Also by Charlotte Young “Mixing Bottle and Breast, it doesn’t have to be all or nothing”
During both antenatal and postnatal consultations, it never fails to amaze me how many mothers expect breastfeeding to hurt.
If I visit antenatally, I hear all the awful experiences people have relayed to the mum-to-be. If I visit at 6 weeks plus and ask what the early days were like, I often get told they experienced “the usual cracking and damage you normally get in the first few weeks”.
We hear it said that nipples need to “toughen up” which goes hand in hand with recommendations from granny to give them a rub with whisky and a rough face cloth during pregnancy. Yikes! Hardly appealing is it?
Breasts exist to feed babies. Before there were any alternatives how did the human race survive? We would have had a pretty tough time if a large percentage of mums simply couldn’t do it without first enduring excruciating pain or shredded nipples.
There are over 5000 species of mammals in the world who feed their young as the norm. Pain would not only hinder acceptance of their young, but also milk supply.
A baby needs to take the breast tissue around the nipple into his mouth when feeding, not just the nipple (discussed more below). The most common cause of pain is the baby isn’t attached deeply enough to the breast, or that he can’t keep this deep attachment as the feed progresses. If the baby is well attached and performing the correct action, the breast is cushioned from the lower gum ridge by his tongue.
You can test this out yourself. Put your thumb in your mouth as a child typically would up to the first knuckle and suck. You will probably feel your bottom teeth touching or digging in to your thumb. Now move your thumb further back until you feel where the roof of your mouth turns soft, and leave it just before this point. Push your tongue forward under your thumb and suck. The first is comparable to the shallow latch a baby would use for a bottle teat, the second deeper and more similar to a baby breastfeeding. This means you should not become sore and you do not have to limit how often, or for how long baby feeds.
If the baby has a shallow latch mum may feel a biting, grinding, flicking or pinching sensation when baby is feeding, and afterwards may note her nipples look blanched (white or blue coloured because squashing the nipple can restrict the blood supply. Nipples may look wedged or pointy, often compared to a new lipstick). This can progress to trauma and cracking as babies feed frequently, and a young baby not properly attached may want to feed more than most if he’s not getting as much as he’d like at each feed. A good comparison is a hose that someone’s partly treading on; the flow is restricted isn’t it? As a result mum may experience blockages and/or a reduction in supply as a result.
There can be different reasons for a shallow latch, sometimes the baby isn’t held comfortably and has to strain during feeds. If he latches symmetrically, rather than taking more areola below the nipple than above, cracking particularly at the base of the nipple can occur if latch is shallow. If the birth has been long or quite rapid, or there has been assistance from say forceps or a c section, some positions may be less comfortable for baby and the nerves associated with the tongue and jaw may be sensitive; this can hinder both how well baby’s tongue moves and how wide baby opens his mouth when latching. Other times it’s as simple as the breast being full and so difficult for baby to grasp well (more below).
Based on the above, it should be easy to avoid sore nipples by ensuring latch is always good. But it’s not always that easy for several reasons.
First – it can be really difficult for non-lactation specialists to tell a good latch from bad. We hear all sorts of things about ears wiggling, baby pulled in close with a double chin, but these are unreliable, and mum often can’t see well from her angle. Sure, if baby is hanging off the end of a nipple it can be quite obvious, but these cases are few.
If mum has a larger breast or one that is full in the upper half, it can very often “fill the gap”, making baby look pulled in snug – gently push the breast back and you see however baby has a small mouth with insufficient breast tissue to milk the breast effectively (see photographs below).
Some babies attach well but can’t maintain it throughout the feed as mentioned above, but as some helpers only watch the start of a feed, this is missed.
Ultimately how it feels is key. Telling a mum who has sore or damaged nipples that she has a good latch, is like telling someone their gloves fit well when they’re so tight they’re making their fingers feel numb!
