Common Problems  in the first weeks of Breast Feeding

My doctor tells me I have inhibited ‘let-down’ reflex. Please tell me what is it? Will I be an incomplete mother always?

No, no don't panic. It's not that bad. Very often sucking difficulties may also result from a child not getting enough milk. This is usually because the reflex, which is essential to enable the milk to come out of the breasts, is temporarily inhibited. This is the ejection / let-down reflex. It does not merely release the milk – but causes muscular contraction in the breast, which forces the milk out. This ejection reflex can be inhibited for a number of reasons. In a maternity ward, it may be because a mother is afraid or embarrassed by the unfamiliar environment or the presence of the strangers, or depressed or nervous about her motherhood or perhaps her future. The reflex is also inhibited if the mother worries too much about her milk, and lacks confidence in her ability to satisfy her infant. Now tell us what's bothering you and if you can't solve it yourself, talk to us.

How do you diagnose if the mother has irregularities in the ejection reflex (the `let-down’ reflex)?

Many common problems with breast-feeding result from inhibition of ejection reflex. This causes symptoms like: ‘baby fussing at the breast’, ‘baby crying again only a short time after having been fed’ or ‘the milk seems suddenly to have disappeared’.

To make a diagnosis, see if you feel tense, prickling ‘let down’ sensation beneath your nipples when the baby begins to suck. However, many successful nursing mothers do not feel these sensations in the early weeks of nursing and some large-breasted women never feel them at any time.

Your judgement of whether the reflex works properly or not may therefore have to be based on whether the baby seems to be getting milk, rather than on probing what you, the mother can feel. The ejection reflex is easily influenced by the mother’s psychological state. Hence treatment must be psychological than physical.

How you can help yourself:

1. Before putting the baby to the breast, try to calm down, for instance by resting for some time, having something nice to drink, etc. This should become a ritual, repeated before each feeding session. For instance you might make a cup of tea and drink it, or lie down with closed eyes for five minutes.
2. Be sure to sit or lie down in a comfortable position and that you can remain undisturbed.
3. Make sure that your baby is sucking strongly, is in a good position, and not causing you pain.
4. Routine and habits may be important. If possible you should feed in the same place each time – i.e. in a particular corner of the house, in one special chair and so on.
5. Sometime for this kind of problem, scheduled feeding is said to be helpful. But give the baby a say in establishing the schedule according to his needs. Starting when an infant wakes up in the morning, you should feed him regularly throughout the day, for instance every two or three hours, thus ‘conditioning’ both the breasts and the infant for scheduled feeding hours.

• When the milk starts flowing, breasts may feel full and uncomfortable.
• Some women have no discomfort at all, others have heavy, stony hard, engorged breasts, and pain.
• A brief spike of fever – even a single chill – may occur at this time. It is sometimes called ‘milk fever’ and it is not due to bacterial infection, and need not cause great alarm. If it persists for more than 24 hours, it may be something serious.

• These symptoms are partly due to an increased amount of tissue fluid in the breast, which decreases spontaneously after some days.
• They are also due to excess milk in the breasts, because at first milk production is poorly adjusted to demand, and often there is enough for two babies.

• The simple answer to this problem of engorgement is to express excess milk – which provides rapid relief of the pain and other symptoms. This may also, by reducing the pressure within the breasts, allow the freer drainage of the tissue fluids, and quicker resolution of the condition.

Will the amount of milk production go on increasing indefinitely if I express the excess milk?

These fears are not justified, as in such a case, after a week or two, production almost always decreases to match the demand of the infant. Also the need of the baby increase, and he becomes more efficient at emptying the breast. At any rate, when congestion due to tissue fluid has decreased, the pressure in the breast decreases and you will feel more comfortable. At this stage, you can safely stop expressing and let your breasts adjust naturally to the infant’s demand. There is less risk of breast abscess at this time so the need to keep on emptying the breast is less.

In any case, the excess milk from high-yielding mothers is extremely valuable, because one can use it for other babies who are in need of extra milk (Breast Milk Banking). Human milk is especially important for premature babies, yet their mothers often find it difficult to express enough for them.

* Doctor, I delivered 7 days ago but have too little milk, my baby is always hungry? Please help!

Some mothers have too much milk before their breasts have adjusted, while others have too little. This does not necessarily mean that you will be less efficient milk producers later on. Most can produce enough milk and are able to feed a baby normally after two weeks or so. But during these few weeks, while you wait for milk to increase, you are in particular need of support, encouragement, and supervision, so that you do not give up.

