OW! IT HURTS!!!
It is generally said that when there is pain, it signifies there's something wrong. What you need to know when beginning to BF, is when the pain is something normal, and when it's an issue which could interfere with breastfeeding – and also whether you need to seek help to get that issue resolved.
Typical problem from a new Mum, and response click here
Common Issues:
Let Down - Engorgement - Positioning and Attachment - Thrush - Mastitus - Milk Blisters
Breastfeeding shouldn't hurt at all after first few weeks and where there is pain, 9 times out of 10 it's a problem with latch or positioning. In many cases the midwives and health visitors simply aren't educated about the mechanics of breastfeeding, or solving breastfeeding problems and simply advise new Mums to stop BF, use nipple shields, or to supplement with a bottle of formula, or to pump and supplement with EBM. In many cases this is the beginning of the end for breastfeeding as the introduction of bottles can mean baby starts to prefer the ease of the bottle to the breast, and often this is the worst advice e.g. where mastitis is concerned and the best advice would be to continue to drain the breast regularly; or supply diminishing and so best advice would be to keep baby at breast suckling as much as possible to restore supply.
When you first begin breastfeeding, you may find that there is some pain - often described as being ‘toe curling' – as baby latches on. Generally this will last no more than 15 seconds at the start of a feed, as the nipple extends in the baby's mouth, and ‘let down' is stimulated. This pain will fade and disappear over the next couple of weeks so that by week three you have all but forgotten about it! Your new baby is initiating the milk production reflexes – known as the ‘let down': there are tiny little muscles and ducts that have not been used previously and so they are obviously going to be tender at first. This is completely normal, and over time will become a slight tingle rather than a sharp pain. You may find that a baby crying in another room, or baby sleeping through a feed time, will also initiate the let down: this is when breastpads become invaluable as they catch the leaks so you don't soak your clothes! One way to stem the flow is to use the heel of your hand to press into the breast through the nipple towards your ribs as soon as you feel the start of a let down – whether that is pain, or tingle.
Early in your breastfeeding time, you may find that you suddenly have enormous and very tender, breasts. This is because your milk has come in and you are now able to feed baby milk rather than colostrum. Your breast may feel lumpy and hot – this is ok as long as you are draining the breast thoroughly by feeding your baby. After a feed there should be no lumps or red or sore areas on your breast. Often if baby sleeps longer than usual even after breastfeeding is relatively well established, or changes their routine, your breasts will become engorged then too, although your breasts probably won't have the monumental size they did when milk first came in! This engorgement, or ‘full' feeling when you have not fed baby for a while, will continue until perhaps 12 weeks or even longer. When you no longer feel full between feeds this is not a sign that milk supply is diminishing, rather that your body is getting better at the supply and demand nature of your baby's feeds, and adapting to the times your baby needs their milk.
Positioning / Latch / Attachment Issues
When BF counsellors are trained they are taught first about attachment and positioning -this is one of the main reason Mums have problems in the beginning. It's hard to describe in written word, but this is the info they give to Mums with pain during or after a breastfeed.
For latching on, follow this (adapted from BfN handout) - read it through first, then get someone to go through point by point and try it out, checking and rechecking:
Your posture:
back supported, shoulders over hips, lap flat or knees slightly raised (use footstool or yellow pages etc), use opposite hand / arm to the breast you will be feeding from to support baby's neck, shoulders etc. So, are you sitting comfortably?
Make sure you are sitting or lying comfortably, with plenty of cushions etc if required to prop your back or support baby's head, a drink, a snack and the remote controls! The more relaxed you are, the easier it is for your milk to be released.
Baby's position:
spine in line (head not dipped, drooping curled or turned), nose naval and knees all facing same direction, facing and at the same height as mother's nipple, supported at that level as appropriate (you might need rolled up towel or pillow here as well as for you in first section), hands free or one arm held down and under by mother (with her free hand, ame side as breast) or wrapped by sides. In many cases where there is pain, the baby is also being held too high up, so try to relax and lower baby so your arm is resting on your lap, rather than trying to raise things up with pillows!
Approach:
baby supported by hand and arm not just hand, baby close to mother - wrapped around and legs tucked under arm if nec, nothing pushing baby's head or restricting movement forwards or back, start with baby facing cleavage, move baby sideways from cleavage, towards nipple. Stop when baby's nose is in front of nipple. You may have to pull baby's feet further round your body to do this if using the traditional 'cradle hold', thereby moving baby more central.
