COPING WITH BREASTFEEDING CHALLENGES

Some women breastfeed without problems. But for many women, it is natural for minor problems to arise at first, especially if it is their first time breastfeeding. The good news is that most problems can be overcome with a little help and support. Some more serious problems may require you to see a lactation consultant or your doctor, and it is important to know the warning signs for these situations. Here are some of the most common problems that you might face, and some solutions to overcome them.

1. Sore Nipples
2. Engorgement
3. Plugged Ducts and Breast Infection
4. Thrush
5. Nursing Strike
6. Inverted, Flat, or Very Large Nipples
7. Going Back to Work
8. Low Milk Supply
9. Special Situations:
   • Jaundice
   • Reflux
   • Cleft Palate and Cleft Lip
   • Twins or Multiples
   • Breastfeeding During Pregnancy
   • Breastfeeding after Breast Surgery
   • Inducing Lactation

1. Challenge: Sore Nipples

Breastfeeding should not hurt. There may be some tenderness at first, but it should gradually go away as the days go by. Poor latch-on and positioning are the major causes of sore nipples because the baby is probably not getting enough of the areola into his or her mouth, and is sucking mostly on the nipple. If you have sore nipples you are more likely to postpone feedings because of the pain, but this can lead to your breasts becoming overly full or engorged, which can then lead to plugged milk ducts in the breast. If your baby is latched on correctly and sucking effectively, he/she should be able to nurse as long as he/she likes without causing any pain. Remember: if it hurts, take the baby off of your breast and try again. Ask for help if it is still painful for you.

Solution:

• Check the positioning of your baby's body and the way she latches on and sucks. To minimize soreness, your baby's mouth should be open wide with as much of the areola in his or her mouth as possible. You should find that it feels better right away once the baby is positioned correctly. See the section on Breastfeeding Know How for information on correct latch and Positioning the Baby at the Breast.
• Don't delay feedings, and try to relax so your let-down reflex comes easily. You also can hand-express a little milk before beginning the feeding so your baby doesn't clamp down harder, waiting for the milk to come.
• If your nipples are very sore, it can help to change positions each time you nurse. This puts the pressure on a different part of the nipple.
• After nursing, you can also express a few drops of milk and gently rub it on your nipples. Human milk has natural healing properties and emollients to soothe them. Also try letting your nipples air-dry after feeding, or wear a soft-cotton shirt.
• Wearing a nipple shield during nursing will not relieve sore nipples. They actually can prolong soreness by making it hard for the baby to learn to nurse without the shield.
• Avoid wearing bras or clothes that are too tight and put pressure on your nipples.
• Change nursing pads often to avoid trapping in moisture.
• Avoid using soap or ointments that contain astringents or other chemicals on your nipples. Make sure to avoid products that must be removed before nursing. Washing with clean water is all that is necessary to keep your nipples and breasts clean.
• Try rubbing pure lanolin on your nipples after breastfeeding to soothe the pain.
• Making sure you get enough rest, eating healthy foods, and getting enough fluids also can help the healing process. If you have very sore nipples, you can ask your doctor about using non-aspirin pain relievers.
• If your sore nipples last or you suddenly get sore nipples after several weeks of unpainful nursing, you could have a condition called thrush, a fungal infection that can form on your nipples from the milk. Other signs of thrush include itching, flaking and drying skin, tender or pink skin. The infection also can form in the baby's mouth from having contact with your nipples, and it appears as little white spots on the inside of the cheeks, gums, or tongue. It also can appear as a diaper rash on your baby that won't go away by using regular diaper rash ointments. If you have any of these symptoms or think you have thrush, contact your doctor and your baby's doctor, or a lactation consultant. You can get medication for your nipples and for your baby.

IMPORTANT: If you still have sore nipples after following the above tips, you may need to see someone who is trained in breastfeeding, like a lactation consultant or peer counselor. See the Where to Go for Help section for more information.

2. Challenge: Engorgement

It is normal for your breasts to become larger, heavier, and a little tender when they begin making greater quantities of milk on the 2^nd to 6^th day after birth. Sometimes this fullness may turn into engorgement, when your breasts feel very hard and painful. You also may have breast swelling, tenderness, warmth, redness, throbbing and flattening of the nipple. Engorgement sometimes also causes a low-grade fever and can be confused with a breast infection. Engorgement is the result of the milk building up, and usually happens during the third to fifth day after birth. This slows circulation, and when blood and lymph move through the breasts, fluid from the blood vessels can seep into the breast tissues. All of the following can cause engorgement:

• poor latch-on or positioning
• trying to limit feeding times or infrequent feedings
• giving supplementary bottles of water, juice, formula, or breast milk
• overusing a pacifier
• changing the breastfeeding schedule to return to work or school
• the baby changes the nursing pattern by beginning to sleep through the night or breastfeed more often during one part of the day and less often at other times
• having a baby that has a weak suck who is not able to nurse effectively
• fatigue, stress, or anemia in the mother
• an overabundant milk supply
• nipple damage
• breast abnormalities

Engorgement can lead to plugged ducts or a breast infection, so it is important to try to prevent it before this happens. If treated properly, engorgement should only usually last for one to two days.

