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Pain and Discomfort ~ (part 3)

Dear parent, breastfeeding or pregnant mom, friend of breastfeeding and interested individual. Jeanelde asked me to answer the questions below as common concerns new or expecting parents might have regarding breastfeeding pain and discomfort.

Breastfeeding should be easy and trouble free. You might have heard the expression: “Breastmilk is FREE”*. Have you ever noticed the little “*” symbol at the end of this wonderful phrase? It stands for *”Terms and conditions apply”.

As mentioned at the end of part 2: The basis of breastfeeding is getting the baby to latch on well. A baby who latches on poorly has more difficulty getting milk and when a baby is latching on poorly, s/he may also cause the mother nipple-pain, which might lead to a decrease in milk supply and eventually premature weaning. So let us look at a few aspects of “Pain and Discomfort”.

How much will breastfeeding hurt?

Breastfeeding should not hurt!

If you have read part one, you will know, the best form of prevention is to get the best possible start and putting the baby to the breast correctly. If sore nipples were due to an incorrect latch, (since the most frequent causes of sore nipples are incorrect positioning at the breast and suction trauma), nipples should be better within a day or 2 after making sure baby latches “correctly”. During this time it might help to offer baby the least sore breast first, as most sore nipples hurt most at the beginning of a feed. DO NOT wait until breasts are very full before feeding, baby may have difficulty latching on (wake baby for feeds if necessary). DO NOT wait until baby cries for a feed. If needing to detach baby, use your finger to break suction.

During the first two to four days after birth, the mother’s nipples may feel tender at the beginning of a feeding as the baby’s early suckling stretches her nipple and areolar tissue far back into her/his mouth, called a nipple-stretching-pain. If a baby is positioned well at the breast, this temporary tenderness usually diminishes once the milk lets down (or maybe within 20 seconds or so), and disappears completely within a week or two. When nipples hurt, breastfeeding is in jeopardy. GET HELP!

Other (all preventable) reasons why breastfeeding might hurt:

“Complaint”	Symptoms	Causes	Treatment	Prevention
Engorgement	? Swelling, tenderness, warmth, redness, throbbing, pain, low-grade fever, and flattening / disappearing of the nipple in breast ? Taut skin on breast(s) ? Usually happens a few days after birth when milk “comes in”, around day 3 – 4	? Poor positioning and attachment ? Delayed initiation of breastfeeding ? Not emptying the breast ? Infrequent feeding	? Apply luke warm compresses/face cloth to breast(s) for a few minutes and gently stroke / massage the breast to get the milk flowing ? Express some milk before feed to soften areola / nipple area ? After feeding / expressing milk, apply cabbage leaves or cold pack / breast gel-packs to reduce swelling (cabbage leaves for a maximum of 20 minutes on skin), repeat every 3 hours ? Breastfeed more frequently and/or longer ? Improve infant positioning and attachment	? Correct positioning and attachment in the first few days ? Breastfeeding immediately after birth ? Breastfeeding on demand (as often and as long as baby wants), day and night, aiming for a MINIMUM of 8 feeds over a 24 hour period
Sore or Cracked Nipples (I have mentioned this, but let us take a look at it again since Cracked and Sore nipples are two of the most common reasons why women stop breastfeeding in the first days or weeks)	? Breast or nipple pain ? Cracks in / around the nipple(s) ? Occasional nipple bleeding / blisters ? Reddened nipple(s) ? Bruise / love-bite on / around nipple(s)	? Incorrect positioning and attachment (most common) ? Thrush (fungal infection) ? Bacterial infection ? Eczema / dermatitis (e.g. allergic reaction to ointment or breast pad) ? Vasospasm (Raynaud’s phenomenon) ? Milk blister / blep ? Washing breast with soap and / or antiseptics ? Tongue Tie	? Begin to breastfeed on the side that hurts less ? Make sure baby is positioned and attached correctly to the breast ? Let the baby come off the breast by him/herself after feeding ? Apply drops of breastmilk to nipples and allow to dry ? Expose breasts to air and sunlight ? Do not wait until the breast is too full to breastfeed. If too full, express some milk first ? Do not stop breastfeeding ? Do not use soap on nipples ? Jack Newman’s APNO (All Purpose Nipple Ointment) ? Have baby’s tongue & mouth checked for tongue tie	? Correct positioning of baby ? Correct attachment to the breast ? No use of soap on nipples
Insufficient Breastmilk – Causing Emotional pain	? Mother’s feeling of not having enough milk ? Insufficient weight gain (baby) ? Number of dirty / pooh nappies (fewer than 3 a day) ? Dissatisfied (frustrated and crying) baby	? Infrequent breastfeeding ? Tiredness, stress, hunger (baby) and pain (mother) ? Incorrect positioning and attachment ? Giving baby dummies or bottles	? Make sure baby is correctly positioned and attached to the breast ? Feed baby on demand (cue), day and night ? Increase frequency of feeds ? Stop giving water, other liquids, formulas, and dummies ? Wake baby up to feed if baby sleeps for too long (feed minimum 8x per 24 hours) ? Know you are able to produce sufficient milk, regardless of breast size ? Understand growth spurts, about every 2 weeks ? Let baby finish one breast first, before offering the second breast ? Check how many dirty / pooh nappies baby has in 24 hours: 3 or more indicates enough milk ? Try galactagogues (foods and drinks believed to increase milk production), e.g. Brewer’s Yeast tablets, Fenugreek ? Check for anemia (fatigue, dizziness), & low thyroid function (hair loss, dry skin, decreased appetite, fatigue)	? Breastfeed frequently ? Baby under 6 months, give only breastmilk, no water, liquids, or foods ? Breastfeed on demand, day and night ? Make sure your newborn (under 1 month old) feeds a MINIMUM of 8 times every 24 hours ? Correctly position and attach baby to the breast ? Encourage support from the family to help with household chores ? Do not give bottles and dummies
Plugged/Blocked Ducts	? Breast pain in affected area ? Redness in affected area of the breast ? Swelling ? Warmth to the touch ? Hardness with a red streak	? Tight clothing and brassieres ? Pressure on the ducts in the breasts from laying on affected area, too hard a hug, infrequent feeds, etc. ? Strenuous upper body exercise	? Give affected breast first during feeding ? Gently massage lump towards the nipple as baby is feeding ? Rest (mother) ? Breastfeed more frequently ? Properly position and attach baby ? Use a variety of positions to hold baby to rotate pressure points on breasts	? Ensure correct positioning and attachment ? Breastfeed on demand ? Avoid holding the breast in scissors hold ? Avoid tight clothing and brassieres ? Avoid sleeping on your stomach ? Use a variety of positions to hold baby to rotate pressure points on breasts
Mastitis	? Breast pain ? Redness in one area of the breast ? Swelling ? Warmth to touch ? Hardness with a red streak ? General feeling of malaise ? Fever	? Plugged ducts and engorgement if not properly treated ? Infection / cracked nipples	? Continue breastfeeding, even on the affected breast ? Apply luke warm heat before breastfeeding ? Breastfeed more frequently ? Correctly position and attach baby ? Seek medical treatment; antibiotics & anti-inflammatories may be necessary ? Increase maternal fluid intake ? Encourage maternal rest	? Breastfeed frequently ? Treat engorgement and plugged ducts ? Ensure correct positioning and attachment

What can I do to prevent sore and cracked nipples?

Well, I think you know the answer by now? Ensure correct positioning and attachment of baby at the breast and if that was not the problem, get your baby’s tongue checked by someone who knows how to assess tongue tie with, for example, the “Hazelbaker Assessment Tool for Lingual Frenulum Function”. Get breastfeeding off to a good start, before the milk supply increases dramatically by day 3 – 4 after birth, by starting breastfeeding as soon as possible after birth and staying in skin-to-skin contact with baby until breastfeeding is going well! GET HELP!

What can you do during pregnancy to prevent sore and cracked nipples? Well, breastfeeding is the natural way to feed baby and because of this, nature takes care of most of the main preparation for you, (which is the growth of milk-producing part of the breasts), so it happens naturally during pregnancy!!

Breast preparation is thus not necessary; what you could do is to wear a well-fitting bra, which gives adequate support to your enlarging breasts and this you could buy during the last weeks of pregnancy to ensure a correct fit. They should be comfortable as you might have to sleep in them for a few weeks or months after birth once your milk is “in” and you might need to wear breast pads for possible leaking. No nipple preparation is necessary, but it might help you to become accustomed to handling your breasts ;-). To protect the natural oils on your nipples, NO soaps, NO alcohol or other agents should be used on nipples, rather clean nipples by only washing them with water. Nothing should be applied to the nipples that would not be applied to the lips.

Get your mind ready for breast feeding: Educate yourself and your partner (and other main support) about breastfeeding basics by attending antenatal classes, reading good books, talking to breastfeeding mothers. Some mothers have seen little breastfeeding among their family and friends. Knowing some main points about positioning and attachment can help breastfeeding to go well. Pregnant mothers are welcome to attend La Leche League meeting where they can witness other mothers breastfeed ;-).

