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3 Common Breastfeeding Challenges Features
Edith Kernerman, IBCLC
Photo: MJ Loiacono by Giselle Salazar Photography

 

Though breastfeeding is natural, it is also a learned behavior and the challenge and joy of this mean that the two of you need to learn together. During this learning process many mothers experience some difficulties with breastfeeding. Some of these challenges come at the onset of breastfeeding, some a few weeks in, and some after a few months when breastfeeding seems to have been well established. The reasons for these difficulties are numerous and varied but I would like to touch upon a few that tend to be overlooked. These are three common breastfeeding challenges.

Separation

In the first few days, a baby who does not seem keen to latch might be a baby who has been separated from his mother. Sometimes separation is necessary (illness or prematurity) but most times it is not 1,2,3. What does this mean, this separation?

Separation can mean the baby is taken off to the hospital nursery at night so that his mother “gets more sleep.” In reality, mothers relax and rest just as well if not better, when the baby is sleeping next to them 4.

Separation can mean the baby is swaddled or wrapped in a blanket rather than keeping him skin to skin with his mother. The intention is that the baby will sleep better—another myth! Swaddling can lead babies to sleep for longer stretches and more deeply than is normal, but the light sleep and frequent wakings that are normal for a baby are important reminders to him to breathe. Swaddling also suppresses the rooting reflex, which causes a baby to search for the nipple, and may prevent the baby from being in the neurological state necessary for him to be aware of his hunger 6,7,8. Swaddling is not useful to babies who are learning to breastfeed.

Babies who are kept skin to skin with their mothers—wearing just a diaper and perhaps a cap if the room is cold feed better, settle more easily, and cry less 9,1. They also have fewer challenges latching 10. A baby kept skin to skin will be able to crawl to the breast and latch on. There are many other reasons for latching difficulties other than separation, but keeping mother and baby together maximizes the chance of a great start and a successful latching.

Separation can mean the baby is taken off to the hospital nursery at night so that his mother “gets more sleep.” In reality, mothers relax and rest just as well if not better, when the baby is sleeping next to them

Compulsion

Another reason babies tend to have difficulties latching on to the breast is because they are pushed on; in essence, forced to feed: either by being awakened to feed or by being pushed onto the breast.

Contrary to popular belief, babies are not designed to be fed according to a schedule or by the clock. They should rather be fed when they show early cues (such as chewing their hands, wriggling, and smacking their lips) and start to look for their mother’s breast 11,12. (Crying is a late cue for feeding.) A well-fed baby who is kept skin to skin will wake by himself when he is ready to feed (read on to see what I mean by well-fed).

If a “helper,” well intentioned, I am sure, pushes the back of a baby’s head, albeit gently, into the mother’s breast then that baby is likely to push back and be resistant to latching on. If the mother lies back and allows her baby to find the breast, he is likely to do so on his own, or if the mother prefers to sit, she can have the baby lead the way and she can guide her baby to find the breast by providing support for her baby’s spine. 13

Crying is a late cue for feeding.

Slow flow

Another challenge mothers have with latching the young baby on the breast is very similar to a challenge that mothers have with the older baby. At three days, three weeks, or three months, babies like the milk to flow. When the milk flows too slowly the three-day-old is labeled lazy because he falls asleep at the breast not having eaten well. The three-week-old will often arch back and pull at the breast and start to cry once the flow slows down and then might be labeled colicky, gassy, or as a reflux sufferer. The three-month-old jiggles and pulls off quickly, is very easily distracted, and isn’t interested in going back on so the mother may think he is no longer hungry. Then he proceeds to suck on everything within his reach—except the slow-flowing breast!

The solution here is quite simple: the mother needs to know how to tell if her baby is actually drinking while at the breast or just going through the motions. In other words, just because the baby is sucking on the breast does not mean the baby is actually drinking at the breast. This is a two-person activity, remember. Not only does the baby need to ask for the food by sucking well, but the mother needs to provide the food i.e. the milk needs to flow. Notice I didn’t say make the food, I said provide. I like to give the following analogy to the moms I see.

In a restaurant we have the chef (that’s the mom), we have the customer (that’s her baby) and we have the waiter (that’s the breast). The chef is always cooking because she never knows when the next customer is going to come in. The customer comes in, the waiter comes over with a little snack while the customer places an order, which the waiter gives to the chef who now starts to make some things to order and gets the cooking going a little more quickly. When the order is ready, the waiter serves it and the customer eats. Good so far? But sometimes the waiter is not so quick to bring out the second course. Or, even worse, the waiter forgets the dessert! So, here is where we need to give the waiter a gentle nudge to keep the food coming until the customer says, “Thanks, I have had enough.” This is where doing *breast compressions comes in. These work beautifully to deliver more food to the customer at a very good speed. Because we know if the service is too slow, the customer is not going to be too interested in hanging around and might leave altogether. Or the customer will complain loudly about the slow service, turn red, get up from the table and refuse to come back. Or he might get so bored waiting he’ll put his head down on the table and sleep—that’s not because he is full but rather because he is too tired to keep asking the waiter to do his job!

When breast compressions no longer do the trick at keeping the milk coming then switching breasts is the best bet. Sometimes a mom needs to switch back and forth between breasts to keep the milk flowing until he is full.