Solution:

• Minimize engorgement by making sure the baby is latched on and positioned correctly at the breast, and nurse frequently after birth. Allow the baby to nurse as long as he/she likes, as long as he/she is latched on well and sucking effectively. In the early days when your milk is coming in, you should awaken a sleepy baby every 2 to 3 hours to breastfeed. Breastfeeding often on the affected side helps to remove the milk, keep it moving freely, and prevent the breast from becoming overly full.
• Avoid supplementary bottles and overusing pacifiers.
• Try hand expressing or pumping a little milk to first soften the breast, areola, and nipple before breastfeeding, or massage the breast and apply heat.
• Cold compresses in between feedings can help ease pain. Some women use cabbage leaves to soothe engorgement. Although their effectiveness has not been proven, many women find them soothing. You can use either refrigerated or room temperature leaves. Make sure to cut a hole for your nipple, apply the leaves directly to your breasts, and wear them inside your bra. Remove them when they wilt and replace with fresh leaves.
• If you are returning to work, try to pump your milk on the same schedule that the baby breastfed at home.
• Get enough rest and proper nutrition and fluids.
• Also try to wear a well-fitting, supportive bra that is not too tight.

IMPORTANT: If your engorgement lasts for more than two days even after treating it, contact a lactation consultant.

3. Challenge: Plugged Ducts and Breast Infection (Mastitis)

It is common for many women to have a plugged duct in the breast at some point if she breastfeeds. A plugged milk duct feels like a tender, sore, lump in the breast. It is not accompanied by a fever or other symptoms. It happens when a milk duct does not properly drain, and becomes inflamed. Then, pressure builds up behind the plug, and surrounding tissue becomes inflamed. A plugged duct usually only occurs in one breast at a time.

A breast infection (mastitis), on the other hand, is soreness or a lump in the breast that can be accompanied by a fever and/or flu-like symptoms, such as feeling run down or very achy. Some women with a breast infection also have nausea and vomiting. You also may have yellowish discharge from the nipple that looks like colostrum, or the breasts feel warm or hot to the touch and appear pink or red. A breast infection can occur when other family members have a cold or the flu, and like a plugged duct, it usually only occurs in one breast. It is not always easy to tell the difference between a breast infection and a plugged duct because both have similar symptoms and can improve within 24 to 48 hours.

Solution:

Treatment for plugged ducts and breast infections is similar, but most breast infections need to also be treated with an antibiotic.

• Soreness can be relieved by applying heat to increase circulation to the sore area and to speed its healing. You can use a heating pad or a small hot-water bottle. Cabbage leaves should not be used for a plugged duct. It also helps to massage the area, starting behind the sore spot. Use your fingers in a circular motion and massage toward the nipple.
• Breastfeed often on the affected side. This helps loosen the plug, keeps the milk moving freely, and the breast from becoming overly full. Nursing every two hours, both day and night on the affected side first can be helpful.
• Rest. Getting extra sleep or relaxing with your feet up can help speed healing. Often a plugged duct or breast infection is the first sign that a mother is doing too much and becoming overly tired.
• Wear a well-fitting supportive bra that is not too tight, since this can constrict milk ducts.
• If you do not feel better within 24 hours of trying these steps, and you have a fever or your symptoms worsen, call your doctor. You may need an antibiotic. Also, if you have a breast infection in which both breasts look affected, or there is pus or blood in the milk, red streaks near the area, or your symptoms came on severe and suddenly, see your doctor right away.
• Even if you need an antibiotic, continuing to breastfeed during treatment is best for both you and your baby. Most antibiotics will not affect your baby through your breast milk.

4. Challenge: Thrush

Thrush (yeast) is a fungal infection that can form on your nipples or in your breast because it thrives on milk. The infection forms from an overgrowth of the candida organism. Candida usually exists in our bodies and is kept at healthy levels by the natural bacteria in our bodies. But, when the natural balance of bacteria is upset, candida can overgrow, causing an infection. Some of the things that can cause thrush include: having an overly moist environment on your skin or nipples that are sore or cracked, taking antibiotics, birth control pills or steroids, having a diet that contains large amounts of sugar or foods with yeast, having a chronic illness like HIV infection, diabetes, or anemia.

