Motherhood 2, breastfeeding: the practice
After having reviewed the basics of lactation in the previous post, let’s get into what one can actually do if things are a bit more challenging than one expected.
First things first, how does one know if the infant is hungry. To begin with the baby will be displaying feeding cues (rooting, lip smacking, sucking on hands, mouth opening and closing). Normally, term newborn feeds up to 12 times a day. If not fed it will proceed to raise the tone of the conversation and will notify you and everyone in vicinity of their discontent. Then if the baby does not receive enough milk, they will develop signs of dehydration:
- dry tongue or inside of mouth
- decreased turgor or wrinkly, non-elastic skin (if pinched lightly, does not rebound right away)
- less than one wet nappy/day and/or less than one stool/day
- orange-reddish crystals on the diaper (these are urate crystals)
- sunken eyes, fontalles or cold limbs (severe)
Generally three to five days after being born the target weight gain is 30 grams/day. Thus if this does not happen, it is suspicious.
Again, it is normal not to be overflowing with milk right after birth so let’s see what one can do to facilitate production. To begin with, do not wait for the baby to cry its head off before putting it to the breast (scheduled feeds popular in the 80s do not compare favorably with feeds on demand). We’re looking at almost every two hours, and sometimes even more often than that. It is a feedback loop: the more the breast is stimulated, the more milk it will produce.
Next, check the positioning of yourself and the baby (ideally, someone at the hospital should observe at least one feeding session and correct it if necessary). It does not really matter which exact position is chosen as long as all parties involved are comfortable and not cramped. An excellent intro article can be seen for illustrations and so much more here. They also demonstrate a good latch and are an overall great source of information on breastfeeding.
Talking about a good latch, which is another common mechanical issue, as it were. Although nipples are quite sensitive, a good latch should not be painful. People tend to think that as long as the nipple is in the baby’s tiny mouth, they’re good, however when latched properly almost all of the areola should be in the baby’s mouth. So instead of putting the nipple directly in, it is advised to basically poke them with the nipple into the philtrum (area of skin between upper lip and nose) to induce rooting. This will make the baby open their mouth wide at which point the mom more or less squishes the breast with one hand to facilitate a fuller areola insertion into the mouth. It’s often called asymmetric latch as when a good latch is achieved, there will be more of the areola visible over the baby’s nose and almost none of it seen below the lower lip. The nose should be close to the breast, but not squished against it. It’s worth mentioning that if feeding is painful or you think the first attempt latch is not good, it is totally ok to gently detach the baby by inserting a finger between their gums and recommence. It is a coordination exercise and both mom and the baby are learning, so correction and repositioning are normal and to be expected. See a great illustration of a proper latch in this Wikipedia article vs suboptimal one or even better a whole series of videos with great examples of not only latching, but also good drinking vs nibbling.
Galactogogues or substances promoting lactation (either medical or herbal, looking at you fenugreek) are not recommended as their efficacy is limited and potential side effects might be concerning. With the herbs it’s compounded by the overall problem with supplements, i.e. who really knows what manufacturer puts in them and in what quantities. At the risk of being repetitive — herbs are dirty drugs and using them is not that much different from a safety point of view than buying street drugs. And even less is known about chemical compounds in herbs and how much of them is excreted in breastmilk. You can look up which medications are excreted in milk here.
Getting back to breastfeeding though, next let’s see what other common issues might arise to impede the success of lactation. Nipple pain (not reduced/eliminated with proper latch) is subcategorized into nipple sensitivity and nipple injury. The first generally explained by increased sensitivity throughout pregnancy, peaking around day 4 postpartum then resolving. It is especially prominent during the first few minutes of breastfeeding. It might be explained by the suction exerted over empty ducts and alleviated as milk comes down. Nipple exercising or toughening prenatally, although seemed plausible, did not prevent sensitivity when put to test, as it were, after delivery.
Nipple injury pain though is different: pain is intense, continuing well after the first week of breastfeeding. Poor latch plays a significant role as it increases the traumatisation of the area leading to abrasions, cracking, even bruises which makes feeding extremely painful for the mom, which in turn negatively impacts milk production, as any other painful or stressful experience will. Badly fitted breast shield contributes to injuring the area. When pain makes milk extraction difficult, it leads to breast engorgement and milk stasis which increases breast discomfort and might lead to fever. All together it not only impacts lactation, but leads to inflammation and infections of the breast. As with any other condition, prevention is the best intervention:
- proper latch and optimal positioning is at the root
- skin care with unscented, non-irritating products, limiting friction and scrubbing, avoidance of overly moist environment (ie, with breast pads; optimally air drying is recommended)
If injury had already occured the first step would be to re-evaluate the latch and positioning, ideally with an experienced healthcare professional (family doc or even better lactation consultant). Next, to avoid further trauma switching to feed from another breast if it is not affected. If impossible or both are affected, continue pumping or hand expressing and feeding the baby with a teaspoon or a cup. Interestingly enough, application of expressed milk to injured nipple might be helpful. Use of lanolin has not been shown to be more beneficial than regular skin care. Vitamin E is contraindicated as it might accumulate in the baby’s body with negative effects. You can also use warm or cold compresses to reduce the pain. Then treating the injured area with antibiotic ointment and non-stick covering. However, if you have fever, the breast is very painful, there is redness and/or a bump on the breast, please please please seek medical help right away.
Another factor that might contribute nipple bleb, which is essentially clogged milk duct pore. Visually it resembles a blocked pore on any other part of your body. It might be tempting to try and pick at it to remove it, however it is painful and can lead to inflammation and scarring, which in turn is a risk factor for a recurring bleb. What you can do instead, is to soak the nipple in warm water or olive oil and then wipe it gently with a washcloth to gently exfoliate the area.
Let’s mention ankyloglossia or a tongue-tie here too, even though most infants with tight frenulum (a vertical membrane below the tongue resembling a bridle) can breastfeed without difficulty. In some it might lead to shallow latch and consequently poor milk evacuation. Upon being born babies are examined to screen for the problem, but if not noticed before and complicating breastfeeding, a lactation consultant would be the person to see.
In the next post on lactation I’ll talk about the Baby Friendly Initiative and problems that arise with the near militant stance on breastfeeding.
Some of the sources used for this post:
