Ina May's Guide to Breastfeeding

6
Problem-Solving During the First Week

Engorgement

If both of your breasts feel hard, tight, and painful during the first week, and the skin of your breasts looks tight and shiny, but you don’t have a fever (your temperature is less than 101 degrees F, or 38.4 degrees C), then your breasts are engorged. This is different from the normal swelling and fullness that is supposed to happen between days three and five after birth, when your breasts feel full but not painful and your nipples are still soft and pliable. With engorgement, this normal swelling becomes much more pronounced, to the point that the nipple and areola may be stretched so hard and tight that the baby has trouble grasping enough breast in his mouth to get a good latch.

Engorgement can look like mastitis—a bacterial breast infection—since both conditions involve swelling, but the two shouldn’t be confused. While engorgement always involves both sides, mastitis usually happens on one side only. With engorgement, there is no infection, so there is no need for you to take antibiotics. The condition usually passes quickly, lasting only a day or two. You can lessen its severity by promptly taking the following steps, which will help reduce your symptoms and will allow your baby to get a good latch more easily.

·         Soften your nipple and areola by manually expressing some milk.

·         Once your breasts are soft enough for your baby to get a good latch, nurse as long and frequently as you can. The idea is to remove as much milk as possible, since doing so will reduce the amount of lymphatic fluid in your breasts, helping to reverse the engorgement.

·         As your baby nurses, continuously press on the breast he is nursing from to help your milk flow to your nipple.

·         Once your baby ends a feeding, express as much milk as possible, as this will lessen any pain or discomfort you feel. If it causes you to make more milk, this is good. You can store any that your baby doesn’t take.

·         Between feedings, apply cold compresses to your breasts for your comfort. Refrigerated cabbage leaves, cupped around each breast three or four times a day, can also be soothing.

·         If you need pain relief for your letdown to happen, take some ibuprofen. It’s a safe choice, because it reduces inflammation but won’t have a negative effect on your baby.

·         Keep up your own fluid intake. Drinking plenty of fluids won’t aggravate engorgement.

It is usually possible to prevent engorgement by nursing your baby frequently during the first few days of life. Keep in mind that if you had an epidural there is a greater chance that you will have engorgement, because extra IV fluids are given with an epidural. It usually takes three or four days for your body to rid itself of this extra fluid load, some of which will be in your breasts, so you may find that you experience engorgement on the fourth or fifth day after your baby’s birth.

Sore Nipples

Nipple soreness is not a condition that you should try to tolerate. You need to discover the cause of your nipple soreness so that you know what to do about it. Get help from a lactation consultant or peer counselor as soon as you notice it, unless you are able to ease the situation yourself right away.

The most common form of nipple soreness indicates that there is something wrong with the way your baby is latching or is positioned at your breast. This type of soreness is sharpest when your baby latches on and during a feeding. If you have soreness like this, it is likely that you have been allowing your baby to suck in a way that has traumatized your nipples. More incorrect sucking will only worsen the problem. Prolonged nipple soreness from a poor latch can lead to a cracked or bleeding nipple and even to mastitis (a bacterial breast infection). If your baby latches the right way, you should experience immediate relief. If this happens, continue nursing sessions until your baby decides to let go. Even if he wants to nurse for a long time, your sore nipples can heal if he is latched correctly.

Perhaps your baby’s first few sucks are a bit painful but the pain subsides after your milk lets down. As long as your nipple doesn’t look asymmetrical or misshapen just after a nursing session or have any pinkish or blistered areas, this kind of soreness shouldn’t progress to something worse. Soreness of this kind is usually gone after a week has passed, given that the latch appears good and your baby is producing the required number of soaked diapers.

However, a nipple that looks misshapen or asymmetrical just after the baby lets go of it is a strong indication that your problem is a poor latch rather than passing soreness. The same goes for a nipple that has a water blister or an area that is pinkish or reddish.

Cracked or Bleeding Nipples

If your nipples are cracked or bleeding on one or both sides, and you have managed to achieve a good latch, it’s a good idea to hand-express a little milk to soften your nipple before offering your breast. Use your less-sore side until your letdown happens and then switch to the more-sore side, making sure that the latch is good. When your baby has finished nursing, express a little milk or colostrum and let it dry on your nipple, as its antibacterial properties will help protect you from infection. I would also recommend that you use a thin layer of over-the-counter antibiotic ointment (Polysporin, for instance) for infection prevention when there is a break in your skin. Don’t worry if your baby swallows any; the drug is quickly metabolized and is considered safe. You also needn’t worry if your baby swallows blood from a damaged nipple. No harm will come to him.