If you have sore nipples that last more than a few days even after you make sure your baby's latch and positioning is correct, or you suddenly get sore nipples after several weeks of unpainful nursing, you could have thrush. Some other signs of thrush include pink, flaky, shiny, itchy or cracked nipples, or deep pink and blistered nipples. You also could have shooting pains deep in the breast during or after feedings, or achy breasts.

The infection also can form in your baby's mouth from having contact with your nipples, and appear as little white spots on the inside of the cheeks, gums, or tongue. It also can appear as a diaper rash (small red dots around a rash) on your baby that won't go away by using regular diaper rash ointments. Many babies with thrush refuse to nurse, or are gassy or cranky.

Solution:

• If you or your baby have any of these symptoms, contact your doctor and your baby's doctor so you both can be correctly diagnosed.
• You can get medication for your nipples and for your baby. Medication for a mother is usually an ointment for the nipples, and your baby can be given a liquid medication for his/her mouth, and/or an ointment for any diaper rash.
• There are medications that have been used for years to treat thrush. More recently, though, Candida is becoming more resistant to these medicines. One of the oldest, but most effective treatments for thrush that does not require a prescription is the herbal gentian violet. It works quickly and is inexpensive. You can buy it over the counter and it is painted in the baby’s mouth and on the nipples with a clean ear swab. The downside is that it is messy and it can stain everything. Before applying it, you can undress the baby down to his or her diaper and you from your waist up. After the inside of the baby’s mouth are coated purple, you can put your baby to breast. This will transfer the gentian violet to your nipple and areola. If your nipples are not purple, you can add more gentian violet with the ear swab until they are covered. You can do this once each day for up to one week. Talk with your pediatrician if you have questions about using gentian violet on your baby.
• If you first try gentian violet and the thrush does not improve after seven days, you should contact your doctor and your baby’s doctor. He or she can give you a prescription medication. Fluconazole, ketoconazole, and itraconazole are anti-fungals that are safe for both you and your baby. Fluconazole is usually taken as a 400 milligram dose at first and then 100 milligrams twice daily for at least two weeks. Besides these treatments, you might also want to make some changes in your diet, such as increasing use of garlic and reducing or eliminating simple sugars and carbohydrates. You also can take supplements of lactobacillus and primadophilus bifidus. Talk with a lactation consultant and your doctor about the best way to treat your thrush.
• Thrush may take several weeks to cure, so it is important to try not to spread it. Don't freeze milk that you pump while you have thrush. Change disposable nursing pads often and wash any towels or clothing that come in contact with the yeast in very hot water (above 122° F).
• Wear a clean bra every day.
• Wash your hands often, and wash your baby's hands often, especially if he or she sucks on his/her fingers.
• Boil any pacifiers, bottle nipples, or toys your baby puts in his or her mouth once a day for 20 minutes to kill the thrush. After one week of treatment, discard pacifiers and nipples and buy new ones.
• Boil daily for 20 minutes all breast pump parts that touch the milk.
• Make sure other family members are free of thrush or other fungal infections. If they have symptoms, get them treatment.

5. Challenge: Nursing Strike

A nursing strike is when your baby has been nursing well for months, then suddenly loses interest in breastfeeding and begins to refuse the breast. A nursing strike can mean several things are happening with your baby and that she or he is trying to communicate with you to let you know that something is wrong. Not all babies will react the same to different situations that can cause a nursing strike. Some will continue to breastfeed without a problem, others may just become fussy at the breast, and others will refuse the breast entirely. Some of the major causes of a nursing strike include:

• mouth pain from teething, or from a fungal infection like thrush, or a cold sore
• an ear infection, which causes pain while sucking
• pain from a certain nursing position, either from an injury on the baby's body or from soreness from an immunization
• being upset about a long separation from the mother or a major change in routine
• being distracted while nursing — becoming interested in other things around him or her
• a cold or stuffy nose that makes breathing while nursing difficult
• reduced milk supply from supplementing with bottles or overuse of a pacifier
• responding to the mother's strong reaction if the baby has bitten her
• being upset about hearing arguing or people talking in a harsh voice with other family members while nursing
• reacting to stress, overstimulation, or having been repeatedly put off when wanting to nurse.

If your baby is on a nursing strike, it is normal to feel frustrated and upset, especially if your baby is unhappy. It is important not to feel guilty or that you have done something wrong. Your breasts also may become uncomfortable as the milk builds up.

