The challenges of breastfeeding, part 1

Feeding often looks peaceful in the pictures you saw before your baby arrived — and some days it will. But the first week is just as often harder than that, and that does not mean anything has gone wrong.

Almost every family we see runs into at least one of four things in the first two weeks: sore nipples, a sleepy baby, more weight loss than expected, or engorgement.

Here’s what each one usually means, and what you can do tonight. We’ll cover the later concerns — thrush, plugged ducts, mastitis — in part two.

Sore nipples

Some tenderness in the first few days is normal. Real pain is a signal, not a verdict.

Early soreness comes from your nipples stretching. It usually sits at a 3 or below, can be sharpest in the first minute of a feed and then eases, and starts improving somewhere around day three to five.

Pain above a 3 for the whole feeding, or pain between feedings, is a different thing. That’s almost always a shallow latch — and a deeper latch is also what keeps your nipples from getting damaged in the first place.

Two other things we look for:

• The shape of your baby’s mouth
• A tight frenulum — what you’ve probably heard called tongue-tie or lip-tie

Here’s a simple check you can do yourself: look at your nipple right after a feed. If it comes out an odd shape, your baby is having trouble getting or holding a deep latch. If it looks normal and the soreness is mild, your body is most likely just adjusting.

Often the fix is simply a wider mouth. Babies are born as tummy feeders — brought to the breast tummy-down, nose to nipple, they open wider and wider on their own, extending the tongue, which pushes the lower lip out. Let your baby be the one who opens. He’ll learn quickly that he can’t latch until he opens wide enough.

To keep him from sliding to the tip of your nipple, lean back while you feed and let gravity hold him in place. A baby who feels himself slipping will clamp down to keep the nipple in his mouth — that’s the other way a nipple ends up misshapen. A couple of pillows under him, or a nursing pillow with a pillow beneath it, does the same job. And you won’t need the props forever; within a few weeks you’ll find your own positions without thinking about it.

When your baby loses more weight than you expected

Some weight loss after birth is expected — sometimes 8 to 10% of birth weight.

What often happens next is a cycle: normal newborn jaundice sets in, your baby gets sleepier, and a sleepier baby doesn’t nurse as effectively. Three things break that cycle.

1. Keep your baby at the breast only while he’s actively nursing — sucking and swallowing regularly. When the activity stops, switch sides.
2. Gently squeeze your breast while he feeds. It increases the flow and he drinks more for the same effort.
3. After both sides, hand express or pump and give him that milk however you prefer.

After a day or two of this, most babies start waking for feeds and staying more active at the breast.

If you only track one thing, track weight gain: about 20–30 grams a day, or ¾ to 1 ounce. And if you want to know exactly how much your baby takes at a feeding rather than guessing, a feeding assessment with test weighing will show you. That’s something we can do with you.

Engorgement

When your milk comes in, swelling comes with it — sometimes into your armpits, where it can feel like a lump.

If milk isn’t moved out often enough, that swelling builds and your breasts can go hard. That’s engorgement. As much as a long nap sounds like exactly what you need once you’re home, it’s often what sets it off.

Tightness and fullness alone will settle in a couple of days if you keep feeding frequently. But once your breasts are very uncomfortable or firm, it becomes hard for your baby to latch and hard for the milk to come out. Any time a feed doesn’t leave you comfortable, hand express or pump until it does.

After the feed, once you’re comfortable:

• Put cold packs or chilled cabbage leaves on your breasts. For the leaves: rinse them, bag them, keep them in the fridge.
• Use enough to cover your breasts completely, and into the armpits if the swelling reaches there.
• Lie down for an hour. You should feel noticeably better afterward.
• Adding in ibuprofen and anti-inflammatory foods help too.

Before a latch or a pumping session, reverse pressure softening can make a real difference.

And if your breasts stay too firm for your baby to latch at all: lie down, put a little coconut or olive oil on your fingers, and glide gently over the breast toward the armpit for a minute or two on each side. You’re moving excess lymph fluid out of the way so the milk can follow. It’s called therapeutic breast massage, developed by Maya Bolman, IBCLC — her demonstration is below, and it’s worth watching once before you need it.

Watch: Therapeutic breast massage demonstration by Maya Bolman, IBCLC

A sleepy baby

Most babies nurse beautifully for the first hour or two after birth, then sleep hard for the next 8 to 12.

You can aim for the recommended eight or more feeds in 24 hours and still have a baby who can’t wake up enough to do a good job of it. So every time you try to nurse, hand express afterward and give him that milk — finger feeding, a spoon, a dropper, whatever works.

It matters more than it sounds like it should. The more he eats, the more he poops; the more he poops, the lower his jaundice level goes; and the lower that goes, the more awake he is for the next feed. A few rounds of that and the whole pattern turns around.