The best way to avoid a scab from forming on a cracked or bleeding nipple is to keep it moist between feedings with Lansinoh brand lanolin. (You can apply this over the antibiotic ointment you’re using.) La Leche League International recommends Lansinoh specifically for sore or cracked nipples, because, unlike some other lanolin brands, it contains no preservatives or additives. Use enough and apply it often enough to keep your nipple area from drying. Steer clear of products such as vitamin ointments, any petroleum-based products such as Vaseline, or anything with alcohol in it. You should also keep soaps and lotions away from your nipples. Any Lansinoh that is present on your nipple when a feeding begins will not harm your baby.

Here is another regimen for cracked nipples, offered by Canadian lactation expert and pediatrician Dr. Jack Newman. You’ll need a doctor to prescribe it for you.

All-Purpose Nipple Ointment:

·         Mupirocin 2 percent ointment (15 grams)

·         Nystatin ointment, 100,000 units/milliliter (15 grams)

·         Miconazole powder to a final concentration of 2 percent

The virtue of this ointment is that it contains antibiotic, antifungal, and steroidal ingredients, which makes it effective against most causes of sore nipples. You can mix up your own version of this ointment using hydrocortisone cream as the steroid, an antifungal such as Lotrimin, and an antibiotic ointment such as Neosporin. This ointment should be applied to your nipples right after feeding and shouldn’t be wiped off. It will not hurt your baby to swallow any of it.

Lactation consultant Bonnie Reed uses a variation on this method that she finds very effective, particularly if she suspects that the cracked nipples are caused by a yeast infection. She advises affected mothers to use vinegar and water to rinse the milk sugar off the nipples after feeding sessions. (This is most easily done by mixing half vinegar and half water in a Ziploc bag with small squares of Viva paper towels.) After this, the all-purpose cream can be applied to the nipples.

If your cracked nipple is so painful that you dread your baby’s next nursing session, you can take an over-the-counter pain medication such as acetaminophen an hour or so before you expect your baby to feed. You might also want to wrap some ice cubes in a washcloth and hold these to your nipple, as this will have a temporary numbing effect.

If your bra has become uncomfortable, leave it off while your nipples are healing, or choose a larger size. Apply Lansinoh or Dr. Jack Newman’s ointment. If you get a larger bra, put a couple of breast shells or tea strainers (with the handles removed and the edges covered with soft adhesive tape) inside your bra to keep any pressure or friction away from your nipples. In general, your bra is too small if you find pressure marks on your breasts after wearing.

Nipple soreness can result from the improper use of a breast pump. See Chapter 8 for more information on breast pumps.

Some women also experience nipple soreness because of having extra-sensitive skin. A Dutch friend, Karin, tells her story:

 Karin: Nursing caused a lot of pain for me because of a skin condition I have. It is not psoriasis, although it is related to it. Mine is called “atopic eczema,” which means it is a nondescript rash that can pop up anywhere. It comes with a very dry and sensitive skin. I tried all the usual cures and creams, to no avail. I called a lactation expert, as it hurt so much that after some weeks I was on the verge of giving up nursing, although I didn’t really want to quit. She told me to try a breast pump for just a few days to give the skin time to heal, and that worked. Another thing that helped was that I always used just one breast at a time, so the other one could dry and rest. I sat around bare-breasted a lot of the time. When I had to get dressed, I used tea strainers. This keeps the fabric away from the skin and allows air in. The skin just needs more time to recover, and if you can find a way to give it a chance to do that, it’ll get firmer and your condition will improve. At any rate, I continued breastfeeding for a year and a half after that bout of soreness with no problem.

Painless Bleeding from the Breast

Sometimes during late pregnancy or the first week following birth, you may experience painless bleeding from your nipples. This condition usually clears up within a few days and is not harmful to you or your baby. It is sometimes called “rusty-pipe syndrome,” a term that is probably meant to ease the alarm and worry that rust-colored milk often causes. If bleeding from the nipples continues for more than two weeks, see a doctor to determine the cause.

Yeast or Thrush Infection

An entire category of nipple soreness is caused by a fungal overgrowth called thrush—the same organism that you have in a vaginal yeast infection (Candida albicans). Thrush infections can occur at any time during the nursing period.