Solution:

• Try to express your milk on the same schedule as the baby used to breastfeed to avoid engorgement and plugged ducts.
• Try another feeding method temporarily to give your baby your milk, such as a cup, dropper, or spoon. Keep track of your baby's wet diapers to make sure he/she is getting enough milk (five to six per day).
• Keep offering your breast to the baby. If the baby is frustrated, stop and try again later. Try when the baby is sleeping or very sleepy.
• Try various breastfeeding positions.
• Focus on the baby with all of your attention and comfort him or her with extra touching and cuddling.
• Try nursing while rocking and in a quiet room free of distractions.

6. Challenge: Inverted, Flat, or Very Large Nipples

Some women have nipples that naturally are inverted, or that turn inward instead of protruding, or that are flat and do not protrude. Inverted or flat nipples can sometimes make it harder to breastfeed because your baby can have a harder time latching on. But remember that for breastfeeding to work, your baby has to latch on to both the nipple and the breast, so even inverted nipples can work just fine. Very large nipples can make it hard for the baby to get enough of the areola into his or her mouth to compress the milk ducts and get enough milk.

Inverted Nipple

Flat Nipple

Normal Nipple

Solution:

• Know what type of nipples you have before you have your baby, so you can be prepared in case you have a problem getting your baby to latch on correctly.
• Talk with a lactation consultant at the hospital or at a breastfeeding clinic for extra help if you have flat, inverted, or very large nipples.
• Sometimes a lactation consultant can help inverted nipples to be pulled out with a small device before your baby is brought to your breast.
• In many cases, inverted nipples will protrude more as the baby starts to latch on and as time passes. The baby’s sucking will help.
• Flat nipples cause fewer problems than inverted nipples. Good latch-on and positioning are usually enough to ensure that a baby latched to a flat nipple breastfeeds well.
• The latch for babies of mothers with very large nipples will improve with time as the baby grows. In some cases, it might take several weeks to get the baby to latch well, but if a mother has a good milk supply, her baby will get enough milk even with a poor latch.

7. Challenge: Going Back to Work

More and more women are breastfeeding when they return to work because they believe in the benefits of breastfeeding and can purchase or rent effective breast pumps and storage containers for their milk. Many employers are willing to set up special rooms for mothers who pump, but others are not as educated about the benefits of breastfeeding. Also, many women are not able to take off as much time as they’d like after having their babies and might have to return to work before breastfeeding is well established.

Solution:

• After you have your baby, try to take as much time off as possible, since it will help you get breastfeeding well established and also reduce the number of months you may need to pump your milk while you are at work. 
• If you plan to have your baby take a bottle of expressed breast milk while you are at work, you can introduce your baby to a bottle when he or she is around four weeks old. Otherwise, the baby might not accept the bottle later on. Once your baby is comfortable taking a bottle, it is a good idea to have dad or another family member offer a bottle of pumped breast milk on a regular basis so the baby stays in practice. 
• Let your employer and/or human resources manager know that you plan to continue breastfeeding once you return to work. Before you return to work, or even before you have your baby, start talking with your employer about breastfeeding. Don't be afraid to request a clean and private area where you can pump your milk. If you don't have your own office space, you can ask to use a supervisor's office during certain times. Or you can ask to have a clean, clutter free corner of a storage room. All you need is a chair, a small table, and an outlet if you are using an electric pump. Many electric pumps also can run on batteries and don't require an outlet. You can lock the door and place a small sign on it that asks for some privacy. You can pump your breast milk during lunch or other breaks. You could suggest to your employer that you are willing to make up work time for time spent pumping milk. 
• After pumping, you can refrigerate your milk, place it in a cooler, or freeze it for the baby to be fed later. Many breast pumps come with carrying cases that have a section to store your milk with ice packs. If you don't have access to a refrigerator, you can leave it at these room temperatures: 66°-72°F for up to ten hours or 72°-79°F for up to six hours. Click here for more information on pumping and storing breast milk.
• Many employers are NOT aware of state laws that state they have to allow you to breastfeed at your job. Under these laws, your employer is required to set up a space for you to breastfeed and/or allow paid/unpaid time for breastfeeding employees. To see if your state has a breastfeeding law for employers, go to http://www.llli.org/Law/LawUS.html?m=0,1,0 or call us at 1-800-994-WOMAN (9662).

8. Challenge: Low Milk Supply

Some women may be concerned that they are not making enough milk for their baby. It will help to first look for the signs in your baby that he or she is getting enough milk from breastfeeding. If you are still concerned about low supply, it is important to try to increase it.

