Common Problems When You Begin Breastfeeding

The following problems are not uncommon during the get-acquainted phase of breastfeeding. Fortunately, such problems are usually worked out successfully before you leave the hospital or by the time your milk comes in abundantly. Don't be discouraged if things aren't picture-perfect; it's all part of the learning process. With patience and practice, both you and your baby will become more proficient in your roles. If you continue to have difficulty after you go home, you should seek expert help without delay. The sooner you detect a breastfeeding problem and get help, the easier it is to remedy.

Baby Won't Awaken to Nurse
Some newborns sleep longer than desired in the early days of life, perhaps as a result of a long labor, medications used during childbirth, birth trauma, or other events. You might be anxious to begin breastfeeding, only to realize it takes two cooperative partners to make the process work. If more than about three and a half hours have passed without a feeding attempt, ask your baby's nurse to help you awaken your infant. Don't wait for your baby to cry to try to feed her. Instead, keep her with you in your room and try to arouse her from light sleep-look for eyelid movement, facial twitches, movements of her arms or legs, or mouthing motions. Unswaddle her from her blankets, change her diaper, remove some clothing, wipe her bottom with a wet washcloth, stroke her head, or massage her feet. Babies naturally open their eyes when placed upright. You can put her in a sitting position on your lap, with your hand supporting her chin, or hold her over your shoulder. Try dimming the lights if bright lights make her close her eyes.

Infant Has Difficulty Latching on to the Breast
Even when the infant is awake, alert, and demanding, he may not latch on to your breast right away. Often the baby cries, acts distressed, and doesn't seem to know what to do. This can be enormously frustrating, especially when a mother has the misperception that breastfeeding should be as easy as falling off a log. It also can feel like outright rejection, and often a distraught mother will announce, "My baby doesn't want my breast." Nothing could be further from the truth. Of course your baby wants to breastfeed, but he doesn't yet know how to grasp your nipple/areola and obtain milk. If your baby is having trouble latching on, try the following measures:

• Stop your efforts that have made you and the baby upset. Take a deep breath and calm down. Soothe your baby with your voice and by swaddling him. Try settling him down by letting him suck on your clean little finger inserted with the palm side (fleshy part) upward against the roof of his mouth. Tell yourself that latch-on difficulties are common and that many women have felt as you do right now. Keep your baby with you so you can try again as soon as he shows interest.

• Help your baby enjoy being close to your breast. Keep him cradled at your breast even when you are not attempting to breastfeed. Remove your top and provide as much skin-to-skin contact as possible. These "breast-friendly" measures will help offset any frustration that either of you might experience from unsuccessful breastfeeding attempts.

• Review the basics of breastfeeding technique: positioning yourself, positioning your baby, and supporting your breast. Correct anything in your technique that could be improved.

• Squeeze a few drops of colostrum onto your nipple to entice your baby or drip a little sugar water onto your nipple from a bottle.

• Enlist a skilled nurse or hospital lactation consultant to help your baby attach correctly to your breast. Then you can apply the effective techniques she demonstrates when you are on your own.

• Use a breast pump to express some milk. Offer this milk, or a small quantity of formula, preferably by cup or spoon, to calm your baby sufficiently to work with him at the breast again.

• If your nipple is flat, use a pump for a few minutes to draw your nipple out and start some milk flowing before trying to attach your baby.

• If your baby is using a pacifier, this could be reinforcing the expectation of a long, rigid nipple. Discontinue the pacifier until breastfeeding is going well.

• As a last resort, start pumping your breasts approximately every three hours with a rental-grade electric pump to keep up your milk supply. Offer your expressed milk by bottle or other method to keep your baby well nourished. Continue to try to attach your baby at every available opportunity. As long as your baby remains well fed and your supply is maintained, your baby can eventually learn to breastfeed. Don't give up! You will need to arrange close follow-up with your baby's physician and a lacta-tion specialist after discharge.

Baby Won't Suck
Some babies will initially attach to the nipple/areola, but then take only a few sucks before coming off the breast and crying. Usually these babies are frustrated at not receiving an immediate reward. Perhaps they have had one or more bottle-feedings and expect a rapid flow of milk as soon as a nipple enters their mouth. If an SNS device is available, it can be used to provide supplemental milk while the baby nurses, and thus keep the baby interested in breastfeeding. Usually, once the baby starts sucking rhythmically while using the SNS, the mother's own breast milk begins to flow. The device might be needed for only a feeding or two until the baby starts nursing effectively.