Signs and symptoms that you have thrush include:

·         Burning pain or itchiness of the nipples.

·         Tiny white spots on the nipples.

·         Sudden-onset pain despite an obvious good latch and positioning.

·         Shooting pain during or after feedings, moving from chest to nipples.

·         Pain despite no visible signs of nipple soreness, such as blistering, pinkness, or a distorted shape of the nipple.

·         Vaginal yeast infection.

Signs of thrush in your baby include:

·         White patches inside his mouth on his cheeks, gums, tongue, or the back of his throat. These patches will look sore underneath if you rub the white patch off. (If the white is on his tongue only, it’s probably not thrush.)

·         Red, raised rash on his bottom.

·         Clicking sounds while nursing, breast refusal, or repeated pulling away from the breast after having latched. This is a strong sign of yeast infection even if there are no white patches.

Thrush should be treated quickly in both you and your baby, as this is the only way to keep you from reinfecting each other. Thrush is quite painful for the mother, but it’s not always painful for the baby (although it can be), so it can be difficult to tell if he’s infected. If you have the symptoms, it is necessary to treat your baby as well, even if he exhibits no symptoms at all.

Thrush infections often occur after oral or IV antibiotics are taken, because antibiotics kill not only the harmful bacteria but also those that are needed to maintain the healthy balance of flora in the body. They are more common in women with diabetes or a history of vaginal yeast infections and in those who use corticosteroids for asthma, whose diets include a lot of dairy products, fruits, and sweeteners (both natural and artificial), and those who use nursing pads or plastic-lined bras.

Treating Thrush

Let’s start with a home remedy. Add one teaspoon of bicarbonate of soda (baking soda) to one cup of water that has been boiled for twenty minutes. It’s best to keep this mixture in a tightly sealed jar so you can use it whenever and wherever necessary for several days. The mixture can be applied to your nipples and your baby’s mouth (and hands) using a gauze pad, a cotton applicator, or a clean cloth soaked with the solution.

Treatment with gentian violet is also an effective and inexpensive— although messy—way to treat a yeast infection. It works quickly, and you can use it on your baby, yourself, and your partner (who, without treatment, may keep you infected through sexual contact). You can buy gentian violet over the counter at a pharmacy. You will want a one percent dilution. Most of the gentian violet that is available is two percent, so you can dilute it by half with sterile water. Apply the purple solution with a cotton-tipped applicator on all of the surfaces where the yeast may have taken up residence. (Be sure to put away any clothes, sheets, or diapers that you don’t want purpled, as this is very staining.) If your nipples aren’t purple after a feeding, apply more until they are. Another good way to get the gentian violet into your baby’s mouth is to apply it generously to your breast and then nurse your baby. If you see purple milk, don’t worry—it’s harmless. The good thing about gentian violet is that it will usually do away with a yeast infection within a couple of days. Repeat the treatment once a day for four days. If the pain continues beyond this time, the problem may be something other than thrush, and it would be wise for you to get good help from a pediatrician who is knowledgeable about breastfeeding.

If you wish to avoid the purple treatment, and the candida infection hasn’t become well entrenched, you might try homeopathic calendula ointment, which you can obtain at any health-food store that carries homeopathic remedies.

Some women have found other ways to quiet down an overgrowth of yeast. These include:

·         Taking acidophilus bifidus (400 million to one billion viable units per day) for at least two weeks after symptoms disappear.

·         Taking grapefruit-seed extract (250 mg three times per day, or five to fifteen drops in five ounces of water two to five times daily).

·         Taking garlic tablets (three triple-strength tablets, three times per day for two weeks or more), zinc (45 mg daily), and B vitamins (100 mg of each from any source besides nutritional yeast).

·         Eating a cup of live cultured yogurt (unsweetened is best) per day.

Another, more expensive option is a prescription product called Nystatin suspension. Nystatin should be used after every feeding for at least two weeks. It’s useful to know that at least one study found it less effective at treating thrush than several other options.

When thrush keeps coming back, and nursing pain continues after other treatments, you might want to try a prescription cream called Diflucan (fluconazole).

Whatever form of treatment you choose, continue breastfeeding your baby; there is no reason to stop. You should rinse your nipples often as you treat for thrush, but avoid soaping them (do, however, frequently wash your hands with soap and water). Wear a clean bra each day and also change the hand towels you use daily. Remember that damp breast pads and wet sheets near your breasts can help to nurture the yeast cells whose growth you don’t want to encourage. Wash your baby’s hands if he sucks his thumbs or fingers. Any toys that have been in your baby’s mouth should be washed in hot, soapy water and rinsed well. Remember that whatever treatment you choose, your partner will need to receive the treatment as well.

