Ina May's Guide to Breastfeeding

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Preparing for Nursing

Once you’ve made the decision to nurse your baby, what can you do during pregnancy to prepare for nursing? As discussed in the previous chapter, your body is doing most of the work for you, but there are some things that you can do to ease the transition.

You may be able to find a breastfeeding class in your area. If so, I would encourage you to find the time to take it if at all possible. Attending such a class is a good way to meet other pregnant women who are interested in nursing, and it will also give you the chance to watch some of the great nursing videos that are available today. An additional benefit is that in many of these classes you will have a chance to meet women who are successfully nursing. Women who have already breastfed are a great source for practical information.

If you are the first person in your family to choose nursing, you may find that your decision meets with some resistance from family members. They may believe that you won’t be able to produce enough milk or that you will be “hogging” the baby, or they may simply be uncomfortable about nursing because they have never or rarely seen it. If this is the case, the statistics in the introduction and the list of resources at the back of this book should be helpful in reassuring your worried relatives.

Breast Care During Pregnancy

Your breasts do a good job of taking care of themselves during pregnancy. In almost every case, the best thing to do is to leave well enough alone. Avoid washing your nipples with any kind of soap that might remove their natural lubrication. Your nipples actually need this lubrication, which is produced by the little oil glands on the areola that grow larger during pregnancy. These little glands—unique to the nipple—also help to maintain an acid balance, which is what creates the antimicrobial atmosphere of your nipples. Sometimes, well-meaning people advise women who intend to nurse to apply different ointments or substances, such as witch hazel or tincture of benzoin, that are supposed to toughen skin. This is a bad idea when it comes to nipple care, as these substances can dry the skin and cause it to crack. It is also a bad idea to rub your nipples hard with a towel to toughen them. Being this rough with them can actually remove the protective layers of skin that develop during pregnancy. If, for any reason, your nipples are already dry and in need of lubrication, you can apply some pure lanolin, but be careful not to cover the tip of your nipple.

One thing you can do to care for your breasts is to keep your nipples as dry as possible, particularly if you experience some leakage of colostrum. This will not be a problem for most women—though most will be able to express colostrum, it is comparatively rare for it to flow without being manually expressed. Generally, the only women who will experience the leakage of colostrum during pregnancy are those with large breasts, where the nipples are the lowermost part. If your breasts are like this, I suggest that you look for a bra that provides good support during pregnancy to minimize such leaking. Avoid wearing a bra with a plastic liner though, as this may irritate your breasts and keep your nipples from staying dry.

Whether you experience noticeable leakage of colostrum or not, a few drops of colostrum are likely to accumulate on the end of your nipple and dry there. This is a little like the dried goop that accumulates in the corner of your eyes during the night. You can remove it without scraping your nipple.

It’s a good idea, when you are 34 to 36 weeks pregnant, to express several teaspoons of colostrum into a sterilized container and freeze it. If you should give birth before 39 to 40 weeks, this stored colostrum can help keep your premature or late-preterm baby from developing jaundice. Follow this same procedure if you are diabetic, as your baby will have an increased need for your colostrum, but start collecting and storing as early as 32 weeks. Such stimulation of the breast does not cause early labor.

If your nipples are quite sensitive beyond the first trimester of pregnancy, I suggest that you spend at least part of your day with them exposed to the air (and, if possible, to a little sunlight). If you are able to go bra-less during part of the day, the slight friction of your nipples against your clothes is a good kind of “nipple conditioning.” In general, you should avoid tight, restrictive clothes, as they will irritate your sensitive nipples. Going bra-less during the night is also a good idea, as your lymphatic system functions best when there is no external pressure on the soft tissue of your torso. Take a towel to bed with you if there is leakage during the night.

Breast massage and stimulation of the breasts or nipples during sexual activity can also be a helpful preparation for nursing. If this is part of your normal lovemaking, there is no reason to discontinue it. Grasping of your nipples can build a protective layer of skin there, making them slightly less sensitive to touch. On the other hand, if you have a history of giving birth prematurely, it’s good not to do any breast stimulation until your baby is no longer premature.

