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An Optimal Milk Supply Starts with an Optimal Latch
Your baby’s ability to drain your breasts is strongly dependent on how well he is attached to the breast. This section explores the process of achieving a deep latch because if baby is not latched on effectively, he cannot remove milk well from the breast.
There Is No One Right Way
Ideas about how to get the baby attached well to the breast have been evolving in recent years. The basic objective is to get the mother’s breast and nipple positioned deeply in the baby’s mouth. At one time, it seemed that lactation consultants believed that there was only one right way to do this and that a mother must follow the “correct” procedure, like a recipe. Many mothers who had been very successfully breastfeeding their babies were amused when they were told by an “expert” that they were “doing it all wrong.” Today, the most skilled lactation consultants understand that there is no single correct way to attach a baby to a breast. Whatever helps baby to get on the breast deeply and comfortably, and results in good milk transfer is the “right” position or technique for you. Breastfeeding can be like dancing: While we all hear the same music, we each may dance to it a little differently depending upon our personal styles and our dance partners. And what works for one baby may not work for another. Because every mother’s breast anatomy and every baby’s oral anatomy are different, it may not matter at all how some babies come to the breast, especially when they are older, but at other times, particularly when babies are very small, techniques that help baby get more milk can make the critical difference for success.
Below is an explanation of a way to latch that might be helpful if having your baby latch effectively has been a problem. The technique that we describe is not necessarily vital for a good latch; rather, it is a tool you can try when your baby is not latching well and something obviously needs to be fixed.
As you read this section, keep in mind that the only essential measures of a good latch are that mother and baby are comfortable, and that milk transfers efficiently. The important part is to recognize the basics of a good latch and how to achieve it. It is also important to know when to seek help. Our philosophy is that the more tools we have in our toolbox, the more likely we are to find the right tool for the job.
If you feel frustrated by these descriptions of ways to latch a baby, it is because breastfeeding is a fluid, active, right-brained behavior, like tennis or dancing, and all we can offer here are left-brained directions and word pictures. Imagine trying to learn bicycle-riding from a book! If you and your baby continue to have problems with latch after trying the technique described below, it may help to have an experienced nursing mother help by standing behind you and “becoming your arms,” holding your baby and breast as if they were her own and doing for you what she has done thousands of times for herself. Then the two of you can analyze what she does that you were not doing. If that doesn’t help, your best bet is to seek the help of a lactation consultant to identify specific problems you may be having and suggest customized positions and techniques that to resolve them.
Your Competent Baby
Lactation consultants are now beginning to understand that the most successful latching methods are often those in which the baby takes the more active role. We are learning that babies are actually remarkably able to latch well all on their own, provided that we give them the right “working conditions,” which serve as clues to help them understand what to do. Many times breastfeeding is difficult because we are overthinking it and making it more complicated than it needs to be. We are also trying to control a situation that nature set up to be baby-driven. Rather than having us work hard to improve our latching technique, most babies really just need us to get out of the way so they can do what they are biologically programmed to know how to do. Some babies do need more help, especially when they have had difficult births or have physical or psychological difficulties. The best way for your baby to latch is going to be individually tailored to him and may involve a lot or very little help from you. The starting place, though, is to assume that he has the ability to latch well all on his own and give him a chance to do it.
Feeding Cues and Positioning: The Key Ingredients
Animal biologists have long known that in order to initiate feeding, mammals need both an order of movements that instinctively signals that a feeding is happening (a feeding cue sequence) and to be in a position that is secure enough to allow them to latch easily (positional stability). Because humans are such highly evolved mammals, it was previously thought that we did not have such a need for a feeding cue sequence or positional stability in order to breastfeed. We are now learning, though, that this may not be true, and understanding the human feeding cue sequence and positional stability can be key ingredients to helping babies latch deeply with minimal help.
Rebecca Glover, RM, IBCLC, was the first to recognize that, like other mammals, humans feed more readily in response to a feeding cue sequence that begins when a baby is brought to the breast with the nipple pointing toward his nose. This prompts him to tilt his head back, which makes him open his mouth wide as he lowers and extends his tongue. He then reaches up and forward toward the breast, brings his chin into the breast first, which prompts him to close his top jaw over the nipple. The end result is a deep, off-center latch.
Dr. Christina Smillie, who is both a pediatrician and lactation consultant, was the first to recognize that human babies also need positional stability in order to manage the feeding cue sequence. She observed that the babies that fed most readily were positioned so that their chests were held firmly up against their mothers with their backs and shoulders supported, which calms them so that they are able to begin the feeding cue sequence when they see the nipple in the right position. She also observed that babies’ hands flailed less and they were much calmer when they were held in this position.
