Problemas comuns encontrados por mulheres que amamentam
Baixa oferta de leite; mamilos planos e invertidos
Problemas comuns encontrados por mulheres que amamentam A amamentação é a maneira como as mulheres alimentam seus bebês desde o início dos tempos, então você deve esperar que o processo ocorra sem intercorrências, certo? Afinal, parece justo que uma mulher que faz a escolha positiva de amamentar seu bebê seja capaz de amamentar pelo tempo que desejar. A verdade surpreendente e decepcionante é que os problemas de lactação ocorrem, mesmo entre as mulheres com as melhores das intenções e a maior motivação para ter sucesso na amamentação. Às vezes, os problemas envolvem os seios e mamilos da mãe ou estão relacionados à sua saúde geral. Outras vezes, os problemas de amamentação envolvem o bebê ou impactam seu bem-estar. Alguns problemas são devidos a circunstâncias fora de nosso controle, enquanto outros são o resultado direto de falta de conhecimento ou falta de confiança, técnica inadequada ou mau conselho. A maioria dos problemas que levam as mulheres a interromper a amamentação antes do desejado surgem nas primeiras semanas, mas uma queixa de amamentação pode se apresentar a qualquer momento durante a lactação. Quer os problemas de amamentação comecem no hospital ou apareçam meses depois, eles podem ser fonte de grande estresse e ameaçar a amamentação a longo prazo.
A importância de obter ajuda antecipadamente
O reconhecimento e tratamento precoce de um problema de amamentação oferece a melhor chance de que a dificuldade possa ser resolvida com sucesso. A mensagem principal é:Obtenha ajuda o mais rápido possível para que você possa resolver seu problema antes que ele se complique por falta de leite. Infelizmente, muitos profissionais de saúde praticam uma abordagem de esperar para ver as queixas de amamentação, esperando que quaisquer dificuldades sejam automaticamente corrigidas entre as consultas. Essa abordagem de não intervenção é compreensível considerando o pouco treinamento que a maioria dos profissionais de saúde recebe sobre o manejo dos problemas de amamentação. Sem medidas corretivas, no entanto, muitos problemas são agravados pelo baixo leite ou um bebê abaixo do peso, piorando uma situação ruim.
Por que os problemas de amamentação são facilmente complicados pela baixa oferta de leite
Dificuldades na amamentação podem causar desconforto físico, exaustão e frustração, bem como agitação infantil e baixo crescimento infantil. Além disso, muitos problemas de amamentação tornam-se facilmente complicados pela baixa oferta de leite. Muitas vezes, as queixas em mulheres que amamentam estão ligadas ao esvaziamento ineficaz ou infrequente do leite. Se o leite não for removido das mamas regularmente, um inibidor químico no leite residual se acumula e diminui a produção de leite. Além disso, a pressão excessiva do leite não esvaziado pode causar danos às glândulas produtoras de leite. Assim, o leite deixado na mama atua para diminuir ainda mais a produção de leite. Problemas que prejudicam a remoção do leite - mamadas pouco frequentes ou curtas, mamilos invertidos, infecções mamárias, mamilos doloridos, ingurgitamento mamário - podem resultar rapidamente em diminuição da produção de leite.
Mamilos planos e invertidos
Um mamilo plano é aquele que não pode ser feito para se projetar com estimulação. Um mamilo invertido retrai para dentro em vez de ficar ereto quando a aréola é comprimida. Tanto os mamilos planos quanto os invertidos podem dificultar a pega correta do seio pelo bebê. Eles também são mais propensos a traumas de esforços iniciais de amamentação, o que pode resultar em rachaduras dolorosas e pele danificada. Quando mamilos planos ou invertidos são descobertos no pré-natal, várias opções de tratamento estão disponíveis para retirar os mamilos. O mais popular deles é o uso de conchas de mama, também conhecidas como copos de leite, sobre os mamilos dentro do sutiã de maternidade. Esses dispositivos em forma de cúpula têm um anel interno que é usado sobre o mamilo. Quando uma concha de mama é colocada sobre um mamilo plano ou invertido, ela aplica uma pressão constante na base do mamilo, o que faz com que ele se projete através da abertura central.
Quando o tratamento pré-natal não é possível ou quando o problema não é detectado até depois do parto, as mães podem precisar de ajuda extra para iniciar a amamentação. Independentemente de seu(s) mamilo(s) plano(s) ou invertido(s) ter sido tratado no pré-natal, a coisa mais importante que você pode fazer quando seu bebê nascer é obter ajuda especializada com a técnica de amamentação adequada e orientação especializada para ajudar seu bebê a se agarrar corretamente ao seio.
Os mamilos planos podem variar desde aqueles que são apenas um pouco menos protuberantes do que o normal, até mamilos que são quase indistinguíveis da aréola circundante. Os mamilos invertidos variam desde aqueles com um leve vinco ou covinha central até inversões centrais profundas que interferem na pega do bebê e impedem que o leite flua normalmente. Dependendo das características de seus mamilos em particular, seu bebê pode pegar e puxar seus mamilos sem nenhum tratamento especial. Se seu bebê está tendo problemas para agarrar seus mamilos planos ou invertidos, você pode tentar as seguintes estratégias:
- Comprima suavemente e role o mamilo entre o polegar e o dedo indicador por um minuto para tentar deixá-lo mais ereto antes de tentar alimentar o bebê. Com paciência e persistência, seu bebê provavelmente pode pegar seu seio e mamar de forma eficaz, mesmo se você tiver mamilos planos ou invertidos.
- Use uma bomba tira-leite para retirar seu(s) mamilo(s) imediatamente antes de amamentar seu bebê. Uma bomba elétrica de nível hospitalar pode estar disponível no andar pós-parto para seu uso conveniente. Se uma bomba elétrica não estiver disponível, uma bomba manual pode ser usada para criar uma sucção suave e constante por cerca de trinta segundos.
- Se um mamilo for mais protuberante que o outro, comece suas tentativas de amamentação usando esse mamilo. Uma vez que seu bebê aprenda a mamar em um seio, ele pode ser mais capaz de puxar o mamilo do outro lado. Você pode aproveitar esse sucesso inicial ao oferecer o lado mais difícil.
- Use protetores de peito por cerca de trinta minutos antes de cada mamada para ajudar a puxar os mamilos para fora. Obviamente, os dispositivos devem ser removidos antes da amamentação. Algumas mulheres podem tolerar longos períodos de uso, mas o uso excessivo de conchas mamárias pode deixar os mamilos doloridos ao reter a umidade. Eles também podem causar ductos obstruídos pressionando os tecidos mamários inchados quando o leite entra. (Qualquer leite vazado que se acumule nas conchas deve ser descartado.)
- Se seu bebê não aprendeu a pegar bem em ambos os seios e mamar de forma eficaz dentro de vinte e quatro horas após o nascimento, recomendo que você comece a ordenha regular do leite. Use a bomba mais eficaz que puder obter, de preferência uma bomba tira leite elétrica de nível hospitalar com um sistema de coleta dupla. Bombeie seus seios por aproximadamente dez minutos após cada tentativa de alimentação. O bombeamento serve a vários propósitos. Ele extrai seus mamilos a cada ciclo de bombeamento e fornece drenagem eficaz de seus seios para garantir que você continue a produzir um suprimento de leite abundante. A extração também obtém leite materno extraído para complementar seu bebê até que ele aprenda a amamentar de forma eficaz.
- Enquanto seu bebê está aprendendo a mamar corretamente, alguns especialistas acreditam que é preferível não usar uma mamadeira para dar o leite suplementar necessário. Eles argumentam que a preferência pela mamadeira pode se desenvolver facilmente em bebês que não aprenderam a mamar de forma eficaz. Esses defensores recomendam a alimentação com copo ou outro método alternativo de dar o leite extra. Outros defensores do aleitamento materno insistem que o uso de mamadeiras não interfere necessariamente no aprendizado da amamentação, desde que a oferta de leite materno seja mantida abundante por meio de bombeamento frequente e o bebê seja orientado sobre a técnica correta de amamentação. Quando um bebê está tendo problemas para aprender a mamar devido a mamilos planos ou invertidos, sugiro evitar temporariamente a mamadeira, se possível, e escolher um método alternativo de alimentação suplementar, pelo menos durante o período em que você estiver no hospital.
Ingurgitamento Ingurgitamento mamário pós-parto
A quantidade de mulheres com ingurgitamento mamário pós-parto é altamente variável. Algumas mulheres mal percebem que o leite chegou, enquanto outras apresentam um inchaço, firmeza e desconforto extraordinários nos seios. A quantidade de ingurgitamento provavelmente é influenciada pela frequência de retirada do leite, o número de glândulas lácteas presentes, a taxa na qual os hormônios caem após o parto e outras diferenças individuais.