Checking Your Nipples

Are you afraid that the shape of your nipples will keep you from nursing? Here are a few techniques that will help you determine if you have flat, inverted, or retracted nipples. It’s unlikely that any of these conditions will prevent you from nursing, but it’s better for you to find out before your baby is born, since there are ways to reshape your nipples if they are severely inverted or retracted.

Here is a quick way to tell if your nipples are inverted or retracted. Grasp your nipple at the base between your thumb and forefinger and press your thumb and forefinger together several times. A flat nipple will remain flat when you do this. An inverted nipple will retreat farther inward. Another way you can tell is that flat and inverted nipples do not become erect when they are stimulated or cold.

Pinching alone can’t make this nipple erect.

If one or both of your nipples are flat, it is generally not necessary to take any action during pregnancy to correct this condition. With good help after birth, you should be able to get your baby well latched to your breast.

Deeply buried nipples, on the other hand, are likely to need help during pregnancy to become more graspable. One method is to stretch the skin of the areola enough to enable the nipple to protrude. You can put your two forefingers on either side of your nipple at the base and gently push your fingers apart. Repeat this procedure all around your nipple, pulling any adhesions loose. You may have to do this several times every day to notice a difference.

If this technique is less effective than it needs to be to develop a nipple that will fit into a new baby’s mouth, you might try wearing a breast shell inside a bra that is one size larger than what you would ordinarily wear. When this device is worn inside a bra, it puts gentle pressure on the areola, gradually stretching your nipple. Wear the shell for a few hours each day, progressively increasing the amount of time you wear it, if you can do this without discomfort. You should wash the breast shells daily if you use this technique.

Breast shell

A chopped-down syringe can coax out an inverted nipple.

A third method involves using a disposable syringe (10 ml in size or—if your nipples are quite large—20 ml). Remove the piston from the syringe and cut off the nozzle with a sharp knife. Reinsert the piston in the cut end of the barrel. Put the smooth end of the syringe over your nipple and gently pull the piston for a few seconds to lengthen your nipple. Once you have loosened any adhesions, grasp your nipple between your thumb and forefinger and gently roll your nipple while stretching it outward to lengthen it.

You can also buy a device called the Evert-it nipple enhancer, which is available on the La Leche League website.

Before any implements such as those mentioned above were available, people used to “redesign” severely inverted nipples by using an empty tobacco pipe and a husband. I remember a nineteenth-century medical text that suggested if the husband couldn’t or wouldn’t help, “an intelligent serving maid” would suffice.

This breast squeeze can reduce swelling in pregnancy or engorgement while nursing.

Dealing with Discomfort from Swollen Breasts During Pregnancy

Some women with extremely large breasts experience so much breast swelling during pregnancy that they long for relief. In cases like this, it often helps to apply the kind of manual pressure illustrated in this drawing. This is best done when you are lying on your back.

Previous Breast Surgery

There is no way to be sure whether previous breast surgery will hinder your ability to produce milk or to allow it to flow from your breast. You will know only if you try. In general, minor surgeries such as a lump removal or a biopsy should not have a negative effect on lactation. Cosmetic surgeries, whether for breast reduction or augmentation, can cause problems with milk production or release, but such problems vary widely from woman to woman and may also depend on the type of surgery performed. Some women naturally produce enough milk to feed several babies. If such a woman has had breast surgery that interferes with her letdown reflex, she may still be able to produce enough milk to feed one baby.

Given the benefits of breastfeeding, it’s usually good to plan to breastfeed if you have had breast surgery, even though it’s possible that you may need to give supplemental feedings. If you are unable to produce enough milk, keep in mind that many babies value suckling enough to continue nursing when supplemental feedings become necessary. Do make sure that your midwife or physician is aware of your surgery, and check your baby’s weight by four days after birth and every couple of days thereafter. By day six, your baby should be gaining about an ounce per day after the initial normal weight loss (no more than ten percent).

Breast-reduction surgery may involve the removal of breast tissue or liposuction—the removal of fat without surgical removal of breast tissue. If your surgery involved liposuction only, it is likely that your milk ducts and nerves were not cut, so your ability to produce and release milk should not be affected. Most kinds of breast-reduction surgeries, however, do involve cutting at least some of the milk ducts and nerves, producing a kind of damage that can interfere with the letdown reflex. Generally speaking, the more tissue that is removed, the greater the chance that supplemental feeding will be necessary. If you had reduction surgery and you still retain some feeling in your areola, there is a good chance that you can breastfeed exclusively. When there is no sensation left at all, your letdown reflex is less likely to function as it should, since this reflex depends upon the messages that travel from your nipple and areola to your brain to trigger milk production and release. Most of the sensation that is going to return following surgery will take place within two years. All this said, there have been some reported cases of women whose milk ducts healed and functioned fully after being cut during surgery. If you have had incisions around your areolae, I recommend that you rent an automatic electric breast pump and begin using it about three days after birth. Pump both breasts for four to five minutes after each feed to stimulate greater milk production. It may take a week or two to build up a good supply, but the only way to find out if this will work for you is to try it.

I have worked both with women who could breastfeed exclusively following breast-reduction surgery and those who needed to supplement. One woman I know was able to nurse her first baby, because she had the extra time she needed in order to do it (her letdown reflex was damaged but not destroyed). When she gave birth to her second child less than eighteen months later, though, she was unable to spend as many hours nursing as the baby required, since doing so would have meant neglecting her older baby—who still needed some undivided attention. The mother would have preferred to breastfeed exclusively, but she ended up resorting to supplementary feedings for her younger baby.

For more advice on breastfeeding after breast-reduction surgery, I recommend Diana West’s Defining Your Own Success: Breastfeeding After Breast-Reduction Surgery. Her website (www.bfar.org) is another good resource.

Breast-augmentation surgery involves the use of either silicone-or saline-filled implants. These may be inserted through an incision around the areola or an incision in the fold under the breast, near the armpits. Again, the extent of the damage is related to the location of the incisions. If the incisions were made around the areola, it is possible that milk ducts or nerves were damaged by the surgery. On the other hand, if your scars are in the folds under the breast or near the armpits, it is likely that your implants were inserted behind your milk ducts. If neither your ducts nor your nerves were cut, your ability to suckle your baby is likely to be unaffected. About half of women with this type of surgery are able to fully nurse their babies, according to one study.1

Augmentation surgery always causes scarring inside the breast, which ever way the surgery is done, and it can sometimes cause discomfort during nursing or put pressure on the milk-producing glands, reducing the milk supply. Another effect of the surgery is that your nipples may be more or less sensitive than normal.

Some mothers wonder if their milk might be contaminated by the presence of their silicone implants. In the 1990s, a small study of six breastfed babies claimed that these implants might cause problems with swallowing. The group that offered this hypothesis was heavily criticized, mainly for how its subjects were chosen.2 Over the next few years, several larger studies with better methodology found no connection between the presence of silicone implants and esophageal disorders in breastfed babies.3–5 Both the American Academy of Pediatrics’ Committee on Drugs and La Leche League International recommend that mothers with implants should breastfeed their babies exclusively if possible.

What Do You Really Need to Buy?
Buying a Sling

There are a few things that you will need to buy if you are planning on exclusively breastfeeding your baby. One product that I would recommend is a good sling so you can tie your baby close to your body between feedings. Many first-time mothers are surprised by how much their newborns like to be held during the first month or two, even when their bellies are full. A sling will allow you to satisfy your baby’s need to be close to you without taking away your mobility. Dads can use these slings too.

Wearing your baby in a sling frees your hands while calming your baby.

When you shop for a sling, keep in mind that you’ll want one that can work as well for a newborn as it can for a two-year-old. I would recommend that you avoid the kind that has a covered metal frame; chances are high that your baby will find this as uncomfortable as you do. The soft cloth sling that cups your baby’s body will allow the kind of contact between you and your baby that he craves, and it will also permit breastfeeding. Another advantage of this kind is its washability.

Buying a Nursing Bra

You will need to buy good nursing bras during your pregnancy. Buying the right bra for nursing can be a little tricky, since your breasts will go through more than one change in size after you give birth. For that reason, I recommend that you buy just one or two that aren’t very expensive for early use until your breasts settle down to the size they will be for the next several months. Then you can buy about three of the style and size that works best for you. This size change may take a couple of weeks.

