Breastfeeding - Difficulties

What kinds of difficulties might I encounter with breastfeeding?

Just as every mother and baby are different, so are their experiences with breastfeeding. Some mothers and babies may have an easy time of it, while others may find it to be an experience full of challenges. Some of the most common difficulties experienced with breastfeeding include:

Over-active let-down:    

Although most babies with breastfeeding difficulties have problems related to getting enough milk, a few have the opposite problem — handling too much milk. Some mothers have such a strong let-down that the baby cannot handle the volume of milk.

If your baby chokes, gags, pushes off of the breast a minute or two after beginning to feed, an over-active let-down may be the cause.

Most babies do learn to handle let-down as they mature, but until then you might take your baby off the breast until the milk flow slows. Try using only one breast each feeding. Some mothers find it helps to position the baby so that the back of his or her throat is higher than the nipple, so that the milk has to travel uphill during a let-down, which slows the flow. Another option is to try pumping through the let-down immediately before a feeding.

Sore nipples:

Sore nipples are probably the most common complaint by new mothers have when starting to brestfeed. They may be caused by different factors, so determining the cause of sore nipples dictates the appropriate treatment. A certified lactation consultant (IBCLC) will be able to help and suggest intervention.

Breastfeeding shouldn’t hurt, and the skin on your nipple shouldn’t break down any more than the skin anywhere else on your body. However, mild tenderness, similar to the kind of tenderness some women experience with their menstrual cycles, is fairly common for the first week or two of breastfeeding. It should go away.

If your nipples feel painfully sore or the nipples or areola feel bruised, it is more likely that it is related to an improper latch-on process or ineffective sucking. Suspect a difficulty with baby's latch or sucking if your nipples become very red, raw, blistered, or cracked. A latch or sucking difficulty or a structural variation in the baby's mouth might result in nipples that look creased or blanched (turn white) at the end of feedings. Certain creams or dressings may promote healing, but others can actually cause more damage. Also, avoid any treatment that might result in drying the nipple tissue, which may lead to cracking of the skin.

When nipples become red and burn, or feel extremely sore after weeks or months of pain-free breastfeeding, it may be due to a yeast infection such as thrush. Yeast may appear as white patches in the baby's mouth or it may show up as a bright red diaper rash. Specific medications are needed to treat yeast infections. Contact your baby's physician for more information and treatment.

Ineffective latch-on or sucking:

Your baby must be able to effectively remove milk from the breast during breastfeeding in order to obtain enough milk to gain weight and "tell" the breasts to increase or maintain milk production. Ineffective milk removal can result in poor weight gain due to inadequate intake of milk by your baby, which is then followed by a drop in the amount of milk being produced for the baby.

Your baby's ability to suck and remove milk may be affected in different ways.

• Prematurity, labor and delivery medication and conditions such as Down syndrome may initially make it difficult for a baby's central nervous systems to remain alert or coordinate suck-swallow-breathe actions.
• Acute health conditions, such as jaundice or infection and chronic conditions, such as cardiac defects may also influence a baby's level of alertness or the ability to suck.
• A "mechanical" issue, such as tongue-tie or a cleft lip or palate might directly interfere with a baby's ability to use the structures in the mouth for effective sucking.

Sometimes, the cause is obvious, but often it is not. It is important to recognize the signs that a baby is unable to effectively remove milk during breastfeeding so that steps can be taken to remedy any problem. Signs of ineffective sucking may include the following.

Your baby consistently: 

• does not wake on his or her own to cue for feedings eight or more times in 24 hours.
• cues to feed 14 or more times in 24 hours.
• latches on and then lets go of the breast repeatedly.
• pushes away or resists latch-on.
• falls asleep within five minutes of latch-on or after sucking for only two or three minutes.
• does not suck almost continuously for the first seven to 10 minutes of a feeding.
• continues to feed without self-detaching at the first breast after 30 to 40 minutes.
• feeds for more than 45 minutes without acting satisfied or full after a meal.
• produces fewer than three stools in 24 hours by the end of the first week (for the first four to eight weeks).
• seems "gassy" and produces green, frothy stools after the first week.
• produces fewer than six soaking wet diapers in 24 hours by the end of the first week.
• has difficulty taking milk by other alternative feeding methods. 