Problemas de amamentação relacionados ao ingurgitamento
Mais de cinquenta anos atrás, um notável médico britânico, Dr. Harold Waller, publicou um artigo perspicaz na literatura médica descrevendo a contribuição do ingurgitamento mamário grave para vários problemas de amamentação. Ele estimou que cerca de 20 por cento das mães de primeira viagem experimentaram ingurgitamento mamário muito dramático e tiveram dificuldade em estabelecer o fluxo de leite. Ele acreditava que esse ingurgitamento excessivo, se não aliviado prontamente, logo levava aos problemas descritos abaixo e era a principal explicação para o fracasso precoce da amamentação. Minhas próprias observações coincidem com as conclusões do Dr. Waller, e concordo plenamente com sua hipótese. Na minha opinião, o ingurgitamento grave ou não aliviado na primeira semana pós-parto representa a maior causa física isolada de amamentação malsucedida . O ingurgitamento grave, se não for prontamente aliviado, pode contribuir para cada uma das seguintes dificuldades:
O inchaço e a firmeza da mama podem tornar o mamilo e a aréola ao redor mais difíceis (certamente não mais fáceis!) de agarrar. Como resultado, uma criança pode pegar incorretamente, pegando apenas a ponta do mamilo, obtendo assim pouco leite e causando desconforto no mamilo. Os bebês que aprenderam a pegar corretamente no primeiro dia ou dois, quando o mamilo e a aréola estão macios e flexíveis, estarão mais bem preparados para mamar de forma eficaz, caso ocorra ingurgitamento excessivo mais tarde. No passado, quando as novas mães permaneciam internadas rotineiramente por vários dias após o parto, a produção abundante de leite começava antes da alta e as enfermeiras estavam disponíveis para ajudar as mulheres a posicionar seus bebês corretamente se o ingurgitamento estivesse presente. Hoje, no entanto, a maioria das mulheres encontra-se em casa quando o leite chega e são deixadas à deriva na experiência sem o benefício da orientação dos profissionais de saúde. Uma visita de acompanhamento precoce dentro de dois dias após a alta hospitalar pode ajudar a identificar bebês com problemas de pega devido ao ingurgitamento grave.
O inchaço da pele do mamilo e da aréola durante o ingurgitamento torna o mamilo mais suscetível a traumas durante as tentativas de amamentação e contribui para a dor. Os danos resultantes - muitas vezes com rachaduras, hematomas ou abrasões no mamilo - levam à dor no mamilo, variando de leve a grave, que pode interferir na amamentação. Assim, o ingurgitamento mamário desconfortável e os mamilos doloridos geralmente andam de mãos dadas, criando o que uma mãe chamou de "golpe duplo" na amamentação.
O ingurgitamento excessivo leva ao leite residual e à pressão elevada nos dutos de leite que causa a diminuição da produção de leite. Quando a pressão do ingurgitamento grave interfere no fluxo de leite, o leite residual nas mamas pode diminuir ainda mais a produção de leite. Assim, uma mulher pode passar muito rapidamente de muito para pouco leite. Mães que amamentam com mamadeira representam um exemplo comum de quão rapidamente o ingurgitamento não aliviado pode causar diminuição da oferta de leite. As mães que amamentam com mamadeira atestam que a extrema firmeza e plenitude dos seios diminuem substancialmente em cerca de 48 horas, à medida que as glândulas produtoras de leite param de funcionar. Assim, o período de ingurgitamento é um momento crítico no início da amamentação, muitas vezes o período do vai ou vem. Se o fluxo de leite for facilmente estabelecido e os seios forem drenados regularmente, a produção de leite total continua. No entanto, se a pressão nos seios tensos e apertados não puder ser aliviada e pouco leite for removido, o corpo da mulher reagirá como se ela estivesse amamentando. Dentro de poucos dias, uma mulher com ingurgitamento mamário não aliviado pode sofrer diminuição da produção de leite. Pode levar dias, ou mesmo semanas, de esforço dedicado para restaurar a produção de leite à sua capacidade total após apenas alguns dias de dificuldades iniciais. Às vezes, o efeito pode ser permanente. O ingurgitamento mamário não aliviado é mais do que um incômodo temporário ou uma inconveniência desconfortável. É uma ameaça muito real para o sucesso da amamentação porque é muito prejudicial para a produção de leite.
O ingurgitamento mamário grave e não aliviado pode dificultar a obtenção de leite suficiente pelo bebê durante a amamentação. Vários fatores podem limitar a ingestão de leite de um bebê durante o ingurgitamento excessivo. Não só a pega correta fica mais difícil quando as mamas estão inchadas e firmes, mas a pressão excessiva pode prejudicar o fluxo de leite. Uma mãe pode lutar na hora da alimentação para que seu bebê pegue e chupe bem, enquanto o bebê faminto chora de frustração por não ser capaz de posicionar adequadamente sua boca na aréola tensa. Ou, um bebê aparentemente pode mamar com bastante frequência, mas permanece subnutrido porque é incapaz de extrair leite de forma eficaz durante as tentativas de amamentação. Com o passar dos dias, o bebê pode perder uma quantidade excessiva de peso, tornando-se menos capaz de mamar de forma eficaz, ao mesmo tempo em que a produção de leite está diminuindo rapidamente. Esta é uma combinação perigosa que muitas vezes segue ingurgitamento mamário grave e não aliviado.
Tratamento do Ingurgitamento
Cronograma de alimentação
Se o ingurgitamento pode ou não ser prevenido por mamadas freqüentes, eu definitivamente concordo que ele é melhorado por enfermagem freqüente e eficaz. Quando o leite chega por volta do terceiro dia, o bebê deve mamar a cada duas ou três horas, pelo menos oito a dez vezes em vinte e quatro horas. Não é incomum que um bebê tenha um intervalo de sono mais longo (espero que à noite!). Normalmente, eu permitiria a um recém-nascido um trecho de cinco horas sem mamar em um período de 24 horas, mas se seus seios estiverem ingurgitados, eu não deixaria esse intervalo único mais longo exceder cerca de 3 horas e meia. Eu recomendo que você não permita que seu bebê use chupeta nas primeiras semanas de amamentação, e isso é especialmente verdadeiro durante o ingurgitamento. Não é bom para o seu bebê sugar de forma não nutritiva em uma chupeta quando seus seios cheios precisam ser drenados. Mesmo que seu bebê tenha mamado há quarenta minutos, se ele apresentar algum sinal de alimentação, coloque-o de volta no seu peito. É bem possível que sua última mamada não tenha sido muito eficaz e que ela tenha obtido pouco leite. Agora ela quer tentar de novo - e deveria! Seguir o relógio ("Puxa, ela ainda não deveria mamar") provavelmente impedirá que seus seios recebam a estimulação e o esvaziamento de que precisam e que seu bebê receba todo o leite de que precisa.
Posicionamento correto na mama
Passar pelos movimentos de mamadas frequentes não adianta muito se o bebê estiver posicionado incorretamente para mamar. Na verdade, pode piorar as coisas, causando mamilos doloridos que interferem nas mamadas subsequentes. Você pode ter que usar uma bomba de mama (veja abaixo) ou expressão manual para tirar um pouco de leite antes de pegar seu bebê. Extrair um pouco de leite primeiro suavizará a área da aréola do mamilo e facilitará a pega do bebê. Além disso, começar um pouco de leite pingando do mamilo ajudará a atrair o bebê para pegar. Segurando o seio no C-hold, com os dedos bem atrás da aréola, pode ser necessário comprimir suavemente o polegar e o indicador para tornar o mamilo e a aréola ao redor mais fáceis de agarrar. Certifique-se de que seu bebê coma uma grande quantidade de mama. Seus lábios devem ser flangeados, não enrolados.
Frio e Calor
Medidas simples como aplicação de frio e calor podem ajudar a aliviar o desconforto mamário e melhorar o fluxo de leite. A terapia fria está sendo cada vez mais reconhecida por seu valor na redução da inflamação e da dor. Bolsas de gelo tradicionais, compressas frias ou compressas frias comerciais - até mesmo sacos de legumes congelados! - podem ser aplicados nos seios ingurgitados por quinze a vinte minutos de cada vez para reduzir a congestão sanguínea e o inchaço dos tecidos. Isso diminuirá a pressão interna na mama e ajudará o leite a se mover pelos dutos até as aberturas dos mamilos.
Muitas mulheres atestam que seus seios começam a pingar leite quando estão debaixo de um banho quente. Essa observação levou à recomendação generalizada de aplicar calor úmido aos seios ingurgitados, principalmente antes das mamadas para aumentar a circulação no seio e trazer o hormônio oxitocina para ajudar a desencadear a descida do leite. Envolver os seios em panos ou toalhas quentes e molhadas por dez a vinte minutos não só é bom, mas também pode começar a pingar leite. Bolsas quentes comerciais estão disponíveis em um fabricante de bombas tira leite. Estas embalagens podem ser reutilizadas aquecendo-as no micro-ondas. Tenha cuidado para não queimar os tecidos mamários já esticados e danificados, especialmente na área sensível do mamilo. Experimente as aplicações de calor e frio para descobrir qual lhe traz mais alívio do desconforto e que ajuda melhor a melhorar o fluxo de leite e diminuir a congestão mamária. Você pode alternar essas terapias da maneira mais eficaz para você.