Some lactation consultants have observed that new mothers are often afraid to bring their babies in closely enough or rest them on a pillow instead of holding them, which result in dangling the nipple in front of baby’s mouth where he must extend toward it, grab it, and “slurp” it in, falling short of taking in all the areola he needs in order to transfer enough milk. As a result, some babies do not seem to know what to do and don’t begin suckling. Until recently, the most common explanation has been that babies need to feel the nipple and breast more deeply in their mouths before their sucking instinct can be triggered. While that may be true to a certain extent, Dr. Smillie believes that positional stability is actually the key element that helps a baby to calm and organize himself enough to be able to focus on his meal; a gap between his mother and himself confuses him and makes him feel physically insecure (a feeling that is very upsetting for newborns).
In learning about positional stability, Dr. Smillie also discovered that in most cases a mother doesn’t need to lift her breast to her baby, but rather the baby can latch very easily wherever the breast is if he is held firmly against her, below the breast with her nipple pointing toward his nose, so that his head tilts back and he must reach up slightly to grasp it. After seeing so many babies latch easily in this position, Dr. Smillie has come to believe that human babies actually expect to be held in this way: tightly against mother, below the breast, with her nipple pointing toward his nose.
Diane Wiessinger, MS, IBCLC, tells a story of having found a baby fawn in the woods behind her home in Ithaca, New York. His mother had died and she and her husband decided to try to save him. They brought the fawn up to their home and Diane’s husband made calls to local veterinarians to try to find someone to take him in. In the meantime, Diane tried to feed the fawn, because she knew it must have been a very long time since he had eaten. First, she went online and found a recipe for making deer formula. When the formula was ready, she tried to feed it to the fawn using a baby bottle. But the fawn refused to take it! Diane is a very knowledgeable lactation consultant and has worked with many fussy babies, so this didn’t bother her at first. She tried a cup feeder, but he wouldn’t drink. She tried to finger-feed him, but he wouldn’t suck. She tried different bottle nipples, but he wouldn’t latch onto them. She tried every technique she could think of to feed that fawn, but nothing was working. She was just about to give up when her husband walked back into the room to tell her he had found a vet who could take the fawn. When he then bent down to pick him up, the fawn’s muzzle touched her husband’s neck and the fawn began a rooting frenzy. Diane was then able to give him a bottle and he drank it down in no time at all.
From this, Diane learned firsthand that mammals do have a sequence of feeding cues and must be in certain positions to feel secure enough to feed. Fawns, foals, sheep, and other mammals look for a high, warm, probably hairless niche, which is what her husband provided. Observing the fawn’s definite need for a feeding cue even when it was starving, Diane began to wonder if what Rebecca Glover and Dr. Smillie had been teaching was true: human babies also have a need for a feeding cue sequence and positional stability. She began applying their theories and discovered that most babies that were held firmly against their mothers with her nipple pointing toward their nose would initiate a feeding cue sequence and latch easily and deeply with very little or no help, unless they had physical or psychological difficulties.
Many other lactation consultants have tried these principles of feeding cues and positional stability and found that they really work for most babies. They now believe that one of most important factors to achieving a deep latch is to hold baby close enough so that his chest is up against his mother and low enough that he has to tilt his head back to look at her nipple at the height of his nose.
Babies seem to recognize and respond to feeding cues and positional stability more readily when they are skin-to-skin against their mothers, wearing only a diaper and with mother’s chest bare. You don’t need to take your top completely off to do this; just wear a top that opens down the front.
When babies have difficulty latching, Dr. Christina Smillie encourages mothers to take advantage of the way that positional stability helps babies initiate the feeding cue sequence by placing baby skin-to-skin (no bra) in an upright position between the mother’s breasts with his head resting just below her chin. Most mothers hold baby with one hand on his bottom and one hand on his back. After a few moments, many babies will begin to bob down to a breast. If the mother supports her baby’s head and his body as he bobs or wriggles down, he will be very likely to self-attach to the breast. This happens most easily when baby’s cheek or chin has frequent contact with the breast as he travels down.
This could be a valuable technique to try if you find that your baby begins rooting during skin-to-skin sessions, but beware: sometimes babies lunge towards the breast so quickly that mothers are caught off guard! In Dr. Smillie’s experience, all calmed-but-hungry babies will make this trip to the breast, though babies with other problems (a history of unhappy breastfeeding experiences, for instance) may not latch successfully once they get there.
Finding the Best Position for Baby to Feed Well
Most breastfeeding books put a lot of emphasis on positioning. With the new understanding of positional stability, though, we are now learning that it doesn’t have to be complicated. In fact, it is really fairly simple. Your baby will probably be most comfortable and best positioned in your arms, not lying on a pillow (see “Do You Need Any Breastfeeding “Tools?” below), with your hand supporting him behind his back so that the heel of your hand is against his shoulder blades, his body held firmly against you and angled down below the opposite breast. If your breasts are large or long, you may find that his hip rests on your thigh, as you keep his front in full contact with your front. If your nipples point downward or your breasts are very large or long, your baby may be more “sunny-side up,” perhaps in your lap with your breast resting gently on his chest. In this position, the weight of the breast itself can help the baby feel stable.
For most mothers, the baby’s legs end up being angled downward rather than perfectly horizontal. This may go against recommendations in other breastfeeding books or websites you may have read that speak strongly of the importance of having baby perfectly horizontal. Many lactation consultants have found, though, that as long as your baby’s chest is firmly against you, it doesn’t matter if he is angled or not. It also doesn’t matter if his bottom is tight up against you. Instead, you may find it works better simply to rest his hip on your thigh.
Experimentation will help you find the best position for your baby to approach each of your breasts. It is not about rules for “the right way,” it is about understanding what your baby needs in order to follow his instincts to latch well, and finding the best fit between you and your baby in order to optimize your baby’s ability to latch on to the breast comfortably and effectively.
How Baby Removes Milk from the Breast
Because the concept of how a baby removes milk from a breast is both complex and elegantly simple, it is often misunderstood. Breastfed babies do not simply “suck” the milk out of the breast like a straw, but use a combination of suction (negative intra-oral pressure caused by dropping the tongue) and peristalsis (wave-like motion in the tongue that starts in front and moves to the back of the mouth) to draw the milk out of the ducts under the areola and into their mouths. The more breast tissue the baby has over his tongue, the more efficiently and effectively he is able to remove milk.
When a newborn is latched well, it is unlikely that you will see the corner of his mouth at all. This differs from older books that emphasized the need to see both lips flanged. Most likely, if you can see the corner of your newborn’s mouth when he begins to feed, his face is a bit too far from your breast. Instead, keep him close enough that his cheeks lie against your breast, hiding all but the baby’s upper lip. As a feed progresses and your breast softens, you may begin to see the corner of your baby’s mouth, but in general a newborn, deeply attached, has his mouth hidden against the breast by his cheeks. If at any point you see the corner of his mouth and it is pinched tight, most likely your baby has taken too small a mouthful, or has slid toward the end of your nipple. A baby who is deeply attached generally has such a wide mouth that there is no sharp angle at the corner. However, it doesn’t matter what his mouth looks like, if you and he are fully comfortable and he is taking milk efficiently.
In addition to being comfortable, a good latch usually results in a deep drawing sensation in the mother’s breast. Baby should make a good seal on the breast and there should be minimal or no “clicking” or “popping” sounds, which indicate suction breaks. The nipple should come out of baby’s mouth as round as it went in, though perhaps somewhat elongated, with no flattening, crimping, creasing, blanching (whiteness), or bruising. With adequate available milk, a good latch results in good milk transfer and in the early weeks, and mother’s breast should feel noticeably softer at the end than when she started.
Rebecca Glover’s discovery of babies’ natural feeding cue sequence has helped us to understand the mechanics of achieving a deeper latch, which is less painful for mother and transfers more milk. In the past, a common latching recommendation was to center the nipple in baby’s mouth, aiming it toward the back of his mouth, much like aiming an arrow to the middle of a bull’s eye. The mother was encouraged to bring both the baby’s nose and chin deeply into her breast. While this works for some babies and there is no need to change what is working, there are other babies who are not able to get enough breast tissue on the tongue when they are guided to the breast in this manner. In the straight-on bull’s eye method, the upper jaw may touch the breast first. As the mouth makes contact, it tries to close into a seal, but if the lower lip and receding lower jaw have not yet landed, they can sometimes slide up to the base of the nipple instead. The result is either a shallow latch or a complete “miss,” with baby slipping off the breast and becoming frustrated. This “bull’s-eye” approach also encourages the baby to come to the breast with his chin lowered and tucked down against his chest. Tucking the chin causes the tongue to retract into the mouth, away from the breast.
To see how this works, try dropping your own chin down as far as it will go and then opening your mouth as widely as you can. Can you feel how your tongue humps up in the back of your mouth? Try swallowing. Is it difficult? Now, tip your head back slightly and try opening widely; is this easier? Try swallowing again. It’s much easier, isn’t it? Notice how your tongue is able to extend and how widely you are able to open your mouth now. This is exactly how it works for your baby. In order to feed effectively, he needs to be able to open widely, extend his tongue, and swallow easily. Feeding with his head tilted back slightly will make feeding much easier and effective for your baby than feeding with his chin tucked.
If you are holding your baby with the arm opposite the side you are feeding on, or if you are holding baby against your side or lying down, it is very important to place your hand so that your index finger and thumb are behind your baby’s ears and the heel of your hand is against his shoulder blades. Don’t cup your hand on the back of baby’s head and try to move his head to the breast. No one wants to have his head pushed toward his dinner plate; it drives away all thought of food. Pushing on a baby’s head also tips his nose, rather than his chin, toward the breast, causing the baby’s all-important chin to pull away from the breast and his tongue to retract. Holding him so that his head is free to rock back allows him to move his head freely and extend it when he needs to.
The Asymmetrical Latch Technique
Based on these new understandings of how deep latching happens, Rebecca Glover in Australia, and Mary Renfrew and Chloe Fisher, midwives in the UK, began teaching a technique that is now popularly referred to as the “asymmetric latch technique.” Instead of trying to bring baby to the breast so that his mouth is dead-center with the nipple, deliberately allow him to latch off-center, with the nipple closer to the roof of his mouth. This results in more breast tissue being in contact with the tongue, allowing for more efficient milk removal.
Another significant difference between the bulls-eye latch and the asymmetrical latch technique is the position of the baby’s nose after he has latched. In the asymmetrical technique, because the chin is lifted and extended with the head tipped back, there is actually a small gap between the breast and the baby’s nose, which keeps the airway clear without any other help from the mother. In any picture of a baby breastfeeding, you can always tell whether the baby was latched asymmetrically by how far away his nose is from the mother’s breast.
An asymmetric latch can be extremely helpful when coping with anatomical challenges. All babies have receding chins, but some recede more than others. When the chin is strongly recessed, the lower jaw and tongue are even farther away from the breast than usual and baby has more difficulty latching on. By encouraging the head to tilt back, the mouth opens even more widely and the lower jaw can “lead,” grasping a larger amount of breast tissue than it would in traditional bull’s-eye latch techniques.
It is usually easiest for mothers to learn the asymmetric latch technique when holding baby with the arm on the opposite side of that she is nursing from. However, if you need to use the arm that is on the same side you are nursing from, just be sure to place your baby’s head on the “meaty” part of your forearm, rather than in the crook of your elbow. This will keep you from having to pull your breast to one side in order to line up your baby with your nipple. It will also keep your baby from having to tuck his chin downward to reach your nipple, which would make latching more difficult.
Position your baby so that his nose, rather than his mouth, is in front of the nipple. If the baby lies across your front, sliding his body so that his head is a little closer to the middle of your body will help. If you are holding baby at your side, pull him more underneath the breast (his hips snuggled around your back) rather than starting him in front. This will naturally result in his head tipping back to reach the breast. Your breast should not rest heavily on baby’s chest. (If your breasts are exceptionally large and the weight would be too much on top of your baby, tuck him in tightly against the breast or angle his legs down so that his hip rests on your thigh, still keeping his front in full contact with your front.) Whichever option you use, baby’s chin should end up touching the breast because that is his cue to open widely.
Once the baby is positioned with his nose in front of the nipple, it is important (and difficult!) to wait for him to open his mouth very wide and drop his tongue. Most babies will do this reflexively when they are drawn close to mother’s body, especially once their chin or lower face touches some part of the breast and their chest is firmly against her, but sometimes it can take a few moments. If baby needs help to know you are ready, gently sweep your nipple downward across his philtrum, the little crease between the baby’s nose and top lip. Most babies will tip their heads back and gape when they feel a gentle downward stroke above their top lip.
A true “gape” is very, very wide, like a yawn, but very brief–you need to catch it quickly. When he gapes and drops his tongue, bring his shoulders snugly against you to bring him deeply onto the breast. His chin will sink into your breast, and as it does so his upper lip will pass over the top of your nipple, perhaps briefly folding it backwards as it does so. The movement must be sure and decisive, but gentle. As you bring him onto your breast, his lower lip can be “caught” by the breast itself, which can serve to pry his mouth open even farther (if needed) and flange his lower lip outward. His upper jaw will then slide onto the breast and you can snuggle his body in close against you. If all goes well, his nose will not be touching your breast, you will be able to see some areola above his upper lip, and his mouth will be open very wide, though you probably will not be able to see it.
You’ll find that your baby is very good at moving his body forward, but not good at all at moving backward. If your “do-it-himself” baby overshoots the nipple and begins to tuck his chin to try and find it again, gently move him back slightly so that the nipple is at the level of his nose again. If he begins to fuss at any point, bring his lower face into contact with some part of your breast. Much of the time, he will stop fussing and begin to seek your nipple again, as if to say, “Oh, that’s right! I forgot what I was looking for!”
An alternative way to encourage an asymmetric latch is to place the nipple in the philtrum, the little indentation between the baby’s nose and mouth. When baby feels the nipple above his lip, he will root toward it if he is hungry, tipping his head back in the process. The nipple can then be slipped into his mouth from the top, causing the breast to “flop” onto the tongue and anchoring the lower jaw away from the base of the nipple.
Some mothers find it helpful to stand up while letting the baby make his way to the breast. Standing, you’ll find you are concerned more about not dropping the baby than about placing your hands just so. You’ll tend to hold him closely without following any preconceptions, and you may find that you have your most comfortable latches that way at first.
If you are not comfortable, if your milk does not begin to flow within a minute or so of attachment, or if you continue to feel pain once your milk begins to flow, break the seal by gently inserting your finger between his jaws against his tongue and pull baby away from the breast. Start over.
If the latch isn’t comfortable the next time you try, it may not be wise to try yet another time. Latching and unlatching too many times can be frustrating for both you and baby, and can result in increased nipple soreness or nipple tissue damage.
What to Do if You Just Can’t Get a Comfortable Latch
If you just can't get a comfortable latch, you have a few options: you can go ahead and let baby latch shallowly and cope with the pain. While it may minimize baby’s frustration, it is likely to also reduce the amount of milk baby gets. Another option is to stop trying to latch and feed baby away from the breast, making sure to pump with a high-quality pump to drain your breasts as thoroughly as possible (in the first few days, this may only be a few drops or tablespoons). This will ensure that your milk production continues at the highest rate. Either way, it will be important to get help quickly from a lactation consultant to find ways to get to baby latched more deeply or rule out a problem with tongue restriction or something else that may be going on, such as painful nipples.
Differences in Breast and Nipple Shapes
Breast and nipple shapes can also influence the way a mother her positions baby and the way a baby latches onto the breast. Small, upright breasts may not be very elastic, which makes it challenging for the baby to draw the breast deeply into his mouth. Large, soft breasts are often pillowy and lack definite form. If the skin is only loosely attached to the glandular tissue, it is possible for the baby to draw in a lot of loose skin without getting enough glandular tissue. Flat nipples lack landmarks for babies to feel, sometimes causing confusion and not stimulating his sucking instinct. Breasts that are extremely firm due to postpartum edema may be difficult to latch onto. A baby who has a very small mouth may find it difficult to grab enough breast tissue. Although shaping the breast is not necessary for most mothers, those who have these kinds of breasts or nipples or a baby with a very small mouth may find that shaping the breast with their hand can help create the landmark that baby’s instincts are seeking. Most babies who need breast shaping are able to latch and suckle well, sometimes for the first time.
Shaping the Breast
For those mothers or babies who do need some breast shaping, either because of the shape of the mother’s breasts or the size of the baby’s mouth, Diane Wiessinger teaches a concept she calls “The Breast Sandwich.” The strategy is to shape the breast into a long wedge that lines up with baby’s mouth. Adults do this every time they eat a really large sandwich. Think about the last time you ate one. The first thing you probably did after you picked it up was to gently compress it so that you would be able to get as much of it in your mouth as possible. You naturally did this in a line that was parallel with your mouth.
If your baby is horizontal against you, his mouth will be vertical. If, better yet, he is tilted at a downward angle, his mouth will be diagonal. In order to get as much of the breast in baby’s mouth as possible, your breast will need to be compressed into a sandwich that is parallel with his mouth, either vertically or diagonally. Interestingly, the “C hold” that is traditionally taught in many breastfeeding classes and books can cause the breast to flatten into a sandwich that is horizontal instead of vertical or diagonal, 90-135 degrees off. This can be like putting a sandwich in front of someone, then turning it vertically and asking him to take a bite—almost impossible!
An easy way to help line up a breast sandwich is to rotate your hand so that your thumb is near baby’s lip, pointing up, and your index finger is near the bottom of his chin, but at least far enough away from his chin so that it’s out of the way when he opens widely. Barbara L. Boston, NP, IBCLC, suggests that mothers think about placing their thumb against their breast so that it seems to make a “moustache” for the baby.
It may be necessary to continue the sandwich hold throughout the feeding for a while as the breast can “spring back” and pull away from baby when released. The experienced baby learns to keep it all together, but new babies sometimes need this help. If you make sure that you’re not holding too tightly or tensely, you should be able to maintain this hold comfortably throughout the feeding. If you do release the sandwich hold during an inexperienced baby’s feed, do so only after baby has begun long, slow, suck-swallows, and do it slowly so that your baby can adjust to the change in shape.
In some cases, latching difficulty is due to temporary edema (excess water) of the breast tissue. For the baby facing a firm, hard breast, offering an oval-shaped breast sandwich can help him get his mouth around what otherwise may feel like a beach ball to him. It may be necessary to move some of the edema out of the tissue, though, in order to make the sandwich. Reverse Pressure Softening (RPS) as taught by Jean Cotterman, RN, IBCLC, may help to push out some of that fluid and soften the breast before trying any shaping. , Simply use the curved fingertips of both hands simultaneously to create a ring of fingertip depressions around your nipple, with the fingernails nearly touching the sides of the nipple. Then, still pressing downward, very slowly pull your fingers away from the nipple. Repeat several times. This will temporarily move the fluid out of the tissue around the areola. If the swelling is very firm, a full two or three minutes of constant pressure will give better results.
Lifting and Holding the Breast
Our breasts are attached to us. They are already fully supported and never fall to the floor. Lifting the breast to baby’s height became a common recommendation when it was thought that babies needed to be lifted into a horizontal position midway between a mother's lap and her face. The most current thinking, though, is that most mothers do not need to lift their breast as baby latches because there is no true reason for baby to be lifted higher than where your breasts naturally lie. When there is no need to lift the breast, there is no need to hold it throughout the feeding. Instead, position your baby just under your breast where it naturally lies, with his nose at your nipple, wherever it may be. At the most, position your fingers up against your ribcage or even on your breastbones so that your fingers are well away from baby’s mouth.
Mothers who have very long breasts or nipples that point straight down are the exception. If your breasts are so long that it's inconvenient to position your baby where your nipple normally is, you may decide to lift your breast somewhat. If your nipple points straight down, you may need to lift the breast slightly so that you’ll be able to position your nipple pointing toward his nose. Remember that if you do lift your breast you will probably have to hold it throughout the feed, to keep it from slipping from your baby's mouth. For this reason, it's worth experimenting to see if there is some way to bring your baby to your nipple's natural level. For instance, some lucky mothers are able to lay the baby face up on their laps and sit fully upright―no hands―to nurse. A nursing bra with a detachable flap can also lift your breasts into a position to makes latching easier, without requiring you to hold your breasts during feedings.
When it comes to nipple pain, it doesn’t do any good to “soldier through” the pain by ignoring it. Pain is a warning signal our bodies give that something isn’t right. No matter what you may have heard, it is not normal for breastfeeding to hurt. If it was, we wouldn’t have survived as a species because, like other mammals, most mothers will not continue to breastfeed through pain. Until just a hundred years ago, unless there was another lactating woman nearby who was willing to help, there were few options for feeding a baby who couldn’t feed from his own mother.
Fortunately, in most cases, breastfeeding can be made comfortable by finding out what the problem is and fixing it. It may be that baby is simply being brought to breast in a way that does not allow him to latch deeply. If that is the case, the latching technique described in this section should help get things back on track. If they don’t, the pain could be caused by one of the baby-related problems described in Chapter 7, which will require the help of a lactation consultant and your pediatrician to determine and treat.
Sometimes it isn’t possible to get a completely pain-free latch because the nipple tissue is so abraded and sensitive that any touch is painful. In these cases, it is important to help the tissue heal as quickly as possible. The first step in doing this is to wash the wounded nipple gently twice a day with plain, non-antibacterial soap and water, rinsing well, as one would care for any wound. Although purified lanolin has been shown to be safe for babies and is commonly recommended for treating sore nipple, research has shown that a mother’s own milk, gently rubbed into the wound, is just as soothing and actually accelerates healing better. , In addition to purified lanolin, there are many creams and ointments that are marketed for soothing and healing sore nipples. Even though they may be advertised to be safe for breastfeeding, some ingredients can be toxic or trigger allergic reactions when babies ingest them. Vitamin E, in particular, can be toxic to your baby.
Some mothers find that water and glycerin based hydrogel dressings designed specifically for nipple healing, such as Ameda’s ComfortGel™ hyrdogel pads, Maternimates™, Mothermates™, and Soothies™, are very soothing to traumatized nipple tissue and accelerate healing, using the same wound-healing technology used by hospitals. The high water content in hydrogel pads also has a cooling effect that provides pain relief. Unlike hydrogel dressings designed for wounds elsewhere on the body, these special products can be removed several times a day to allow breastfeeding without disrupting the healing process. If you use hydrogel dressings to help soothe and heal your sore nipples, it is important to avoid touching the nipple and areola area with your hands just before applying them, which includes massaging your milk into your nipples, because your hands can introduce bacteria and fungus that is trapped under the dressing and could result in a bacterial or fungal infection.
If your nipples do not heal in a few days, they may be infected with yeast or bacteria, which will require a prescription topical ointment that is safe for breastfeeding. Most do not need to be removed prior to feeding and may also contain a small amount of steroid to further accelerate healing. , , , , Dr. Jack Newman recommends an ointment containing a combination of three ingredients that seems to help for many causes of sore nipples, including poor latch, yeast or bacterial infections, and dermatologic conditions. The ointment, which he calls the “All-Purpose Nipple Ointment” is not available as a pre-packaged product, but can made up by prescription at a compounding pharmacy (see Resources for a location near you). There are also over-the-counter substitutions for each ingredient, which may not be quite as effective, but may work well for most mothers.
This combination of prescription antibacterial, steroid, and anti-fungal ointments or creams, with over-the-counter substitutions, is also described in a case report by Janice Porter, RD, MPH, IBCLC, and Barbra Schach, RN, BSN, IBCLC about their work in a breastfeeding clinic at the University of California, Davis, Medical Center in Sacramento, California.
Dr. Newman recommends mixing all ingredients and applying as a single ointment. Janice Porter and Barbra Schach have a different approach, suggesting that mothers use only the ointment or cream that they feel targets the problem they are having. For example, the antibiotic is used when there is a suspected bacterial infection, the steroid is used when the nipple tissue is irritated and to speed healing, and the anti-fungal is used when there is a suspected topical yeast infection. Of course, it is often hard to know if the infection is bacterial or fungal (they also can happen together), and irritation almost always accompanies infection, so it may be necessary to use two or all three ingredients at the same time. If you have an allergic skin reaction to the combined ingredients, using them individually at least once should help you determine the culprit.
The ointments and creams should be applied in very small amounts so that they are fully absorbed into the skin and there is no noticeable residue (although the tissue will appear to be moisturized), 3-4 times a day for up to 14 days. In most cases, the active ingredients in these ointments and creams are fully absorbed by the time of the next feeding, so it is not necessary to wipe them off prior to breastfeeding even if there is residue. In fact, the abrasive action of removing them can disrupt the healing of delicate tissue in a way that breastfeeding normally does not, with the exception of shallow latching and tongue restriction (see page ___).