Plugged Milk Duct

If you develop a lump or a tender spot in your breast without a fever or flulike symptoms, it is likely to be a plugged milk duct, which means that milk is no longer moving freely through that part of your breast. This causes inflammation and soreness, which usually affects only one breast at a time. Plugged milk ducts are often caused by bras that are too tight, so if this might be the case with you, it would be wise to go bra-less, at least for several days. Some nursing mothers who sleep on their bellies find that this position can cause a plugged duct. In general, you should watch out for any pressure that you might be putting on your breast that could restrict the milk flow, whether it is from constrictive clothing, wearing or wrapping a baby too tightly at the breast, carrying a bag with straps that put pressure on a portion of your breast, your older baby biting you, or using too small a flange or the wrong pressure setting on your breast pump. Dehydration can also contribute to a plugged duct, so make sure that you cut down your caffeine intake and drink enough water.

When you have a plugged duct, it is essential for you to keep feeding your baby from the affected breast. The flow of milk through the congested part of your breast—the stronger the flow, the better—will help to prevent the more serious and painful problem of mastitis. (If you have recurrent plugged ducts, you are more likely to experience an episode of mastitis.)

Vary nursing positions, as long as your baby is able to latch well from each position used, and pay attention to see if a position that is different from the one you usually use helps to soften the sore area. I’ve seen a blocked milk duct get fixed when the mother knelt over her baby, who was lying on his back with his legs extended toward his mother’s head. Though you shouldn’t do anything that is painful or uncomfortable, be as creative as you want in working out alternative positions. The closer his lower jaw is to the plugged duct, the greater the chance that his sucking will remove the blockage.

Put a warm compress on the sore area or soak in a warm bath for ten minutes or so three times a day, then nurse your baby while your breast is still warm. Try massaging the sore area gently, using a circular motion at first, moving from above the sore area toward your nipple. Combine these movements with the compression that is always good to use when you want maximum milk flow to get to your baby.

A blocked milk duct is not a bacterial breast infection and therefore needs no treatment with antibiotics. If you need pain medication, ibuprofen is a good choice, as it can relieve inflammation as well as pain. For greatest effect, take it an hour before you anticipate a feeding.

Some women get a milk blister (bleb) along with a blocked duct. This is a white blister on the end of the nipple that contains some thickened milk. If it’s quite painful, you can open it yourself (after a feeding) by using a sewing needle that you’ve sterilized in a flame. Squeeze out any fluid from behind the blister to keep it from re-forming, and prevent an infection by applying a topical antibiotic ointment such as Polysporin on that spot for a week after feedings.

Here’s how one mother, June, solved the blocked-duct problem she experienced with her seventeen-month-old son:

 June: My son, Malik, still nurses at night. The night before last, I woke up at around five A.M. and realized he was asleep but still attached to my breast. It felt uncomfortable, and I picked him up and moved him up to pillow level, without taking him off properly. He usually pops right off when he’s asleep, but this time his mouth didn’t open, and as I pulled him off, his bottom teeth made a small cut on my nipple. OUCH! I was in pain and stayed in bed for a few hours trying to fall back asleep, without any luck.

That little injury affected me all through the next day, with extreme soreness on the nipple, especially when he was nursing. I didn’t want to slow down feeding on that side, so I really had to just deal with the pain, hoping to prevent engorgement. The following morning I woke up with a hard lump at the top of my breast. I noticed it was becoming painful, and I lay in bed dreading the worst: that it would worsen into mastitis. I knew I had to get out of bed and take care of it right away. I was pretty sure that this was a blocked duct, so I spent the morning trying everything I could think of to help move it through. I tried running hot water on the area, I took some ibuprofen to help with inflammation, I tried to hand-express the milk out, and when Malik nursed, I tried to angle him so that his chin was directly on the clogged duct. Nothing seemed to help, and the lump seemed to get bigger and more painful.

After almost an hour soaking in a hot bath and using the shower spray with hot water directly on the sore area, I noticed something when I was hand-expressing. There was a small white dot that appeared only when I was squeezing the milk out. Milk was coming from the other nipple pores but not from this one small white dot. It suddenly occurred to me that this was where the milk was being redirected, since the milk could not exit where the small cut was healing over.