If your infant loses too much weight (more than 10 % of his birth weight), or shows signs of dehydration,(create hyperlink) you can give the child-expressed breast milk (EBM) from the Breast Milk bank so that the energy needs are met. Or, if EBM is not available, you can give carefully controlled supplementary feeding, which of course is not as good.

Lately I find my baby is too tired to suck properly. What could be the reason & what can I do?

This could be either due to a problem in the child or effect of some drugs given to the mother. Sedatives given during delivery may reach the foetus through the umbilical cord. The infant then may be too sleepy to suck properly. This may last for some days after birth (you have not mentioned your baby's age).

Jaundice and other illnesses may have the same effect. In neither case, however, is there any reason to postpone the breast-feeding sessions. The child should be offered the opportunity to suck even though he may not seem interested. If he can be persuaded to suck for a few minutes at a time, this is very valuable, and should be repeated 6 – 8 times daily.

A word for your family - In such cases the most important task for you all is to keep up the mother’s spirits by reassuring her that her infant will wake up soon, and become stronger and more satisfying to nurse.

Even though I produce enough milk, my child has difficulty sucking and most often remains hungry. Why does this happen and what can I do to help him?

Most babies suck easily and naturally. But occasionally a baby seems to have to ‘learn’ to suck. For you this is an exercise in patience. You should not give up trying, but at the same time you should not exhaust herself (or the infant) by incessantly trying to succeed. You should allow yourself and the baby time to rest and regain strength in between the sucking periods. Usually, the presence of a person whom you know, and who is kind and calm is likely to help you. But if you don't like it you may better try alone.

A baby sucks because this is a reflex that he is born with. To start the sucking reflex something has to touch the baby’s hard palate. Normally, it is the nipple that touches the palate, but to do this, it has to be right inside the baby’s mouth. If a nipple is very short, it may not go far enough into the mouth to start the reflex. This is the reason why flat nipples may cause problems in the early days. Most flat nipples are sufficiently protractile for normal sucking once they have been stretched a little. But some help may be necessary in the first few days.

If a breast is engorged, the nipple may be stretched flat and not easy protractile. The baby can only ‘chew’ at the tip of the nipple, and cannot get it far enough into the mouth to suck properly. As a result, the baby fails to extract milk, and also harms the nipple. The infant then becomes impatient, cries and turns away from the breast and from the despairing mother. On such occasions, the assistance of an experienced and calm person is invaluable.

Just see, which of the above apply to you. Write in again, it helps many more like you.

I feel I produce enough milk but my problem is that I have flat nipples and my breasts feel full, heavy and painful. As a result of my flat nipples my baby is not able to suck enough milk and remains hungry and cranky. What do I do?

The management of flat nipples – however much engorgement contributes to the problem – is this:

• Try to manipulate the nipple a little, to make it more erect and easy to grasp.
• It is often helpful to remove some of the milk so that the breast becomes a little softer – you can either express by hand, or use a breast pump.
• Gently and patiently, put the infant to the breast for another try. One drop of milk left at the tip of the nipple may act as an ‘appetizer’.
• Remember that the nipple and the areola (the dark skin round the nipple) must both be put well into the baby’s mouth. Sometimes to do this you have to press the baby rather firmly on to the breast. Don’t be afraid to do this – if you think the breast is going to block the baby’s nose, use a finger to hold the breast clear of the nose – don’t pull the baby’s head away!

If the baby still does not succeed, let it suck through a nipple shield for a few days, until engorgement subsides and the nipple has stretched.

Every time I try to feed my baby she starts crying and refuses to feed. I produce enough milk, but I do not know why my child reacts like this and what do I do?

Sometimes nipples are too big. An infant may seem to gag and choke if the nipple is so long that it goes past the hard palate and touches the soft palate. Your baby may react by fighting. When put to the breast he may turn his head, cry, and move his arms and legs. This can easily be corrected by holding the infant a little away from the breast.

A similar effect is produced when a mother has too much milk and it flows too fast out of the breast due to a forceful ejection reflex. The milk fills the infant’s mouth too quickly, and chokes him. In this case, the mother should express some milk before she feeds the infant.

All these are reasons why a baby may seem to refuse the breast, and yet in most cases the mother has more than enough milk, and keeps wondering why the child is refusing feed.