If breastfeeding is simply too painful to bear and the wounds never heal because they reopen each time baby breastfeeds, it may be beneficial to take a short 2-3 day break from breastfeeding to allow your nipples to heal. During this time, baby can be fed away from the breast using the methods described in Chapter 3. It will be important to keep your milk production up by expressing milk as often as baby would feed by hand expressing or using a high-quality pump, preferably rental-grade, which will be less traumatic for your wounds than a lower quality pump. This will also provide milk for your baby, even if you also need to give formula. If you like, you can nurse your baby once or twice each day to keep the connection going. If that idea is painful to you, wait until your nipples are better healed before nursing.
Do You Need Any Breastfeeding “Tools?”
Many breastfeeding mothers assume that a special “breastfeeding pillow” that positions baby horizontally, high in the lap is an essential tool for achieving a good latch with a newborn. These special products are sold by the tens of thousands in every baby superstore and baby boutique. They come in darling fabrics with seemingly clever innovations. They can be fun to buy, especially since they seem to be a product that supports breastfeeding. However, lactation consultants are increasingly discovering that these pillows, or even regular bed pillows used on the lap to support baby, are often more of a problem than a solution. With the discovery that babies need to have their chests and shoulders held firmly against their mothers, which usually places baby at an angle, and with the new understanding that babies latch more instinctively when they approach the breast from below it, we can now see that pillows in the lap can directly hinder instinctive latching.
Mothers often place babies on pillows in their lap “for support,” but allowing the pillow to support the baby usually results in mothers not holding their babies tightly enough against them, so that the babies are no longer positionally stable, even though they are “supported.” This means the baby is likely to drift away from his mother, which can result in a shallower latch. Pillows can also cause problems by creating a valley between mother and baby, into which the baby is likely to roll, turning downward so he has to turn his head to get to the breast. Pillows can also result in a mother hunching over her baby instead of leaning back comfortably with the baby’s weight supported largely by her stomach. Even more crucial to successful breastfeeding, unless a mother has a very long torso, a pillow raises the baby above her natural nipple height, so that the mother ends up lifting her breast to meet her baby. In order to keep the nipple at the right height, she has to hold the breast throughout the feeding. Eliminate the pillow, lower the baby to nipple height, and you have a hand free!
Having explained that breastfeeding pillows are not necessary, it is important to point out that pillows placed on your side that support the arm that is holding baby can be very helpful in the early months when he is so small and the arm supporting him can get tired after long feedings. Of course, a pillow is still not absolutely necessary. Some mothers just move close enough to one side of a sofa that they can use the armrest or they use a chair that has armrests at the right height. A pillow placed behind your back may also help by making a too-deep couch or chair more comfortably “shallow.” The important thing to remember is that pillows are best used to support you, not your baby. You are the best support for your baby.
One item that may make a big difference in your comfort, depending on your height and the height of your furniture, is a low, slightly inclined footstool. This can raise the height of your lap, making it easier to keep your baby at a comfortable level. Raising your knees makes it easier to keep your baby snuggled closely against you. It can also help to relax your lower back, which might otherwise tire after several hours of nursing. There are footstools designed just for this purpose, marketed for breastfeeding mothers, and they are not usually very expensive. Some glider ottomans have built-in footstools below. It is not necessary to buy a special product, though; you may have something around the house that would do: several phone books, the rung of a coffee table, or a small waste basket on its side might be just right.
Maximizing Milk Removal: Breast Massage and Compression
Once baby is latching on well, the next most important strategy is to maximize breast drainage so that the signal to the breast to make more milk is amplified. One of the difficulties of low milk production is that the milk ejection reflex (let-down) is often less effective when it has less volume to work with. Thus, milk may not be completely drained by the baby or a pump. An easy and effective way to maximize removal of milk is to massage the breasts, both before and during feeding (or pumping). One study looked at the effect of simultaneous massage with pumping and found that there was 40 to 50 percent more milk removed when pumping with massage than without it. This is a simple and very effective way to increase breast drainage.
One popular version of breast massage is called breast compression and uses external pressure with the hand to push out any remaining milk that has not been moved through the ducts with the milk ejection. Although this technique does not directly increase milk production, it assists by getting all the residual milk out so that the body will work to replace that larger amount rather, than replacing only the amount that was removed by the baby or pump alone.
Dr. Jack Newman developed the following breast compression technique, that many mothers have found results in faster flow and more milk expression. Breast compression can be utilized at any time milk is being expressed, either while the baby is actively nursing or when the mother is pumping. For more information and a video of breast compression, check out Dr. Newman’s website at http://www.drjacknewman.com.
- Hold the breast, cupping the breast from underneath with your thumb on one side of the breast and your fingers on the other.
