Breastfeeding, latch, nipple pain, jaundice

Managing breastfeeding latch, nipple pain, redness, yeast infections and baby's jaundice

Low milk supply--is my baby getting enough to eat/drink?

How to deal with enlarged / engorged breasts (Day 3 or 4 especially)

How can I measure how much the baby eats / drinks?

How do I know when I have a letdown of milk?

How can I collect milk from one side while I feed with the other?

How to prevent leaking while breastfeeding

How can I increase my milk supply?

Sandy: Hi Deb, such good news, I was just thinking about you these past few days. How is breastfeeding going? If you need any help, I have advanced training, we will be happy to help you.

In any case, there was this great study about the moms in Papua New Guinea who would attach the babies to their chests as they went out to forage and the babies were able to decide how often they wanted to feed because they could latch on themselves without having to ask the moms. Anyway, I'm pretty sure they fed about every 24 minutes.

And the formula companies want you to think you should feed every 3 to 4 hours, this is how they get you to fail.

So, try to feed often while the baby is awake and you will have great success, also please massage your breasts, especially today (day 3), tomorrow, the next day and the day after that, these are the most challenging days, massage, massage, massage to get all the lumps out and the milk flowing, Especially the outer, lower, quadrants of the breasts, and especially the area around the nipple to get the breast nice and soft so the baby can latch, over the next day, you will see, your breasts will get really firm and massage will resolve it.

Deb: Thank so much. Good advice. Going well so far. Feeding frequently. Will start to do the massages.

Three days after birth

Sandy: Are your breasts crazy enormous yet?

Deb: Yes, yes and yes. Trying to massage. Baby has high bilirubin so was told to pump to supplement. He is so drowsy.

Sandy: In my opinion, newborn health professionals get a little too freaked out about bilirubin, and I don't agree with the pumping.

Sometimes they even offensively call it "breastfeeding jaundice." In reality they should call it "lack of breastfeeding jaundice." If your milk has come in and you feed often and massage to loosen up the milk so he can get it, soon the milk will flush all the jaundice away and everybody can relax. Of course, if your health provider is worried about this, please work with him/her and allow the baby the treatment recommended. But increasing the volume of breastmilk is the best way to resolve the situation, so please try to put intense effort into it.

The latch can be quite difficult to get just right. With my son, I learned to kind of pry his mouth open by dropping my breast on his lower lip, pushing down to get his mouth open wide and using my finger to make sure his lower lip was turned outward and then pulling his head upward so he could close his mouth and latch. It's tricky, it seems to take 10 hands to figure out how to do it at first. If his lower lip is not turned outward it will hurt and also be ineffective.

Try to get the biggest mouthful of breast possible so he can extract more milk each time he suckles. And if he's too sleepy, crank up the music! Try not to use a bottle yet, it will undermine your latch I know I'm giving you a lot of unsolicited advice right now. I just want to make sure you get through days 3 and 4 ok — they are the toughest, then I will stop bugging you!

Deb: I appreciate it Sandy. About how many cc's does a baby get per feeding at this stage would you say? Having a hard time knowing how much breastmilk to push after he feeds for 20 mins. He is falling asleep at that point.

Sandy: Hi Deb, the formula industry has seeped into the brains of healthcare workers. This whole freakout about jaundice and supplementing thing—try to set aside what they are telling you and just focus on developing a good breastfeeding relationship with your baby. Also, the focus on how many cc's the baby is getting—that is a concept of the formula industry. They want you to measure feeding success by being able to measure exact volume. The only way you can know the measurable volume a baby is taking in is if you feed through a bottle—caring about exact volume is a victory for the formula industry. Try to set that aside as well. Instead what matters in terms caring about sufficient intake is examining the effects feeding has on the baby. Frequency of wet diapers and poopy diapers. Sunken fontanelle. Drowsiness. Skin turgor (tightness).

He's been getting dehydrated over the past couple days and is now about to be flooded with milk. The milk will wash away the jaundice and drowsiness. My suggestion—try to get a sense of when your milk lets down.

Let down is usually preceded by intense thirst 30 seconds before it lets down. You will know you are having a letdown because the breast will feel heavy and the breast you are Not feeding from will start leaking. (And hopefully the baby will start gulping milk.) That is the sensation of your milk letting down.

Once you get the letdown, try to feed for 5 minutes then stop. Take a break. Set the baby down and take a cat nap, anything. Then 15 minutes later pick the baby up and feed from the other side for 5 minutes after letdown. Then another break. This will wake the baby up, get lots of milk into him. You might think—"but wait, the baby keeps feeding and feeding for 20-30 minutes, I can't stop after 5 minutes!" But most of the milk comes out in the first 5 minutes and then after that the breast becomes more of a pacifier than a feeding device. (In a few weeks, you might feed for 10 minutes so the baby gets the high-fat hind milk, but don't worry about that now—he needs volume.)

