Q. My baby is due in a month, and I'm very eager to breastfeed. However, my nipples are flat, which I've heard can make latch-on more difficult. Do you have any suggestions that will help my baby breastfeed successfully?
A. While protuberant nipples can make grasping the breast easier for a baby, an infant can certainly learn to nurse effectively from flat, and even inverted, nipples. Try the following latch-on technique for nursing using the traditional cradle hold: Support your baby using your arm on the same side you will be breastfeeding. Her head should be resting in the crook of your elbow or on your forearm. Rotate your arm to turn your baby's whole body toward you, so the two of you are chest-to-chest. During the learning period, it is important that you support your breast using your opposite hand to help your baby stay well attached. Cup your four fingers under your breast, placing your index finger and thumb parallel to your baby's jaws and well behind the margin of your areola, the dark circular area surrounding your nipple. Your baby needs to grasp the entire nipple, plus at least one inch of surrounding areola and breast so her jaws are situated over your milk ducts.
With your baby turned toward you, lightly stroke the midpoint of her lips against your nipple until she opens her mouth widely, as if yawning, and then quickly pull her onto your breast. When she is latched on correctly, her mouth will be wide open with her lips flared out (a bit like a fish), her nose resting against your upper breast, and her chin against the underside of your breast. She will not grasp sufficient breast tissue if you try to push your nipple into her mouth or attempt to attach her when her mouth is only slightly open.
Some health-care providers recommend the use of breast shells, also known as milk cups, for women with flat or inverted nipples. These hard, plastic, dome-shaped devices can help make the nipple more protuberant by directing it forward through a central opening in the shell. This opening is situated over your nipple, and the device is held in place by a maternity bra during the last month or two of pregnancy. (Breast shells can also be worn between feedings after the baby is born.) Another strategy for making a flat or inverted nipple easier to grasp is to use a breast pump to draw it out before you feed your infant.
Don't be afraid to ask for help if you're having difficulty. Ideally, your first breastfeeding session will occur within 30 to 60 minutes after giving birth, when your baby's sucking instinct is most intense and help from a knowledgeable lactation consultant or nurse is readily available.
Contributing editor Marianne Neifert, M.D., is co-founder and medical consultant to the HealthOne Lactation Program in Denver, Colorado, and author of Dr. Mom's Guide to Breastfeeding.
Haven't Got Time for the Pain
Q. I developed painful cracks on both nipples three days after delivery. Now, a week later, nursing is still so uncomfortable that I actually dread it. My friends tell me to tough it out, but if the pain continues much longer, I'll quit. Am I doing something wrong?
A. Most women experience mild, temporary discomfort for the first few days of breastfeeeding, but the painful, cracked nipples you describe at ten days postpartum are not a normal part of nursing. If your baby's doctor or your own is not comfortable examining your nipples and assessing your breastfeeding technique, ask to be referred to a lactation consultant. Even if you have to pay for this service, this is money well spent.
Although the major cause of severe or chronic sore nipples is trauma from incorrect latch-on and sucking, other factors can play a part in exacerbating the problem. For example, inappropriate nipple care -- such as overdrying or excessive moisture¿ -- can delay healing. Furthermore, nipple cracks and wounds are easily infected by bacteria or yeast present in the baby's mouth. So first make sure your baby is latched on correctly, then take care of your nipples. Try applying medical grade ultrapure lanolin after feedings or wearing new moisture-retaining, hydrogel dressings between feedings for a soothing skin barrier. In addition, your doctor can prescribe an antibiotic or an antifungal medication if an infection is present.
To continue nursing more comfortably while your nipples heal, begin breastfeeding on the least sore side to trigger your milk-ejection reflex. Once milk flow has begun, the baby should suck less vigorously when brought to the second, more irritated breast. Frequent, short feedings are preferable, since delaying the interval between feedings results in greater breast engorgement and a ravenously hungry baby -- a combination that can cause further trauma during nursing.
