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Protecting the Bond 

Overcoming Common Breastfeeding Problems

by M. Sara Rosenthal, Ph.D.

This article is adapted from The Breastfeeding Sourcebook, 3rd edition (McGraw-Hill, 2000) which is recommended by The Journal of Human Lactation. For more information, visit www.sarahealth.com.

This article outlines and offers solutions to common breast feeding problems that can arise, enabling you to protect the bond you've established through breastfeeding. Your newborn can be "turned off" breastfeeding if you are sensing pain during breastfeeding and grow to dread feedings; if the baby is not getting enough milk, or your breast is not being emptied each feeding, which results in the baby getting too much of the "foremilk" and not enough "hindmilk," leaving him or her unsatisfied, gassy, and hungry after feedings.Keeping your baby cool will help them stay awake during nighttime feedings.  

Feeding A Sleepy Baby

After delivery, it usually takes a newborn about 20-30 minutes of looking around before s/he's interested in feeding. On the first feeding, it's recommended to feed for about 30 minutes while the baby's alert. This helps get you both off to a good start. After, if the baby has not had any medications, s/he'll fall into a deep sleep and then wake up regularly at least every 2-3 hours to feed. Unless the baby's feeding every two to three hours at first, your body will not be able to establish the right amount of milk. In order to do this, your newborn needs to nurse at least 8-12 times in a 24-hour period. Each feeding should consist of active nursing for at least 10-15 minutes at each breast so the baby can obtain the hindmilk and stimulate the production of more milk. You should hear the baby swallowing after every one or two sucks once your milk letdown has occurred. Swallows become less frequent later in the feeding. Babies usually grow out of their sleepiness in the first couple of weeks of life. In the meantime, here are some suggestions for feeding sleepy babies.

Waking the baby 

There is a solution to feeding a sleepy baby: wake the baby up to feed, and if need be, wake the baby up during suckling if s/he keeps falling asleep at the breast. Prior to waking the baby, try to determine whether s/he's in a deep or light sleep. In a lighter sleep state, the baby's eyes are moving under the eyelids, the lips make sucking movements, and the body is stirring. It's easier to rouse the baby from a lighter sleep. Touching the baby gently will usually wake him/her from a lighter sleep. One technique that works for rousing a baby in a deep sleep is to cool off the baby. Do this by loosening or removing blankets or unwrap the baby down to the diaper if the room is warm. A baby is the right temperature if the head is warm and the hands cool. Warm hands or a sweaty neck mean the baby is too hot. If this doesn't work, you can try to elicit some reflexes in the baby by supporting the baby's head while his/her upper body rests along your forearms. The baby's buttocks are resting on your abdomen if you're sitting up or on your chest if you're lying down. You then slowly bring your forearms forward, until the baby's head almost touches you, and then you quickly move the baby away again. You'll probably need to repeat this a few times for the baby to open his/her eyes. As soon as s/he does open his/her eyes, try to get him/her to look at you and follow your eyes while you move your head from side to side. Talk, sing or coo to the baby while you do this. ("Hello...look who's awake? Are you awake? Hello there!") Once you catch the baby's attention, this is the time to do your latch on technique and begin to breastfeed. Other techniques for waking the baby include using your fingertips to gently "walk" up the sides of the baby's spine from the buttocks to the base of the skull; circling the baby's lips a few times with your index finger; stroking the bottom of the baby's feet; and giving the baby a body massage.

Keeping the baby alert during feeding 

Sleepy babies tend to fall asleep as soon as they begin feeding. If your baby starts to fall asleep after only a few minutes of nursing, undress the baby down to the diaper to cool the baby off and keep him/her more alert. You can also switch breasts before the breast is empty. Keep moving the baby back and forth from one breast to the other until both breasts are empty. This provides more milk with less effort for the baby. If your breasts are not completely empty by the end of the feeding, express/pump your milk to keep up your milk supply. Experts suggest that you also talk to your baby while s/he nurses and/or play cheerful, lively music, which helps the baby stay awake. Some other ways to keep the baby alert during nursing include:

Positioning the baby's head higher than his/her body.
Gently massaging the baby's crown in a circular motion.
Stroking the baby's spine, tugging at your breast (if there's a good, strong latch), or stretching the corners of the baby's mouth by quickly pushing outward in opposite directions with your thumb and forefinger.
Keep the room cooler. You can always cover the baby by blanket if necessary. Babies will fall asleep if they're too warm.
Between sides, change the baby's diaper or burp the baby in a sitting up position. 
Dim the lights during nursing. Bright lights may make the baby close his/her eyes.
Manipulate baby's arms and legs in a gentle pat-a-cake game.
Wipe the baby's forehead and cheeks with a cool, damp cloth.
Express milk onto the baby's lips.