Just insert your finger in between your breast and his mouth to break the seal after 5 minutes is up. If he protests, then he has woken up! You can switch sides and he can drink more from the other side. The breast that is not doing the feeding—when it leaks, there is this device called Milkies Milk-Saver that you can put in your bra to collect the milk while you feed on the other side. This is nice because you can collect the milk without needing a pump. You just collect what you leak out. Save this milk and put a star on it for future months the first time the baby gets sick. Early milk has the most immune factors.

Alternatively, if you don't have these Milkies right now (let me know, I can send them to you), you can use your forearm and press firmly on top of your nipple to stop the milk from leaking all over you. Just press for two minutes and then it will stay stopped.

Deb: Thanks Sandy. Doing what you said- well trying. He is getting enough with just me and that feels better.

One week later…

Sandy: 😅 How's it going, Deb?

Deb: Hi!! Slowly but surely. Sandy: Your baby is beautiful, Deb!

Deb: Thanks Sandy! I am really enjoying him. Two questions - any tips for that lower lip? He has a pretty prominent lower lip suck. Also. I have a hard and red region on one breast. I am going to apply heat before feeding later and have been trying to massage when I am feeding. Would you express if he doesn't get it out breastfeeding?

Sandy: Hi Deb, Hard red region, yikes. can you send a photo?

Deb: It is not severe. And it softens a little. I don't want it to turn into something worse

Sandy: Try to massage that area intensively with fingertips, very deep while he is feeding until the log jam breaks and the lumps come out

Deb: Ok- that has been my strategy. So I am on the right track.

Sandy: Push your fingers straight in at a 90 degree angle for about 30 seconds at a time with increasing pressure. You can massage while he's not feeding, but if you massage while he is feeding it works better because he applies the suction to get that milk out of there. You've got to constantly keep all the tubules flowing. Every time you feed you've got to feel the entire breast for lumps and massage them until they clear out. The beginning of a feeding session is most important because that's when most of the milk departs your breast.

When he feeds, is his lower lip turned outward so that only the inner mucosa is touching your breast? None of the lip itself should actually touch the breast, or at least not much.

I don't think you have to express separately from when he is feeding, just try to get him to feed on the problem breast every 30 minutes while awake until you clear out that red area. But if it takes a while to improve the problem breast, you night want to pump on the healthier side to keep it flowing. The baby provides better suction so have him feed on the problem side until it's better

Deb: Ok- the lip goes inward, not outward, which causes me pain. I remember you saying you worked on that with your son.

Sandy: Oh, yes, we've got to fix that. When you get him to latch, put him on your lap with a pillow, let's say it's your left breast you want to feed with. Pick up your entire breast with your right hand and brush the nipple down his nose and upper lip, hopefully this will get him to open his mouth.

Then when he opens his mouth, find the position on your breast that you would like to rest on his lower lip. Everyone has a different sized areola, if it's about average size, his lip would be on the edge of the areola. If you have a small areola his lip will actually be beyond the areola on the skin.

Then once you find this spot, rest your breast on his lower lip and release the weight of your breast from your hand so the gravity in the weight of your breast will pry open his mouth.

It sounds a little more forceful than it is, I need a better word than "pry." Before you do this, his head and body will be parallel to the floor, and when the breast opens his mouth wide then you can tilt his head up onto the rest of your breast and get a latch. Then his head should be closer to a 45 degree angle to the floor. The main focus should be on the breast not only prying open his mouth but also flipping his lip outward.

Deb: Got it. Been trying to do that positioning. The lip is stubborn but will be conscious of that.

Sandy: If somehow he is still pulling his lip inward, put your finger under his lower lip and manually flip it outward. I know it seems right now it will take 10 hands to do this, so if it the lack of hands seem to be a problem, just rest him on the sofa and use both hands to fix the latch and then when you get that squared away then you can scoop him up with your arms.

If you fix the lip at the beginning of a feeding session it will feel instantly better for both of you and once he gets use to that's how it should be he will do it from the start.

Two months of age:

Sandy: Hi Deb, checking in. How are you doing?

Deb: Hello! I am good. Nipples are still raw- trying to heal them. We are figuring things out. I cannot believe how quickly the time is going. He turned 2 months yesterday.

Sandy: I am worried about your nipples, they should not be raw. Do you think it's are yeast infection?

Deb: I have tissue that is trying to heal and it gets re-injured when he feeds.

