Breastfeeding Problem Solving-Dr. Rosner

Many pregnant women are interested in breastfeeding their soon-to-be-born babies, but as the realities of mothering a newborn develop, they become discouraged by the problems they begin to encounter. The purpose of this article is to delineate some common issues that may come up in order to be able to deal with them proactively, before they lead to the mother becoming frustrated to the point that she is ready to give up on breastfeeding entirely. As there are no diagrams, it is meant to educate on some key points but does not replace consulting a more extensive book on the subject or a real live lactation consultant for more explicit instructions.
The time to begin to prepare oneself for breastfeeding is in the 8th month of pregnancy. At that time an experienced lactation consultant should examine the woman to determine whether the shape of her nipples will allow for her baby to latch on and suckle the breasts. Some women have nipples that are inverted- meaning they point inward, or flat, making it difficult for the baby to recognize them as nipples at all. If this problem is identified a few weeks before delivery, special stretching exercises can be done in order to stretch out the nipples. In addition, breast shells may be worn inside the bra for the last few weeks of pregnancy, which also help the nipples to be pulled into a more favorable shape.
The time to initiate breastfeeding is as soon as the baby is born- if possible in the delivery room. Amazingly, babies are usually born extremely alert (for a short while) and with an innate ability to find the mother’s nipple and to latch on to it and suckle. The nursing in the delivery room also stimulates the mother’s oxytocin hormone which helps her uterus contract back to its normal size after the baby is born. In the first few days, and sometimes weeks, it is important for the baby to exclusively breastfeed- especially if the mother has less than optimal nipples. This is to avoid a phenomenon known as nipple confusion- where a baby exposed to a bottle decides he’d rather suck from a bottle and stops trying to latch on to the breast. The other advantage of not supplementing breastfed babies with bottles is that the more the baby suckles, the faster the mother’s milk will come in.
It is extremely important to properly position the infant on the breast from the very first nursing. This means that when the baby opens his mouth wide, the nipple as well as most/all of the areola is inside the baby’s mouth. This allows the baby’s jaws to massage the milk ducts that are located around the periphery of the areola and spares the nipple from being traumatized. A baby who is not properly positioned on the breast will not effectively allow for the milk to flow and will cause the mother’s nipples to become sore. It is generally ok for the first few sucks to be slightly painful but if nursing continues to hurt, help must be gotten to attain proper positioning of the infant on the breast.
During the first few days, while the mother’s milk is coming in, many women have painful swelling and hardening of the breasts known as engorgement. Often there is enough milk for twins even though there is only one baby. This makes nursing difficult as the baby has a hard time latching on to a more firm breast and the mother is generally uncomfortable. Pumping before nursing is helpful to soften the breast and allow for the baby to latch on properly. The milk can then be stored (it keeps for a few months in the back of the freezer) for future use. Some mothers worry that pumping when they have so much milk will only stimulate more milk production, but it seems that after the first couple of weeks, the milk production becomes tailored to the baby’s needs whether or not the mother pumped out the extra milk. The downside of not pumping is that engorgement can lead to painful blockages of the milk ducts and even to mastitis- a breast infection.

If a woman feels a firm, tender area of the breast when the rest of the breast is soft, this is usually a blockage of one of the milk ducts which empty out of the breast through the nipple. Sometimes the blockage is actually seen as a white dot on the nipple. The treatment for this is to apply heat to the breast and to nurse the baby with his nose pointed to the firm area of the blockage. If a white dot is visible on the nipple, it can be scrubbed off with a wash cloth and sometimes relieve the obstruction. If the area becomes reddened and or if the mother develops a fever a doctor should be consulted as these are signs of mastitis. Often, antibiotics are needed in such a case.
It is currently recommended that babies feed on one breast per feeding. This allows them the benefit of the hind milk- meaning the later milk to flow which is more rich in fat and calories. In addition it allows time for the nipple to dry and heal in between feedings. Some women still experience painful sores and cracks on their nipple. Various healing salves and ointments (such as lanolin) are available to apply in between feeds. Many women find that their breasts leak milk in between feeds. Nursing pads are helpful to avoid embarrassing stains on clothing and as a covering after application of ointments. Once nursing is established the mother should not be in pain when the baby sucks. If a mother notices that her nipples have become red or that they are sore, this may caused by thrush. This is a yeast that is found on the skin of mothers and in the mouths of babies. A doctor should be consulted and both mother and baby should be treated with antifungal gel simultaneously until the problem is resolved.
Some nursing mothers are faced with the issue of the infant who is not thriving or putting on enough weight. This can be very discouraging and cause much guilt and grief to the mother. There are a variety of reasons for this problem and an experienced pediatrician should be involved to determine the correct plan of action. At times the infant himself has a problematic suck and is therefore unable to stimulate the breasts well enough to produce milk. In other cases the baby is hungry and sucks with gusto but the breast does not produce enough or the quality of the milk is poor. In still other cases, the breasts are full of milk but the baby has no appetite. In any case, the causes are too numerous to delineate but each case must be addressed individually by an experienced provider. Some general advice to keep in mind is that mothers must be well enough rested and drinking plenty of fluids and eating plenty of calories in order to maintain an adequate milk supply. New mothers need plenty of support from family in order to meet those needs. They also should not be on low fat diets to lose the extra weight they gained in pregnancy.
If it is determined that a baby needs formula supplementation, the mother should not think of the entire endeavor as failure. The baby and mother both benefit from any amount of nursing that is achieved. If the mother is able to continue, partially nursing a baby is still a valuable experience for both the mother and the baby.

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