Solution:

If you find that your milk supply seems too low, try the following tips:

• Talk to a lactation consultant to help get to the root of the problem.
• Try to get your baby to breastfeed often and for as long as he or she would like to.
• Offer both breasts at each feeding. Have your baby stay at the first breast as long as he or she is still sucking and swallowing. Offer the second breast when baby slows down or stops.
• Let your baby decide when to end the feeding. This may happen by your baby falling asleep and detaching from the breast after about 10 to 30 minutes of active sucking and swallowing.
• Make sure your baby is latched on and positioned well.  Your baby may do well with "switch nursing" – switching breasts two or three times during each feeding. Switch breasts when the sucking slows down and your baby swallows less often.
• Try to limit or stop pacifier use while trying the above tips at the same time. If you are supplementing the baby’s feedings, even temporarily, try using a spoon, cup, or a nursing supplementer.
• Avoid giving your baby formula or cereal as it may cause him or her to not want as much breast milk. This will decrease your milk supply. Your baby doesn’t need solid foods until he or she is four to six months old.
• Make sure to get enough rest, eat healthy foods, and drink enough fluids.

There also may be times when you think your supply is low, but it is actually just fine:

• When your baby is around six weeks to two months old, your breasts may no longer feel full. This is normal. At the same time, your baby may nurse for only five minutes as a time. This can mean that you and baby are just adjusting to the breastfeeding process – and getting good at it!
• By about six weeks following the birth, you no longer have colostrum in your milk. This can cause fewer bowel movements, which is normal and likely not a supply problem.
• Growth spurts can cause your baby to want to nurse longer and more often. These growth spurts can happen around two to three weeks, six weeks, and three months of age. They can also happen at any time. Don’t be alarmed that your supply is too low. Follow your baby’s lead – nursing more and more often will help build up your milk supply. Once your supply increases, you will likely be back to your usual routine.

9. Special Situations and Breastfeeding

Some babies have conditions that may interfere with or make breastfeeding more difficult. But, in all of the following cases, breastfeeding is still best for a baby's health.

Jaundice

Jaundice is a condition that is common in many newborns. It appears as a yellowing of the skin and eyes and is caused by an excess of bilirubin, a yellow pigment that is a product in the blood. All babies are born with extra red blood cells that undergo a process of being broken down and eliminated from the body. Bilirubin levels in the blood can be high because of higher production of it in a newborn, an increased ability of the newborn intestine to absorb it, and a limited ability of the newborn liver to handle large amounts of it. Many cases of jaundice do not need to be treated—your baby's doctor will carefully monitor your baby's bilirubin levels. Sometimes infants have to be temporarily separated from their mothers to receive special treatment with phototherapy. In these cases, breastfeeding may be discouraged and supplements or other fluids may be given to the baby. But, the American Academy of Pediatrics discourages against stopping breastfeeding in jaundiced babies and suggests continuing frequent breastfeeding, even during treatment. If your baby is jaundiced or develops jaundice, it is important to discuss with your baby's doctor all possible treatment options and share that you do not want to interrupt nursing if this is at all possible.

Reflux

It is not unusual for babies to spit up after nursing. Usually, babies can spit up and show no other signs of illness, and the spitting up disappears as the baby's digestive system matures. As long as the baby has six to eight wet diapers and at least two bowel movements in a 24 hour period (under six weeks of age), and your baby is gaining weight (at least 4 ounces a week) you can be assured your baby is getting enough milk.

However, some babies have a condition called gastroesophageal reflux (GER), which occurs when the muscle at the opening of the stomach opens at the wrong times, allowing milk and food to come back up into the esophagus (the tube in the throat). Symptoms of GER can include:

• severe spitting up, or spitting up after every feeding, or hours after eating
• projectile vomiting, where the milk shoots out of the mouth
• inconsolable crying as if in discomfort
• arching of the back as if in severe pain
• refusal to eat or pulling away from the breast during feeding
• waking up frequently at night
• slow weight gain
• problems swallowing
• gagging or choking
• frequent red or sore throat
• frequent hiccupping or burping
• signs of asthma, bronchitis, wheezing, problems breathing, pneumonia, or apnea

Many healthy babies might have some of these symptoms and do not have GER. But there are babies who might only have a few of these symptoms and have a severe case of GER. Not all babies with GER spit up or vomit.

Some babies with GER do not have a serious medical problem, but caring for them can be hard since they tend to be very fussy and wake up frequently at night. More severe cases of GER may need to be treated with medication if the baby, in addition to spitting up, also refuses to nurse, gains weight poorly or is losing weight, or has periods of gagging or choking.

