Not everyone can or wants to breastfeed. But for those who do, breastfeeding challenges can turn a cherished opportunity into a painful and stressful experience.
Cluster feeding is when baby demands feeds close together or feed on and off for several hours at certain times of the day. Cluster feeding is most common in the evening, although it may differ between babies. Cluster feeding is widespread in young babies and one of the biggest challenges to navigate on your breastfeeding journey (16).
We don’t know precisely why babies cluster feed; however, experts suggest that cluster feeding is a way that baby triggers a boost in milk production. Cluster feeding does not indicate that you have a low milk supply. Instead, it is nature’s way of changing the milk quality or quantity.
If you feel that supplementing with formula is a great short-term fix, please be aware that your body will not receive the signals that your baby is sending. If this is the case, you may well find you aren’t making enough milk now, and your concerns have now become a self-fulfilling prophecy. If this is your story, you may be able to correct it and get back on the right path. Please talk to a lactation consultant for advice.
If you have sore or cracked nipples, the odds are that it is the result of positioning or attachment. Sometimes a crack in the nipple can be seen on the nipple itself, where the nipple joins to the areola, or the crack can be more like a graze – very fine and hard to see, but it stings so you know it’s there. Breastfeeding with cracked nipples is painful, and severely cracked nipples may bleed during feeding.
To stop the problem, you need to find the cause, however, this can be one of breastfeeding challenges. If your positioning and attachment are good, then other factors may be responsible, such as:
- infection or dermatitis on your nipples,
- your baby may have a tongue-tie,
- damage from the incorrect use of breast pumps.
You may need to feed your baby on the other side for 12–24 hours to let the nipple rest and begin healing. If this is the case, you can express from the damaged side to maintain your supply and for comfort. You can then feed your baby your expressed breastmilk.
A build-up of fluid in your breast causes engorgement. This fluid may be milk, blood or other liquid. Your breasts may feel larger, heavy, firm, warm and uncomfortable when your milk ‘comes in’, usually at about day 3 (2-6, depending on your circumstances) after your baby’s birth.
This level of engorgement is normal and part of the adjustment that your body makes when you transition from colostrum to mature milk. It should not affect your milk flow or your baby’s attachment. Still, please be aware that during this transition period, the fullness of your breasts is one of breastfeedings challenges and does not always reflect the amount of milk you have.
However, sometimes a woman’s breasts become very hard, swollen and tender, and her nipples become flattened and taut. This situation can be painful for the mother and make it difficult for the baby to attach well to the breast. Engorgement can be prevented by feeding your baby frequently and ensuring correct positioning and attachment.
If you find that your breasts are engorged, you can use the following strategies to manage it:
- Take your bra off before beginning to breastfeed.
- Use warmth (heat pack, shower or warm wet cloth) before feeds to help trigger your letdown reflex.
- If your baby has trouble attaching to your breast, use ‘reverse pressure softening’ to soften your breast or express some milk
- Gently massage the breast while you are feeding.
- Express for comfort after feeds if you need to.
Milk ducts carry the milk from the breast tissue to the nipple. These ducts can become blocked, allowing your milk to build up behind the blockage – forming a lump and causing pain and redness over the affected area. You can avoid blocked ducts by feeding your baby often, avoiding tight or restrictive clothing, ensuring your breast is empty after feeds, and by changing the position of your baby from one feed to the next.
If you suspect that you have a blocked duct:
- Apply warmth to the affected area before a feed to trigger your let-down reflex
- Feed baby from the affected breast first
- Check your baby’s position and attachment
- Gently but firmly massage the duct from the furthest point and down toward your nipple during feeds.
- Change baby’s position during and between feeds to help empty the breast
- Hand express before and after feeds if you need to
- Using cold packs after feeds may help with pain and inflammation.
Mastitis usually happens when a milk duct becomes blocked. This blockage causes milk to build up behind the duct and gets forced into the surrounding tissue. The tissue then becomes inflamed. This inflammation is called mastitis (mast = breast, -itis= inflammation).
Early mastitis symptoms are flu-like, and you may get the shivers and aches. However, some mothers do not get any early signs and get mastitis very quickly and without warning. The breast will be sore, hot, red and swollen. The skin may be shiny, and there may be a red patch over the affected area.
As painful as it is, the way to get through mastitis is to continue to feed; the most crucial aspect of treating mastitis is to keep your breasts as empty as possible. Your baby is the most effective method for doing this. Baby will drain your breast more effectively than expressing ever will, and the milk is safe for baby to drink.
Here are some tips for dealing with mastitis:
- Feed more often than usual
- Let your baby suck long enough make sure that the breast has drained well.