If your nipple pain is so severe that you must interrupt breastfeeding, you can temporarily express your breastmilk using a fully automatic, electric breast pump, which usually is more comfortable than your sucking baby. Use the pump at regular feeding times, and feed the expressed milk to your infant until your nipples have healed.
Q. While breastfeeding my 2-month-old baby, I experienced several painful plugged ducts -- twice on one breast and once on the other. Is there anything I can do to avoid a recurrence?
A. A plugged duct, also known as a blocked duct or a caked breast, results when one of the milk ducts draining the lobes of the breast becomes partially obstructed. It creates a firm, tender, engorged area of the breast, and often an elongated lump can be felt. Since milk glands are concentrated in the outer areas of the breast, blocked ducts are common near the armpits. If not quickly remedied, a blocked duct can progress to a breast infection known as mastitis (discussed below), which should be suspected whever redness is present.
A blocked duct usually occurs when you haven't breastfed your baby often or long enough. Women who produce abundant milk are particularly prone to this problem, and being separated from your infant or going a long time without nursing is another common risk factor. In addition, constrictive clothing, such as a tight underwire bra or straps from a baby carrier that are pulled too tight, can interfere with milk flow.
The most effective way to relieve a blocked duct is to nurse your baby as much as possible. Starting several consecutive feedings on the affected side will help, since babies nurse more vigorously and take more milk from the first breast. You can also place your baby so that her chin points toward the plugged duct, a position that will help promote drainage. Warm compresses or a warm shower can trigger your let-down reflex and improve milk flow, and gentle massage of the blocked area is often effective in relieving the obstruction. Be careful not to press too firmly, however, as causing trauma to your breast increases the risk of mastitis. If, for some reason, your breast isn't well drained after nursing, use a breast pump to remove extra milk.
Recurrent clogged ducts can be a sign of breast inflammation or low-grade infection; treatment with antibiotics sometimes curbs the problem. Occasionally, a breast lump is mistaken for a clogged duct. Any lump which persists for more than several days should be checked by a doctor.
Q. I returned to work full-time when my baby was 12 weeks old. I continue to breastfeed when I'm with my baby, and I pump at the office. Since I have been back, however, I have had two bouts of mastitis, both in the same breast. What causes mastitis, and what can I do to avoid it?
A. Mastitis, or a breast infection, occurs in at least two percent of breastfeeding women. Flu-like symptoms are typical -- fever, chills, headache, body aches, and fatigue -- along with an area of the breast that is tender, red, and firm. Mastitis is often preceded by a clogged duct, an infected cracked nipple, irregular or ineffective milk removal, or simple exhaustion. Working mothers often develop mastitis when they are unable to express their milk at regular intervals and become sleep-deprived and physically depleted.
Mastitis should be promptly treated with appropriate antibiotics for 10 to 14 days. If infection occurs while you are breastfeeding a healthy baby, you should continue nursing. If you don't, your milk production will likely decrease, making breastfeeding more difficult after the infection has cleared. Nurse your baby on the unaffected breast first, and move him to the painful breast only once the let-down reflex has been triggered. Ibuprofen can help reduce inflammation and pain, and ice or warm packs can provide comfort. If direct breastfeeding is too painful or milk flow is impaired, you should express your milk.
Recurrences often happen when an ineffective antibiotic is prescribed or when the course of treatment is too short. The best way to avoid another bout of mastitis: Pump on a regular schedule while you are at work (at least every four hours), and nurse your baby often when the two of you are together. To reduce your level of fatigue, curtail any unnecessary activities, enlist help with household chores, try to get extra sleep, drink plenty of fluids, and eat regular meals.
Fill 'Er Up
Q. My first baby was formula-fed, but my doctor is urging me to breastfeed my second baby, who's due in three months. I'm used to seeing how much milk a baby takes from a bottle, and I'm concerned that I won't know if my newborn is satisfied with breastfeeding. How will I be able to tell?