I asked my husband for a needle, and he brought me a small sterile lancet. I carefully pricked the little white dot, and milk came out in a perfect stream. Holding my breast like a sandwich and rolling my fingers and thumbs a few inches down toward the nipple, I hand-expressed for three to five minutes and watched streams of milk come out almost exclusively from this nipple pore. The other milk ducts were empty from the nursing and hand-expressing that had already taken place. After these few minutes, the hard lump was gone, and I felt an extreme sense of relief.

Mastitis

Mastitis is caused by bacteria—usually Staphylococcus aureus—that take up residence in your breast. It’s easier to develop an infection if you have a sore or cracked nipple, if your immune system is weakened, if engorgement leads to such fullness in your breasts that your letdown reflex isn’t happening, if a plugged duct isn’t resolved, if you are going through a time of high stress and extreme fatigue, or even if your genetic inheritance gave you especially thin skin.

Symptoms of mastitis include a sore spot or lump in your breast that is hot to touch, chills and fever (more than 101 degrees F, or 38.4 degrees C), and/or flulike symptoms. Keep in mind, though, that these symptoms could also indicate that you have the flu and nothing more than a painful blocked duct. You will have a better idea that your problem is mastitis if your breast is also red and swollen, with or without red streaks (note: These symptoms do not occur in all women with mastitis).

An increased susceptibility toward mastitis runs in some families. If you have family members who have had a history of recurrent bouts of mastitis, though, you shouldn’t be discouraged from breastfeeding. With experience, you will learn how your body functions and develop a list of strategies that will help you quickly recover from mastitis or even ward it off preemptively. Incidentally, if susceptibility to mastitis runs in your family, you might want to invest in a good electric breast pump to fight engorgement.

·         If you think that you have mastitis, you should respond immediately to its early symptoms—there are several steps you can take over the next twenty-four hours to improve your condition and to shorten your illness. I’ve listed below the steps that I’ve found to be most effective.

·         Follow all the steps for curing a plugged milk duct.

·         Make sure that all your family members understand your needs and know how to help you; you’ll need help with housework and meals and will need someone to care for any older children that you may have. This will allow you to get all the rest you need.

·         Apply heat to the sorest part of your breast, and massage the affected area gently.

·         Take twenty to forty drops of echinacea (purple coneflower) tincture six times during the first day of symptoms. You can add it to water if you like. If this treatment seems to be working, follow these instructions: On days two through five, drink two glasses of water, each containing a half drop of echinacea tincture for every pound of your body weight. On days six through ten, drink one glass of this tincture–water mixture each day. Though echinacea tincture is easier for most people to obtain than echinacea root, herbalist Susun Weed prefers to treat mastitis with echinacea infusions, prepared in the following manner: Steep one ounce of the root per pint of boiling water for at least eight hours. Drink two cups daily until the fever comes down. Then make a lighter infusion, with one ounce of the root per quart of boiling water, and drink one to two cups daily for an additional week.

·         Contact your lactation consultant, physician, or midwife. You will likely be prescribed an antibiotic. It’s good to have this on hand in case the echinacea remedy doesn’t substantially improve your symptoms during the next twenty-four hours. You should try the echinacea tincture first, though, because it is an herbal treatment. Unlike a prescription antibiotic, it won’t create the conditions for a thrush infection.

·         Apply a poultice of parsley or comfrey directly to your breast. Here’s how: Wrap a handful of fresh or dried parsley in a clean cotton cloth, tie it with a string or rubber band, and steep it in simmering water for ten to fifteen minutes. Let the parcel cool to the point where you can tolerate it directly on your breast.

·         Keep a bottle of hand sanitizer near you and wash your hands before each nursing session. Clean any phones, remote devices, or other items that you handle as well, so you minimize chances of reinfecting yourself.

While you are treating mastitis, you should continue breastfeeding frequently from the affected breast, whether you are taking an antibiotic or an herbal medicine. It may take as long as twenty-four to forty-eight hours before some of your symptoms subside. Your milk will not hurt your baby—even if there is a little blood in it—and the suction will help your condition.

Women can sometimes fight off a threatened bout of mastitis by heeding the early warning signs during the twenty-four hours after the first appearance of symptoms. Echinacea can be taken preventively: ten to fifteen drops of tincture in a glass of water twice a day for a minimum of five days.

