Breastfeeding: Common Breastfeeding Challenges (cont.)

Inverted, flat, or very large nipples

Some women have nipples that turn inward instead of protruding, or that are flat and do not protrude. Nipples can also sometimes be flattened temporarily due to engorgement or swelling while breastfeeding. Inverted or flat nipples can sometimes make it harder to breastfeed. 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. Often, flat and inverted nipples will protrude more over time, as the baby sucks more.

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.

What you can do

  1. Talk to your doctor or a lactation consultant if you are concerned about your nipples.
  2. You can use your fingers to try and pull your nipples out. There are also special devices designed to pull out inverted or temporarily flattened nipples.
  3. 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.

Ask for help if you have questions about your nipple shape or type, especially if your baby is having trouble latching well.

Breastfeeding a baby with health problems

There are some health problems in babies that can make it harder to breastfeed. Yet breast milk and early breastfeeding are still best for the health of both you and your baby - even more so if your baby is premature or sick. Even if your baby cannot breastfeed directly from you, it's best to express or pump your milk and give it to your baby with a cup or dropper.

Some common health problems in babies are listed below.

Jaundice

Jaundice is caused by an excess of bilirubin, a substance that is in the blood usually in very small amounts. In the newborn period, bilirubin can build up faster than it can be removed from the intestinal track. Jaundice can appear as a yellowing of the skin and eyes. It affects most newborns to some degree, appearing between the second and third day of life. The jaundice usually clears up by two weeks of age and is not harmful.

Two types of jaundice can affect breastfed infants - breastfeeding jaundice and breast milk jaundice.

  • Breastfeeding jaundice can occur when a breastfeeding baby is not getting enough breast milk. This can happen either because of breastfeeding challenges or because the mother's milk hasn't yet come in. This is not caused by a problem with the breast milk itself.
  • Breast milk jaundice may be caused by substances in the mother's milk that prevents bilirubin from being excreted from the body. Such jaundice appears in some healthy, breastfed babies after about one week of age. It may last for a month or more and it is usually not harmful.

Your baby's doctor may monitor your baby's bilirubin level with blood tests. Jaundice is best treated by breastfeeding more frequently or for longer periods of time. It is crucial to have a health care provider help you make sure the baby is latching on and removing milk well. This is usually all that is needed for the infant's body to rid itself of excess bilirubin.

Some babies will also need phototherapy - treatment with a special light. This light helps break down bilirubin into a form that can be removed from the body easily. If you are having trouble latching your baby to the breast, it is important that you pump or hand express to ensure a good milk supply. The same is true if the baby needs formula for a short time - pumping or hand expressing will make sure the baby has enough milk when you return to breastfeeding.

It is important to keep in mind that breastfeeding is best for your baby. Even if your baby experiences jaundice, this is not something that you caused. Your health care providers can help you make sure that your baby is eating well and that the jaundice goes away.

Ask for help! If your baby develops jaundice once at home, let your baby's doctor know. Discuss treatment options and let the doctor know that you do not want to interrupt breastfeeding if at all possible.

Reflux disease

Some babies have a condition called gastroesophageal (GASS-troh-uh-SOF-uh-JEE-uhl) reflux disease (GERD), which occurs when the muscle at the opening of the stomach opens at the wrong times. This allows milk and food to come back up into the esophagus, the tube in the throat. Some symptoms of GERD 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 often at night
  • Slow weight gain
  • Gagging or choking, or problems swallowing

Many healthy babies might have some of these symptoms and not have GERD. But there are babies who might only have a few of these symptoms and have a severe case of GERD. Not all babies with GERD spit up or vomit. More severe cases of GERD may need to be treated with medication if the baby refuses to nurse, gains weight poorly or is losing weight, or has periods of gagging or choking.

Ask for help! See your baby's doctor if he or she spits up after every feeding and has any of the other symptoms mentioned here. If your baby has GERD, it is important to continue breastfeeding. Breast milk is more easily digested than infant formula.

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 forming a good seal around the nipple and areola with his or her mouth, or effectively remove milk from the breast. 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.

Right after birth, a mother whose baby has a cleft palate can try to breastfeed her baby. She can also 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 his or her surgery.

Ask for help! If your baby is born with a cleft palate or cleft lip, talk with a lactation consultant in the hospital. Breast milk is still best for your baby's health.

Premature and/or low birth weight

Premature birth is when a baby is born before 37 weeks gestation. Prematurity often will mean that the baby is born at a low birth weight, defined as less than five and a half pounds. Low birth weight can also be caused by malnourishment in the mother. Arriving early or being small can make for a tough adjustment, especially if the baby has to stay in the hospital for extra care. But keep in mind that breast milk has been shown to help premature babies grow and ward off illness.

Most babies who are low birth weight but born after 37 weeks (full term) can begin breastfeeding right away. They will need more skin-to-skin contact with mom and dad to help keep them warm. These smaller babies may also need more frequent feedings, and they may get sleepier during those feedings.

Many babies born prematurely are often not able to breastfeed at first, but they do benefit from expressed milk. You can express colostrum by hand or pump as soon as you can in the hospital. You can talk to the hospital staff about renting a hospital grade electric pump. Call your insurance company or local WIC Office to find out if you can get reimbursed for this type of pump. You will need to express milk as often as you would have breastfed, so around 8 times per a 24-hour period.

Once your baby is ready to breastfeed directly, skin-to-skin contact can be very calming and a great start to your first feeding. Be sure to work with a lactation consultant on proper latch and positioning. Many mothers of premature babies find the cross cradle hold helpful.  It may take some time for you and the baby to get into a good routine.

Did you know? If you leave the hospital before your baby, you can express milk for the hospital staff to give the baby by feeding tube.