I have been breast-feeding regularly for some time, but now I have suddenly developed soreness and redness on my nipples. Breast feeding now has become very painful. Help me, I'm worried. What should I do?

When nursing, you must hold the baby close enough for its chin to touch her breast. Frequent, short nursings promote speedy healing. Let the baby suck first on the least affected breast. The initial sucking is the strongest, and thus the most painful. Again, if both sides are equally painful, very careful hand milking may elicit the ejection reflex, and the baby can then be put to the breast when the milk flows. You can apply a thin coat of edible oil to the nipple between feedings. This often gives symptomatic relief.

A mother’s nipples may become sore at any time during lactation, but it is more common in the early weeks. It may encourage you to know that the soreness seldom lasts more than a week (although one week in this case may seem a very long time for you).

The most common kind is the ‘positional’ sore nipple, which is self-explanatory.

Soreness can also result from:

1. Sudden exposure to the unaccustomed action of sucking;
2. Faulty sucking technique
3. Letting the infant suck too long in a bad position
4. Soreness is more likely to occur in engorged breasts; and
5. When the nipples are flat and it is difficult for the baby to grasp the nipple properly.
6. Bite by older children (with milk teeth).

Sore nipples do not have nice looking wounds. Often one sees a little redness. But the nipples are so well supplied with pain fibers that even very small lesions are extremely painful. The pain is worst when the baby first begins to suck, and the skin is stretched. It gets less as nursing proceeds, especially after the ejection reflex is working, and the milk is flowing. The early pain is often so strong that a mother may be found bracing her whole body to ‘take it’. Sometimes the severe early pain inhibits the ejection reflex, which leads to further problems.

When nursing, you must hold the baby close enough for its chin to touch her breast, and so that nipple and areola can both go completely inside its mouth.

If, in spite of taking these precautions, sore nipples start to develop, there are a number of things that have proved helpful:

• It may sound brutal –but frequent, short nursings promote speedy healing. It would seem logical to suppose that letting the nipples ‘rest’ for as many hours as possible would have a healing effect. This is however not the case. If a crust is allowed to cover the wound, it only cracks open again as soon as the baby sucks. The wound however heals in spite of frequent feeding.
• Let your baby suck first on the least affected breast. The initial sucking is the strongest, and thus the most painful. When the ejection reflex has started to work, change him over to the sorest side.
• If both sides are equally painful, very careful hand milking may elicit the ejection reflex, and the baby can then be put to the breast when the milk flows. If oxytocin preparation are available (either in the form of a nasal spray or of tablets which are absorbed through the mucosa of the mouth) this may be the kind of situation in which they are helpful in eliciting the ejection reflex.
• Nursing the baby in a different position from usual may also help. In this way, the parts of the nipple, which are subjected to most traumas by sucking, are changed.
• You can apply a thin coat of edible oil to the nipple between feedings. This often gives symptomatic relief. Lanolin and Vaseline are good and harmless agents, and do not have to be removed before the baby sucks. But you must allow the skin to dry before applying the ointment. Wetness held on the skin by the ointment, makes the skin softer and weaker.
• Never apply tincture of benzoin or surgical spirit. They cause severe pain, and can damage the nipple skin even more.
• There are several substances of both modern and traditional origin that people claim are helpful for healing sore nipples, such as lemon-juice, oestrogens, disinfectants, vitamin-E-containing ointments, etc. Some of the recommended methods for treating sore nipples are dramatic, others more ordinary. In the end, only the common sense and general experience of the doctor can help you decide whether or not to encourage or discourage any particular remedy.
• If a nipple becomes extremely sore, it may become necessary to temporarily discontinue breast-feeding until the nipple responds to treatment. But it is essential, both to prevent an abscess forming and to maintain milk production. You should express the milk (either manually, or if that is too painful, with a pump). Unfortunately, in this situation, the milk production often diminishes. It may be necessary to stimulate it to increase again.

If sore nipples are persistent, it may be because the baby has a thrush infection  in his mouth which has spread to the nipples.

Whenever a mother has sore nipples, she must always check her baby for thrush so that it can be treated before the soreness becomes persistent. A baby with thrush has a white coated tongue or white lesions that look like milk curds inside the cheeks. If you are not sure, try to wipe them away. If you can remove the white easily, it is milk, if you cannot remove it, then it is probably thrush. You can treat thrush with gentian violet (0.5-1 per cent), or lapis (2 per cent) which you apply twice daily for 5-7 days, repeat the treatment.

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