How can I treat sore and cracked nipples?

While you are working on correct positioning and latching of baby, research has found that warm, moist compresses (if a yeast infection is not present) can be soothing for sore nipple. The best part is you already have the best treatment for your nipples: your breastmilk!

Applying freshly expressed breastmilk to the nipples will not only soothe them but also reduce the chances of infection, as breastmilk has anti-bacterial, anti-fungal and anti-infective properties. Breastmilk also contains an epidermal growth factor which will assist with any healing. DO NOT apply moist tea bags or hair dryers or sunlamp as it may promote drying and cracking.

As mentioned, feed from the least sore side first, if possible. If it is necessary to remove your baby from your breast, break the suction gently by putting your pinky in the corner of baby’s mouth and push the bottom jaw down.

Correct positioning and latch, together with expressed breast milk, is the remedy of choice in much of the world. Even though your nipples might be sore due to an incorrect latch, once the latch is correct, the pain should be much less since the nipple will be in the comfort zone, way at the back of baby’s throat, along the palate, where there will be no abrasions or frictions.

What about a nipple shield? Will it create nipple confusion?

Kathy Parkes, IBCLC, said in a LEAVEN article that nipples shields, (artificial nipples worn over the mother’s nipple during a feeding) have, since the 1500s, been manufactured to provide a means of assisting infants at the breast or to protect a mother’s sore or damaged nipples. While nipple shields may permit breastfeeding to continue in some special cases, more often they give the illusion of solving a breastfeeding problem doing nothing to treat the cause of the soreness.

Nipple shields are frequently used (or misused) for the treatment of sore nipples (protection and/or prevention), flat nipples, engorged breasts, breast refusal, premature infants and when baby has “neurological challenges”. Problems frequently associated with nipple shield use are, a decreased in baby’s ability to remove milk from the breast, leading to a decrease in mom’s milk supply and babies may develop a preference to the taste or sensation of the shield, which may interference with proper direct latching on the breast.

When someone suggests a shield as a quick fix to the breastfeeding issues, make sure to answer these questions first:
◉Have you been helped to get the baby to the breast correctly or is the nipple shield the “first line of attack”? ◉Does the benefit of the shield outweigh the risks? ◉Does the use of the nipple shield fit your breastfeeding plan? ◉Will you be able to receive and comply with careful follow-up? ◉Do you understand that nipple shields are a temporary measure?

When the decision has been made to use a shield, follow these precautions for nipple shield use:
Help by a knowledgeable lactation consultant through assessment of and assisting in baby’s positioning and latch.
Use of a hospital-grade electric pump (to draw out flat or inverted nipples AND) to protect the supply after every breastfeed through a shield, (offer this expressed breastmilk with a cup, spoon, finger-feeding method as an additional top-up) until we know baby is able to get what s/he needs through the shield alone. This way you are feeding the baby (rule #1) and protecting your supply (rule #2).
Monitor baby’s weight gain weekly.
If you have not done so already, seek help addressing the initial problem that prompted the use of the shield.
Try to wean your baby from the shield as soon as possible, when ready.
Latch on with the shield and try to remove it when baby takes a break.
Feed with the shield on the 1st side, offer 2nd side without the shield.
NEVER cut a silicone shield to promote transition back to the breast.

What is nipple confusion?

Nipple confusion happens when a baby is given artificial nipples or pacifiers (dummies) and “forgets” how to breastfeed. Baby may start to root for the breast but either can’t latch or doesn’t move her/his tongue correctly when s/he does latch. When baby arch, cry, scream or actively push away or simply turn away in disinterest after exposure to bottles, it may be due to a flow preference. Once baby has become accustomed to the instant gratification of a bottle that flows immediately and never stops until its empty, it can be harder for the breast to compete.

Nipple preference can happen when there is a significant mismatch between mom’s nipple shape and the shape of the artificial nipple. E.g. when mom has a small nipple that protrude only slightly and the artificial nipple is large and long and easier to grasp, now baby gets confused between the prominent artificial nipple and the soft breast and small nipples (which was perfect to start off with).

About half of all babies have trouble going back and forth between breast and bottle. Possible problems that may develop includes: breast refusal, ineffective suckling and suckling changes that cause sore nipples. Babies are not born with labels, so you will not know if your baby is susceptible to these kinds of problems until after they occur. Baby’s suckling action on the breast is also completely different to that on a bottle or dummy; a different set of muscles is used.