If your baby spits up after every feeding and has any of the other symptoms mentioned above, it is best to see his or her doctor for a correct diagnosis. Other than GER, your baby could have another condition that needs treatment. If there are no other signs of illness, he/she could just be sensitive to a food in your diet or a medication he/she's receiving. If your baby has GER, it is important to try to continue to breastfeed since breast milk still is more easily digested than formula. Try smaller, more frequent feedings, thorough burping, and putting the baby in an upright position during and after feedings.

Cleft Palate and Cleft Lip

Cleft palate and cleft lip are some of the most common birth defects that happen as a baby is developing in the womb. A cleft, or opening, in either the palate or lip can happen together or separately and both can be corrected through surgery. Both conditions can prevent babies from breastfeeding because a baby cannot form a good seal around the nipple and areola with his or her mouth, or get milk out the breast well.

Cleft palate can happen on one or both sides of a baby’s mouth and be partial or complete. Right after birth, a mother whose baby has a cleft palate can try to breastfeed her baby, and she can start expressing her milk right away to keep up her supply. Even if her baby can’t latch on well to her breast, the baby can be fed breast milk by cup. In some hospitals, babies with cleft palate are fitted with a mouthpiece called an obturator that fits into the cleft and seals it for easier feeding. The baby should be able to exclusively breastfeed after surgery.

Cleft lip can happen on one or both sides of a baby’s lip, but a mother can try different breastfeeding positions and use her thumb or breast to help fill in the opening left by the lip to form a seal around the breast. With cleft lip repair, breastfeeding may only have to be stopped for a few hours.

If your baby is born with a cleft palate or cleft lip, talk with a lactation consultant in the hospital for assistance as soon as possible. Human milk and early breastfeeding is still best for your baby’s health.

Twins or Multiples

Mothers of twins or multiples might feel overwhelmed with the idea of breastfeeding more than one baby at a time. The benefits of human milk to both these mothers and babies are the same as for all mothers and babies. But mothers of multiples get even more benefits from breastfeeding:

• Their uterus contracts, which is helpful because it has stretched even more to hold more than one baby.
• Hormones are released that relax the mother, which is helpful with the added stress of caring for more than one baby.
• Eight to ten hours per week are saved because there is no need to prepare formula or bottles and the mother’s milk is available right away.
• It is estimated that breastfeeding saves a mother of twins $2000 or more during the babies’ first year on feeding costs alone (La Leche League, 2003).

Breastfeeding early and often for a mother of multiples is important to keep up her milk supply. A good latch-on for each baby is important to avoid sore nipples. Many mother find that it is easier to nurse the babies together rather than separately, and that it gets easier as the babies get older. There are many breastfeeding holds that make it easier to nurse more than one baby at a time. If you are having multiples, talk with a lactation consultant about more ways you can successfully breastfeed your babies.

Breastfeeding During Pregnancy

While most mothers who are nursing a toddler stop breastfeeding if they find out they are pregnant, it is an individual choice to decide whether to keep breastfeeding during the pregnancy. It is not unsafe for the unborn child if you continue to breastfeed an older child during this time. But, if you are having some problems in your pregnancy such as uterine pain or bleeding, a history of preterm labor or problems gaining weight during pregnancy, your doctor may advise you to wean. Your child also may decide to wean on his or her own because pregnancy changes the amount and flavor of your milk. Some women also choose to wean at this time because they have nipple soreness caused by pregnancy hormones, are nauseous, or find that their growing stomachs make breastfeeding uncomfortable.

Breastfeeding after Breast Surgery

If you have had had breast surgery, including breast implants, you might be worried about whether you will be able to breastfeed. The most important things that affect whether you can produce enough milk for your baby are how your surgery was done and where your incisions are, and the reasons for your surgery. For example, women who have had incisions in the fold under the breasts are less likely to have problems producing milk than women who have had incisions around or across the areola. Incisions around the areola can cut into milk ducts and nerves, where milk is produced and travels. And women who have had breast surgery to augment breasts that never fully developed may not have enough glands to produce a full milk supply.

If you had breast surgery and are worried about how it will affect breastfeeding, talk with a lactation consultant. If you are planning breast surgery and worried about how it will affect breastfeeding, talk with your surgeon about ways he or she can preserve as much of the breast tissue and milk ducts as possible.

Inducing Lactation

Many mothers who adopt want to breastfeed their babies and can do it successfully with some help. Many will need to supplement their breast milk with donated breast milk or infant formula, but some adoptive mothers can breastfeed exclusively, especially if they have been pregnant before. Lactation is a hormonal response to a physical action, and so the stimulation of the baby nursing causes the body to see a need for and produce milk. The more the baby nurses, the more a woman’s body will produce milk.