Folhas de repolho
Durante séculos, o repolho tem sido usado em muitos países como remédio popular para uma grande variedade de doenças. Todos os tipos de aplicações medicinais foram sugeridas para o repolho, incluindo comê-lo cru ou levemente cozido, beber suco de repolho fresco ou aplicar um cataplasma de folha de repolho cru. Nos últimos anos, vários especialistas em lactação sugeriram que envolver seios ingurgitados em folhas de repolho traz alívio rápido e eficaz do desconforto e facilita o fluxo de leite. Muitas mulheres atestam os benefícios desse tratamento, mas ainda faltam comprovações científicas para confirmar se tal terapia realmente é eficaz para o ingurgitamento mamário. O remédio caseiro é usado da seguinte forma:
- As folhas de repolho bem lavadas e secas, refrigeradas ou à temperatura ambiente, crocantes e verdes são preparadas retirando a veia grande antes de aplicar as folhas sobre o peito ou os seios ingurgitados. As folhas podem ser usadas dentro do sutiã ou como compressas cobertas por uma toalha fria. Buracos podem ser feitos nas folhas, se necessário, para permitir que os mamilos sejam mantidos secos. As compressas de folhas de repolho são deixadas no local por cerca de vinte minutos, ou até murcharem, quando podem ser substituídas por folhas frescas. A maioria das mulheres relata alívio significativo em oito horas. A aplicação continuada até dezoito horas foi recomendada para mães que precisavam desmamar abruptamente ou para mães que amamentavam com mamadeira severamente ingurgitadas que queriam secar completamente.
- As aplicações devem ser descontinuadas assim que o resultado desejado for obtido; alega-se que o sobretratamento reduz a oferta de leite. Os praticantes que usam folhas de repolho relatam que as mulheres geralmente precisam de apenas uma ou duas aplicações para estabelecer um bom fluxo de leite.
Muitas mulheres relutam em bombear ou extrair leite durante o ingurgitamento por medo de que possam estimular muito leite e exacerbar a condição. Mas o ingurgitamento é mais um problema de baixo fluxo de leite do que a produção excessiva de leite. A retirada do leite é essencial para reduzir a pressão nas mamas e o backup de leite que eventualmente pode diminuir a produção de leite. Melhorar a facilidade do fluxo de leite dos seios torna mais fácil para o bebê obter leite durante a amamentação. Como a situação muitas vezes é agravada por dificuldades infantis na amamentação, uma bomba tira leite pode ser extremamente útil no controle do ingurgitamento. Uma ampla variedade de bombas está disponível, desde bombas manuais baratas até bombas elétricas de nível hospitalar. Eu recomendo fortemente que você obtenha uma bomba elétrica de aluguel de nível hospitalar com um kit de coleta dupla que possa esvaziar os dois seios simultaneamente se seus seios ficarem gravemente ingurgitados. Como o ingurgitamento não aliviado pode ser tão angustiante e sua resolução imediata é tão crítica para o sucesso contínuo, você desejará ter os meios mais confortáveis, convenientes e eficazes de esvaziar seus seios. Se seu bebê não estiver mamando bem ou se seus seios permanecerem desconfortavelmente cheios após a amamentação, bombeie após as mamadas para extrair o leite restante e reduzir a firmeza da mama. Dez a quinze minutos de bombeamento com uma bomba elétrica geralmente são suficientes em uma sessão. Tempos de bombeamento mais longos podem danificar os mamilos e os tecidos mamários inchados. Para ingurgitamento grave, algumas mulheres obtêm melhores resultados bombeando uma mama de cada vez, em vez de ambas. Use a mão livre para massagear suavemente o seio durante a extração. A pressão constante aplicada às áreas de firmeza geralmente inicia o fluxo de leite, pelo menos brevemente. Quando o fluxo de leite parar, mude para a mama oposta. Massageie e bombeie no segundo lado enquanto estiver obtendo resultados. Em seguida, mude novamente quando o fluxo de leite parar. Após quinze a vinte minutos de esforço total, espere uma ou duas horas antes de tentar novamente.
Relaxamento
Faça o seu melhor para relaxar e visualizar seu leite fluindo. Estar ansioso e tenso só provavelmente inibirá seu reflexo de ejeção de leite. Toque música calmante ou pratique técnicas de relaxamento, como a respiração Lamaze. Peça ao seu parceiro para fazer uma massagem no pescoço ou massagem nas costas. Estenda os braços acima da cabeça e abaixe-os lentamente para os lados. Repita este exercício de "anjo voador" várias vezes. Muitas mulheres acham que ajuda o leite a descer.
spray nasal de ocitocina sintética
O hormônio que seu corpo produz para desencadear o reflexo de ejeção do leite e iniciar o fluxo de leite é conhecido como oxitocina. Uma forma sintética deste hormônio foi anteriormente comercializada como um spray nasal conhecido como Syntocinon (Sandoz Laboratories). O medicamento foi prescrito para mulheres que amamentam para ajudar a desencadear seu reflexo de descida e promover o fluxo de leite quando se pensava que o reflexo de ejeção do leite estava inibido. A ocitocina sintética às vezes era prescrita para mães de bebês prematuros e mães empregadas que precisavam de ajuda para condicionar seu reflexo de ejeção de leite ao usar uma bomba de mama. A medicação também foi recomendada para ajudar a aliviar o ingurgitamento mamário grave, desencadeando o reflexo de ejeção do leite e estimulando o fluxo de leite. Infelizmente, Syntocinon não está mais sendo comercializado. No entanto, um farmacêutico manipulador pode preparar um medicamento equivalente com receita médica. Um farmacêutico de manipulação é um farmacêutico que faz medicamentos sob medida a partir do zero. A Academia Internacional de Farmacêuticos de Manipulação oferece um serviço de referência para pacientes para ajudá-los a localizar um farmacêutico de manipulação em um raio de 80 quilômetros de seu CEP (consulte Lista de Recursos, página 451). Se outras medidas para aliviar o ingurgitamento não ajudaram, pergunte ao seu médico se vale a pena tentar o spray nasal de ocitocina sintética no seu caso.
Atraso na enfermagem; falha do leite; mamilos doloridos Ingurgitamento além do período pós-parto
Embora o ingurgitamento mamário represente o maior problema durante a primeira semana pós-parto, ele pode ocorrer novamente sempre que a remoção do leite for atrasada. Mesmo com a amamentação bem estabelecida, pode ocorrer plenitude e firmeza desconfortáveis sempre que os seios não são drenados regularmente. Permitir que as mamas fiquem marcadamente ingurgitadas coloca a nutriz em risco de várias complicações. Primeiro, seu suprimento pode diminuir como resultado do leite residual e do excesso de pressão nas glândulas mamárias. Em segundo lugar, uma mulher é mais propensa a uma infecção mamária sempre que seus seios não são bem esvaziados. Aqui estão alguns cenários comuns que podem levar ao ingurgitamento mamário prejudicial após a primeira semana pós-parto.
- Uma mãe decide pular algumas mamadas para descansar os mamilos doloridos e descobre que seus seios ficam duros e doloridos.
- Uma mãe volta ao trabalho oito semanas após o parto e não bombeia os seios durante o dia de trabalho. Ao meio-dia ela está desconfortavelmente cheia e começando a vazar leite (veja o capítulo 8 para obter conselhos sobre como combinar com sucesso a amamentação e o emprego).
- Uma mãe deixa seu recém-nascido de três semanas com sua irmã enquanto ela faz alguns recados e descobre que ela se foi por mais tempo do que esperava. Sua irmã dá uma mamadeira de fórmula para o bebê na ausência da mãe. Quando a mamãe finalmente chega em casa, seus seios estão completamente ingurgitados, mas seu bebê está dormindo com a barriga cheia e não mama.
- Um bebê de dois meses de idade totalmente amamentado, que anteriormente mamava uma ou duas vezes por noite, agora começa a dormir até de manhã. A mãe acorda com os seios desconfortavelmente duros e cheios.