- Watch for the baby’s swallowing. The milk flows more rapidly when baby is drinking with an open— pause—close type of suck. Open— pause—close is one suck; the pause is not a pause between sucks, but of milk flowing into his mouth before a swallow. You may notice the same pause yourself when fluid flows in as you drink deeply and continuously. If using compressions while pumping, watch for sprays of milk.
- When baby is nibbling or no longer drinking with the open—pause—close type of suck, compress the breast gently but firmly (not so hard that it hurts) and try not to change the shape of the areola (the part of the breast near the baby’s mouth). With the compression, baby should start drinking again briefly with the open—pause—close type of suck.
- Keep the pressure up until the baby no longer drinks even with the compression, then release the pressure. Often the baby will stop sucking altogether when the pressure is released, but will start again shortly as milk starts to flow. If the baby does not stop sucking with the release of pressure, wait a short time before compressing again.
- Releasing the pressure allows your hand to rest and milk to start flowing to the baby again. If the baby stops sucking when you release the pressure, he will start again when he starts to taste milk.
- When the baby starts sucking again, he may drink (open—pause—close). If not, rotate your hand position and compress again as above.
- Continue on the first side until the baby does not drink even with compression. You should allow the baby to stay on that side for a short time longer, since you may occasionally get another milk ejection and the baby will start drinking again, on his own. If the baby no longer drinks, however, allow him to come off or take him off the breast.
- If the baby wants more, offer the other side and repeat the process.
- You may wish to switch sides back and forth in this way a few times.
If you find a way that works better at keeping the baby sucking with an open—pause—close type of suck, use whatever works best for you and your baby. As long as it does not hurt your breast to compress, and as long as the baby is "drinking" (open—pause—close type of suck), breast compression is working. If you don’t find compressions helpful, try them again a few days or a week later. Techniques that aren’t helpful at one stage of your production-building efforts may be helpful at another.
An older term “RAM,” for Rapid Arm Movement, was often used to help mothers conceptualize being quicker and more decisive in pulling baby onto the breast; however, it was sometimes used too literally, traumatizing the baby with unnecessary force.
Ramsay, D., Mitoulas, L., Kent, J., et al. Ultrasound imaging of the sucking mechanics of the breastfeeding infant. Unpublished study (2004), The University of Western Australia, Crawley; Dept. of Biochemistry and Molecular Biology.
Glover, R. Lessons from innate feeding abilities transforms breastfeeding outcomes. Best Practice: Supporting Breastfeeding Worldwide. International Lactation Consultant Association 2004 Conference.
Cotterman, K. Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latching During Engorgement. J Hum Lact May 2004; 20: 227 - 237.
Voni, M. and Riordan, J. Treating Postpartum Breast Edema With Areolar Compression. J Hum Lact May 2004; 20: 223 - 226.
Mohrbacher, N., Stock, J. The Breastfeeding Answer Book, 3rd Rev Ed. Schaumburg, IL: LLLI, 2003; 495.
Mohammadzadeh, A., Farhat, A., Esmaeily, H. The effect of breast milk and lanolin on sore nipples. Saudi Med J 2005 Aug;26(8):1231-4.
Morland-Schultz, K. and Hill, P. Prevention of and therapies for nipple pain: a systematic review. J Obstet Gynecol Neonatal Nurs 2005 Jul-Aug; 34(4):428-37.
Dodd, V. and Chalmers, C. Comparing the use of hydrogel dressings to lanolin ointment with lactating mothers. J Obstet Gynecol Neonatal Nurs. 2003 Jul-Aug;32(4):486-94.
Wilson, P. Hydrogel dressing for the treatment of sore nipples during early lactation: should we be promoting these products? J Hum Lact 2001; 17(4):295-96.
Centuori, S., Burmaz, T., Ronfani, L., et al. Nipple Care, Sore Nipples, and Breastfeeding: A Randomized Trial. J Hum Lact 1999; 15(2):125-130.
Livingston, V. and Stringer, J. The Treatment of Staphyloccocus Aureus Infected Sore Nipples: A Randomized Comparative Study. J Hum Lact 1999; 15(3):241-246.
Riordan, J. The effectiveness of topical agents in reducing nipple soreness of breastfeeding mothers. J Hum Lact 1985; 1(3):36-41.
Zeimer, M., Paone J., Schupay J., et al. Methods to Prevent and Manage Nipple Pain in Breastfeeding Women. West J Nurs Research 1990; 12(6):732-744.
Zeimer, M. and Pigeon, J. Skin Changes and Pain in the Nipple During the 1st Week of Lactation. JOGNN 1993; 22(3):247-256.
Janice, P. and Schach, B. Treating Sore, Possibly Infected Nipples. J Hum Lact May 2004; 20: 221 - 222.
Jones, E., Dimmock, P., Spencer, S. A randomized controlled trial to compare methods of milk expression after preterm delivery. Arch Dis Child Fetal Neonatal Ed 2001; 85:F91-F95.
Newman, J. Breast Compression. Handout #15: Jan 2003.