Breastmilk is recommended as the sole nutrient for a full-term baby for the first six months of life, yet only 13% of mothers actually achieve this goal. Although breastfeeding is considered a basic instinct that ensures survival of the newborn, it is not always easy.
The recommended minimum of exclusive breastfeeding for six months, but most mothers give up earlier due to various breastfeeding difficulties.
In 2016 an article in the Canadian Medical Association Journal (CMAJ Open) stated that approximately 60-80% of women admit to having some problems with breastfeeding, and 90% of those women give up within 6 weeks. In fact, 42% of all women who start out breastfeeding their babies stop within 6 weeks because they feel overwhelmed by related difficulties.
In this article I will be focusing on the 11 most common breastfeeding difficulties and issues that are reported by mothers and I will give the possible causes and solutions.
Baby having difficulty getting a proper Latch on
Almost 50% of first-time mothers often complain that their babies are not getting a good grip on their nipples and the breast keeps falling out of their mouths. This usually causes the babies to cry a lot and the mothers become frustrated and even depressed.
The upper lip of the baby has a connective tissue attachment which can be too short and tight. That can restrict the movement of the upper lip, making it hard for baby to latch on properly.
Your baby might have a tongue-tie for which you may see your pediatrician or lactation consultant, who can help you.
If your baby doesn’t have a tongue-tie, and you are still having trouble in nursing, you can check if there is a lip-tie by lifting upper lip of the bay.
Some mothers have flat or inverted nipples and although this might present a challenge ,it is not impossible. Pumping the breast for about 2 minutes before feeding or using a nipple shield might help to facilitate latching.
Preterm babies may take a while to latch on properly because their mouths are small, they are not strong and they may tire easily, but with perseverance and patience this can be achieved. Your doctor or a lactation professional may be able to assist.
The mother must ensure that the baby is not clamping on the nipple. The dark area around the nipple is called the areola and this is the portion of the breast that the baby should be clamping onto.
Allow the baby to “root” for the breast and if the baby is clamping onto the nipple simply use your finger to apply slight pressure above the upper lip and push the breast further into the baby’s mouth in a rapid, smooth motion. This should be done without removing the baby from the breast.
The entire nipple and part of the areola should be inside the mouth when the baby is properly latched to the breast and it should not be a painful experience.
There are different ways to hold the baby when trying to achieve a proper latch on and a successful feed.
I will now share a latching technique video made by Lactation Consultant Corky Harvey.
What is rooting?
Babies are born with certain reflexes and one of them is called the “rooting reflex”.This occurs when the cheek or the corner of a baby’s mouth is stimulated by touch. This will cause the baby to turn its head in that direction and open the mouth, aka “root” to initiate sucking.
The pain associated with breastfeeding may have several underlying reasons, which include the following:
The Baby clamps on to the nipple instead of the areola, as noted above.
Breast Engorgement or overfilling of the breast
This might be due to inadequate emptying of the breast during feeds and the mother may have to express some of the breast milk before or between feeds.
Infection of the breast or nipple
Breast infection is one of the reasons is caused due to mastitis or even thrush which might originate from the baby’s mouth or from the mother.
Trauma to the breast
This may be due to tight fitting bras, or clothing or even from being bitten by the baby.
If a mother experiences pain when breastfeeding she should consult her healthcare provider who will evaluate and treat her accordingly. She may or may not require prescribed medication.
Sore / Cracked Nipples
The frequent feeding of a baby may be traumatic to the nipples and they may get sore and cracked initially, causing nipple pain. Sometimes there is even bleeding. However, this is only temporary and usually heals within a few days.
The first-time mother might not be able to completely avoid sore nipples, but she can try to prevent it by ensuring that the baby latches properly and not onto her nipples. It is also a good idea to keep the nipples clean and dry between feeds. Breast pads can be worn to collect any milk that might drip between feeds.
If the nipples are sore there are a few simple remedies that can be used to hasten healing:
- Apply some breastmilk to the area.
- Wash the area with salt water after feeds and dry with a soft cloth.
- Apply a thin layer of lanolin or other over the counter breast cream between feeds.