Falha na lactogênese:o leite nunca entrou
Algumas mulheres sofrem de ingurgitamento extremo e outras ficam no extremo oposto do espectro, deixando-as em dúvida se o leite chegou. Ocasionalmente, a lactogênese, o início da produção abundante de leite dois a cinco dias após o parto, é atrasada entre as mulheres que têm complicações do trabalho de parto e parto. Raramente encontro mulheres cujo leite quase não sai. Muitas vezes, essas mulheres têm problemas médicos, como pressão alta, infecção ou anemia. Outros experimentaram extrema turbulência emocional. Em casos de estresse físico ou mental profundo, o corpo da mãe pode deixar de amamentar completamente para preservar a saúde da mãe. Como a lactação é o único processo eletivo realizado pelo corpo da mãe, não me surpreende muito que a produção plena de leite seja ocasionalmente inibida quando a mãe está muito doente. Às vezes, à medida que os problemas de saúde da própria mãe se resolvem, sua produção de leite aumenta constantemente se ela perseverar na amamentação.
Se você duvida que seu leite tenha nascido no quarto dia após o parto, eu aconselho você a verificar seu bebê para ter certeza de que ele não perdeu peso excessivo. Seu médico, um consultor de lactação ou uma enfermeira com experiência em ajudar mães que amamentam devem saber se sua produção de leite aumentou normalmente ou não. Se o seu leite não chegar em abundância até quatro dias após o parto, você deve começar a bombear após cada mamada para garantir que seus seios recebam estimulação e esvaziamento adequados para ajudar a aumentar seu leite. A sucção do seu bebê por si só pode não fornecer estimulação suficiente para aumentar sua produção de leite. Usar uma bomba elétrica de aluguel de nível hospitalar após a amamentação pode ajudar a aumentar a produção de leite. Raramente, uma mulher deixa de produzir leite suficiente sem culpa própria, tornando necessário que seu bebê receba suplementos regulares de fórmula.
Mamilos doloridos
A amamentação deve ser uma experiência agradável e, após a primeira semana, confortável. Estou surpreso com quantas mães aceitam mamilos doloridos como uma parte inevitável e desagradável da amamentação que deve ser suportada por mulheres excepcionais. Meus colegas e eu avaliamos mais de trezentas mães de primeira viagem quatro a oito dias após o parto e descobrimos que 13% estavam sentindo dores nos mamilos tão intensas que as levavam a temer as mamadas. Isso é mais de uma em cada dez mulheres que amamentam para quem a dor foi uma grande desvantagem para a amamentação. A maioria dessas mulheres assumiu que uma mãe que amamenta tinha que ser estóica para ter sucesso na amamentação. Isso simplesmente não é verdade. Embora a maioria das mulheres sinta um leve desconforto nos mamilos no início das mamadas durante os primeiros dias de amamentação, a dor intensa ou persistente nos mamilos não é uma parte normal da amamentação. O desconforto intenso está quase sempre ligado à técnica inadequada de amamentação e, quando presente, requer avaliação e tratamento.
Consequências de mamilos doloridos
Mamilos doloridos são mais do que apenas um incômodo. Essa queixa é uma das principais causas de interrupção precoce do aleitamento materno. A maioria das mulheres que optam por amamentar imagina que a amamentação envolverá interações descontraídas e gratificantes com seu filho. A dor associada à alimentação logo destrói a imagem tranquila de uma mãe que amamenta satisfeita e seu bebê satisfeito. A dor pode causar uma ruptura entre uma nova mãe que amamenta e seu bebê que amamenta. Lembro-me da súplica francamente triste de uma mãe desanimada com mamilos extremamente doloridos que implorou a seu bebê inocente:"Por favor, não acorde e precise de mim".
A dor no mamilo não só pode interferir na relação mãe-bebê, mas também pode levar à insuficiência de leite e ao crescimento infantil prejudicado. Você pode estar se perguntando como o desconforto materno pode estar relacionado à ingestão nutricional de um bebê. Na verdade, a causa mais comum de mamilos doloridos graves ou persistentes é o posicionamento inadequado da boca do bebê no seio da mãe. Se o bebê não agarrar todo o mamilo e a aréola circundante suficiente, a dor resultará e o bebê não extrairá o leite de forma muito eficaz. Se ela falhar repetidamente em esvaziar bem os seios, a produção de leite subsequente será reduzida.
Outras razões pelas quais os mamilos doloridos podem predispor uma mulher a leite insuficiente incluem alimentação restrita e diminuição da produção de leite. As mulheres que temem as mamadas tendem a pular, adiar ou limitar as mamadas, o que pode levar à diminuição do suprimento de leite. Além disso, a dor e outros estímulos nocivos podem prejudicar o reflexo de ejeção do leite, reduzindo assim o fluxo de leite durante as mamadas dolorosas. Você pode perceber que uma combinação de fatores está em ação para tornar a diminuição do suprimento de leite uma complicação comum da dor crônica nos mamilos. Eventualmente, mamilos doloridos persistentes podem levar a um ganho de peso infantil inadequado. Um ciclo vicioso pode acontecer, porque um bebê frenético e faminto pode mamar de forma irregular e produzir ainda mais traumas nos mamilos.
Sensibilidade precoce do mamilo
Desconforto leve nos mamilos geralmente está presente no segundo dia de amamentação e melhora quando o leite começa a chegar em abundância. O desconforto é maior no início das mamadas e raramente dura durante toda a amamentação. A melhora acentuada geralmente é notada a partir do quinto dia. Geralmente, nenhum tratamento específico é necessário e você deve esperar que a amamentação seja confortável após a primeira semana de início.
Mamilos doloridos causados por pega inadequada do bebê ou sucção incorreta
The most common cause of severe nipple pain or persistent pain beyond the first week is improper positioning of your infant's mouth on your nipple and surrounding areola. The most common error is to allow the baby to grasp only your nipple, instead of taking at least an inch of surrounding areola and breast tissue. The particular shape of your nipple and areola, the size and configuration of your baby's mouth, and your baby's unique sucking habits also can contribute to nipple discomfort. The problem of improper grasp is so common that I urge you to seek expert help in the hospital to assure that your baby is nursing correctly before you go home.
Babies' mouths and oral habits vary tremendously. Some infants have a receded chin at birth, making it difficult for them to position their mouth correctly on the lower portion of the nipple and areola. Others have a high-arched palate that affects the position of the nipple-areola in the baby's mouth. Some babies are born with oral habits they have been practicing in the uterus, such as tongue sucking or sucking their lower lip, that interfere with correct latch-on. When you add to all this the wide diversity of women's nipples-long, flat, inverted, creased, bulbous, large, and small-you can see why I consider that bringing a mother's nipple/breast and a baby's mouth together as a functioning unit is a true art form! Indeed, correct infant attachment is the foundation for breastfeeding success. It should be learned with the assistance of skilled helpers in the hospital, not by trial and error at home.
Some infants have a disorganized or abnormal sucking pattern that can produce nipple tenderness and create feeding problems. For example, some infants tend to clench or bite instead of sucking. Others may ball up their tongue instead of using it correctly to compress the milk duct sinuses and extract milk during breastfeeding.
The attachment of a baby's tongue to the lower mouth, known as the frenulum, can be too tight in some infants. The condition, known as tongue-tie, can prevent the tongue from protruding normally. The baby's tongue may not be able to extend beyond the gums or lips, and sometimes the frenulum extends clear to the tip of the tongue, causing an indentation when it is extended. Most tongue-tied babies are not bothered at all by the condition. In a few, however, tongue-tie can cause an infant to have difficulty breastfeeding and a mother to have extremely sore nipples. The limited mobility may prevent the tongue from cushioning the breast against the lower gums during nursing. In addition, limited mobility of the tongue occasionally leads to speech problems when a baby gets older. In cases where tongue-tie is believed to be causing sore nipples, surgically clipping the tight frenulum sometimes results in immediate, or gradual, improvement in breastfeeding and reduction of nipple pain. Clipping a short frenulum usually represents a simple procedure that is performed in a doctor's or dentist's office, although it is sometimes done under general anesthesia. Some controversy surrounds the practice, which was commonplace in past decades, but is seldom performed today. Since few physicians are aware that tongue-tie can cause breastfeeding difficulties, some may be reluctant to recommend clipping it. Among those practitioners who have experience performing the procedure are ENT specialists (otolaryngologists), oral surgeons, pediatric surgeons, and some dentists, pediatricians, and family physicians.
Treating sore nipples; blood in milk Routine Treatment of Sore Nipples
Assure that your infant is properly positioned to nurse and grasps your breast correctly. Carefully review the detailed guidelines for correct positioning and latch-on. Cup your breast in a C-hold, with four fingers below and thumb above. Make sure your fingers are placed well behind the areola. With your baby well supported, aligned with your breast, and turned completely to face you, gently tickle her lips with your nipple. When she opens her mouth wide, quickly pull her toward you so that she grasps a large mouthful of breast, with the nipple centered in her mouth. Do not let your baby munch onto your nipple or just grasp the tip without any surrounding areola. That is a sure setup for discomfort and ineffective milk extraction. It's always better to remove your baby and let her reattach to your breast than to continue to let her nurse with an improper grasp. The football hold makes it easier for a baby to attach correctly since this position affords the mother a good view of the baby's mouth on her nipple.