- Avoid opiates where possible: Pain medication in labour that have a tranquilising effect (like pethidine) can impact on baby’s reflexes and sucking skills. It may also cause baby to be excessively sleepy which can make feeding generally more difficult to establish. Mums often find if they can find good support for a natural birth, this can lower pain levels and need for medication, or they may choose a different form of pain relief (your midwife is the best person to discuss this with). 1, 2
- Avoid immediate separation post delivery where possible: Of course some situations require urgent medical attention for baby or mum making separation essential, but where possible baby should stay skin to skin with mum for at least the first hour. Evidence shows when this happens, healthy term babies will follow a series of instinctive behaviours before crawling and self attaching to the breast. Whilst it can take over an hour for baby to reach the breast, these movements start around 20 minutes after birth, therefore if separation does occur, returning baby to mum before this time can help. There is lots of information about the breast crawl here http://breastcrawl.org/science.shtml Mum can wrap a shirt around herself and baby, or put a blanket on the top of them both, if she would prefer to be covered. 3,4
- Try feeding leaning back: A study conducted at hospitals in the UK and France examining whether traditional feeding positions (such as cradle and cross cradle) were actually the best when it comes to getting breastfeeding off on the right foot, found the opposite was in fact true. Traditional positions could actually hinder natural feeding reflexes. Whereas previous advice was to pile up the cushions and swaddle a baby trying to get his hands away from the breast, laid-back breastfeeding, called “biological nurturing” by the researcher, was found to encourage the use of natural reflexes. Newborns have the grasp reflex which allows them to find the nipple, and they also retain their “stepping” reflex for a couple of months that enables them to crawl to the breast after birth. Therefore, some mums find letting baby lead the way can help. You do not need to be in skin contact to try laid back breastfeeding. You can read more here http://www.biologicalnurturing.com 5
- Ensure appropriate positioning: If using a traditional hold, ensure baby is pulled in close so he is not twisting or straining at the breast. Cradling baby in the crook of your arm doesn’t work well for breastfeeding, baby needs to be facing the breast and in front of where it naturally sits to avoid dragging the tissue. With larger breasts some people recommend lifting the breast and then elevating the baby to meet it. However this can cause problems as the breast becomes less full and naturally drops, which can drag the nipple from baby’s mouth. Whilst it can be easier to see with the breast lifted, it can be worth practising leaving the breast in its natural position and lowering baby to match. A qualified breastfeeding counsellor or lactation consultant will be able to help with this if needed.
- Ensure a deep latch in traditional holds: I could write a lengthy description about how to hold and latch baby. But this video from Ameda perfectly highlights why nose to nipple and baby held close help attain effective attachment http://www.ameda.com/resources/video.
It can seem illogical to align baby’s nose with the nipple, when ultimately you want it to end up in his mouth – after all you don’t usually put your dinner in front of your nose! Although you might if you were eating a thick sandwich or a burger, something that you need to place well into your lower jaw; and there is logic behind this proven technique!
We now know that a baby can obtain milk more efficiently if they are latched asymmetrically, as shown in the image on the right and below.
This means a baby tips his head back slightly and leads with his chin and lower jaw, taking more areola below the nipple than above; this also results in the nose being clear of breast tissue. (If baby’s mouth is aligned with the nipple, you will then have to squeeze/shape the breast to obtain effective attachment and avoid a symmetrical latch.)
The La Leche League link below in the next point discusses this in more detail – if you’re still unsure, try out the balloon experiment described on their page.
- Employ advanced techniques: for some mums with flatter or “shy” nipples, which protrude but retract with contact, or who have a full breast which can cause tightness, there are a couple of techniques that can help:
- http://www.breastfeedingonline.com/rps.shtml (for full breasts)
These techniques can also be handy for babies who don’t open their mouths wide at the breast. However, if this persists it can be worth seeking qualified support. Feeding is an instinctive behaviour for newborns, and in practice I can often identify why baby isn’t comfortable opening his mouth wide in the feeding position used. Sometimes something as simple as shifting a hand or arm can make a huge difference.
- Check for breast blockages: Blocked ducts around or just behind the areola can cause intense pain when latching, as can a blocked nipple pore or bleb. More information on how to identify and treat these problems, see here: http://www.pamf.org/children/newborns/feeding/blebs.html
- Rule out thrush: Whilst I feel nipple thrush (candida) is over-diagnosed, if you have a fungal infection prompt treatment is important to resolve pain and cracking. Antibiotics can increase the risk, particularly if you are prone to other types of thrush. The Breastfeeding Network produce a leaflet for both health professionals and parents here http://www.breastfeedingnetwork.org.uk/pdfs/BfN_Thrush_leaflet_Feb_2009.pdf. If treatment is appropriate it is important to treat both mum and baby at the same time, so the thrush doesn’t get passed back and forth. A shallow latch that is restricting blood supply to the nipple can also cause intense pain after a feed both in the nipple and deep into the breast. If there are no visible signs of thrush always check there is no pinching, squashing or change of colour to the nipple after feeding.
- Watch how much baby is actually swallowing: Sometimes shifting the position of baby can resolve pain for mum, but doesn’t increase how much milk baby is actually taking. With the initial milk ejection or letdown, baby starts a regular suck, pause, swallow pattern. Whilst he will take regular pauses, he should continue swallowing after each suck; not doing lots of sucks without swallowing. If in doubt call in qualified support.