When Baby Pulls Away From The Breast

This is a frustrating problem for mother and baby alike, but there is usually a logical explanation for your baby's behavior. One common reason why babies pull away from the breast during nursing is because they either don't like the position you're using to hold them, or they're sensitive to where your fingers are placed on their bodies. For instance, when someone taps you on the shoulder, your immediate instinct is to turn around. It's the same thing with many babies. As soon as they feel a finger on one side of their face, they may also immediately turn around. Therefore, any position where you're touching the baby's face or head can cause the baby to keep turning around in a "What IS that?" reflex. The solution: don't do this! If you must touch the baby's face or head, do it in a firm, constant way so you're not distracting the baby. Your hand should be at the shoulders and base of the baby's head, supporting his/her head, neck and shoulders with your fingertips behind and below the level of the baby's ears. Sometimes babies pull away from the breast because your milk letdown is too forceful.

When Your Cup Runneth Over (Overactive Letdown)

An overactive letdown can be just as problematic as a poor letdown or a deficient milk supply. This is sometimes called "Forceful Milk Ejection Reflex (Let-Down)". When your letdown is overactive, the baby may choke and sputter, and even pull away to let the heaviest part of the flow go by before latching on again. As soon as you feel the letdown reflex, detach the baby from the breast when the milk starts to flow. Use a towel, glass or bottle to catch the overflow. Put the baby on the breast when the flow subsides. You should also position the baby in an "uphill" position, with his/her neck and throat higher than the nipple. This means that if you're in the football hold, lean back; in the cradle hold, prop the baby in your lap on two pillows and lean back in a rocking chain or recliner; and when lying down, place a folded towel under the baby so that s/he looks down toward the breast. And, for a completely different position, nurse in the Australia position: The baby lies on top of you while you lie flat on your back and support the baby's forehead with your hand. The excess milk will trickle out the sides of the baby's mouth onto a diaper or towel. A different problem may arise if you have an overabundant milk supply, which simply means that you're making too much breast milk -- more milk than the baby needs. It can be the cause of a fussy or gassy baby (see further).

Poor letdown 

Poor letdown, the opposite of overactive letdown, can be triggered by pain, fear, fatigue, stress, or alcohol. Decreased nipple stimulation will also lead to poor letdown, the result of a poor latch, topical anesthetics on the nipple, and nipple shields. The final consequence of poor letdown can be an exacerbation of the problem that caused the soreness to begin with, which caused the poor letdown: more engorgement, which can lead to both a plugged duct or mastitis. All of this can affect your baby, who may not get enough milk (see chapter 6), and your entire milk production, which will gear down. To avoid this unfortunate chain of events, make sure you investigate the origin of your breast pain and get pain relief, and don't stop breastfeeding. Avoid topical anesthetics, nipple creams, and nipple shields. Follow the guidelines for self-care discussed in earlier sections of this chapter. If you need help with letdown, request an oxytocin nasal spray. Also review the section in chapter 4 on letdown foreplay. Don't use nipple shields.

The arching baby

This is another frustrating problem where the baby arches his/her head and body away from the breast and screams everytime you start to nurse. In some cases, arching babies even roll away from the breast by one month. One common reason why the baby arches from the breast is because the breast isn't satisfying his/her hunger. The baby's behavior is telling you: "Look, this isn't working for me!" This problem usually results from a bad latch, forcing the breast on the baby, or even a weak suck. But an overactive letdown or colic can cause arching, too. In the case of a bad latch, unless it's corrected, the hindmilk will not be available to the baby, which will satisfy his/her hunger. What you need to do in this case is to first have the baby's health evaluated to rule out an underlying medical condition. Then, see a Lactation Consultant to make sure that your position and latch is correct. Sometimes just nursing in a different position will solve the problem. There are a variety of different nursing positions you can be shown, which will prevent the arch and support the baby. Express your milk via pump to keep up your milk supply until the problem is solved.

Arching babies need some calming before nursing. You can do this by massage, or holding him/her firmly. You may also find that after the baby arches a few times, s/he may just settle down to nurse. Try a modified version of the football hold to nurse the baby. Position the baby's buttocks against a hard surface with his/her legs pointing upward so his/her feet do not touch anything (this may trigger an arch). Hold the baby's head so his/her chin almost touches his/her chest, which helps his/her tongue move correctly. Elevate your leg so that your thigh can support the arm holding the baby. A pillow or folded blanket can also help support your hand and forearm. Arching babies can also nurse well in the cradle position if they're held firmly flexed in a cloth sling. The sling helps prevent your arms and shoulders from getting tired.

Fussiness

Fussiness does not necessarily mean that the baby is malnourished or colicky. In fact all babies usually have fussy times that occur in the late afternoon or evening, but this does not necessarily make them fussy babies. If the baby seems to want to eat every hour or so, and always seems to be hungry, fussy, and gassy, then this may mean the baby is suffering from infant lactose overload, which means "too much milk". This is discussed further on.