Begin feeding on the least sore nipple to trigger your milk ejection reflex. Once milk flow has begun and your baby has taken part of her feeding, she will be less hungry when brought to the second, more painful side. Your baby will nurse less vigorously after the let-down reflex has been triggered, making breastfeeding more comfortable. As soon as possible, resume alternating the breast on which you begin feedings to prevent a lopsided milk supply.
Frequent, shorter feedings are preferable to lengthy nursings spaced at wider intervals. Temporarily, limit feedings to ten minutes per side if your nipples are very sore. Many women with sore nipples postpone feedings because they dread the pain associated with nursing. However, this can result in a ravenously hungry baby who nurses more frantically and produces more trauma. Also, the longer feedings are postponed, the more engorged the breasts become, and the harder it is for the baby to correctly grasp the breast. Finally, less frequent feedings can diminish a mother's milk supply, which already has a tendency to be low in women with sore nipples.
Gently pat your nipples dry with a clean cloth after nursing to remove surface wetness. Excessive moisture on the skin surface can delay healing and cause chapping. If you wear breast pads, change them as soon as they become wet, and remove surface moisture after each feeding. However, don't go to extremes and excessively dry your nipples, as this can worsen the condition of your skin. In the past, many breastfeeding experts gave erroneous advice that led to excessive drying and cracking of nipples. Women were advised to use a hair dryer on a low setting or to expose their nipples to prolonged air drying in low-humidity environments. We now recognize that, just as excessive drying can crack and split chapped lips, it can contribute to breakdown and delayed healing of damaged nipple skin.
If you have cracks or other breaks in the skin, keep your nipples covered with a soothing emollient to maintain internal moisture. Applying a soothing ointment to sore, cracked nipples will protect them from excessive moisture loss and will speed healing. A coating of USP Modified Lanolin (medical grade) is the superior emollient to use on your nipples. This ultrapure grade of lanolin is sold as Lansinoh for Breastfeeding Mothers and PureLan. Apply the lanolin to your nipples after each feeding just as you would keep chapped lips covered with lip balm to maintain the normal moisture present in the skin and promote healing. Emollients like medical-grade lanolin are particularly effective in climates with low humidity to protect nipples from excess drying.
Many breastfeeding experts tout the well-known healing properties of milk itself. They recommend expressing a few drops of milk after each nursing, and gently coating the nipple with it, then allowing the milk to dry on the nipples. Although I have little firsthand experience with this practice, the many proponents of the technique claim it promotes healing of sore nipples. However, the nipples of nursing mothers inevitably are bathed in milk much of each day, affording them the benefit of milk's anti-infective properties. The reason I don't routinely recommend coating damaged nipples with milk after nursing is my belief that cracked nipples are similar to chapped lips. The constant wet-to-dry effect that results from frequent licking of chapped lips only provokes more drying and cracking. Rather than allowing milk to dry on nipples, it would seem prudent to remove surface wetness and then keep nipples protected with lanolin to avoid the wet-to-dry cycles that further damage skin.
Health professionals who specialize in wound healing have found that the use of moisture-retaining occlusive dressings are effective in promoting healing of wounds in other body sites. Recently some physicians and lactation specialists have tried this treatment with sore nipples. They are reporting good results using hydrogel dressings applied to the nipples between feedings to maintain a moist environment for nipple healing.
Wear wide-based breast shells over your nipples between nursings. These devices minimize discomfort from a crack or open wound and accelerate healing by preventing direct contact with nursing pads or your bra. Without these devices protecting your nipples, your bra or nursing pad might stick to a cracked or irritated area of nipple skin, causing the wound to reopen every time you remove the covering.
If your nipple pain is so severe that you are unable to tolerate nursing your baby, a hospital-grade rental electric breast pump can be used to express your milk comfortably. Pumping provides a convenient means of emptying your breasts and maintaining or even increasing your milk supply, while allowing your nipples to heal. Previously, I had been taught to believe that "no pump is as gentle or as effective as your nursing baby." We now appreciate that not every baby necessarily nurses correctly or effectively. Persistent pain during feedings is a sign that healing is not occurring. Trying to be tough and enduring the pain just subjects your nipples to continued trauma. In this case, the best electric pumps probably will be more gentle and more efficient than your baby's improper, uncomfortable sucking. We are fortunate to have highly effective hospital-grade electric pumps to break the devastating pain cycle, preserve milk production, promote healing, and provide the option of returning to breastfeeding after calm has been restored to a family. I recall one woman whose nipple pain was so excruciating that she admitted in private:"I expected breastfeeding to make me feel more connected to my baby. Instead, I look at her and dread the thought of having to feed again. The discomfort of breastfeeding is straining my relationship with my baby." This distraught woman was elated when pumping proved to be pain-free. Her whole attitude improved and she began to enjoy her baby more when she stopped associating her infant with pain. While her nipples healed, she fed her expressed milk to her infant, then cautiously resumed breastfeeding with expert guidance to assure proper technique. For this woman, breaking the pain cycle was the key to her ultimate breastfeeding success.
Blood in breast milk
I also recommend pumping instead of nursing when the breast milk contains blood from a cracked nipple (or other causes). Although many babies ingest blood-tinged milk without parents or health professionals ever knowing about it, drinking bloody breast milk is not entirely benign. For one thing, blood is irritating to the gut and can have a purgative effect. I recall a newborn who was admitted to the hospital for "bloody diarrhea" and was subjected to numerous diagnostic tests to determine the cause before it was found that the blood being passed was the mother's and not the infant's. The mother had been unaware that her painful, cracked nipple was bleeding, nor that her baby was obtaining bloody milk with breastfeeding. Ingested blood also can increase a newborn baby's bilirubin level, worsening infant jaundice. Furthermore, blood in breast milk can increase a baby's risk of acquiring certain infectious diseases while breastfeeding (if the mother is infected herself).
In general, hand pumps, battery pumps, and small electric pump models are not as comfortable or effective as the hospital-grade rental electric pumps.
If you decide to use a pump to interrupt breastfeeding and allow your nipples to heal, plan to pump your breasts every time your baby needs to be fed. This will be a minimum of eight times in twenty-four hours. You will want to express at least as much milk as your baby requires to be satisfied. A more generous milk supply is even better, and the excess milk can be frozen. When a mother's milk supply is abundant, her baby obtains milk more easily and is less likely to damage her nipples. Beginning about two to three weeks postpartum, the amount of milk you should expect to get from both breasts combined is about an ounce for every hour that has elapsed since you last pumped or fed your baby. Thus, if you pumped after a three-hour interval, you should get about three ounces. If you slept for a five-hour stretch at night, you would expect to pump about five ounces when you awoke. You can feed the expressed milk by bottle, cup, or other method approved by your baby's doctor. Keep in mind that a healthy baby shouldn't require more than thirty minutes to complete a feeding.
If you use an electric pump to heal sore nipples, I must emphasize the importance of obtaining expert help with your breastfeeding technique when you are ready to return to nursing. I recall one woman who spent nearly a week pumping and healing her severely cracked nipples, only to have the wounds reopen when she resumed nursing her baby using the same inappropriate technique that had damaged her nipples in the first place. Synthetic oxytocin nasal spray can be used to help facilitate the let-down reflex in women with sore nipples. As mentioned earlier, the pain of sore nipples can cause a woman to tense up at feeding times, resulting in inhibition of the milk ejection reflex. This only compounds the problem of sore nipples because a baby sucks more vigorously before milk lets-down. You can try simple strategies to help trigger your milk ejection reflex, such as breast stroking and massage, drinking a beverage, or using relaxation breathing. Synthetic oxytocin nasal spray is an additional aid that might prove helpful to some women with sore nipples by triggering their milk let-down.
First Do No Harm
One of the most important principles in medicine is "first do no harm." The sad truth is that inappropriate treatments often prove worse than no treatment at all. Over the years, some nipple creams have been marketed that were useless at best or that actually aggravated sore nipples. Many women are sensitive to the additives in various nipple creams. Some that were used in the past contained alcohol and other drying agents. One reason I recommend USP Modified Lanolin (medical grade) is that it is free of any other ingredients to which a woman might react. Although a popular belief exists that women who are allergic to wool will react adversely to lanolin, dermatologists insist that true lanolin allergies are very rare. Most women "allergic to wool" are sensitive to the fibers. If you suspect you may be allergic to lanolin, apply a small amount to your inner arm to see if you react before trying it on your nipples.
Most breastfeeding experts agree that medical-grade lanolin is the most effective and safest substance that can be applied to sore nipples to promote healing. PureLan and Lansinoh for Breastfeeding Mothers are the purest and safest brands of USP Modified Lanolin and do not need to be removed before feedings. I cannot recommend other creams, ointments, or topical applications because they are not as effective and some are not safe for infants.