Poor Tongue Habits

Some babies have trouble sucking effectively because they have developed tongue habits that interfere with a good latch—for example, a baby may suck his tongue, push the nipple out of his mouth with his tongue, hold his tongue in the back of his mouth, or curl its tip upward. Any one of these habits can keep him from drawing the breast far enough back into his mouth to be able to get milk. One sign that he is using his tongue incorrectly is a vertical red strip on your nipple and a feeling that he’s chewing instead of sucking.

If any poor tongue habit has become ingrained, you may need the help of a lactation consultant to solve the problem, but when a baby is less than a week old, it’s often possible to help him learn how to use his tongue correctly.

The baby who keeps his tongue in the back of his mouth can sometimes be coaxed to drop his tongue and bring it forward if you brush your breast lightly across his lips. Bring him to the breast as soon as you see the lowered, extended tongue and open mouth. Patience and precision timing are needed to teach your baby a new habit.

If your baby clenches his lips tightly during a feeding session, it’s best not to keep pushing him. You don’t want to give him a negative experience when you are trying to teach something important. Rocking your baby gently can help to relax his mouth and tongue, as well as his body. Once he is well relaxed, it’s good to try nursing again. Begin by manually expressing a little colostrum and getting some on his lips or tongue. Once he gapes well, cuddle him to you so he can reach your breast.

If your baby retracts his tongue and uses it to push against your nipple, you should put gentle pressure on the middle part of his tongue with your clean finger (cut your fingernail first, please) until his tongue begins to cup your finger. Dripping some of your milk into his mouth may also help him bring his tongue down and forward into the proper position. Rock your baby gently to relax him and then brush his lips with your breast, pulling him toward or away from your breast according to whether he is opening his mouth wide and dropping his tongue low (pull toward) or giving you a more pursed mouth with his tongue held high or sticking out slightly (pull away). You need to observe him closely as you do this and respond to his changes immediately. Be patient with him as he learns.

The Tongue-Tied Baby

An easily solved problem that is frequently missed during the first days of a newborn’s life is when the frenulum is too tight to permit effective suckling—in popular language, this condition is called “tongue-tie.” The frenulum is the thin membrane under the tongue that attaches the tongue to the bottom of the mouth and keeps us from swallowing our tongues. When it’s too tight, it doesn’t permit the baby enough free movement of the tongue to allow his lips to curl around the areola, making a good seal. A tongue-tied baby can’t extend his tongue past his lower lip. Many babies with this condition quickly hurt their mothers’ nipples enough to lead to several problems with breastfeeding, which may include injured nipples and infection of the breast for you and too little milk, trouble swallowing, and a slow weight gain for your baby. Tongue-tie runs in families and occurs in about one to five percent of all babies. It’s important to know that tight frenula rarely fix themselves, so this is a problem you should address promptly if you notice that it is preventing your baby from nursing properly.

Tongue-tie occurs in varying degrees of severity. In severe cases, the tongue is heart-shaped instead of coming to a point at the end. In more moderate cases, the frenulum may look less tight toward the end of the tongue but still be tight enough farther back to keep the tongue from cupping the breast well when the baby attempts to latch—when this happens, your baby will get little milk for his efforts. In more-minor cases of tongue-tie, babies are sometimes able to grasp and draw their mothers’ nipples back into their mouths and thus have no problem suckling.

Babies who don’t get the reward of milk soon become frustrated with or tired of nursing. Some will begin to clamp their gums together onto their mothers’ sensitive nipples, causing pain and injury (this will also decrease the stimulation of milk flow); others will express their frustration by arching away from the breast. Though the tongue-tied baby may appear to have a good latch, he will probably not be getting enough milk from you to prosper. If your baby seems well latched but is fussy and unsettled during feedings, check him for tongue-tie. A baby who gets enough milk at the breast will relax his entire body once the milk begins to flow well and he is busily feeding. A baby who is working hard at the breast while getting little reward will remain tense.

The tongue-tied baby

The remedy for tongue-tie is to snip the frenulum. This used to be a common procedure that a family physician, midwife, or pediatrician completed in a few seconds. I remember my mentor, Dr. John O. Williams, Jr., explaining to my midwife partner and me how this was the easiest thing a doctor or midwife could do, with the biggest reward, in the shortest amount of time. The cut itself is close to painless (less so than ear piercing) and ordinarily involves no more than a drop or two of blood (although the baby might cry from being held still). The benefits are instant; the baby can take the breast after the cut is made. While most babies will be able to latch on immediately, some others may have to be encouraged to stick their tongues out before they can suckle effectively.