Sandy: Your skin sounds so thin I think you might have a yeast infection. How is your sugar intake? How do you feel about walking around exposing your nipples to sunlight? I think you need Clotrimazole cream. What part hurts the most? Just your nipples but not further out on the Areola? I'm wondering if he takes in enough breast tissue when he latches.

Deb: The tip and a bit further on the sides I am trying to get him to take more

Sandy: Try to see if you can get a bigger mouthful of breast into his mouth. Try to position his lower lip outside of your areola as you begin latching and then bring his head forward and let him finalize the latch on top. I am not positive it's a yeast infection but my general inclination is to assume it is a yeast infection until proven otherwise.

If you do decide to get some of that Clotrimazole, make sure you get a brand that is unscented. When I had a yeast infection, I got one tube of it and it had some perfume in it that smelled so, so bad and I could not use it of course on my breast which was then going into my son's mouth...

Deb: I will try. He doesn't open that wide. Do you think occupational therapy would help?

Sandy: I think you can do this. You have to force him to open up wide. Think of your breast as somewhere between a weight and a crowbar.

Deb: Ok/ I will try. I have been on ibuprofen and acetaminophen every 6 hours for 2 months.

Sandy: When he opens his mouth, place your breast about an inch and a half away from the tip of your nipple on his lower lip and then use your breast to push down and force open his mouth and then you can drop the rest of your breast into his mouth and then he can latch on top. Don't be afraid to push, just let him know if he wants to make the latch work he has got to get this enormous amount of breast into his mouth. And if the starting point is an inch and a half or 2 inches away from the nipple, he really has the open wide to get all of it in there. If the starting point is only a half an inch away from the nipple, he doesn't have to get as much breast into his mouth. As soon as his lower lip connects with the breast, just push down and don't let him have access to the top of your breast until his mouth is open wide enough.

This isn't the best tutorial and it may be repetitive but see if it helps The latch does not have to be centered, Best to have ~70% be a latch from the lower breast, because the lower jaw does all the work, I am not sure I'm explaining that very well.

Deb: That was a great tutorial. I was pulled away so am just seeing now. I will definitely work on that.

Several days later...

Sandy: Any luck?

Deb: Yes. I realize that I had been trying to latch that way but he likes to drift back to less of the breast.

Sandy: He has developed that habit, but with persistence, you will prevail. You got to give him no choice. If he slips back to suckling on the nipple, break the seal and relatch.

Deb: Ok- have done it a few times.

Sandy: Good, does it feel better when he has a huge mouth full of breast?

Deb: Yes- although initially it i feel the open sore a little more because of the new position.

Sandy: I wish I could be there to watch you. Is there a way you could reposition him so he is a little bit twisted by 25°? Perhaps it is called the football hold? He is lying next to you on the pillow you sitting up, him let's just say by your right side and his right side would be connected to your right side his feet would be sticking out behind you, anyway this would rotate his latch by 25 or 45° or so and might provide some relief for the area that's bothering you the most.

Deb: Sure. I am doing the football hold too. I forgot to tell you that I also have Raynaud's of the nipple - they both turn white spontaneously which is very painful. I just want to heal the sores.

Sandy: mmmm. That sounds painful. I wonder if some EMLA lidocaine cream would help you for a few days or week or so, — put it on at least an hour before the baby feeds so basically just put it on after the baby has last fed, and gently wipe it off before he feeds

Deb: Ok. I have a tube in my cupboard for a different issue but not this brand.

Sandy: Oh, great! As long as it doesn't have a bad smell to it it will be fine.

Sandy: When I needed it when I was breastfeeding I got one tube of clotrimazole that was great, no scent was in it, and another one that just had so much disgusting perfume in it.

Deb: That would help

Sandy: Yeah, I used some to pierce my ear and I didn't feel it at all, I think I had it on for two hours before I pierced it and I believe that's what the directions say.

Deb: Apply twice per day? And doesn't Nate need to take something?

Sandy: For the yeast infection?

Deb: Yes

Sandy: Ideally he should have his mouth swabbed with nystatin. I think you should put the cream on every time after you feed. A mixture of lidocaine and Clotrimazole.

Five months of age

Deb: I don't know if I ever fully expressed my gratitude for helping me so much with the breast feeding. You correctly diagnosed his latching and a yeast infection which, after treatment, took care of the pain. It is so wonderful to breast feed now and I never dreamt I would say that those first few months.

Also see our other breastfeeding articles:

Is formula just as good as breastfeeding?

How often should I breastfeed my baby?

Is pumping just as good as breastfeeding directly?

Author: Sandy Summers, RN, MSN, MPH, biography

The views expressed herein do not necessarily reflect those of the Board Members or Advisory Panel of The Truth About Nursing.