Some breastfeeding counselors recommend applying ice to sore nipples. They claim that ice treatments temporarily desensi-tize sore nipples sufficiently to allow some women to tolerate nursing. While I advocate ice in the treatment of engorgement, mastitis, sports injuries, and other conditions, I do not recommend it for sore nipples. First, I don't believe in numbing the pain to make nursing tolerable. Discomfort while nursing is a warning sign that the baby is latched on incorrectly or that mechanical trauma is continuing and is preventing healing. I also think there is some risk of ice causing cold injury to the sensitive skin of the nipples.
Yeast infection; bacterial infection; sensitive skin Sore Nipples Caused by a Yeast Infection
Persistent nipple pain sometimes results from a yeast infection of the nipples. The problem occurs more commonly than appreciated, as few medical personnel are familiar with yeast infection of the nipples. Most women know about vaginal yeast infections, and new mothers soon learn that a persistent infant diaper rash can be due to a yeast infection. Yeast, also known as candida, thrive in moist environments, such as the mouth, the vagina, the diaper area, and the nipples of a breastfeeding woman. Although yeast commonly are harbored in these areas, they normally live in balance with bacteria and cause no symptoms. Certain conditions make a yeast infection more likely to occur. For example, treatment with antibiotics diminishes the growth of normal bacteria and allows yeast to overgrow and produce symptoms. Yeast aren't likely to invade normal skin, but once the skin barrier has been broken, damaged skin is more susceptible to a yeast infection. An ordinary diaper rash might develop when a wet/soiled diaper is left on too long. Once the rash persists for a few days, you should suspect that a yeast infection is now present.
Because some yeast are present in every infant's mouth, candida can easily be transferred to a mother's nipples. A yeast infection is more likely to develop if a mother has chronic nipple trauma from improper infant latch-on or incorrect suckling or if she has a crack, fissure, or opening in the nipple skin. A crack that has been present for several days may become infected by yeast, which can keep it from healing. Most breastfeeding specialists recognize the symptoms of a suspected yeast infection of the nipples. Unfortunately, relatively few obstetricians, pediatricians, or family physicians are familiar with the problem, which is seldom mentioned in traditional medical textbooks. An awkward situation often arises when a lactation consultant suggests the diagnosis, and the mother's physician is reluctant to prescribe treatment since he or she is unfamiliar with the condition. Some dermatologists will diagnose and treat yeast nipple infections.
The diagnosis of a yeast infection of the nipples is often based on circumstantial evidence. Proving that yeast are the culprit can be difficult, as culture results may be inconclusive. The following clues will help you suspect that your nipple pain is due to a yeast infection:
The timing and nature of the pain
The pain from yeast nipples typically starts after the first couple of weeks, although it can begin anytime. Usually, the mother has weathered early, mild sore nipples and has been nursing comfortably before pain starts anew. Mothers frequently describe their discomfort as burning, shooting, or stabbing pain that radiates from the nipples deep into the breast. Pain is present both during feedings and after nursing. Often, discomfort is so severe that the mother decides to wean. Nipple pain can be very chronic, sometimes present for weeks or months, virtually spoiling a woman's breastfeeding experience.
Appearance of the Nipples
Yeast infection of the nipples may cause surprisingly little change in nipple appearance. In fact, some practitioners wonder how a mother could complain of severe pain when her nipples may look relatively normal. Occasionally, they will appear pinkish. Rarely, the skin is inflamed with reddened bumps, typical of a baby's yeast diaper rash. I tend to suspect yeast if a crack, fissure, or other irritated area has been present for several days. Any break in the skin can be invaded by yeast.
Previous Problems with Yeast
Yeast infection of the nipples occurs more commonly among women who have experienced vaginal yeast infections during pregnancy and previous problems with yeast. Some women seem to be more yeast-prone than others. o Recent treatment of mother with antibiotics. Yeast infection of the nipples often starts during or after a mother's treatment with antibiotics. The antibiotics promote an overgrowth of yeast by destroying bacteria. A woman may have received a course of antibiotics to treat a uterine infection, breast infection, or other illness before she began experiencing nipple pain.
The Presence of Yeast Diaper Rash or Oral Thrush in the Baby
The possibility that nipple pain is due to a yeast infection should be considered whenever a baby has thrush (yeast in the mouth) or a yeast diaper rash. Yeast infections in the baby often occur after a course of antibiotics, for example to treat an ear infection. Oral yeast, called thrush, causes white patches on the baby's tongue (often assumed to be milk). It also can look like stringy white matter inside the baby's lips or cheeks (see photograph page 246). A yeast diaper rash looks bright red (common in the thigh creases and between the buttocks), with red bumps at the margins.
Other Risk Factors for Yeast
Diabetic women suffer more yeast infections than others, making them more prone to yeast nipples. Yeast infections are also more common among women taking birth control pills.
Treatment for Yeast Infection of the Nipples
If you suspect that you could have a yeast infection of one or both nipples, you will need to see a practitioner who can diagnose the problem and prescribe medication, such as your obstetrician or family physician. Although a lactation consultant may be more familiar with the problem, she may need to ask your doctor to write a prescription for you. A few pediatricians are willing to treat the problem in lactating women, and occasionally women seek help from a dermatologist. No studies have been conducted to determine the most effective treatment for yeast nipples, but several therapies are commonly prescribed, including a topical antifungal cream or ointment and/or an oral antifungal medication widely used to treat vaginal and other yeast infections (brand name, Diflucan; generic, fluconazole). Sometimes a topical cortisone cream is also recommended to reduce inflammation.
If the baby has a yeast diaper rash or oral thrush, proper treatment of the infant's yeast infections should be considered an essential part of your own therapy. Some practitioners recommend treating the baby even when no infant symptoms are present. Other things that will help combat a yeast infection of the nipples include the following suggestions:
Exercise good hygiene
- Wash your hands often, including after changing your baby's diaper or using the toilet and before and after breastfeeding.
- Keep your nipples free from surface moisture. Remember, yeast thrive best in a moist environment. Change your breast pads as soon as they become wet. Allow your nipples to air dry a few minutes after nursings.
- Boil pacifiers and bottle nipples at least once daily. Pacifiers and bottle nipples can harbor yeast and reintroduce it into your baby's mouth while you are trying to treat a yeast infection. If you use a breast pump, boil the breast shield that is placed over your nipple and the bottle at least once a day.
- Observe your baby for any signs of a yeast diaper rash or oral thrush. Ask your pediatrician or family physician to treat a possible yeast infection in your infant. Creams and ointments are available for diaper rashes and an oral medication is available for thrush. Babies and mothers often reinfect one another, so simultaneous treatment of the breastfeeding dyad is best.
- If you have any signs of a vaginal yeast infection, ask your obstetrician or family physician to prescribe treatment for you. Women with vaginal yeast infections are more prone to nipple yeast problems. One advantage of oral therapy is that it can eradicate yeast from other sites as well as your nipple infection.
- Consider interrupting breastfeeding temporarily by using a hospital-grade rental electric breast pump. Sometimes, when nursing is too painful to tolerate, pumping proves to be a comfortable alternative. Temporarily pumping instead of nursing also can speed your recovery from yeast nipples by breaking the mouth-nipple cycle of reinfection.
- It is popularly believed that yeast infections can be prevented by making dietary changes. Advocates of this belief recommend reducing one's intake of sugary foods and eating more yogurt with acidophillus.
Sore Nipples Caused by Infection with Bacteria
Sore nipples can also become infected with bacteria. When bacteria invade the broken skin barrier, the result can be worse pain, delayed healing, and the risk of progressing to a full-blown breast infection. The offending germs that invade a crack or break in the skin usually are those found in the baby's mouth, including staph germs. Germs found in feces also can cause nipple infections, especially when breastfeeding women forget to wash their hands after diaper changes. Yellowish drainage and surrounding redness may be evident in the infected area. A bacterial infection of the nipple is more likely to be present when a mother's nipple pain is severe, when a break in the nipple skin is present, and when the baby is less than one month old. A bacterial infection is also likely when an older nursing baby bites the mother's nipple and breaks the skin. Your doctor can confirm such an infection by taking a culture with a swab or make a presumptive diagnosis by judging from the appearance of the nipple. In addition to correcting any problems with the baby's latching technique, bacterial infections of the nipple should be treated with a course of oral antibiotics to assure prompt healing and to prevent mastitis. If you are prone to yeast infections, your health care provider may prescribe an anti-fungal medication to be taken simultaneously.
Sore Nipples Caused by Sensitive Skin
In addition to the causes of sore nipples just described, differences in skin sensitivity make some women more prone to nipple discomfort during breastfeeding. In the past it was commonly accepted that redheads and fair-skinned women were more likely to have sore nipples. While some experts dispute this popular belief, others, including myself, find some truth in it. In my experience, women who have very sensitive skin on other parts of their bodies often have more trouble with sore nipples. I think seasonal and geographic differences have an influence as well. In Denver, we see more women with nipple complaints in the fall and spring. Our humidity is so low that excessive drying of the nipples contributes to nipple breakdown. You might accurately guess that lanolin is very popular here!