Low milk production, or perceived low milk production

You may go through a period of questioning whether your milk supply is adequate, which can cause anxiety. In many cases, this turns out to be a false alarm — signs like the lack of a feeling of “fullness” in your breasts, changes in the length of time your baby nurses or changes in the amount of milk you pump can be misinterpreted. None of these are signs of low milk production.

Occasionally, a delay in the time when milk "comes in" turns into an ongoing problem with low milk production, or you may be producing sufficient amounts of milk and then production slowly or suddenly, decreases. Fortunately, true low milk production is rare and it’s often possible to increase production.

Talk to a certified lactation consultant, your baby's nurse, physician or a breastfeeding support leader if:

• You aren’t producing a daily total of at least 16 ounces of milk by seven to 10 days after your baby’s birth.
• You begin obtaining less and less milk each day for three or four consecutive days.
• Your daily total dips below 12 or 13 ounces for more than two or three consecutive days.

What causes low milk production?

Research has yet to discover whether the cause for a delay in or low milk production is due to health, pregnancy or birth-related conditions, certain medical treatments for these conditions or a delay in beginning frequent milk expression that often occurs with such conditions.

Some conditions, or treatments, that experts think may contribute to a delay for milk to “come in” include the following:

• stress
• cesarean (surgical) delivery
• postpartum hemorrhage
• retained placenta fragments
• infection or illness with fever
• diabetes (juvenile, adult-onset, or gestational)
• thyroid conditions
• strict or prolonged bed rest during pregnancy

Other factors can also lead to insufficient or low milk production include:

• maternal smoking
• some medications and herbal preparations
• hormonal forms of birth control, especially any containing estrogen
• becoming pregnant again
• previous breast surgery that may have cut nerves, milk-making tissue or milk ducts

Occasionally, a maternal health condition may delay the large increase in milk production usually seen between three to five days postpartum. Some mothers do not begin to obtain large amounts of milk until seven to 14 days after giving birth. If this happens to you, do not feel discouraged. Keep pumping.

You may not actually have a problem with low milk production if:

• your baby is nursing for shorter sessions. As babies get older, they become more efficient at extracting milk.
• your baby is nursing for longer or more frequent sessions. This is often a growth spurt.
• your baby is gaining weight well on breast milk alone.
• you get very little or no milk when you pump. This is not an indication of milk supply.
• your breasts don’t leak or stop leaking milk, or the amount of leaking decreases.

If you are experiencing chronic low milk production, your healthcare provider may order blood tests to determine whether there may be an underlying condition such as:

• Anemia
• Hypothyroidism
• Pituitary disease

If insufficient milk production seems to be a problem, yet the baby seems to be sucking effectively, your physician or certified lactation consultant may recommend the following:

• Increase the number of breast feedings to 10 to 12 in a 24 hour period.
• Increase the amount of skin-to-skin contact you have with your baby. Take off your shirt (and your baby's shirt) and place your baby on your chest with a sheet or shirt over both of you.
• Ask your healthcare provider to review your health history with you to discover if there may be a health condition, treatment or medication interfering with milk production.

You may also want to:

• Pump your breasts for several minutes after breastfeeding, using a hospital-grade electric breast pump.
• Ask your physician or a certified lactation consultant (IBCLC) about taking a galactogogue, which is a medication or herbal preparation found to have a positive effect on milk production.
• Join a support group or online forum to connect with other mothers in similar situations.

Most importantly, stay positive. Although insufficient milk production usually can be reversed, any amount of milk you produce is valuable for your baby. Try to remember that your baby is 25 to 90 percent breastfed rather than feel discouraged that he or she is also receiving a breast milk substitute.

How you can help with the breastfeeding process:

When a difficulty with latch-on or sucking persists beyond the first several days after birth, it can be discouraging. Although most babies will learn to breastfeed effectively if given time, it is important to work with your baby's physician and a certified lactation consultant (IBCLC) if your baby has difficulty sucking. Until the issue resolves there are several things you can do to help breastfeeding progress while you make sure your baby is getting enough to eat. Always consult your baby's physician for more information.

• Wake your baby to breastfeed every two to three hours if he or she is "sleepy" and still has not mastered feeding cues.
• Your baby probably will do better for some feedings than others. Do not be discouraged if he or she is too sleepy or seems to "forget" from feeding to feeding.
• Some feedings will last longer than others, and your baby may need time to "get going" at the breast for some feeds.
• Massage your breast with downward and inward strokes to deliver milk into the baby's mouth when he or she begins to fall asleep at breast too soon after starting to feed.
• Chart the number, amount, and color of urine and stools for wet and dirty diapers on a daily record.
• Use a hospital-grade, electric breast pump to ensure milk removal. Express milk for several minutes after breastfeeding. How long you will need to continue to pump depends on how quickly your baby learns to breastfeed effectively.
• Weigh your baby regularly or record a test-weight before and after one or more daily feedings.
• Offer additional calories by giving your baby any expressed breast milk available first or a prescribed infant formula based on his or her progress at the breast. The amount used and the alternative feeding method used should change as your baby's sucking ability improves.
• Certain breastfeeding devices or alternative feeding methods may encourage effective sucking or provide your baby with additional nutrition during the "learning to breastfeed" process. Although a specific device may have advantages for your situation, every device also has disadvantages. To avoid pitfalls, any breastfeeding device should be used with the guidance of a certified lactation consultant (IBCLC). Devices that may be helpful in certain situations include the following:
  • Nipple shield - A thin silicone or latex nipple shield, which is centered over the nipple and areola, has been shown to encourage a better latch, more effective sucking pattern, and better milk intake during breastfeeding for certain babies.
  • Feeding tube system - A feeding-tube system may be taped to the breast or your finger so that your baby receives additional milk through the tube when the baby sucks. When a thin feeding tube is attached to a syringe and taped it to the breast or your finger (finger-feeding), you or a helper can gently press the plunger to deliver a few drops of milk in your baby's mouth if he or she "forgets" to suck. Commercial feeding-tube systems are also available.
  • Alternative feeding methods - In addition to a feeding-tube system, there are other alternative feeding methods that will ensure that your baby gets enough food, but are less likely to interfere with long-term breastfeeding. These include cup-feeding, syringe-feeding, spoon-feeding, or dropper-feeding. If using a bottle, bottle nipples with a slower rate of flow usually are preferred.
• If any structural variation in your baby's mouth is found, work with the proper healthcare professionals to correct or treat it. Depending on the type of variation, this may involve anything from oral exercises taught by an occupational therapist to some type of surgical treatment.

General tips and suggestions:

•  Skin-to-skin contact seems to help babies get to the breast more effectively, sooner and it helps you maintain milk production.
• If your baby has the basic idea of effective sucking but cannot seem to do it consistently, try pumping one breast while breastfeeding your baby on the other.
• You may want to limit a breastfeeding if you or your baby gets too frustrated or if the feedings take more than 40 to 45 minutes. By stopping when frustrated or limiting the time of feedings, you will have more time to pump and remove milk effectively and you may find it is easier to remain patient through the learning process.
• You may want to let your baby's father or other family members and friends handle alternative feedings, so you do not become overwhelmed. This frees you to concentrate on breastfeeding, maintain pumping sessions and enjoy periods of cuddling skin to skin with your baby.
• Do not throw away any breastfeeding device or an alternative feeding method because you did not like it or it did not work when first suggested. The device or method that did not help one day may work great the next and vice versa.
• Once your baby is growing and developing properly and his or her nutritive sucking ability is improving, ask your baby's physician when you might eliminate test-weighing. Ask when you can stop waking your baby for feedings and begin to wait to see if he or she will demonstrate feeding cues. You will also want to know when it is safe to start decreasing supplementary breast milk or formula.
• Keep thinking positively.
• It’s normal to get frustrated and think your baby will never learn to breastfeed effectively.
• It’s normal if some days seem an eternity of breastfeeding practice, alternative feedings and breast pumping sessions.
• It’s normal for your confidence to rise and fall.
• Try to maintain perspective by having a sense of humor.
• Think about how far your baby and you have come since his or her birth rather than how far you still may have to go.
• Get support. In addition to staying in touch with a certified lactation consultant (IBCLC), contact a representative of a breastfeeding support organization, who will have lots of information and will provide you with moral support whenever you need it.