- Rule out underlying causes: An under-diagnosed cause of breastfeeding pain is tongue tie. The baby’s tongue and lips need to create a seal when feeding, whilst the tongue lifts and lowers like a wave. If a baby cannot do this effectively he may slip/fall off the breast easily (some mums feel they have to support the breast and sit super-still to prevent this), or move gradually to a shallower latch as the feed progresses, causing symptoms of a shallow latch as discussed above. Some will curl their top lip under to try and compensate with pressure for an ineffective tongue action. If problems persist after a session of positioning and attachment support, seek help from someone who specialises in tongue ties and full oral assessment.
- Pain after pain-free nursing: Thrush, return of ovulation or other hormonal change such as pregnancy, and the appearance of top teeth are common causes of soreness further down the line. The last typically resolves within a couple of days of teeth appearing, as baby adjusts his latch to suit how his mouth now feels.
- Know what you don’t want: Some things have been shown to be unhelpful or even cause further problems establishing feeding. These include:
- Pushing baby’s head to the breast: If you’re unsure why, get your partner to shove your head in your dinner! Babies’ heads are sensitive, and nerves linked to the tongue and mouth run down the back of the head and neck. Pushing the head forward can very easily trigger protective reflexes that result in baby doing the opposite, and pulling his head back. Pull baby’s shoulders and chest in closer, rather than his head.
- Nipple shields: Nipple shields are often misused to mask a problem, rather than as a tool to help whilst the underlying issue is being addressed. For babies who are clamping or “biting”, shields may not improve pain, and severe nipple trauma can still occur. If baby is unable to attach deeply to mum’s breast, he may also struggle to attach deeply with a shield, and therefore it is important to monitor output and weight more closely when using them.
- Passive breastfeeding support: This goes along the lines of “stick at it and things will click”, “some babies just need to learn”, “if you can get to 6 weeks things will get easier” – “you’ve given it a shot, it’s time to give formula!”. If you are in pain or your baby isn’t gaining weight, seek help elsewhere.
Treating Sore Nipples:
- Nipples heal remarkably well providing whatever was causing the damage or pain has gone.
- Some mums find it can help to offer small frequent feedings, using the least painful side first, as baby will typically feed with less vigour when the edge has been taken off his appetite.
- If you have nipple cracks, moist wound healing (keeping the surface humid which allows skin cells to slide across the surface of the wound) has been shown to be twice as effective as air drying, which some older sources recommend. Moist wound healing also prevents a scab forming, which can be disturbed with each feed, causing more discomfort. Some theorise that applying breastmilk can help because of its epidermal growth factors, and it is used in many cultures for various skin irritations. A very thin smear of medical grade lanolin or a hydrogel dressing can also be used.
- If you need to remove baby from the breast, always remember to pop your little finger in the corner to break the suction to prevent further soreness.
Copyright © 2012 Charlotte Young. All Rights Reserved.
Also by Charlotte Young “Mixing Bottle and Breast, it doesn’t have to be all or nothing”
1. Nissen, E., Lilja, G., Matthiesen, A.-S., Ransjo-Arvidsson, A.-B., Uvnas-Moberg, K. and Widstrom, A.-M. (1995), Effects of maternal pethidine on infants’ developing breast feeding behaviour. Acta Paediatrica, 84: 140–145. doi: 10.1111/j.1651-2227.1995.tb13596.x
2. Nissen, E., Widström, A.-M., Lilja, G., Matthiesen, A.-S., Uvnäs-Moberg, K., Jacobsson, G. and Boréus, L. (1997), Effects of routinely given pethidine during labour on infants’ developing breastfeeding behaviour. Effects of dose-delivery time interval and various concentrations of pethidine/norpethidine in cord plasma. Acta Paediatrica, 86: 201–208. doi: 10.1111/j.1651-2227.1997.tb08869.x
3. Henderson, A. (2011), Understanding the Breast Crawl. Nursing for Women’s Health, 15: 296–307. doi: 10.1111/j.1751-486X.2011.01650.x
4. Anderson GC, Moore E, Hepworth J, Bergman N. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database of Systematic Reviews 2003, Issue 2. Art. No.: CD003519. DOI: 10.1002/14651858.CD003519.
5. Colson, S. D., Meek, J. H., & Hawdon, J. M. (2008). Optimal positions for the release of primitive neonatal reflexes stimulating breastfeeding. Early Human Development, 84(7), 441-449.