- Ice packs or cold compress might be quite soothing to the affected nipples.
- A nipple shield may be helpful to alleviate the pain and tenderness during the healing process.
Sore or cracked nipples should be evaluated by your healthcare provider because they might be infected with bacteria (mastitis) or fungus / yeast (thrush). You will receive appropriate medication and be able to breastfeed without interruption.
3 days after birth your breasts become hard due to the build up of milk supply and can be very painful.
They may even have difficulty getting their baby to latch on properly. This is referred to as engorgement. This is due to production of milk and an increase in the blood supply to the breasts. Engorgement may recur later under certain circumstances.
This is a bigger problem for first time Moms since seasoned Moms have been through this earlier and your breasts have been through this already
The best way to resolve this uncomfortable situation is to express some of the milk to soften the areola and then allow the baby to feed. The other breast might begin to drip, and this milk can be collected in a breast shell or you may attach it to a breast pump and avoid wasting the milk. There are certain tips that may be useful to prevent engorgement, these include:
This can be eased by nursing frequently and also using a warm compress before feeding and a cold compress after, massaging your breasts, switching positions and using a well fitting nursing bra
- using a warm compress before feeding and a cold compress after
- massaging your breasts during a warm shower
- switching positions
- using a well fitting nursing bra
- Put the baby to the breast within the 1st hour after birth
- Breast feed exclusively and feed on demand
- Offer the baby both breasts at each feed
- Allow the baby to empty each breast
- Avoid excessive pumping between feeds
- Do not skip feeds – nurse frequently
- If you are supplementing with formula feeds, try to express during those formula feeding episodes
- Avoid weaning too early (before 6 months)
- Express the milk into sterile bottles
- Take anti-inflammatory medication such as ibuprofen if the pain is overwhelming
Recurrent breast engorgement may be due to underlying problems that are best treated by your doctor.
Lump / Mastitis
There are many women who mention that they sometimes have a lump in one breast while breastfeeding. This might be a blocked milk duct which will sometimes disappear on its own but there are other times when they experience an area that is painful, tender, warm and swollen.
This may be due to Mastitis, which results from a blocked and infected milk duct. There may be other associated symptoms such as fever, weakness, decreased appetite and feeling generally unwell. This is usually associated with cracked nipples.
These cases should be seen by a doctor for early diagnosis and treatment. There are a few suggestions to aid with the uninfected cases:
- Do not press on the breast during feeds
- Allow baby to empty the breasts during feeds
- Apply a warm towel to the breast during feeds
- Avoid tight clothing
- Wear supporting bras without any underwires
- Avoid engorgement
- Exclusively breastfeed and on demand
- Wean gradually after 6 months
Thrush and Breastfeeding
Thrush is a yeast infection that is commonly seen in babies. The organism that causes thrush is called candida albicans and it is a fungus that normally lives in our digestive tracts and on our skin.
However, it tends to multiply and cause an infection under certain conditions such as:
- Immature immune system, as in babies
- Suppressed immune system as in patients who take certain medications like chemotherapy, steroids, and other drugs
- Diabetic patients
- Patients with certain illnesses such as AIDS
- Patients taking certain antibiotics
The organisms thrive in warm, moist, sweet, and dark environments; therefore, the baby’s mouth is a common site for thrush. The diaper area is also a favorite location for this infection. Some women get recurrent vaginal yeast infections.
To prevent your baby from getting thrush, it is important to:
- Avoid putting unsterilized objects into the mouth example pacifiers, nipples, and wash cloths
- Do not put honey or sweeteners in the mouth
- Keep the breast clean and dry, wear breast pads without plastic lining
- Wash hands properly after each diaper change
- Wash hands properly before breastfeeding
- Avoid baby going to sleep with milk in the mouth
This infection may be passed from the baby to the mother’s breast and can be quite painful.
Both mother and baby should be treated at the same time otherwise re-infection will occur.
The doctor will prescribe medication to be placed in the baby’s mouth and the mother will get medication to put on her nipple and areola. Depending on the circumstances, she may also have to be given medicine to be taken by mouth.