Fussiness has a lot in common with crying; the origins are often the same, ranging from overtiredness and overstimulation to loneliness and physical discomfort. And like adults, babies simply have different temperaments, which is why one baby will react completely differently in a given situation than another. Once you get to know the fussy pattern of your baby, you'll develop your own tricks for speedily handling the problem. Until this day comes, eliminate and experiment with the following: burping; a diaper change; dressing or undressing baby; checking for crumbs or hair in a sock or between the toes; bathing baby; massaging baby; rocking baby or putting him/her in a sling or carrier (studies show that babies who are carried around or "worn" cry less); changing the environment (go from a noisy room to a quiet room or vice versa); go for a walk outside; give baby a back rub. Then again, none of these suggestions may help! Sometimes the only way over a fussy period or fussy time is to just go through it! 

Neonatal Jaundice

Anytime someone turns yellow, s/he has jaundice. Neonatal jaundice is an extremely common problem affecting roughly 50% of all normal, full-term infants within the first week of life. Breastfeeding is usually the best medicine for a jaundiced baby, yet despite this undisputed medical fact, jaundice is still the most common excuse for stopping breastfeeding. In most cases of jaundice, there is absolutely no reason to stop breastfeeding, although there are some exceptions.

While there are three types of neonatal jaundice, about 95%of all cases take the form of normal jaundice (a.k.a. physiological jaundice). When your baby has jaundice, his/her skin will turn yellow because the red blood cells that are being retired from service result in the production of a yellow pigment called "bilirubin". Bilirubin builds up faster thanbaby's immature liver is able to handle. In essence, neonatal jaundice is caused by too much bilirubin. The good news is that bilirubin will simply pass through the baby's stools. The more the baby poos, the faster the bilirubin will be eliminated. So where are all these red blood cells coming from? Whenthe baby is still in utero, less oxygen is available to the baby than outside the uterus, when the baby begins to actually breathe air. Therefore, a fetus' body will manufacture more red blood cells in order to have enough oxygen for its brain and heart. Normally, it's the liver's job to remove blood waste likebilirubin from the body. But in this case, the baby's liver is new, and cannot work fast enough to remove the bilirubin. The result is the development of jaundice by the second or third day of life. The jaundice will usually peak between the fifth and seventh day, and then begin to recede.

The symptoms of jaundice are jarring because the baby will turn yellow. First, the eyes will turn yellow, then the face, followed by the trunk of the body. The last body parts to turn yellow are the baby's fingers, toes, palms and soles. Unless the baby is breastfeeding often, without any imposed time limits, s/he will not get enough colostrum to stimulate his/her bowels. When this happens, the symptoms may be more severe as the levels of bilirubin rise. When a baby is jaundiced, s/he will also be sleepier. You may need to wake the baby up to breastfeed. Breastfeeding as long as possible and as often as possible is the best treatment. Usually, the jaundice will clear up within two to three days of good breastfeeding. You should be seeing dark greenish brown stools (the green is meconium, backlog waste from intrauterine life), which go to brown as the meconium is cleared. Meconium stools are a sign that the baby is clearing out his/her gut. The baby should not be given any supplement such as water or glucose water unless there's a good medical reason and that supplement is administered via feeding tube at the breast. That way the baby will still be able suckle colostrum from the breast. Otherwise, not only are these supplements completely useless in lowering bilirubin levels, but they will fill up the baby and prevent him/her from breastfeeding as often as s/he should be aggravating the jaundice. If a supplement is needed and cannot be given by feeding tube at the breast, pumped milk or formula are the best solutions (in that order), not glucose water. If the jaundice is more severe, or is thought to be caused by something in the breastmilk itself (known as breastfeeding jaundice, which accounts for 2-4% of neonatal jaundice), discuss treatment options such as phototherapy with your pediatrician.

Nursing Strike

When your baby suddenly refuses to breastfeed, seems perfectly healthy otherwise, and will feed via cup, spoon or bottle, this is known as a "nursing strike". And you should take it personally. In this case, your baby is trying to tell you something by refusing your breast. Some reasons why your baby is on strike include:

  • Hurt feelings. Someone has hurt the baby's feelings. A babysitter may have dropped the baby; someone may have yelled at the baby.
  • A bad experience at the breast. Perhaps the baby bit you accidentally, causing you to scream. Perhaps the smoke detector went off when the baby was in the middle of feeding and you jumped up and scared the baby. There could be a million different scenarios causing your baby to associate the breast with something "bad".
  • A sudden switch to a new schedule. Whether you're weaning, going back to work, or traveling, your baby may have a strong reaction to any changes in his/her feeding schedule. 
  • Pain that worsens during feeding. If your baby has sore gums from teething or even an ear infection, breastfeeding may be uncomfortable, resulting in a strike. 
  • A more serious illness or infection. If your baby is suffering from a urinary tract infection, gas, or the zillions of pediatric ailments that can arise, s/he may suddenly refuse to nurse. However, nursing strike is more common when the baby is in perfect health.
  • A change in your milk due to a menstrual period (the baby will want to breastfeed after your period, however) or even pregnancy.
  • A reaction to a new deodorant, body powder, lotion, perfume, hair spray, detergent, fabric softener, and so on. 