One thing you can do to prepare is to pump every three hours around the clock for two to three weeks before your baby arrives, or you can wait until the baby arrives and starts to nurse. A supplemental nursing system (SNS) or a lactation aid can help ensure that your baby gets enough nutrition and that your breasts are stimulated to produce milk at the same time.

Some mothers have found that also taking prescription or herbal medicines can help increase milk supply. Domperidone, a drug that is frequently used in Canada and other parts of the world to treat certain gastric disorders, but also used for increasing milk supply, is not available through most pharmacies in the U.S., but can be ordered from other countries with a prescription. In 2004, the U.S. Food and Drug Administration (FDA) issued a warning about the health risks linked to this drug. There have been several published reports and case studies of abnormal heart rhythms, cardiac arrest, and sudden death in patients receiving an intravenous form of domperidone. In countries where the oral form of domperidone continues to be sold, labels for the product contain warnings against use of it by breastfeeding women and note that the drug is excreted in breast milk that could expose a breastfeeding infant to unknown risks. Because of the chance of serious adverse effects, FDA recommends that breastfeeding women not use domperidone to increase milk production.

Fenugreek and blessed thistle are two herbs that have been reported by many mothers to help increase milk supply. But, no controlled studies are yet available to prove they are effective. Before you use any prescription or herbal medicines, it is important to talk with your doctor about their side effects. If you are an adoptive mother who wants to breastfeed, you should see both a lactation consultant and your doctor for help in establishing an initial milk supply.

Current as of August 2007

The following publications and organizations provide more information on breastfeeding challenges:

Publications

1.   Breastfeeding and Travel - This fact sheet provides general information about travel for women who are breastfeeding.

   http://wwwn.cdc.gov/travel/yellowBookCh8-Breastfeeding.aspx.aspx

2.   Coping with Breastfeeding Challenges - This Internet site explains how to deal with several common breastfeeding challenges and lists resources for more information.

   http://www.womenshealth.gov/breastfeeding/index.cfm?page=229

3.   LactMed: Drugs and Lactation Database - The Drugs and Lactation Database (LactMed) is a peer-reviewed and fully referenced database of drugs to which breastfeeding mothers may be exposed. Among the data included are maternal and infant levels of drugs, possible effects on breastfed infants and on lactation, and alternate drugs to consider.

   http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT

4.   Overcoming Breastfeeding Problems - This publication contains information on common breastfeeding problems, including nipple soreness, engorgement, let-down reflex problems, inadequate milk supply, plugged milk duct, breast infection, and thrush.

   http://www.nlm.nih.gov/medlineplus/ency/article/002452.htm

5. Breastfeeding a Cleft Lip-Palate Baby (Copyright © SMILES) - This fact sheet provides helpful information on the possible uncertainties associated with breastfeeding and caring for a child with a cleft lip, palate, or both a cleft lip and palate.

   http://www.cleft.org/breastfeeding.htm

6.   Breastfeeding after a Natural Disaster (Copyright © OTIS) - This fact sheet contains questions and answers about what things a mother could be exposed to during a natural disaster that might be passed to her baby in breast milk. It explains how to keep your breast milk as safe as possible and what to do if you have to use formula.

   http://otispregnancy.org/pdf/breastfeeding.pdf

7. Breastfeeding and Returning to Work (Copyright © AAFP) - Going back to work and keeping up with breastfeeding can be a challenge for many new mothers. This publication answers some commonly asked questions about how to transition back to work after having a child and still maintain a breastfeeding schedule.

   http://familydoctor.org/827.xml

8. Breastfeeding During Pregnancy (Copyright © LLLI) - This publication has information on the benefits and risks of continuing to breastfeed if you become pregnant. It also outlines what to expect with regards to your milk supply and changes that may occur to your body during pregnancy.

   http://www.lalecheleague.org/FAQ/bfpregnant.html

9. Breastfeeding the High-Risk Newborn (Copyright © UUHSC) - This on-line resource offers information on the benefits of breastfeeding high risk newborns including how to overcome difficulties in breastfeeding, how to express breast milk, and how to maintain milk production.

   http://www.uuhsc.utah.edu/healthinfo/pediatric/Hrnewborn/bresthub.htm

10. Can I Breastfeed My Adopted Baby? (Copyright © La Leche League International) - This publication discusses options for breastfeeding-adopted babies. It explains induced lactation and links to articles from mothers who have breastfed their adopted children.