Hold baby round the shoulders but support the head – if you try to push baby's head to you, they will push back against your hand.
Attachment:
wait for wide open mouth (baby should have to tilt head back slightly): tongue to be down and just appearing above lower gum margin. Move baby in towards body, not mouth towards nipple, so that lower jaw approaches first, and top lip last. The top lip should be latching on just over the nipple, with the lower lip as far away and taking in as much areola as possible - this is called the asymmetric latch. Make sure that the baby's chin is well into the breast, but the nose is free. There should be no pain or discomfort, though if you have had damage you may be able to feel it - but not as PAIN.
Suckling should follow the pattern (which may be repeated during the feed) of rapid shallow suckling then deeper, steadier suckling, occasional set of suckling with pauses / swallows, baby coming off breast - and at this point check that nipple shape is unchanged though nipple may be enhanced / bigger of course, but there should be no 'pointiness', or white patches at the end.
Signs baby is positioned correctly:
* when baby latches on, if you can see a bit of the areola at the top of their mouth that is fine, as long as all or most of the lower areola is in their mouth;
* baby's ears will move slightly as they massage the areola and swallow milk;
* there's no clicking noise;
* baby is swallowing deeply: if they stops swallowing they may be asleep (in which case tickle the feet or blow on the face) but if they still swallows but doesn't suckle now and then, its because they have massaged the areola enough to stimulate a milk 'let down' and the milk is released so baby needn't suckle for a little while!
Basically, to have the best supply of milk, your baby needs to massage the areola with tongue and jaw movements which encourage the milk to come out of the nipple via the 'let down' reflex. If you get your baby to take a lot of areola, the nipple is then pushed further to the back of his mouth where the soft palate is and it wont cause any pain: when there is pain, blistering, cracking or bleeding of the nipple, the most likely cause is that your nipple is rubbing on the hard roof of baby's mouth and getting sore. Any open wound may also have led to thrush, so check your infant's mouth for little white spots. You can get Fluconazole, Nyastin and other treatments for this from your GP if this is the case. See http://www.breastfeedingnetwork.org.uk/information/thrush.php for further details
Breastfeeding shouldn't hurt at all after first few weeks and where there is pain, 9/10 times it's usually a problem with latch or positioning. In many cases the midwives and health visitors simply aren't educated about the mechanics of breastfeeding, or solving breastfeeding problems and simply advise new Mums to stop BF, use nipple shields, or to supplement with a bottle of formula, or to pump and supplement with EBM. In many cases this is the beginning of the end for breastfeeding as the introduction of bottles can mean baby starts to prefer the ease of the bottle to the breast, and often this is the worst advice e.g. where mastitis is concerned and the best advice would be to continue to drain the breast regularly, or supply diminishing and so best advice would be to keep baby at breast suckling as much as possible to restore supply.
Sometimes, pain breast might indicate mastitis. Other symptoms such as Flu like symptoms and a sore red patch or blocked duct in the breast are further indicatiors. Mastitis often occurs when a milk duct gets blocked and the milk in side cannot get out so the duct becomes infected. If you have problems with positioning during a feed then perhaps the breast hasn't fully emptied, or perhaps your bra is rubbing or constricting, causing a blackage. If you think you have mastitis the following tips can help relieve the pain and hopefully clear it up:
1) A nice warm bath - expressing in the bath works well too.
2) Continuing to breastfeed is the best possible way to empty the breast as the baby's jaw and feeding technique are perfectly designed to suckle milk. The milk in the blocked duct doesn't adversely affect your baby at all.
3) Use a warm wet cloth on the painful breast to relieve pain and also massage the breast with your knuckles gently, known as ‘breast compression', to help move milk through the blocked duct while expressing.
4) Try to feed your baby in different positions: your baby will empty the part of the breast that his jaw stimulates the most so try to position his jaw where the pain is if you can, some mums find it can help to lean over the bed with their baby feeding upside down; try feeding lying down on your side, or with baby lying on you, perhaps holding baby under your arm (known as the ‘rugby ball' hold), and any other positions you can think of.
5) If you get or already have flu like symptoms, see your GP ASAP because if you get it badly you will need antibiotics to clear it up. If your GP is not available, make an emergency appointment with an out of hours service where available.