In order to understand the difference between the way a baby uses a bottle nipple and a human nipple, here is a vivid demonstration: put your index finger in your mouth, closing your lips on the first knuckle. Begin sucking. Feel how your tongue flattens your fingertip up to the roof of your mouth. Now feel how your lips close around your finger very tightly. Feel the strength of your jaw and how your teeth make contact with your nipple. This simulates the way a baby sucks from most artificial nipples. It is also the same way a baby sucks when s/he is latched shallowly on the breast.

Now, put your finger in your mouth to the second knuckle. Notice that the tip of your finger almost touches the back of your soft palate. Begin sucking and feel the motion of your tongue, which is now elongated, curved around your finger, and massaging it. Feel the way your lips are slightly open and completely relaxed. Feel the way your jaw is more open and relaxed. Feel the way your teeth on your finger are now barely or not at all touching. This sucking technique approximates the way a baby sucks when s/he is latched deeply and correctly on the breast. Very different to the first-knuckle-finger sucking, don’t you think?

Breastfeeding directly also supports the normal development of a baby’s jaw, teeth, face, and speech. The activity of breastfeeding helps exercise the facial muscles and promotes the development of a strong jaw and symmetric facial structure. Several studies have shown breastfeeding to enhance speech development and speech clarity. An increased duration of breastfeeding is associated with a decreased risk of the later need for braces or other orthodontic treatment and the rate of misaligned teeth (malocclusion) requiring orthodontia could be cut in half if infants were breastfed for one year.

A word of caution: dummies are not remote-controls to put in baby’s mouth as soon as s/he says “eeee”, and you feel good, because it shut her/him up? Breastfeeding takes a few weeks to establish and breastmilk supply takes a few weeks to establish and dummies are sugarless gum for babies, it is an imitation of what a baby really needs. You already have two of the real thing! Dummies masks baby’s feeding cues and throws off his unique feeding rhythm. If used often enough, dummies can reduce the number of feedings per day during a time baby is working to set your milk supply. So during the first month to 40 days it is best to put away the dummy. Also think about it: baby’s tongue fills her/his whole mouth. The shape of baby’s palate is influenced in utero and after birth by the pressure of the tongue as it rests against the palate in the closed mouth. So where does the tongue go when we put a bottle or dummy in baby’s mouth? It is the bone that will eventually move not the muscle, causing the malocclusion mentioned above.

Are you worried about baby not taking a bottle when you have to go back to work? Researches have found that most babies will take the bottle easily whether started at 1, 2 or 3-6 months. When preparing to return to the work-force; speak to your lactation consultant on how to bottle-feed your breastfed baby, using the “paced-bottle feeding” method. You could also read “Balancing Breast and Bottle: Reaching Your Breastfeeding Goals” by Amy Peterson, and Mindy Harmer, Hale Publishing, 2009.

When and where to get help:
Breastfeeding should be easy and trouble free. If breastfeeding is difficult, especially during the 1st week, prompt and reliable assessment is vital! Breastfeeding families can get reliable help from an IBCLC** or a La Leche League Leader (LLLL)***. Great online resources are www.kellymom.com and www.nbci.ca (previously www.drjacknewman.com).

**IBCLCs (International Board Certified Lactation Consultants) have passed a rigorous examination that demonstrates their ability to provide competent, comprehensive lactation and breastfeeding care. IBCLCs may have different areas of expertise, so you might have to seek further help if you needs are not met. Email southafrica@iblce.edu.au for a list of IBCLCs in South Africa or on Facebook: Lactation Consultants (ibclc) South Africa or on Facebook: Breastfeeding Clinic.

***A La Leche League Leader is a mother who has successfully breastfed her own child for at least a year, and has been trained by La Leche League International in helping other mothers breastfeed. La Leche League Leaders are excellent in answering breastfeeding questions over the phone, and they are a perfect resource for older-baby breastfeeding question. Find a LLLL here: https://www.llli.org/southafrica.html or on Facebook: groups/lalecheleaguesouthafrica.

Next time, (and the last in this series of posts on breastfeeding), we will look at dietary requirements, alcoholic beverages, what to do if have flu or a stomach bug, taking vitamins and taking care of yourself while breastfeeding. Take care and have a great week!

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Leana, a mother of 3 beautiful breastfed children, has a degree in Nursing (from University of Stellenbosch) and she is a qualified Perinatal Educator (University of Johannesburg). She has been helping many parents prepare for birth and early parenthood through antenatal classes in Stellenbosch and Somerset West. Leana is also a La Leche League Leader and IBCLC (International Board Certified Lactation Consultant). Over many years, together with two colleagues at “The Breastfeeding Clinic” in Somerset West and Stellenbosch, she has helped many families nourish their babies with breastmilk

Visit Leana at The Breastfeeding Clinic
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