    http://www.lalecheleague.org/FAQ/adopt.html

11. Extended Breastfeeding and the Law (Copyright © LLLI) - This publication discusses the evidence in favor of extended breastfeeding and how mothers can cope with reports of abuse or neglect from people who think extended breastfeeding is abnormal or wrong.

    http://www.lalecheleague.org/Law/LawExtended.html

12. FAQ on Breastfeeding Twins (Copyright © LLLI) - This publication provides information on breastfeeding twins. It includes positioning techniques, feeding plans, and ways to care for oneself.

    http://www.llli.org/FAQ/twins.html

13. FAQ: How Do I Prevent Sore Nipples? (Copyright © LLLI) - This publication contains information on what you can do to help heal or prevent sore nipples after breastfeeding. It gives suggestions on how to properly position the baby at the breast in easy-to-follow steps.

    http://www.lalecheleague.org/FAQ/sore.html

14. High Risk Newborn: Moving Toward Breastfeeding (Copyright © UUHSC) - This breastfeeding guide contains information on special breastfeeding concerns for mothers of a high-risk newborn. It includes signs that a baby is getting ready for breastfeeding, stages in breastfeeding progression, helpful hints for beginning to breastfeed, hints for breastfeeding at home, and relaxation techniques for the mother.

    http://www.uuhsc.utah.edu/healthinfo/pediatric/Hrnewborn/mtbf.htm

15. How Can I Deal with My Leaking Breasts (Copyright © LLLI) - This publication discusses nursing pads, patterned clothing, and frequent breastfeeding as ways to deal with leaking breasts.

    http://www.lalecheleague.org/FAQ/leak.html

16. If Breastfeeding is so Natural, Why Doesn't it Seem to Come Naturally? (Copyright © LLLI) - This publication encourages mothers to not give up on breastfeeding when they face challenges.

    http://www.llli.org/FAQ/natural.html

17. Ineffective Latch-On or Sucking (Copyright © UUHSC) - This on-line fact sheet offers information on ineffective latch-on and sucking during breastfeeding. It also offers information on what one can do to help with the breastfeeding process and other ways to help the baby with ineffective sucking.

    http://www.uuhsc.utah.edu/healthinfo/adult/Pregnant/diffltch.htm

18. Is Thrush Causing My Sore Nipples? (Copyright © LLLI) - This publication contains information on what thrush is, what causes it, and how to relieve it.

    http://www.lalecheleague.org/FAQ/thrush.html

19. My Breast Hurts. What Can I Do? (Copyright © LLLI) - This fact sheet explains the causes and treatments for sore breasts.

    http://www.lalecheleague.org/FAQ/mastitis.html

20. Special Challenges to Breastfeeding (Copyright © AAP) - This publication contains information on obstacles that may create special challenges in breastfeeding, including maternal illness, plastic surgery, mastitis, and cracked nipples.

    http://www.medem.com/search/article_display.cfm?path=n:&mstr=/ZZZHCCBXQ7C.html&soc=AAP&srch_typ...

21. What are the Benefits of Breastfeeding my Toddler? (Copyright © La Leche League International) - This publication describes how breastfeeding your toddler can help their ability to mature and their understanding of discipline as well as provide protection from illness and allergies.

    http://www.lalecheleague.org/FAQ/advantagetoddler.html

22. Will the Breast Surgery I had in the Past Prevent Me From Being Able to Breastfeed My Baby? (Copyright © LLLI) - This publication explains some of the complications that a mother who has had breast surgery may experience. It also provides a list of signs that the baby is not getting enough milk.

    http://www.lalecheleague.org/FAQ/surgery.html

23. Would Weaning Make My Life Easier? (Copyright © LLLI) - This publication encourages mothers to look at the reasons why they feel weaning will be easier than continuing to breastfeed. It also offers suggestions on dealing with the barriers to breastfeeding that they may be experiencing.

    http://www.lalecheleague.org/FAQ/wean.html

Organizations

1.   Centers for Disease Control and Prevention, HHS
2.   Maternal and Child Health Bureau, HRSA, HHS
3.   Special Supplemental Nutrition Program for Women, Infants and Children, (WIC) USDA
4.   Womenshealth.gov, OWH, HHS
5. American College of Nurse-Midwives
6. Breastfeeding After Reduction (BFAR)
7. Human Milk Banking Association of North America
8. International Lactation Consultant Association (ILCA)
9. La Leche League International
10. National Healthy Mothers, Healthy Babies Coalition
11. Smiles
12. World Alliance For Breastfeeding Action

= Indicates Federal Resources