Jaundice; leaking milk; clogged ducts Breast-Milk Jaundice
Jaundice is a yellowish skin coloration that becomes evident in more than half of all newborns. The yellowish color results from a substance in the blood known as bilirubin, which is released when red blood cells break down. Newborn jaundice can be due to many causes, ranging from benign to serious. The yellow color always should be reported to your baby's doctor.
It is generally agreed that breastfed newborns have a higher incidence of jaundice than formula-fed babies. There are two distinct reasons for increased levels of jaundice in breastfed babies. The most common explanation is known as breastfeeding jaundice. In this case, jaundice becomes exaggerated due to poor breastfeeding and low milk intake. Usually the baby is not nursing often enough or is not breastfeeding effectively. The infant may have lost excessive weight after birth or be failing to gain weight. Jaundice is noticed around the third day of life and continues for several days. The treatment of breastfeeding jaundice should be aimed at improving breastfeeding technique and assuring that the baby gets adequate nutrition. The bilirubin level falls rapidly once the baby is well fed.
The other type of jaundice that is linked with breastfeeding is called breast-milk jaundice. In this case, the bilirubin level becomes elevated as a result of an unknown factor in some mothers' breast milk that increases the absorption of bilirubin from the newborn intestines. This delays the excretion of bilirubin into the stools and causes the baby to remain jaundiced. The problem usually begins toward the end of the first week and can continue for many weeks.
With breast-milk jaundice, the baby nurses well, obtains plenty of breast milk, appears healthy, and gains weight normally. Although low levels of breast-milk jaundice occur quite commonly in breastfed infants, the bilirubin level rarely gets high enough to require specific treatment. If the bilirubin rises to a worrisome level (usually over 20 milligrams percent), or if the baby's doctor is getting anxious about whether some other medical problem could be causing the jaundice, the doctor may recommend that you discontinue breastfeeding for twenty-four to thirty-six hours to see if the bilirubin level drops. A dramatic fall in the bilirubin level within a day or so of interrupting breastfeeding confirms the diagnoses of breast-milk jaundice. During the time that breastfeeding is interrupted, the baby is fed formula. After breastfeeding is resumed, the bilirubin may rise slightly before it gradually declines to a normal level over a couple of weeks.
If your baby's doctor requests that you temporarily stop breastfeeding due to breast-milk jaundice in your baby, it is critical that you use an effective breast pump to empty your breasts at regular feeding times while your baby is formula-fed. This way, you will maintain an abundant milk supply and can resume breastfeeding easily. You don't need to discard your expressed milk while breastfeeding is interrupted. It can be frozen for later use.
Sometimes when a mother must interrupt breastfeeding due to breast-milk jaundice in her infant, she may assume there is something wrong with her milk and wonder whether she should return to breastfeeding. Please know that your milk provides perfect nutrition for your baby and that breastfeeding certainly is worthwhile! Many babies each year are needlessly weaned because of the diagnosis of breast-milk jaundice. Interrupting breastfeeding should be only rarely necessary for this condition. However, both mothers and doctors can become anxious when jaundice persists in a newborn baby, and your doctor may feel compelled to make a diagnosis and resolve the problem. Even when breastfeeding is interrupted, you should be able to resume nursing your baby within about thirty-six hours.
Excessive Leaking of Milk
Most women experience leaking of milk when their milk ejection reflex is triggered, perhaps upon hearing their baby cry or shortly after starting to nurse. Milk usually drips from one breast while a mother is nursing on the other side. For the majority of breastfeeding women, leaking milk represents little more than a minor inconvenience. Some even find it amusing to watch their milk spray during feedings or in the tub or shower.
I consider leaking milk to be an encouraging sign of a well-conditioned milk ejection reflex. Seeing milk flow freely makes me optimistic that a woman will succeed at breastfeeding. Despite my own enthusiasm over leaking milk, for some women, leaking is an irritating and embarrassing problem that represents a definite drawback to breastfeeding. Excessive leakers may complain of drenched clothing, soiled bedding, and constant wetness. To these women, breastfeeding is more messy than convenient. Women not only leak to different degrees but also react to leaking in different ways. For example, you may already have observed that your milk lets-down during lovemaking. Some women find this connection between breastfeeding and sexuality to be fascinating, even erotic, while others find it off-putting.
If leaking milk is a problem for you, let me help you reframe the issue so you might view it in a more positive light. You see, leaking is more than just normal-it's a wonderful marker for breastfeeding success. Leaking usually signals a highly effective milk ejection reflex and an abundant milk supply. When milk flows readily, babies usually nurse easily. Of all the breastfeeding problems I've encountered, I think leaking is the preferred one to have.
I don't mean to trivialize your concerns if you are one of those women who leak excessively and are bothered by it. The following pointers will help you better understand and deal with leak-ing milk:
- Leaking is usually worst from two to six weeks. It takes a week or two for the milk ejection reflex to start working well. Within several more weeks, the capacity of the milk ducts increases, so less milk leaks from the nipple openings when milk is letting-down.
- The sensations of the milk ejection reflex will alert you that your let-down is being triggered. You can stop milk from leaking by applying pressure against the nipple openings. To do this discreetly in public, cross your arms in front of your chest and press your thumbs against your nipples. No one needs to know what you are doing.
- To protect your clothing, wear washable or disposable breast pads inside your nursing bra to absorb any leaking milk. Change wet pads frequently, however, to keep your nipples free of excess surface moisture. Don't try to reuse disposable pads after they have dried, as they get very stiff and rough. Wash reusable pads and your nursing bra daily. If you don't want to purchase nursing pads, you can stitch together reusable ones from 100 percent cotton cloth. Even an all-cotton handkerchief works fine.
- You can wear plastic breast shells to prevent leaking milk from soiling your outer clothing. Breast shells, also known as milk cups, can be worn over your nipples and held in place by your nursing bra (see the photograph on page 59). Among their many purposes, breast shells are used by some women to collect leak-ing milk. (Don't try to save the milk that drips into breast shells.) Some employed breastfeeding mothers wear breast shells to protect their clothing since leaking at the workplace can prove especially embarrassing.
Sometimes one or more of the lobes of the breast don't drain very well, causing a temporary backup of milk, known as a clogged duct or caked breast. Unlike generalized breast engorgement, a clogged duct is a localized blockage of milk. A tender, hard knot can form in the affected duct system, and the surrounding area of the breast usually feels full and tender. Most often, the outer lobes near the armpits are involved, since more milk glands are concentrated in those areas. The problem usually results from incomplete emptying of milk from the breast or by going too long between nursings. A clogged duct also can be caused by breast trauma and chronic inflammation from a low-grade, unrecognized breast infection. Women who have an overabundant milk supply are more prone to getting clogged ducts. A few women are plagued by the problem.
A clogged duct can be quite uncomfortable, and if it doesn't get relieved promptly, it can progress to a full-blown breast infection. Don't ignore a clogged duct. It's an important warning sign and calls for your immediate attention to prevent a breast infection from occurring. The following simple measures usually provide relief for a clogged duct within eight hours:
- Nurse more often. A clogged duct is the result of incomplete or irregular removal of milk from the breast. The best way to counter it is to nurse more often. This is easier if you can be more available to your baby. Cut back on other activities as much as possible so you can concentrate on relieving the problem.
- Gently massage the clogged area. Gentle pressure applied to any tender knots or caked portions of the breast will help milk to flow from the obstructed area. Keep your massage gentle, as overly rough manipulation of the breast increases the risk of mastitis. Massage and pressure work best when applied prior to and while nursing your baby.
- Start several feedings in a row on the clogged side. A baby's most vigorous nursing occurs at the first breast suckled. To help drain the clogged side, you can start several consecutive nursings on the affected breast. Be careful, however, not to let the second breast remain overly full or you could develop a blocked duct on that side or a decline in your milk supply.
- Vary your nursing position to empty all lobes well. Different nursing positions result in better drainage of different lobes of the breast. In addition to the traditional cradle hold, try the cross-cradle hold, the football hold, and lying down to nurse to find which position works best to empty your clogged area. Try pointing his chin toward the plugged duct.
- Take a warm shower or apply warm compresses to the caked area. Heat usually helps trigger the let-down reflex and facilitates milk flow. Many women spontaneously drip milk in the shower or bathtub. Try applying warm compresses to the clogged area, especially just before nursing and in conjunction with breast massage.
- Use a breast pump to empty the engorged area well. If your baby doesn't nurse well or you are separated from your baby during part of the day, you may need to use an effective breast pump to relieve a clogged duct. Women who have an overabundant supply may need to periodically express some surplus milk to soften their overfull breasts.
