Is Enough

What if I feel a pinching sensation?

While a bit of initial discomfort is to be expected in the first two to four days of breastfeeding, persistent pain usually means your baby is not latching on properly. To improve Baby's latch-on, be sure his mouth is wide open as he takes the breast; both of his lips should be turned out (everted). When your baby takes the breast with mouth open wide, he'll have a "fish mouth" look as he nurses, and you should not be able to see your nipple. Be sure your baby's tongue is between his lower gum and your breast. (If you pull down gently on Baby's lower lip, you should be able to see his tongue.) If his bottom lip is pulled inward instead of outward, use the index finger of the hand that is supporting your breast to pull out that lower lip. (You may need a helper to take a peek under the breast and do this for you while Baby is latched on.) This "lower lip flip," as we call it, may be all that's needed to keep your infant from tight-mouthing your nipple.

If your baby doesn't get onto the breast well at the first try, take him off (break the suction with your little finger inserted into his mouth) and try again, waiting for that wide-open mouth. Don't settle for a less-than-great latch-on: Be patient, keep trying, and soon your baby will learn exactly what to do.

How can I tell if my baby is getting enough milk?

In the first few weeks, many mothers worry about whether their babies are getting enough breast milk. There's no handy way to measure the ounces going in, and the amount of milk you can pump bears little relation to how much milk your baby is getting from the breast. It's better to watch the baby for signs that he is getting enough to eat. Do you notice a few drops of milk leaking from the sides of your baby's mouth and hear him swallow after every one or two sucks? Does he seem content after a feeding? By the fourth day after birth, your baby should wet about six diapers a day. Pale, almost water-colored urine suggests baby is getting enough milk to stay adequately hydrated; darker, apple-juice-colored urine suggests that he is not. Baby's stool output is another helpful indicator. Within a day or two of your milk coming in, your baby's bowel movements change from sticky black meconium to "milk stools." These are yellow, seedy, mustard-colored and the consistency of cottage cheese. Babies between 1 and 4 weeks who are getting enough milk will produce at least two to three of these stools a day, often more. If a lot of urine and stools come out in the diaper, rest assured that enough milk is going in. (During the second or third month, some breastfed babies may have only one bowel movement a day while still getting enough milk.) You'll also observe that your breasts feel softer after a feeding in which baby takes plenty of milk.

The bottom line is baby's weight gain. After the normal initial loss of five to seven percent of their birth weight (five to seven ounces for an average 6-pound baby), babies should regain their birth weight by two weeks of age. As a general guide, a baby getting sufficient milk should gain four to seven ounces a week, or a minimum of a pound a month. If you think your baby is not getting enough milk, take immediate steps to improve nursing (a lactation consultant or your doctor can help) and take your child to the pediatrician every few days.

What if I have cracked nipples?

Cracked nipples are usually caused by improper latch-on. When your baby doesn't get enough breast tissue into his mouth, all the sucking pressure is concentrated on the nipple.

Try feeding Baby first on the side that is the least sore. Usually the most uncomfortable part of a feeding is the minute or two of sucking it takes to trigger your milk-ejection reflex. Once the milk is flowing freely, nursing will probably be more comfortable. Mothers with sore nipples are often tempted to nurse less frequently, but this aggravates the problem, since your breast can become engorged, making it more difficult for Baby to latch on. Try to feed more frequently while being vigilant about proper latch-on. After nursing, you can massage medical-grade ultrapure lanolin ointment onto the cracked area. If the crack does not improve within a day or two, call a lactation consultant. If it becomes infected (if your baby has thrush, for example, the yeast can infect your breasts), your doctor can prescribe medication.

Clogged Ducts and Feeding After C-Section

How do I handle a clogged milk duct?

If you notice a tender lump somewhere in your breast, it may mean that a duct leading from the milk-producing glands to the nipple is blocked with milk. Untreated, the area can become inflamed and even infected (a condition called mastitis). To treat a clogged duct, apply warm moist compresses to the area for a few minutes before feeding. Breastfeeding on the sore side first often helps, as your baby is more likely to dislodge the plug at the beginning of a feeding when her sucking is strongest. As Baby nurses, gently massage the area down toward the areola to encourage the plug to clear. If you start to develop flu-like symptoms (fever, chills, body aches, and fatigue), you may have mastitis. Your doctor can prescribe antibiotics.