A. Even though your breasts don't have calibrations, a number of indicators can help reassure you about your baby's milk intake. The most reliable is your baby's weight. Although your newborn will lose a little weight at first, once abundant milk production begins about the third day postpartum, he will start drinking greater quantities of milk and gain weight rapidly. He will likely surpass his birth weight by 10 to 14 days of age. On average, breastfed babies gain about an ounce each day, or nearly a pound every two weeks, for the first two to three months of life, after which their rate of weight gain tapers.
Since "what goes in must come out," you should also watch the contents of your baby's diaper. Well-fed newborn babies should have at least four sizable, yellow, seedy bowel movements each day. Infrequent or scant bowel movements, or failure to start passing yellow stools by the fourth day of life, indicate that a baby may not be getting enough milk. In addition to moving his bowels, a well-nourished, breastfed newborn can be expected to wet his diaper after each feeding. The urine should be clear, not dark.
Your baby should nurse 8 to 12 times in a 24-hour period with 10 to 15 minutes of active suckling per breast at each feeding. A newborn who has obtained adequate milk will usually fall asleep contentedly after nursing, while an underfed infant may act fussy, suck on his hands, and frequently require a pacifier.
OK to Supplement?
Q. My baby was born a few weeks early and had a lot of trouble latching on to nurse during the first week. Now, at 3 weeks of age, she is still below her birth weight, and her doctor is insisting that I should start supplementing her with formula. I am hesitant to do so, however, as I am afraid that this will prevent her from ever breastfeeding successfully. Is there any other way to get breastfeeding on track after such a poor start?
A. In my opinion, your breastfeeding problems are not likely to self-correct with perseverance alone. Because of your baby's relatively small size, preterm birth, and poor nursing, I suspect that your milk supply has steadily decreased over the past three weeks. Your underweight baby cannot be expected to build it up on her own. I recommend you immediately focus on making sure your baby receives adequate nutrition and on increasing your milk production. Once these goals have been accomplished, you have a good chance of returning to full breastfeeding.
First, breastfeed your baby approximately every 3 hours, for 5 to 10 minutes per breast. Then offer her as much formula as is necessary to satisfy her appetite. In addition, you should use a breast pump (preferably a fully automatic electric pump) for 10 to 15 minutes immediately after nursing your baby. The pump will remove any milk your baby was unable to take and provide an effective stimulus to maximize your milk production. The residual high-fat hindmilk you obtain with the pump can be used to supplement your baby at the next feeding. Your spouse or a friend can give your baby her supplemental milk while you use the pump so as to shorten this triple-feeding process.
As your milk supply increases and your baby's nutritional status improves, she will obtain more milk by breastfeeding and require less supplemental formula. As you return to full breastfeeding, wean your child from formula before you end your pumping regimen.
Too Much of a Good Thing
Q. I am breastfeeding my 6-week-old daughter, and my milk production seems out of control. I leak onto my bed at night and soak through my blouse during the day. My baby gulps and sputters her way through her feedings, and sometimes cries in frustration. What do you recommend?
A. I agree that an overabundant milk supply can be a mixed blessing. While it's nice to know that your baby is getting plenty of milk, leaking is inconvenient, overly full breasts are prone to mastitis, and your baby can feel like she is drinking from a fire hydrant.
Try nursing your baby from one breast at each feeding. She should be better able to control the flow of milk as the initial spraying subsides. A few hours later, you can nurse her from the opposite side. (At first, it may be necessary to pump some of the excess milk from the unsuckled breast to prevent engorgement.) Your baby may also find it easier to nurse if you are leaning back in a recliner, so that the top of her head is slightly above the top of your breast.
Fortunately, leaking tends to diminish after 6 to 8 weeks, when the capacity of your milk ducts increases to better contain the milk released during let-down. I predict your supply will gradually come to match your baby's demand as she gets bigger. Meanwhile, wear breast pads to help deal with the hassles of leaking.
Breastfeeding After Surgery
Q. I had breast-reduction surgery a few years before I got pregnant, and I was advised that the procedure could interfere with breastfeeding. Is this true?