Oddly, the trouble that many women with tongue-tied babies encounter is that their pediatricians refuse to snip the frenulum, because they see no point in performing this simple procedure and are ignorant of the possible negative impact tongue-tie can have on breastfeeding. Lactation consultants often disagree with pediatricians in these cases, but, even though they know more about nursing, they may be outranked by the pediatricians.

When a short frenulum is discovered on the first day or two, it’s not necessary to do anything—as long as your nipples aren’t sore and your baby seems to be getting enough milk. Your baby may be one of the lucky few whose tight frenulum stretches enough as he moves it to allow for successful breastfeeding. But if your nipples are sore during the first week after birth (even though your baby’s latch looks good) and your baby’s frenulum makes it hard for his tongue to reach his lips, you should seek the opinion of your lactation consultant. If your lactation consultant and your pediatrician disagree, I recommend that you continue to work with your lactation consultant to find a doctor or dentist to make the snip.

Candace’s story shows what a miraculous difference snipping the frenulum can have on tongue-tied babies.

 Candace: My twin girls were born strong and healthy, after an easy labor. I felt high with the magnificence of the whole experience and thought all my worries were over.

Anna nursed quite vigorously. I found the sensation horribly unpleasant, but I let her stay on for about an hour. When she came off the breast, my nipple was deformed. Over the next thirty-six hours I repeatedly asked for instructions to get a comfortable latch, but my doula, Carla, and the nurses thought the latch looked correct. I delivered on a weekend, so there was no lactation consultant on duty.

My first night home went well; the babies weren’t particularly hungry. I nursed throughout the following day but felt things weren’t quite right. My babies never relaxed. That evening all hell broke loose as the babies screamed in desperation while I tried to figure out how to get them latched on. By the end of this eight-hour ordeal, they had developed an aversion to my breasts and were limp and silent with exhaustion. I felt unfathomable despair.

I had an appointment with their pediatrician that afternoon and hoped he would be able to instruct me. I tried many more times to nurse the babies, but they had given up on feeding. Before we left for their checkup, I expressed about an ounce of colostrum, which I divided and poured into each of their mouths.

While waiting to see our pediatrician, I felt my milk come in. When the nurse weighed the babies, she found that they had lost seventeen percent of their birth weight. The pediatrician came in and informed us that the babies were malnourished and jaundiced. He told me that while he was for breastfeeding, he was not for breastfeeding to the detriment of any infant. (I’d never heard of deleterious effects of breastfeeding before!) He said I didn’t have enough milk for twins and gave me some formula. He told me that he would give me forty-eight hours to turn their health around, or he would admit them to the hospital.

Driving home I felt horrible, but I was informed enough to know that the doctor was wrong about my milk supply. I knew that the volume of milk I could produce was as yet untested, since flow hadn’t been established. At home the babies drank formula, courtesy of their grandparents, while I sat down and figured out how to use the electric pump we had bought in preparation of my eventual return to work. I pumped continuously for the next forty-eight hours, stopping only to feed the babies what I extracted.

At first, the amount I made closely matched the amount the babies were able to eat. It started out at about one ounce per side, then increased to one and a half, then two and so on, and the babies kept up until about three and a half ounces. By day two my supply far outstripped the size of the babies’ stomachs, and by day three I could extract fourteen ounces every two hours. I fed them two to three ounces every two to three hours and stored the surplus in the freezer. When we returned to the pediatrician, the babies had gained about six ounces each.

I asked him how I could get the babies to suckle and he told me to call the hospital lactation nurse. We met, and after three hours it became quite clear that my problems weren’t as simple as latch and position. She did teach me, however, not to hold the back of the baby’s head to the breast—which causes her to resist in fear of being smothered—but to support the neck where it meets with the shoulder so that when a baby wants, she is free to move her head as she pleases. At my two-week postnatal checkup, I described my breastfeeding difficulties to the midwife, and she called an independent lactation consultant, Hannah, for me.

Hannah came over to my house that week, and after another three hours had both babies latched on and nursing. However, even though we had the best latch possible, it was still quite painful. Hannah convinced me to call a chiropractic office that specialized in cranial–sacral therapy for newborns. She pointed out that Anna’s head was stuck in a flexed position and that she was scowling as if in pain, even during sleep. Anna’s head was compressed at the temples, causing the cranium to bulge. She explained how these situations interfered with the full range of jaw movement that a baby needs to breastfeed well.