Plugged ducts are most likely to occur when your infant is nursing less often -- if you're away from home, or when she suddenly begins to sleep for longer stretches at night. To prevent them from recurring, breastfeed frequently, especially if your breasts feel full. (If your baby isn't hungry, pump and store the milk.) Feeding your baby in different positions also helps. Avoid tight bras and sleeping on your stomach, as both can put unnecessary pressure on your breasts. Most important, get adequate rest: Recurrent mastitis can be a sign of a run-down immune system.

I'm scheduled for a c-section. How will I breastfeed during my recovery?

After a cesarean birth, your body must be allowed to heal while you learn to care for your baby and breastfeed. You need extra help: Ask the nurses or your lactation consultant for help with early feedings, and have them show your partner how to help you get positioned for nursing. Breastfeed in the side-lying and clutch-hold positions to keep Baby's weight off your incision. Use lots of pillows: If you nurse lying down on your side, you'll need two pillows behind your back, a pillow between your knees, one under your head, and one to support baby on his side. Wedging a "tummy pillow" between the bed and your abdomen can help keep the pressure off your incision. You can also nurse while sitting up in bed; a day or two after surgery, you may be more comfortable nursing while sitting up in a chair, with your infant on pillows in your lap. Some mothers mistakenly assume that they should refuse pain medication, but there are medications that are safe for breastfeeding moms to take. Pain will only suppress your milk production and keep you from enjoying your first few days with your new baby. The anesthesiologist can give you a long-acting anesthetic immediately after the birth to ease postoperative pain when you are first holding and nursing your baby. It may take a bit longer for your milk to come in following a cesarean birth, and longer for the baby to learn to latch on, but mothers who have surgical births can be just as successful at breastfeeding as mothers who deliver vaginally.

Supplements and Biting

What if I need to supplement with formula?

"Combo feeding" (breastfeeding and supplemental formula) can work, but it's important to get breastfeeding off to a good start for a few weeks before introducing commercial nipples. Otherwise, babies can become "nipple confused," which means they try to suck at the breast the way they get milk out of a bottle. This is not very effective, and it can be painful! If formula supplementation is medically necessary within the first month, a lactation consultant can help you try supplementing with a syringe or a nursing supplementer, a handy device that delivers breast milk or formula through a flexible tube attached to your nipple, while baby breastfeeds. Supplementers help babies learn to suck from a mother's nipple. As an added perk, mother gets the milk-making hormonal stimulation as Baby sucks at her breast.

Breastfed babies sometimes refuse to take bottles offered by Mom because it just doesn't feel right. Dad or a substitute caregiver may be more successful at persuading a baby that food can come from other sources. Choose a nipple with a wide base so that baby has to open his mouth wide as he does at the breast. This will minimize problems with lazy latch-on when baby is fed at the breast.

Don't take it personally if your baby appears to prefer pumped breast milk or formula from a bottle. It usually doesn't take as much effort to get milk from a commercial nipple. (This is a good reason to avoid them in the early weeks.) If you are planning to combine breastfeeding with formula supplements, or if you find yourself doing this, try to give breastfeeding priority. The more you substitute formula feedings for feedings at the breast, the less milk your breasts will make, and it's possible that your baby's interest in breastfeeding will also wane. Combo feeding works for many mothers, but use some caution or your baby may stop breastfeeding before you had planned on weaning.

Help! My baby bites during feedings!

Babies eventually sprout teeth, with the first ones arriving around six months of age, and when they get them, they experiment with them, which can lead to a startled "ouch" from Mom when she gets nipped during nursing. Even though babies do bite the breast that feeds them, you don't need to be a human pacifier. And, this doesn't mean it's time to wean (even toddlers with lots of teeth can breastfeed without causing pain). It is time to teach your baby some nursing manners. It's okay to holler "ouch!" when Baby clamps down. To pry your nipple out of your child's mouth without any further damage, wedge a finger in between his gums and hook it around your nipple. If he bites down again before the nipple is out of his mouth, your finger will protect your tender nipple. That startled "ouch" may frighten some babies and intrigue others. If your baby cries at your reaction, calm him and immediately resume nursing. If he bites again -- with a curious gleam in his eye -- it's time to end the feeding and do something else together. Eventually, your infant will associate biting with an end to the feeding, and will stop biting. Another trick used by mothers of biters, me included, is to draw the baby in closer to the breast as soon as you feel that first nip, or even when Baby looks like he's about to bite. He'll automatically let go in order to breathe.

Breastfeeding requires large doses of commitment, a helping of patience, and a sense of humor. While you may experience some problems, rest assured that with help, you will likely be able to work through these challenges and enjoy this special bond with your baby.

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