Inadequate Supply of Milk
Although many mothers are anxious about their ability to make enough milk for her baby to grow and develop healthily, the fact is that about 95% of mothers can produce more than adequate milk for their babies.
Only 1-5% of women are unable to produce enough milk for their baby and only about 2% are unable to breastfeed..
For the few women who have insufficient milk, there are several factors to be considered and most can be corrected
Factors associated with Inadequate supply of milk:
- Delayed first feed – Mothers should be allowed to nurse their babies with skin to skin contact within the first hour. This will facilitate the “let-down” reflex as the brain gets the message to allow milk production to begin in the breasts.
- Length of spacing between feeds– Milk is produced on a supply and demand basis, therefore if the feeds are too widely spaced the milk supply may be inadequate because of insufficient demand. After the first feed, babies may sleep for 2-4 hours on the first day, then they start to wake for feeds between 1-4 hours. This usually averages at 8-12 feeds per day.
- Duration of feeds – Initially the first milk or colostrum might not flow readily but the baby should be allowed to suck and feed for about 10 minutes on each breast. By the 4th day, the milk flow should be enough to satisfy the baby after feeding 10-30 minutes on each breast.
- Baby not latching properly –If the latch is inadequate the baby might get frustrated and refuse to suck. This will cause a decrease in demand and consequently a decrease in production. However, mom can express/pump the milk from the breast regularly and offer the milk in a bottle. This should be done as frequently as the baby requires to be fed.
- Preterm babies may not feed strongly enough, and the milk supply might decrease accordingly.
- Maternal obesity may affect the ability of the breasts to produce an adequate supply of milk.
- Previous breast surgery or breast implants may decrease the ability to produce adequate milk.
- Supplemental feeds – Babies who are offered several bottles of formula, especially in the first few days, might not feed well at the breast. This may be due to nipple confusion. This is because the mechanism of sucking the breast differs from that of the nipple of the bottle and the milk flows faster from the bottle than the breast. This might cause the baby to get confused and frustrated resulting in him/her choosing the easier bottle-feeding route.
- Mother’s emotions – The mother’s hormones influence her production of milk, so if she is highly stressed, exhausted, or depressed, her milk production may be inadequate.
- Mother’s medication – There are some medications that will decrease the quantity of milk produced by the mother and these should be avoided. These include some common over-the- counter cough medicines, as well as prescribed pain relievers, contraceptives and diuretics used for the treatment of high blood pressure.
- Mother’s health – The mother’s health status also plays a significant role regarding the production of milk. Several common conditions include diabetes, high blood pressure, obesity, and the abuse of alcohol, caffeine, and other drugs.
Frequency of feeds
Many mothers are concerned about how often they are supposed to breastfeed especially in the first 48-72 hours when the flow of the colostrum or first milk is somewhat scant. They become anxious because they are unable to measure the amount of milk per feed. This fear is understandable but there are guidelines which can alleviate those anxieties.
Babies should be fed on demand and should appear to be satisfied after feeding. In the first few weeks, they usually spend most of their time sleeping and wake up mainly to be fed. There are different meal-time cues that they may give before they start to cry. These include:
- Hands to face
- Crying is a late sign and should be avoided when possible.
- The first breast feeding should occur within 1 hour of birth and then between 1-4 hours on demand.
- In the first 72 hours allow baby to feed for about 10 minutes per breast for each feed. As he gets older and stronger, the feeds may last longer and be spaced out at wider intervals.
- Babies usually feed about 8-12 times per day in the first few weeks, which averages to approximately every 2-3 hours.
- By day 5 they should have at least 6 very wet diapers per day
- After passing black then green then yellow stools in the first few days they should transition to about 3-4 yellow, seedy stools per day, by day 5. After 4-6 weeks, the number of stools may decrease.
- For the first few weeks the baby should be allowed to breastfeed for 10-30 minutes per breast for every feed
- Once the milk is flowing well consistently, allow the baby to empty one breast before switching to the other.
- Always offer both breasts per feed and alternate the starting breast for subsequent feeds.