Another reason babies may not suck is that they may "shut down" when put to the breast. If previous attempts at feeding have been negative experiences, perhaps due to rough handling of the baby or aggressive efforts to push the nipple into his mouth, the baby may react to such distress by shutting down and refusing to feed. Other possible signals that your baby may be experiencing sensory overload and needs you to back off include hiccups, yawning, and the "stop sign," raising his hand with palm facing outward. Don't let any feeding session turn into a power struggle. Hold your baby tenderly, speak reassuringly, and let him rest securely against your breast. It might become necessary to pump and feed your expressed milk until feedings, in general, become a pleasant experience before resuming attempts at the breast. Since poor feeding can be a sign of infant illness, I must also caution that it's always essential for the hospital staff to evaluate a baby who isn't feeding well.

Baby Takes One Side Only
Often, the baby latches on more readily to one breast than the other. Perhaps one nipple is easier to grasp, or the milk on that side flows more freely. It is important to keep working with the baby to take the less-preferred side as quickly as possible, to assure that both breasts receive adequate stimulation and emptying. You can start feedings on the "difficult" side and see if the baby cooperates more when he is hungry. If he starts to fuss too much, switch to the preferred breast and let him settle and nurse. Then, building on this success, resume your attempts on the other side. If your baby isn't taking both breasts well by the time your milk comes in abundantly you should start using a hospital-grade rental electric breast pump to regularly remove milk from the breast that isn't being suckled. (I actually recommend pumping both breasts simultaneously since it takes no longer than pumping one side and will help keep the overall milk production generous.) Breast preferences very quickly can cause a lopsided milk supply, which only aggravates the problem. The baby's preference for using one breast results in greater milk production on that side, which in turn makes the baby prefer the better-producing breast even more. Many mothers attest to the effectiveness of a simple maneuver to entice the baby to take the less-preferred breast. Start nursing on the favored side (a cross-cradle hold works well) and then slide the baby over to the second breast without changing his position. As one woman explained, "My baby just thinks I have two left breasts."

Nipple Pain
During the first couple of days of breastfeeding, women often will complain of slight nipple discomfort for the first minute after latch-on. Severe nipple pain that lasts throughout the feeding, or nipple discomfort that doesn't improve once your milk comes in, suggests that the baby is either attached incorrectly or is sucking improperly. You shouldn't need a high pain threshold in order to breastfeed. Severe pain means something is wrong, so don't ignore this important clue. Get help right away with your nursing technique. The most common problem is that the baby is not opening wide enough and is latching on to the tip of the nipple instead of taking a large mouthful of breast. Other strategies to improve sore nipples include patting the nipples dry after feeds and applying USP Modified Lanolin (medical grade); nursing for shorter periods at more frequent intervals; and starting feedings on the least-sore side, then moving the baby to the more pain-ful side once let-down has been triggered.

Baby Isn't Satisfied After Nursing. Some new mothers become frustrated because their baby nurses for prolonged periods but doesn't seem satisfied. Often these are larger babies, over eight or nine pounds, who act persistently hungry until the mother's milk increases around the third day. Sometimes the baby will settle when swaddled snugly, held by his mother or father, or allowed to sleep on a parent's chest. Despite what I said earlier about not using a pacifier, such a baby might need one for a day or so. As long as the baby nurses well and often, short-term use of a pacifier is not likely to interfere with subsequent breastfeeding. If supplemental milk is temporarily required until your milk increases in volume, it can be offered by SNS, cup, or bottle. (Ask about using a hypoallergenic formula if you have a family history of allergies, asthma, or other allergic disease.) If the baby is already a proficient nurser, he probably will continue to breastfeed just fine. Be sure to nurse as often as possible and try to discontinue any supplements as soon as your milk starts to increase. If the baby still isn't being satisfied by the fourth day, notify your baby's doctor and seek additional help with breastfeeding. It's possible the infant isn't nursing correctly and may not be obtaining the milk he needs.

Uncomfortable Breast Engorgement
Few mothers these days are still in the hospital when their milk starts coming in abundantly. More typically, postpartum breast engorgement occurs once a mother has gone home. Exceptions to this include some mothers with C-section deliveries and those with longer stays due to medical complications. Milk coming in abundantly typically causes noticeable breast swelling, tenderness, and firmness. Latch-on may become more difficult due to flattening of the nipple and firmness of the areola. The result can be improper attachment and nipple pain. For some women, engorgement can be a source of discomfort and frustration, especially when excessive pressure interferes with milk flow. When engorgement is unrelieved, the residual milk and pressure can cause the mother's milk supply to decline rapidly.

Early and frequent nursing (at least every two to three hours) is the best way to prevent excessive breast engorgement. Applying warm compresses before nursing often helps start milk flowing, while cool compresses between feedings help relieve pressure and discomfort. Express some milk before nursing, preferably using a hospital-grade electric breast pump, to soften your breasts and draw out your nipples. Pay careful attention to proper nursing technique to assure your baby latches on correctly and obtains the maximum amount of milk.

From Dr. Mom's Guide to Breastfeeding by Marianne R. Neifert. Copyright © 1998 by Marianne R. Neifert. Used by arrangement with Plume, a member of Penguin Group (USA) Inc.

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