Choose one cup size larger than is comfortable during pregnancy and possibly one size larger than your usual number, especially if you’re already using the loosest fastening. Take enough time in the fitting room to notice if you can uncover one breast without tightening the fabric on any part of your other breast, since such pressure could cause a blocked milk duct, which could lead to mastitis. You should not buy any bra that leaves marks on your shoulders or any other area, as a too-tight bra can also cause a blocked duct. For this same reason, you should avoid a bra with plastic-lined cups or underwires.

Look for a style that allows you to drop a flap at a time with one hand without having to look. All-cotton is the best choice for fabric, because most synthetic fabrics trap moisture next to your skin (your nipples should be dry between feedings). Adjustable, wide nonelastic straps are best. If your breasts are really heavy, you might like slightly padded straps as well.

If your breasts are small, you may not even need a bra for support. You might choose a simple stretch bra (not too tight), that can hold absorbent breast pads if you are prone to leaking. This kind of bra can be pulled up for nursing.

If you need to return to your outside job, you might find a hands-free bra to be useful. This kind of bra is worn only while pumping. It’s a bustier that is worn over your regular nursing bra. If you plan to give birth at a hospital or birth center, be sure that in addition to a nursing bra(s) you buy a nightgown or pajama top that has an opening that will work for breastfeeding.

How Necessary Is a Breast Pump?

If you plan to be at home with your baby for the first year or so of life, you can most likely do without a breast pump—unless you are faced with circumstances that require you to travel without your baby. If you have an outside job that you’ll be returning to after giving birth, see Chapter 8 for advice on buying breast pumps and for information on other preparations that can help you to continue breastfeeding once you return to your job.

Make Your Home Comfortable

While you are still pregnant, it’s a good idea to create at least one good place in your home for nursing. You’ll want a comfortable chair, a way to prop your feet up, a table within reach where you can put a large drink, a snack, a television remote, or a phone—whatever you might need while you are suckling your baby. Many women enjoy listening to audio books while they are nursing, so it might be a good idea to buy some or check some out from the library.

Lullabies

Learn some lullabies while you are pregnant, if you don’t already have some favorites. You don’t have to be a great singer to sing to your baby. Your baby won’t know the difference and will appreciate whatever you do. The advantage of singing to your baby during pregnancy is that he will learn the songs while he’s still in the womb and will respond to them well after birth. A great lullaby is a way of calming yourself and your baby at the same time, and a calm baby usually nurses the best.

A French friend taught me a captivating lullaby called “Bébé Lune,” which she began singing to her son when he was a newborn. When he was nine, she would still sing it to him at bedtime, and he found it such a powerful sleep inducer that he would beg her not to sing it yet when he wanted to hear another story. Every great lullaby has a slow, calm rhythm.

Dietary Needs

Developing a good relationship with food is an important part of preparing for a healthy pregnancy and breastfeeding experience. Inadequate nutrition during pregnancy and the nursing period can result in your being unnecessarily fatigued and less resistant to illness. Remember that, in general, eating a well-balanced and varied diet of foods is better than relying on supplements to meet your nutritional needs and those of your growing baby. It’s less expensive as well.

Your diet should include fresh vegetables and fruits, protein-and calcium-rich foods, and whole grains or cereals. Whole-grain crackers, nuts, cheese, yogurt, fresh fruits, sprouts, and raw vegetables are some of the nutritious foods that you might want on your list.

It’s best to eat food and only food—that is, eat foods that are as close as possible to their natural state, and keep away as much as possible from highly processed products that contain chemical additives such as preservatives, artificial colorings, and artificial sweeteners. The same goes for what you drink. If you are addicted to sweet beverages, try cutting down or even swearing off them during pregnancy and breastfeeding, drinking more water and noncaffeinated teas instead. Sugar adds calories without nutrition, and chemical sweeteners come with unpleasant side effects such as dizziness, memory loss, and even weight gain. Have a sweet treat now and then (sugar or honey is preferable to artificial sweeteners), but remember that most of the calories you consume should directly benefit you and your baby.

It’s good to know that grilling, steaming, boiling, roasting, and baking are ways to heat and cook foods without adding excess calories of fat. Fried foods, on the other hand, add many calories without providing added nutritional benefit.

Now let’s examine the elements you will need most from your diet to ensure that you have a healthy pregnancy and are prepared for nursing.

