Common Problems Encountered by Breastfeeding Women

Delayed nursing; milk failure; sore nipples

Engorgement Beyond the Postpartum Period
While breast engorgement poses the greatest problem during the first postpartum week, it can reoccur whenever milk removal is delayed. Even with well-established breastfeeding, uncomfortable fullness and firmness can result whenever the breasts are not regularly drained. Allowing the breasts to become markedly engorged places the nursing mother at risk for several complications. First, her supply can diminish as a result of residual milk and excess pressure on the milk glands. Second, a woman is more prone to a breast infection whenever her breasts are not emptied well. Here are some common scenarios that can lead to harmful breast engorgement after the first postpartum week.

• A mother decides to skip a few nursings to rest her sore nipples and finds her breasts become hard and sore.
• A mother returns to work at eight weeks after delivery and doesn't pump her breasts during the workday. By noon she is uncomfortably full and starting to leak milk (see chapter 8 for advice on successfully combining breastfeeding and employment).
• A mother leaves her three-week-old newborn with her sister while she runs some errands and finds she is gone longer than she expected. Her sister feeds a bottle of formula to the baby in the mother's absence. When Mom finally gets home, her breasts are thoroughly engorged, but her baby is sound asleep with a full tummy and won't nurse.
• A fully breastfed two-month-old who previously nursed once or twice each night now starts to sleep through until morning. The mother awakens with uncomfortably hard, full breasts.

Most of these examples leading to potentially damaging engorgement could be prevented by practicing unrestricted breastfeeding. This requires keeping nursing mothers and babies together as much as possible. If you must be separated from your infant or cannot nurse regularly, the next best option is to use an effective breast pump to empty your breasts at regular feeding times. As long as you are fully breastfeeding, you should avoid going long periods without emptying your milk. Allowing your breasts to become hard and lumpy due to infrequent emptying not only causes discomfort but also can harm your milk supply and lead to a breast infection.

Failure of Lactogenesis: Milk Never Came In
Some women suffer extreme engorgement and others fall at the opposite end of the spectrum, leaving them to doubt whether their milk came in. Occasionally, lactogenesis, the onset of abundant milk production two to five days postpartum, is delayed among women who have complications of labor and delivery. Rarely, I encounter women whose milk scarcely comes in at all. Often these women have medical problems such as high blood pressure, infection, or anemia. Others have experienced extreme emotional turmoil. In cases of profound physical or mental stress, a mother's body may fail to lactate fully in order to preserve the health of the mother. Since lactation is the only elective process a mother's body performs, it doesn't surprise me terribly that full milk production occasionally is inhibited when a mother is very ill. Sometimes, as a mother's own health problems resolve, her milk supply steadily increases if she perseveres with breastfeeding.

If you doubt that your milk has come in by the fourth day after delivery, I would advise you to have your baby checked to be sure she hasn't lost excessive weight. Your physician, a lactation consultant, or a nurse with experience helping breastfeeding mothers should be able to tell whether your milk production has increased normally or not. If your milk hasn't come in abundantly by four days postpartum, you should start pumping after each nursing to guarantee that your breasts receive adequate stimulation and emptying to help increase your milk. Your baby's sucking alone may not provide sufficient stimulation to increase your milk supply. Using a hospital-grade rental electric pump after nursings may help increase milk production. Rarely, a woman fails to produce sufficient milk through no fault of her own, making it necessary for her infant to receive regular supplements of formula.

Sore Nipples
Breastfeeding should be an enjoyable and, after the first week, comfortable experience. I am surprised at how many mothers accept sore nipples as an inevitable, unpleasant part of breastfeeding that must be endured by exceptional women. My colleagues and I evaluated over three hundred first-time mothers at four to eight days postpartum and found that 13 percent were experiencing nipple pain so severe that it caused them to dread feedings. That's more than one in ten breastfeeding women for whom pain was a major drawback to breastfeeding. Most of these women assumed that a nursing mother had to be a stoic in order to succeed at breastfeeding. This simply isn't true. Although most women experience mild nipple discomfort at the beginning of feedings during the first few days of nursing, severe or persistent nipple pain is not a normal part of breastfeeding. Severe discomfort is almost always linked to improper breastfeeding technique and, when present, requires evaluation and treatment.

Consequences of Sore Nipples
Sore nipples are more than just a nuisance. This complaint is a major cause of early discontinuation of breastfeeding. Most women who choose to nurse imagine that breastfeeding will involve relaxed, rewarding interactions with their child. Feeding-associated pain soon shatters the tranquil image of a contented nursing mother and her satisfied baby. Pain can drive a disruptive wedge between a new breastfeeding mother and her nursing infant. I recall the candidly sad plea of one discouraged mother with exquisitely painful nipples who implored her innocent baby: "Please don't wake up and need me."