A. Although little scientific research is available on this topic, practitioners who work with nursing mothers agree that breast-reduction surgery poses a risk to successful breastfeeding. While it is remotely possible that you will be able to provide all the milk your baby requires, it is more likely that your infant will need to drink some supplemental formula in addition to the milk he obtains from you.
Although many techniques can be used to perform a breast reduction, the procedure usually requires a surgical incision around the areola, which can cut milk ducts. Disruption of these ducts will partially prevent milk from flowing to the nipple openings.
Although you can still breastfeed your baby, your infant's weight will need to be closely monitored after birth. Your baby's doctor or a lactation consultant can determine how much milk he takes from each breast at a typical feeding by weighing your baby in the same clothes before and after breastfeeding. I also encourage you to use a breast pump after most feedings for at least the first week of your baby's life to help maximize your milk production.
Even if you need to supplement with formula, your baby will enjoy the pleasures of "comfort nursing." Your breasts represent far more than nutrition to your infant. Breastfeeding provides security, physical intimacy, and skin-to-skin contact -- it certainly doesn't have to be exclusive to be of significant value to you and your baby.
Q. I am struggling with postpartum depression, and my doctor thinks medication would help. Can these types of drugs harm my breastfeeding baby?
A. You are certainly not alone in your struggles with depression; it's the most common psychiatric illness in new mothers. I believe that you will be a happier, more effective mother if you receive treatment. Your baby is likely to benefit as well, since depressed mothers are usually less able to meet their children's needs.
While virtually all drugs taken by a nursing mother appear in her breastmilk to some degree, these minimal amounts usually pose no risk to a nursing infant. (Premature or sick newborns may be more vulnerable to the effects of drugs than older, healthier infants.) For this reason, very few medications are actually restricted for breastfeeding mothers. Those that are include cancer chemotherapy agents, drugs that suppress the immune system, and all illicit drugs.
While little specific information is available about the safety of commonly prescribed antidepressants during breastfeeding, several studies show that a number of drugs have no adverse effects on nursing infants. Among the newer medications, Zoloft seems to be one of the safest, because very little drug enters the breastmilk, and none has been detected in breastfeeding babies whose mothers had taken the drug. Although many nursing mothers have taken Prozac, it has been found in some infants, and reports have suggested it may cause infant colic, sedation, or insomnia. Whatever medication your doctor prescribes, inquire about its safety during breastfeeding, inform your baby's pediatrician that you are taking the drug, and watch your infant closely for possible side effects.
Q. I was hoping to breastfeed my baby for at least one year, but she is only 7 months old and is starting to refuse to nurse. She drinks bottles of my expressed milk (plus some formula) while I am at work, but when I try to nurse her at home in the evening, she pulls away and cries. I'm definitely not ready to wean, so what should I do?
A. It sounds like your baby is showing signs of a "nursing strike," which is a sudden refusal to breastfeed. This problem is often seen in babies like yours who have been receiving bottles and may have developed a preference for the ease of bottlefeeding, although many babies have no problem with a breast/bottle combination.
I find that a nursing strike is often related to a low milk supply. Since your baby is receiving formula while you are at work, I suspect that you are no longer pumping all the milk your baby needs. Because she gets milk easily from the bottle, your baby may find breastfeeding to be frustrating, especially in the evenings when your supply is typically lower.
One of the best ways to get her breastfeeding again is to offer your breast while she is drowsy or asleep. Most babies will automatically breastfeed in their sleep, and many will continue to nurse without protest when they awaken. Never try to force your baby to latch on, however, as this may only increase her aversion to breastfeeding.
In the evenings, try to offer your breast before your baby becomes frantically hungry. If she seems frustrated by the rate of milk flow, you may need to give her a little formula to take the edge off of her appetite before she can enjoy the comfort and security of nursing. Whenever she does not breastfeed well, use your breast pump to express your milk in order to keep your supply up.