Protein-rich foods include fish, poultry, eggs, meat, dairy products, legumes (dried beans of various types), tofu, and nuts. You need these to nourish not only your own body but your baby’s as well, whether you are pregnant or nursing. High-protein foods tend to “stick to your ribs” longer than grains, fruits, or vegetables do. If you are concerned about gaining weight too fast (or not losing as quickly as you’d like while you nurse), continue to eat protein-rich foods, fruits, vegetables, and whole grains, and reduce the amount of sweet foods you eat. Remember that one of the symptoms of inadequate protein intake is a strong craving for sweets. If your budget is tight, take note that legumes and tofu cost less than meat and dairy products and are just as nourishing.

Vitamin-and mineral-rich foods include green vegetables such as green beans, Swiss chard, kale, spinach, bok choy, different kinds of lettuce, green peppers, and collards, and yellow vegetables such as sweet potatoes, yams, carrots, and red and yellow peppers. Sprouts are another excellent choice, and finely chopped cabbage or kale can be a tasty addition to a fresh salad. If you include a good variety of these foods in your daily diet, you should not need to add supplements.

You are an exception to this rule if you are a vegetarian who eats no eggs or dairy products. You will need to supplement vitamin B12, as a deficiency in this important vitamin can result in pernicious anemia, which can cause serious fatigue, miscarriage, and premature birth. The recommended amount is about three to four milligrams per day. Look for this supplement at a food store, or look for “nutritional yeast” (Saccharomyces cerevisiae, a food yeast grown in a molasses solution). Yellow or gold in color from its riboflavin content, it is easily digestible and tasty. Besides containing plenty of B12, it also contains all of the essential amino acids. It is not the same as brewer’s yeast or torula yeast.

Calcium-rich foods include dairy products, dark-green leafy vegetables, whole grains, legumes, tofu, blackstrap molasses, carrot juice, oats, beets, nuts, and sesame seeds—all of which contain several other nutritionally important components as well. If you like fish, try eating mackerel, salmon, and sardines, all of which are good sources of calcium. Taking calcium supplements during pregnancy or while nursing will not affect calcium levels in your milk, so it is safe to stick to four servings of calcium-containing foods per day instead of taking supplements.6–7 Contrary to popular belief, breastfeeding does not increase your risk of osteoporosis in later life. Although bone density decreases slightly during the nursing period, once you wean, your body returns to prepregnancy bone-density levels. The traditional diets of Japan and China, where women have the lowest rates of osteoporosis in the world, include lots of dark-green vegetables and almost no dairy products. All this said, some pregnant women do experience insomnia or leg cramps during the night, which indicates that they should increase their calcium intake, either by adding calcium-rich snacks or taking a calcium supplement. If you choose the latter, I recommend that you get a calcium lactate supplement, preferably one that is blended with magnesium at a 2:1 ratio (calcium to magnesium). Take it just before bedtime, as calcium is more readily absorbed while you sleep.

Iron-rich foods are good to eat while you are pregnant or nursing. Sources include dark molasses, egg yolk, whole grains, legumes, leafy vegetables, raisins, prunes, brewer’s yeast, liver, and nuts. The normal increase in your blood volume during the second trimester of pregnancy may make your hemoglobin and hematocrit levels drop a bit. If your iron stores are low enough during pregnancy or after birth to make you feel fatigued and listless, six to eight alfalfa tablets per day can improve them quickly, and these tablets also seem to have a beneficial effect on milk production. If you do take an iron supplement, choose ferrous citrate or ferrous gluconate instead of ferrous sulfate, as these forms are more easily utilized and less likely to cause constipation or liver damage.

Iron is similar to calcium in that the iron levels in your milk are not affected by the amount of iron you consume in your diet or by supplementation. Full-term babies are born with ample iron stores, which normally last them well past the age of six months. At that time they are usually ready to eat some solid foods as they continue to nurse. Solid foods plus the iron in your milk can supply the dietary iron your baby needs from then on. A premature baby, on the other hand, may need iron supplementation before starting solid foods, since his iron stores will be lower at birth than those of a full-term baby.