If you do go to the GP or HV and they tell you that you need to stop breastfeeding, please bear in mind that not all doctors and nurses are trained where breastfeeding problems are concerned: if you stop draining the breast either through breastfeeding or expressing your milk, and allow it to get more infected, it is possible for the infection to develop into an abcess which is a much bigger problem. Also, most antibiotics are fine to take whilst breastfeeding – make sure the doctor gives you one which is appropriate. For more information, see the BfN leaflet http://www.breastfeedingnetwork.org.uk/information/mastitis.php
Advice from the Breastfeeding Answer Book.
"White or clear nipple blisters, also known as milk blisters, may be caused by a plug, such as a granule of thickened milk, blocking the milk flow near the opening to the nipple, or a thin layer of skin blocking the opening of a milk duct from the outside.
For both causes, the treatment is the same: apply very warm compresses to the blister to soften it then immediately put baby to the breast, paying careful attention to god positioning and latch-on. The heat will cause the duct to expand slightly, which may allow the plug to pass through. If skin over the duct is the cause of the problem, the heat will thin the skin as it expands.
In most cases, once heat has been applied, the force of the mother's let-down reflex, in combination with the baby's suck will be enough to open the blister. After that, treat as you would any other sore nipple to help speed healing."
Some comfort measures to speed healing: smear some expressed milk onto the niple and leave to air dry; use lansinoh to keep the nipple moist between feeds; express to achieve letdown BEFORE latching baby on if baby's strong sucks make the pain worse; consider taking some pain relief.
If the above heat compress treatment does not open the blister and bring quick relief, then I'm afraid you need a health care professional to open it for you: some women pop the surface with a sterilised pin or similar, but this can result in infection and is not recommended.
Any lumpy engorgement puts you at risk of mastitus, so do try to get the lumps massaged out ASAP. The hot compresses should help there too, once you've got the blockage sorted.
NSAIDs (ibuprofen etc) might help stave off mastitus, and paracetamol will help with your current pain and any resultant fever. Both of these are fine in BFing mothers, but as ever read the label or seek advice.
Here's a typical cry for help from a new Mum, and a pretty standard response from Fiona:
"My baby is only a week old and I am in so much pain I don't think I can carry on with breastfeeding. My midwife told me that my latch is fine, but even with a nipple shield the pain in my breasts when I breastfeed my little one is almost unbearable and I am finding I dread the next time she wakes for a feed, and not enjoying her at all. I have cracks appearing on my nipples and blood comes out. I want to breastfeed because I know it's the best start for my baby but maybe I can express and bottlefeed my baby the milk?"
Congratulations on sticking with breastfeeding for a week even though you are obviously finding it very hard and distressing. It's really great that you've got this far.
Have you had any help and support with your problems so far? The commonest reason for nipple pain is that your baby isn't latching on quite perfectly. It may be that she's not getting your nipple quite far back enough into her mouth and so her tongue is repeatedly rubbing against the end of your nipple, and making it sore, even with nipple shields on.
There are other possibilities, like a thrush infection, but a "not quite right" latch is the commonest reason. Sometimes it can be quite subtle, but a slight change to the way you're holding her or getting her to open her mouth a little wider may make the world of difference. Some MWs and HVs are great with breastfeeding problems, but others have only very basic training and aren't so helpful. For extra help, you could contact one of the breastfeeding support organisations and talk one to one with a trained supporter about the problems you're having. You can find all the phone numbers here. You don't need to be a member of any of the organisations, and apart from the cost of the phone call the help is free, so it's really worth giving them a call. Have a look at these links about positioning too - there might be something that helps.
http://www.lalecheleague.org/FAQ/sore.html
http://www.lalecheleague.org/FAQ/positioning.html
It is possible to exclusively express and feed breastmilk by bottle, but direct feeding is easier in the long run. It's simpler, no need for sterilizers and all the paraphenalia that goes with bottle feeding, less time consuming and more convenient. Mums who feed directly also tend to have less worries about supply, as baby's suckling stimulates the breast to make milk more efficiently than a pump. I expect right now you're struggling to imagine breastfeeding even being bearable, never mind convenient and enjoyable, but if you can find a way through these early weeks, it can be. Many, many women will be able to relate to how you're feeling. These early weeks can be very hard, and "sore nipples" may sound trivial to some, but anyone who has experienced that pain knows how truly horrible it can be. But there is light at the end of the tunnel - please contact someone for the one to one support you need and deserve.
Fiona