See why it is critically important to know the difference between sucking without drinking and sucking with drinking? Look at the rhythm in the movement of the chin. When the baby’s jaw goes up and down rhythmically and quickly, the baby is just sucking and not getting much milk. When the chin drops down and holds in an open position and then goes back up—that means the baby just got a mouthful of milk. That’s drinking. How long does that baby need to drink on each breast? Who knows? In fact, there is not a single person on this planet who can tell you how long any particular baby needs to drink on a breast before being full or needing to switch to the other breast. And any helper who gives a number to the mother and says your baby should drink X number of minutes per side is giving her false information 14. The reason is, we don’t actually know what the baby is drinking at any given time.

the mother needs to know how to tell if her baby is actually drinking while at the breast or just going through the motions.

Breast milk is a living substance and it changes in composition from feeding to feeding and from day to day 14. So, because we don’t know if the baby is getting salad breastmilk (the low-fat milk at the beginning of the feeding), burger and fries breast milk (the high-fat milk squeezed out of the milk-producing cells later in the feeding) or something in between, we can’t know how long he needs to feed to satisfy his hunger. Allowing him to fall asleep if all he’s had to eat is salad might mean the newborn is then too weak to wake by himself. Stopping a feeding when the baby squirms and jiggles or even gets angry because the waiter has stopped serving might lead to a hungry baby or even a baby who is put on medication because the doctor suspects a reflux problem. Waiting for the baby to pull away and refuse to go back on to the breast might lead to a baby who is no longer gaining as well as he used to 15.

So what’s the answer? Keep the baby skin to skin with his mother; let the baby tell his mother when it is time to feed and lead the way with his mother guiding and not pushing him to the breast; help him to achieve a deep latch that doesn’t hurt and allows him to get milk; and know the difference between drinking and just sucking. Keep the baby drinking well by using compressions and switching sides when compressions no longer work.

These suggestions won’t help with every latching difficulty but they will certainly address many of the issues in these three common breastfeeding challenges.

*Breast compression. This technique can help your baby to breastfeed actively and take more milk.

1. Hold your breast with one hand—thumb on one side, fingers on the other.

2. Wait while your baby breastfeeds actively (his jaw
is moving all the way to the ear). When he is no longer swallowing, squeeze your breast firmly. Hold it squeezed until he stops nursing actively and then release.

3. Rotate your fingers around the breast and repeat step 2 as needed on different areas of the breast. Go gently—this should not hurt.


References

1. Christensson, K, Siles, C, Moreno, L, et al. Temperature, metabolic adaptation and crying in healthy full term newborns cared for skin to skin or in a cot. Acta Paediatr 1992;81:488- 936.

2. Michelsson, K, Christensson, K, Rothgänger, H, et al. Crying in separated and non-separated newborns: sound spectrographic analysis. Acta Paediatr 1996;85:471-55.

3. Rapley, G. Keeping mothers and babies together–breastfeeding and bonding. RCM Midwives. 2002 Oct; 5(10): 332-4.

4. Kendall-Tackett, K, Cong, Z., Hale, T. Mother-infant sleep locations and nighttime feeding behavior. Clinical Lactation 1, no. 1 (2010): 27–30.

5. McKenna, J. Why babies should never sleep alone: a review of the co-sleeping controversy in relation to SIDS, bedsharing and breast feeding… Paed Resp Rev. 2005; 6(2):134-52.

6. Bystrova, K, Matthiesen, AS, Widström, AM, et al. The effect of Russian Maternity Home routines on breastfeeding and neonatal weight loss with special reference to swaddling. Early Hum Dev. 2007; 83(1):29-39.

7. Ferber, SG, Makhoul, IR. The effect of skin-to-skin contact (kangaroo care) shortly after birth on the neurobehavioural responses of the term newborn: randomized, controlled trial. Pediatrics 2007; 113: 858-865.

8. Bergman, N, Linley, L. et al., Randomized controlled trial of skin-to-skin contact from birth versus conventional incubators for physiological stabilization in 1200 to 2199 gram newborns. Acta Paediatr 93:779-785, 2004.

9. Levine, S, Wiener, SC. Psychoendocrine aspects of mother-infant relationships in nonhuman primates. Psychoneuroendocrinology 1988;13:143-154.

10. Svensson, KE, Marianne, I, Velandia, Matthiesen, A, et al. Effects of mother-infant skin-to-skin contact on severe latch-on problems in older infants: a randomized trial. International Breastfeeding Journal 2013, 8:1.

11. Kent, J C., Mitoulas, LR, Cregan, MD et al. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics March 2006; 117:3 e387-e395; doi:10.1542/peds.2005-1417.

12. Hornell, A, Aarts, C, Kylberg, E et al. Acta Paediatr 1999; 88: 203-11. 1999.

13. Colson, SD, Meek, JH, Hawdon, JM. Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Hum Dev. 2009;84(7):441-9.

14. Kent, JC, Mitoulas, LR, Cregan, MD et al. Volume and frequency of breastfeedings and fat content of breast milk throughout the day. Pediatrics. 2006 Mar;117(3):e387-95. PubMed PMID: 16510619.

15. Newman, J. Slow Weight Gain Following Early Good Weight Gain International Breastfeeding Centre. Information Sheet Revised 2008, 2009.


Edith Kernerman is an International Board Certified Lactation Consultant and clinician in Toronto, seeing over 2000 breastfeeding families each year. She is co-founder and President of the International Breastfeeding Centre (IBC), co-founder and Clinic Director of the Newman Breastfeeding Clinic, (NBC), senior faculty at IBC’s Centre for Breastfeeding Studies, an IBLCE mentor, and co-founder and President of the Ontario Lactation Consultants Association.


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