Vitamin D is another important component of breast milk, entering your body through dietary sources and exposure to sunlight. Most babies who get only breast milk will not be at risk for developing rickets, a disease that can result from vitamin D deficiency, because the vitamin D in mother’s milk plus the amount they themselves synthesize from sunlight exposure is sufficient to prevent it. It is possible, however, that dark-skinned women whose skin is seldom exposed to sunlight may have lower-than-desirable vitamin D levels when they begin their pregnancies. (The more pigmentation in skin, the more exposure to sunlight is necessary to get the same amount of vitamin D synthesis.) If you and your baby are dark-skinned and you are nursing exclusively, you should give him several minutes per day of exposure to sunlight on as much skin area as possible. If your own vitamin D intake is low and there is no way to make sure that your dark-skinned baby is regularly exposed to sunlight (maybe you avoid vitamin-D-supplemented dairy products and rarely get sunlight on your skin because of sunscreen or clothes that cover your skin), your pediatrician may recommend supplementation of 5 to 7.5 mcg of vitamin D per day for him. To combat your own low vitamin D levels, you may want to supplement with about 1,000 IU per day. However, it’s not good to take too much vitamin D, as it can cause kidney stones.

Salt your food to taste, as salt is necessary for a normal pregnancy. If you like spicy flavors, there is no reason to avoid them during pregnancy or while nursing. The flavor of your milk will vary according to what you eat, but most babies tolerate these flavor changes without complaints. That said, there are babies who occasionally become cranky or show symptoms of temporary digestive upset when their mothers eat dairy products, citrus fruits and juice, cabbage, broccoli, cauliflower, garlic, onion, cinnamon, or chocolate. Signs that a baby isn’t tolerating a food well include fussiness at the breast, redness around the anus, greenish poop, vomiting, and sudden refusal to nurse.

Dietary supplements, especially DHA supplements, are heavily marketed to breastfeeding mothers. Docosahexaenoic acid (DHA) is an omega-3 fatty acid found in breast milk and certain other natural sources such as cold water, oily fish, algae, pumpkin seeds, flax seeds, walnuts, soy beans, navy beans, and kidney beans. Although there is no definitive research pointing to a need for breastfeeding mothers to supplement with DHA to improve their milk, a common theme of the marketing campaigns has been that taking such supplements is a way of boosting babies’ intelligence.

Caffeine deserves a special mention, since you are likely to receive so many mixed messages about it. Many babies can tolerate their mother’s intake of a limited amount of caffeine without becoming irritable or cranky. Some babies, however, are more sensitive to their mother’s caffeine consumption and exhibit colicky symptoms. If you suspect that there might be a connection between your caffeine intake and fussiness in your baby, limit or eliminate caffeine and see if he settles down over the next two days or so. Be aware that coffee, many iced and hot teas, colas, some soft drinks, and several over-the-counter pain-relief medications are all sources of caffeine (Excedrin, Midol, and Anacin are examples). If your caffeine intake is relatively high, an abrupt elimination of all caffeine is not a good idea, as your reward may be a withdrawal headache. Substitution of a decaffeinated drink (like decaf coffees and teas) may make it easier for you to limit caffeine in your diet.

Getting to a Healthy Pregnancy Weight

A normal weight gain during pregnancy ranges between 25 and 40 pounds (11 to 18 kg), depending upon your metabolism and activity level. Please don’t be disappointed just after giving birth if you don’t lose all your “baby weight” immediately. Almost no one does. The reason for this is that the weight of your baby, placenta, and amniotic fluid (the amount to be lost at birth) amounts to a little more than half of the normal pregnancy weight gain. More than forty percent of total weight gain is due to your increased blood supply, your heavier uterus and breasts, and some fat stores that will gradually melt off your thighs and hips as you nurse your newborn. This weight is best lost gradually over several weeks or even months after birth. It is never a good idea to go on a weight-loss diet while pregnant or nursing, as doing so can have negative effects on your health. Stay away from weight-loss drugs and “water” pills (also called diuretics), as these can be dangerous and even reduce your milk supply.

If you are not already in the habit of counting calories, it is not necessary to do so. A good general rule is to eat until your hunger is satisfied. Pregnant and nursing women often find that eating smaller, more-frequent meals works better for them than keeping to a three-meal-a-day plan. If you are accustomed to counting calories, the approximate number you’ll need per day (while pregnant or lactating) is about 2,200. Don’t eat less than 1,800 calories per day, especially if you are an active person.