If the baby is not feeding well, he may be too weak to wake up at regular intervals and may have to be awakened and encouraged to feed.
NB: Any baby who is not feeding well should be urgently evaluated by a pediatrician because there may be underlying medical problems that need to be addressed.
Does Breastfeeding Cause Jaundice?
Jaundiced Baby with Yellow Eyes Jaundiced Baby Receiving Phototherapy
Yellow discoloration of the skin and eyes is called jaundice. Up to 60% of newborn babies will have a mild yellow tinge to the white portion of the eyes by the third day. This is called normal or physiological jaundice.
- The baby’s fetal red blood cells have a shorter lifespan than the regular red blood cells and when they rupture, the yellow bilirubin pigment inside the cell is released into the circulation.
- If the amount of bilirubin pigment reaches a certain level, the eyes and skin will have a yellowish appearance.
- The pigment is removed from the body through the stool and the urine. Therefore, if the baby feeds frequently there should be more frequent passage of urine and stool, resulting in a speedier removal of the pigment from the circulation.
If the baby is not getting enough milk during breastfeeding, the baby may appear jaundiced. This breastfeeding jaundice usually occurs during the first week, and it is different from breastmilk jaundice.
- If the quantity of the mother’s milk is not enough, this is one of the rare occasions when supplemental formula feeds may be recommended.
- To encourage milk production, the baby should be allowed to breastfeed at each meal and then offered the formula for “topping up” after being fed on each breast.
Breastmilk jaundice usually occurs later, during or after the second week and may last for several weeks. This is not because of insufficient milk. It is due to a factor/s in some mothers’ milk that affect the way the bilirubin is metabolized by the liver. Only 0.5-2.4% of newborns have this problem.
The baby may be allowed to continue breastfeeding but if the amount of bilirubin is too high the baby may be treated with a special light / phototherapy and offered formula. The mother may be advised to discontinue breastfeeding for 12-48 hours. During this time, she can express her milk to avoid engorgement.
Baby’s Growth and breastfeeding
It is important to know that breastfed babies may lose up to 10% of their birthweight in the first week but if they are adequately fed, they should regain their birthweight by 10 days of age and then continue to gain weight at a rate of 4-7 ounces per week up to age 6 months.
In the first 3 months of life breastfed babies tend to grow faster than the formula fed ones but in the next 3-12 months the trend moves in the opposite direction.
Babies are expected to double their birthweight by 5 months and triple it by 1 year. Variations in values that are either above or below their anticipated range are of more concern than their actual weight.
The baby’s doctor has growth charts that give an objective measure of the baby’s height, weight, and head circumference. The pattern of growth along with other parameters will determine whether the baby is thriving adequately. A small baby does not necessarily mean that the milk supply is inadequate.
If the baby crosses 2 or more percentile curves on their charts the doctor will be more concerned than if he / she maintains a specific growth pattern.
Some mothers worry that their babies might not grow as fast as the formula-fed babies in their circle of friends. This might appear to be true at times, but such comparisons should be discouraged. The genetic makeup of the families must be considered.
Growth chart of a small girl
When to stop Breastfeeding
The American Academy of Pediatrics (AAP) recommends that babies should be breastfed for the first 12 months and exclusively for the first 6 months. The World Health Organization (WHO) recommends breast feeding up to 2 years. The timing of when to wean her baby is the mother’s decision. The weaning process should be slow and methodical. Some babies stop breastfeeding after a few months while others never want to stop.
- Weaning may begin when solids and bottle feedings are readily accepted by the baby.
- The mother might be able to skip one feeding every 3-5 days until the baby only nurses at nights or stops completely.
- If the weaning is done too quickly the mother might experience pain from engorgement, blocked milk ducts, mastitis, and overfilling. She may also experience emotional mood swings.
Breast milk is the most economical and the best nutrient for infants. It is rich in antibodies that protect babies from many childhood diseases, including diarrhoea, respiratory tract and ear infections. The mother also receives benefits that include protection from uterine, breast and ovarian cancer. Every effort should be made to encourage and support mothers to breastfeed, especially for the first 6 months.