- Take care not to let the other breast become too full, by either feeding or expressing.
- Use COLD packs on the affected breast to reduce swelling and relieve pain.
- Use WARMTH only sparingly and just before a feed to help trigger your let-down reflex to help clear the blockage.
If you think you have mastitis, start treatment straight away and see your doctor if it does not improve in a few hours. Some cases of mastitis require antibiotic treatment.
Most mothers are concerned from time to time that they have a low supply. This issue is common when the baby is going through a growth spurt, and you can’t seem to fill them up. It is also one of the common challenges when a baby is cluster feeding.
If your baby:
- is being fed on demand
- attaches well
- changes rhythm while sucking,
- pauses during the feed and starts again without prompting
- comes off the breast when they are ready, looking full, satisfied and sleepy, and
- has plenty of wet nappies
- is putting on weight
The odds are that your milk supply what your baby needs it to be.
If you find that your baby:
- does not have at least six wet nappies per day,
- still acts hungry after a feed,
- does not settle between feeds,
- or is not gaining weight,
Your milk supply may need a bit of a boost.
Building your supply
- Ensure correct position and attachment
- Breastfeed more often
- Offer the breast every 2–3 hours during the day for a few days
- Increase feeds by offering the breast in between feed times
- Offer the breast to soothe your baby for a few days, rather than a dummy (if you use one)
Remember that to increase your supply, you will need to fit in more feeds than your baby would usually have in 24 hours. These extra feeds don’t need to be long feeds; even a few extra 5-10 minute ‘snacks’ can help. If you find your supply remains low, you may benefit from the use of a supplement or medication that increases milk supply.
Inverted or flat nipples
Inverted nipples do not protrude out from the areola but retract inwards. Some nipples can be severely inverted (fully stuck inwards), others may be drawn out with stimulation, such as a breast pump. Flat nipples sit level with the areola. For mothers with inverted or flat nipples, early breastfeeding initiation is essential. As the baby is more likely to attach and feed well if he gets used to the work of drawing out the nipple. If the baby is struggling to do this, the mother may be able to draw her nipple out before feeds either manually or with a breast pump.
If your baby has ongoing problems with attachment once your milk comes in, a nipple shield may be helpful.
The reluctant feeder
All babies are different. They will have different sleep and wake cycles, different likes and dislikes and have different times of the day that they like to feed more frequently.
As a general guide, however, your baby should feed at least six times in 24 hours. Some babies are reluctant feeders. They may be sleepy, or tired, or grumpy or struggling with attachment and each of these causes their feed time to be a challenge. These babies need encouragement to make sure that they feed frequently enough, and that they get enough milk.
If you find that you need to wake your baby for feeds, try these tips:
- Change your baby’s nappy.
- Undress your baby down to his nappy and place him skin-to-skin
- Give your baby a warm bath.
- Talk to him and make eye contact.
- Gently massage his back in circular motions.
- Stroke his feet and hands.
Reasons for reluctant feeding include:
- long labour (baby has work to do too)
- mum who has had opiates in labour
- a premature or jaundiced baby
- mum who is missing feeding cues
- unwell baby
If your baby is reluctant to feed in the first few days, please speak to your midwife. In the meantime, you should express 3-4 hourly to build up your milk supply and prevent engorgement.
A tongue-tie is a piece of skin under the baby’s tongue (called the lingual frenulum) that is unusually short or thick and sometimes presents challenges to breastfeeding. It restricts the movement of the tongue and specifically affects the baby’s ability to lift the tip of the tongue toward the roof of the mouth. This movement is necessary for breastfeeding. When a tongue tie is severe, it is not mobile enough to allow proper attachment to the breast.
A tongue-tie does not always mean that your baby won’t be able to attach to the breast and suck well. Mothers of these babies may have resulting challenges such as nipple damage, recurrent blocked ducts and mastitis, and poor feeding and low weight gains in the baby.
Many women who have had breast surgery (a breast reduction or augmentation, for example) may be concerned that their breastfeeding may be affected. The good news is that most mothers who have had breast surgery can breastfeed, if not wholly, then to some extent.
There is no way of knowing before the birth which challenges the surgery has created. Factors such as maternal choice, the reason for surgery and changes to the breast anatomy contribute to breastfeeding success in these women.
A breast reduction is more likely to cause milk supply problems than a breast augmentation. The nipple may have been moved to a new position during the surgery disrupting the nerves or resulted in damage to the milk glands. Women who undergo breast augmentation may also have problems with milk supply. However, if the implant is under the pectoral muscle, then challenges should be kept to a minimum.
Dr Janelle McAlpine (PhD), Clinical Midwife
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