Nipple pain not only can interfere with the mother-baby relationship but also can lead to insufficient milk and impaired infant growth. You may be wondering how maternal discomfort can be related to an infant's nutritional intake. In fact, the most common cause of severe or persistent sore nipples is improper positioning of the infant's mouth on the mother's breast. If the infant does not grasp the entire nipple and sufficient surrounding areola, pain will result, and the baby will not extract milk very effectively. If she repeatedly fails to empty the breasts well, subsequent milk production will be reduced.

Other reasons why sore nipples can predispose a woman to insufficient milk include restricted feedings and impaired milk let-down. Women who dread feedings are apt to skip, postpone, or limit nursings, which can lead to diminished milk supply. In addition, pain and other noxious stimuli can impair the milk ejection reflex, thus reducing milk flow during painful feedings. You can appreciate that a combination of factors is at work to make diminished milk supply a common complication of chronic nipple pain. Eventually, persistent sore nipples can lead to inadequate infant weight gain. A vicious cycle can ensue, because a frantic, hungry baby may nurse erratically and produce even more nipple trauma.

Early Nipple Tenderness
Early mild nipple discomfort is often present by the second day of nursing and improves once your milk starts to come in abundantly. The discomfort is greatest at the beginning of feedings and seldom lasts throughout a nursing. Marked improvement is usually noticed beginning around the fifth day. No specific treatment is usually required, and you should expect breastfeeding to be comfortable after the first week of getting started.

Sore Nipples Caused by Improper Infant Latch-on or Incorrect Sucking
The most common cause of severe nipple pain or persistent pain beyond the first week is improper positioning of your infant's mouth on your nipple and surrounding areola. The most common error is to allow the baby to grasp only your nipple, instead of taking at least an inch of surrounding areola and breast tissue. The particular shape of your nipple and areola, the size and configuration of your baby's mouth, and your baby's unique sucking habits also can contribute to nipple discomfort. The problem of improper grasp is so common that I urge you to seek expert help in the hospital to assure that your baby is nursing correctly before you go home.

Babies' mouths and oral habits vary tremendously. Some infants have a receded chin at birth, making it difficult for them to position their mouth correctly on the lower portion of the nipple and areola. Others have a high-arched palate that affects the position of the nipple-areola in the baby's mouth. Some babies are born with oral habits they have been practicing in the uterus, such as tongue sucking or sucking their lower lip, that interfere with correct latch-on. When you add to all this the wide diversity of women's nipples-long, flat, inverted, creased, bulbous, large, and small-you can see why I consider that bringing a mother's nipple/breast and a baby's mouth together as a functioning unit is a true art form! Indeed, correct infant attachment is the foundation for breastfeeding success. It should be learned with the assistance of skilled helpers in the hospital, not by trial and error at home.

Some infants have a disorganized or abnormal sucking pattern that can produce nipple tenderness and create feeding problems. For example, some infants tend to clench or bite instead of sucking. Others may ball up their tongue instead of using it correctly to compress the milk duct sinuses and extract milk during breastfeeding.

The attachment of a baby's tongue to the lower mouth, known as the frenulum, can be too tight in some infants. The condition, known as tongue-tie, can prevent the tongue from protruding normally. The baby's tongue may not be able to extend beyond the gums or lips, and sometimes the frenulum extends clear to the tip of the tongue, causing an indentation when it is extended. Most tongue-tied babies are not bothered at all by the condition. In a few, however, tongue-tie can cause an infant to have difficulty breastfeeding and a mother to have extremely sore nipples. The limited mobility may prevent the tongue from cushioning the breast against the lower gums during nursing. In addition, limited mobility of the tongue occasionally leads to speech problems when a baby gets older. In cases where tongue-tie is believed to be causing sore nipples, surgically clipping the tight frenulum sometimes results in immediate, or gradual, improvement in breastfeeding and reduction of nipple pain. Clipping a short frenulum usually represents a simple procedure that is performed in a doctor's or dentist's office, although it is sometimes done under general anesthesia. Some controversy surrounds the practice, which was commonplace in past decades, but is seldom performed today. Since few physicians are aware that tongue-tie can cause breastfeeding difficulties, some may be reluctant to recommend clipping it. Among those practitioners who have experience performing the procedure are ENT specialists (otolaryngologists), oral surgeons, pediatric surgeons, and some dentists, pediatricians, and family physicians.