Common Concerns During the Early Weeks of Breastfeeding

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When Is Poor Feeding a Sign of Infant Illness?
One of the most important clues to infant well-being is the frequency and quality of feedings. Parents, especially mothers, quickly become attuned to their baby's usual feeding pattern and readily notice any changes in feeding frequency, duration, or vigor. Young infants have few ways to communicate illness. Poor feeding is one of the strongest indicators of a medical problem, and it must not be ignored. Sleeping through feeding times, showing less interest in feedings, suckling for a shorter period of time, or nursing with less stamina all could indicate some type of medical problem, such as an infection or a heart condition. You should promptly report any change in your baby's feeding pattern to your infant's doctor.

What Does Infant Jaundice Have to Do with Breastfeeding?
Many newborn babies develop a yellowish color to the whites of their eyes and their skin, a condition known as jaundice. Parents often wonder about the significance of newborn jaundice. In adults, jaundice rarely occurs and represents an important sign of illness, such as hepatitis. Jaundice in adults must never be ignored; its cause always must be investigated. Unlike adults, some degree of jaundice is evident in nearly half of all newborns, usually by the third day of life. Most cases of newborn jaundice are mild and require no treatment. The yellow color results from a substance known as bilirubin, a breakdown product of hemoglobin, which is present in red blood cells. Normally, the liver metabolizes bilirubin and excretes it in a modified form into the intestines where it gets passed from the body in bowel movements.

Many factors contribute to higher bilirubin levels in newborns during the first week of life. First, babies are born with more red blood cells than adults and these cells have a shorter life span than that of adult blood cells. In addition, many babies experience bruising during the birth process, and the red blood cells trapped in a bruise quickly add to the bilirubin load. Thus, newborns must handle proportionately more bilirubin than normal adults. Ironically, the immature newborn liver is less effective in metabolizing bilirubin. Furthermore, even when the liver does its job and excretes bilirubin into the gut, bilirubin can be reabsorbed from the infant's intestines into the bloodstream, especially if the baby stools infrequently. Since breastfed babies often obtain less milk compared to formula-fed babies during the first few days of life, breastfed babies may stool less often and develop higher levels of bilirubin. In fact, many studies have confirmed that breastfed babies, on average, have higher bilirubin levels than bottle-fed babies.

Now you can appreciate why so many healthy newborns develop some visible jaundice. Numerous medical disorders can further exaggerate the bilirubin level, such as blood type mismatches between mother and baby that cause the baby's red blood cells to break down faster than normal; liver disease that impairs the metabolism of bilirubin; infection; heart disease; or a low level of thyroid hormone. Thus, whenever jaundice is present, it is important not only to monitor the level of bilirubin but to identify the cause of its elevation as well. Normal, or physiologic, jaundice must be distinguished from serious underlying causes of jaundice that require treatment.

Another reason we worry about jaundice is that high levels (usually over 25 milligrams percent) are toxic to the newborn brain and can cause brain damage and/or hearing loss. Permanent damage can be prevented by monitoring bilirubin levels carefully with blood tests, searching for and treating any identified causes, and using phototherapy (in the form of bilirubin lights or phototherapy blankets) to bring the level down. (Rarely, the bilirubin level rises so high that an exchange transfusion becomes necessary to lower the level rapidly.) Proper treatment of jaundice involves more than just "making the yellow go away." It should include finding and treating any underlying medical conditions contributing to the problem. Inadequate breastfeeding is a common cause of newborn jaundice that needs to be recognized and treated.

If you observe any yellowish color to your baby's skin or the whites of her eyes, notify your baby's doctor, who will decide whether to order a bilirubin level. Ask to have your infant weighed. Many doctors don't appreciate that inadequate breastfeeding can contribute to jaundice in a breastfed infant. When breastfeeding is going poorly for any reason, the result can be insufficient caloric intake by the infant, excessive weight loss from birth, inadequate weight gain, infrequent stooling, and an elevated bilirubin level. If your baby has jaundice, your doctor can help you determine whether the level is high enough to pose any danger and whether inadequate breastfeeding might be contributing to the problem.

Review the expected normal patterns for breastfed infants described earlier. Is your baby latching on correctly and feeding on an appropriate schedule? Is she wetting and stooling normally? Has your milk come in? Is she emptying your breasts well? Has she lost excessive weight or started to gain consistently?

Bilirubin levels usually peak around three to five days of age, just when your milk is coming in abundantly and your breasts are maximally engorged. At the point when your breasts need to be drained well, your sleepy, jaundiced baby may not be the most effective candidate for the job. I usually recommend a hospital-grade rental electric breast pump for mothers whose jaundiced infants are not nursing vigorously. By pumping after nursing, you can stimulate a generous supply, improve milk flow, and obtain expressed milk to be used to supplement your baby if necessary.

Unfortunately, many doctors mistakenly believe that it is necessary to discontinue breastfeeding temporarily when a baby's bilirubin level gets high. In fact, this is almost never necessary. Most often, exaggerated jaundice in a breastfed baby is due to inadequate breastfeeding. What's needed are measures to improve the baby's intake of milk, not a temporary switch to formula (which often turns out to be permanent).

Why Do I Get Cramps When I Breastfeed?
The hormone oxytocin that plays a role in breastfeeding is the same hormone that causes your uterus to contract during labor. In the first days after delivery, oxytocin released during breastfeeding causes the still-enlarged uterus to contract. The resulting cramps, known as afterpains, help the uterus shrink to its prepregnant size. The discomfort usually is worse for women who have given birth previously than for first-time mothers. While afterpains can be quite uncomfortable, they are short-lived, usually lasting only seven to ten days. These uterine cramps not only help you recover from childbirth, but they are a good sign that your milk ejection reflex is working well.