When my twins were six weeks old, Hannah called me and asked if I would bring the girls to an in-service at the chiropractic office, since they were the youngest patients in the practice and she wanted to have babies of all ages. The girls would receive a free treatment and be evaluated by the teaching physician, Dr. Coryllos. Hannah explained that Dr. Coryllos had just completed a five-year study on the effects of tongue-tie. Hannah said that it was unlikely that my girls had tongue-tie but that the physicians attending the in-service would get to practice diagnosing the disorder on other babies who would be present.

I went and spent the first half of the day listening to a fascinating lecture on tongue-tie and its effects on babies’ facial development, nursing ability, digestion, speech pathology, and how it feels to the breastfeeding mother. Many mothers said it was like being licked by a cat’s tongue. I perked up because that described my experience perfectly.

Also, because it is such hard work for a baby to compensate and nurse with tongue-tie, she takes longer to feed, becomes exhausted, and then must nurse again soon after, sometimes within fifteen minutes. When Dr. Coryllos examined my infants, she found that they both had posterior tongue-ties, the most difficult kind to diagnose, since it’s deep in the flesh of the tongue just behind the salivary glands. All the physicians crowded around my babies’ mouths with interest.

The doctor then demonstrated the procedure on another infant. The infant was swaddled and held firmly on his back by four pairs of hands while the physician used a dental tool to expose the tight frenulum. Orajel was applied and the frenulum clipped with a small blunt-tipped scissors. A two-inch square of cotton gauze was applied to the cut for no less than two minutes to stanch any bleeding. [Posterior tongue-ties tend to bleed more than the common kind of tongue-tie.] The baby was then put to his mother’s breast.

Dr. Coryllos invited my babies to be her demonstration patients at an in-service the following day. Both had the procedure. Not only was I able to exclusively breastfeed, but their growth rocketed, since they were now getting my hindmilk. A breast pump doesn’t extract fatty hindmilk nearly as efficiently as a baby does.

Since this happened, I ask every little kid I talk with to stick their tongue out for me. When I see a tongue-tie, which is quite often, I ask the mother if she nursed her baby. A couple of them were able to, but most say that they didn’t enjoy breastfeeding, it was painful, or they didn’t think they had enough milk because the baby was never full. I don’t judge women who say they couldn’t breastfeed anymore, because I know that it can break your heart. Looking back, I spent the majority of my time and energy preparing for labor and making sure I was able to deliver twins safely and naturally. The birthing was a nonissue, but I did labor long and hard to breastfeed. It, too, was worth it.

The Baby Who Needs More Fluid

In general, young babies get all of their fluid requirements from breastfeeding. It is possible, though, for a baby to become dehydrated enough to upset his electrolyte balance. In this case, it can be a good idea to give a very young baby supplemental liquid.

Here is an example of what I mean: I was once asked to examine a young baby (five or six days old) who was born to an Old Order Amish woman during an extreme Tennessee heat wave. The baby’s mother was worried because, instead of waking during the day to feed, as all her other babies had, her new son slept all day long, waking to feed only two or three times at night. The family lived in a small cottage with a metal roof in a yard with no shade, and the Old Order Amish still dress their babies as if they were born in northern Europe, in long-sleeved dresses and bonnets, regardless of season.

When I arrived, I could see right away what the problem was. His clothes were damp with sweat from the intense heat in the house, and he was dehydrated and lethargic. Because there was no electricity in the house, there was no way to set up a fan. To solve the problem, I recommended that the baby be dressed in clothing light enough that he didn’t sweat (in his case, a diaper only), and we gave him two ounces (60 g) of an electrolyte as a temporary measure. This combination proved enough to return the baby to a more normal pattern of waking every two to three hours to suckle, night and day.

The Baby Who Arches Away from the Breast

Some babies have such great muscle tension that they have trouble staying on the breast once latched. Instead of curling forward as babies usually do in cradle hold, they arch their head and upper body away from the breast. Babies like this are more likely to hold their legs extended, rather than to flex them at the knees and hips. They suck a few times and then let go before they can fall into a regular pattern of sucking and swallowing. It may help to rock the tense baby into a calmer state of mind before introducing him to the breast again. Some tense babies eat more effectively when they are sleepy than when they are alert and wide awake. It often helps to hold a tense baby belly-down on your lap and gently massage his back to help him calm down before bringing him to the breast. This baby may relax and nurse better while lying on top of you. Swaddling may prove helpful in getting him to relax before nursing.