Nursing strike is often confused with a baby's natural tendency to wean. To make the distinction, it's important to note that a nursing strike is characterized by:

  • Abrupt refusal of the breast vs. gradually prolonging intervals between nursing.
  • Clear distress when offered the breast vs. disinterest and nursing just to be "polite". 
  • Clear acceptance of breastmilk from other feeding tools, such as cup, spoon or bottle vs. a disinterest in breastmilk altogether and a desire for solids. 
  • Breast refusal by a baby under one year of age vs. a baby older than a year.

Negotiating a nursing strike

In order to get your baby back on the breast, the first thing you need to do is rule out any physical cause for the strike. Check for sore gums, an ear infection and a urinary tract infection. If the baby appears to be in perfect health, you need to review the chain of events that most recently preceded this strike. Was someone other than yourself looking after the baby? Do you recall anything unusual when you last breastfed? Whether you can or cannot remember anything out of the ordinary, apologize profusely and repeatedly to the baby. Talk to the baby when you apologize; many mothers report that their apologies are accepted. As you apologize, cuddle the baby. Then, take the baby to bed with you, cuddling and comforting the baby. Try to get that skin-to-skin contact. This will help to make the baby drowsy and comfortable and more ready to accept the breast. Keep apologizing and keep cuddling. Something has disturbed the baby's universe; order needs to be restored in the baby's eyes before s/he will breastfeed again. Nursing strikes should usually resolve in about a day. If the strike continues for longer than a day, take the baby to the doctor and have his/her health evaluated. You may need to pump/express your milk until things are back on track.

   

Too Much Milk (Infant Lactose Overload)

When the baby is "overdosing" on breastmilk, it's called "infant lactose overload". In this case, you're making more milk than your baby needs or can handle. The following have been cited as factors that can cause the breasts to overproduce milk:

  •   Breasts that are oversensitive to the suckling (this may even run in families. Increased stimulation due to nursing multiples or too much pumping/expressing milk between feedings.
  •   Certain medications that increase milk supply (check with your doctor or pharmacist).
  •   Too much caffeine, causing the baby to sleep less and eat more. 

When your breasts produce too much milk, the baby is full before even finishing one breast, never getting to the fat-rich hindmilk. The baby winds up getting only the protein-rich foremilk, which digests quickly and leaves the baby unsatisfied. Worse, the foremilk is loaded with lactose, something which the friendly bacteria in the baby's intestines thrive on; the more bacteria, the more gas. The result is a hungry, gassy, and fussy baby. You'll also notice that the baby is constantly peeing, pooing, and gaining more weight than is normal for his/her age. In addition, too much breastmilk can increase the risk of plugged ducts, mastitis, and even engorgement.

The solution is to make sure the baby finishes one breast and simply pump out the other until it's comfortable. Prior to feeding, you can also express a little milk to avoid overfilling the baby. Don't switch breasts mid-feeding, and don't offer the second breast until the first breast is completely emptied -- even if that takes two or more feedings. By doing this, your breasts should eventually make less milk because they will not be as stimulated. To relieve the baby's gas, you can give the baby 5-15 drops of lactase (Lactaid) before you nurse. In some cases, no matter what you do, your breasts continue to overproduce milk. The only thing to do in this case is to express the milk and toss it.

Painful Nursing

Anytime you're in physical pain or discomfort during breastfeeding, it's a sign that something's wrong. When nursing hurts, there is always a reason; in order to continue breastfeeding comfortably, the source of the pain hurt must be investigated, and if possible, treated. Frequently, women will stop breastfeeding because it hurts too much. Pumping breastmilk until the problem is solved is a good solution. However, to simply stop the process altogether and allow your milk to dry up is a most unfortunate decision, particularly if the source of your pain is an easily-solved problem. Engorgement, skin irritations on the nipple, mastitis and plugged ducts are the most common sources of pain - all treatable. Just as no one would "stop" urinating because of a urinary tract infection, no one should be forced to stop breastfeeding because of a breast infection or irritation that is treatable. For more information on these topics, see Chapter 7 of my book, The Breastfeeding Sourcebook, 3rd edition.