- Try to identify and eliminate any risk factors you may have, especially if you have a recurring problem with clogged ducts. As mentioned earlier, women with superabundant milk supplies are at increased risk for clogged ducts whenever their breasts don't get well drained. Other risk factors include an erratic feeding or pumping schedule-typical of employed mothers-or wearing a constrictive bra. In addition, breast trauma, such as being bitten or kicked by the baby or massaging the breast too vigorously, can produce inflammation in a duct system and interfere with milk drainage. If you suffer frequent clogged ducts, I suggest you review your breastfeeding practices with a lactation consultant.
I have encountered more than one woman in my career who had a cancerous breast lump which was mistaken by her physician for a clogged duct. Although the mass persisted for months, proper diagnosis of the malignancy was inappropriately delayed, while treatments were prescribed for the presumed "clogged duct." Please never label a persistent breast lump as a clogged duct. Clogged ducts come on abruptly, are painful, and resolve within a day or so. Only a few things can happen with a true clogged duct. It will clear quickly, and the tender lump will disappear; it will progress to mastitis, which will become painfully obvious; it won't empty well, so the lobe will partially dry up, in which case the lump will disappear; or, it will temporarily resolve, but return at a later date. Any lump that persists for days or weeks must be accurately diagnosed. It is not a clogged duct.
Mastitis Breast Infection (Mastitis)
Mastitis is the medical name for a breast infection. It is a miserable, "flu-like" illness that is accompanied by an area of pain and redness in the breast. The condition seldom occurs in women who are not lactating, but it is not uncommon among breastfeeding women. As many as 10 percent of nursing mothers will have a breast infection during the course of breastfeeding.
A breast infection is usually caused by bacteria, often the same germs that are normally present on the nipple and in the baby's mouth. Many factors can increase a nursing mother's susceptibility to mastitis. Chief among these is irregular or incomplete removal of milk from the breast. Poor emptying can result from many causes, such as too long an interval between feedings; ineffective removal of milk by the infant or by a breast pump; having a clogged duct that prevents proper milk drainage from a particular lobe; or wearing a tight-fitting bra that impedes milk flow. Infecting bacteria can enter the breast through a cracked nipple or duct opening to cause mastitis. Any type of breast trauma will also predispose a lactating woman to mastitis. The trauma can result from infant teething, incorrect infant latch-on or abnormal infant suckling, generating excessive vacuum pressures with a breast pump, or by an older baby pinching the breast. In my experience, maternal exhaustion also leaves a mother vulnerable to mastitis. The infection often strikes employed mothers, sleep-deprived women, or mothers with house guests or holiday plans. The typical symptoms of mastitis are outlined below.
Achy, "Flu-like" Feeling
Women coming down with or suffering from full-blown mastitis mistakenly may assume they have a bad case of the flu. Because flu-like symptoms are so common with mastitis, physicians are taught that "flu" in the breastfeeding mother is mastitis until proved otherwise. Indeed, women unaware that they have mastitis may call their doctor to request treatment for the flu or to inquire whether their baby might catch the flu from them by nursing. Only after gathering more information does it become evident that the mother is really suffering from mastitis. I also recall a woman who telephoned to ask whether the over-the-counter medication she was taking for her flu symptoms could harm her nursing baby. Further probing revealed that she actually had mastitis. If you become ill with body aches and flu-like symptoms, it is possible that you have mastitis, and you should notify your doctor.
Breast Pain, Redness, and Firmness
Most women with mastitis will be able to pinpoint a painful area in one or both breasts. The affected spot is usually pink or red and firmer than other areas of the breast. The pain can range from severe, even exquisite, to a vague achiness or tenderness to the touch. Usually, an entire wedge-shaped lobe of the breast will be involved, starting at the nipple and extending toward the chest. Any portion of the breast can be affected, but the outer areas next to the armpits are common sites, since the milk glands are concentrated in these locations. The skin over the tender area can range from faintly pink to fiery red and tight. The painful area is usually firmer than the surrounding tissues due to obstructed milk flow from the infected lobe. In some cases, the entire breast becomes hard and swollen. I recall one woman in whom the first symptom of mastitis was unexplained diffuse engorgement of one breast. Fever, redness, and flu-like symptoms eventually followed within eighteen hours, but the initial sign of mastitis was sudden obstruction of milk flow from one breast.
Fever and Chills
Mastitis usually produces some degree of fever, but the achiness and breast pain often precede the temperature elevation. While some physicians won't treat mastitis unless a fever is documented, I recommend antibiotics if flu-like symptoms and a red, tender area of the breast are present. I had mastitis once myself when Mark, my youngest, was eleven months old. I awoke in the middle of the night, certain that something was wrong. My nipple and areola were exquisitely tender and by morning my breast hurt and I felt awful. I sought medical attention, convinced that I had mastitis, but my caring, knowledgeable doctor was hesitant to treat since my temperature was barely elevated. By late afternoon, I was much sicker and had a definite fever, so antibiotics were started. I subsequently have seen other women with the same progression of symptoms, so now I recommend treatment even if a fever is not yet present.
Headache
Few physicians or parents associate a headache with a breast infection, but an unexplained headache often is present in women with mastitis. Of course, a headache can have many causes, ranging from sleep deprivation to high blood pressure. If you have a headache along with any other symptom of mastitis, you might have a breast infection. Even if you have no other symptoms of mastitis, any severe or persistent headache should be reported to your doctor.
Nipple or Areolar Pain
A breast infection can start when bacteria enter the milk ducts at the nipple opening. At first, the infection might be contained in one of the lactiferous sinuses under the nipple, before progressing into the breast. An area of the areola that is tender to the touch or painful during nursing can be a symptom of an early breast infection. The infection can quickly spread from the duct system to affect a whole lobe of the breast.
Can I Continue to Breastfeed with Mastitis?
In the past, physicians believed that women with mastitis needed to wean, both to speed their recovery and to prevent their babies from becoming ill. This belief arose in the pre-antibiotic era, when the postpartum hospital stay was lengthy and when severe mastitis often occurred in epidemic form in a large hospital ward. Today, mastitis is milder and occurs sporadically, not in epidemics, and it is readily treatable with antibiotics. Not only is continued breastfeeding allowed, it is preferable. Women who wean abruptly when they have mastitis are at greater risk of developing a breast abscess (a walled-off pocket of pus that must be drained). Most cases of mastitis are caused by germs from the baby's own nose and throat. Medical authorities generally agree that a mother who gets mastitis while nursing her healthy infant can safely continue to breastfeed through the illness. Of course, whenever a mother or other family member is sick, the baby should be observed carefully for any signs of illness, such as poor feeding, irritability, listlessness, difficulty breathing, or fever. It is possible, although not likely, for a baby to develop a serious infection with the same germs that have caused mastitis in the mother.
In a few instances, I believe that a baby should NOT be fed milk from an infected breast. For example, if a mother is pumping her milk for her premature or sick newborn and develops mastitis, this is a different situation from the woman who comes down with a breast infection while nursing her healthy infant. I recommend that mothers who are pumping milk for high-risk infants discard all milk expressed from the infected breast until their symptoms clear up. Meanwhile, the baby can still be fed the milk pumped from the unaffected breast. Such decisions should always be made in consultation with your baby's doctor. I also recommend "pumping and dumping" when the milk from the infected breast contains visible blood or pus.
Treatment of Mastitis
Call your obstetrician or family physician promptly if you have any symptoms of mastitis. The sooner you start treatment, the sooner you will feel better and the less likely complications, such as a breast abscess, will occur. A breast abscess is an exceptionally painful walled-off pocket of pus that cannot be treated effectively by antibiotics unless the pus is drained. Ultrasound may help diagnose a breast abscess. Usually, a breast abscess results from inadequately treated mastitis.
Take the antibiotic your doctor prescribes for the full course of therapy, even if you feel much better after a few days. Mastitis should be treated for ten to fourteen days to be sure the infection is thoroughly eradicated and that an abscess doesn't occur. A number of antibiotics can be used to treat mastitis successfully. Recurrences do occur when the wrong antibiotic has been used, when the infection is treated for less than ten days, or when medication doses are taken irregularly. Although most antibiotics used to treat mastitis are compatible with breastfeeding, you always should let your baby's doctor know what medication you are taking since some of it will pass into your breast milk.
Rest in bed as much as possible for a day or two. Take my word for it, mastitis is a miserable illness. Being run-down probably made you more susceptible to infection in the first place. Now is the time to pamper yourself so you can get well before attempting to resume all your responsibilities. Enlist all the help you can from your partner, extended family, friends, neighbors, or members of your church. For at least two days, arrange to be relieved of all your duties, except breastfeeding your baby, of course, and pumping if necessary. Try to find other caretakers to supervise older children, perform household chores, and care for the baby when you are not nursing. Don't try to be a martyr. Instead, learn to ask for what you need and to be a gracious receiver of care from others. With full-blown mastitis, it can take thirty-six to forty-eight hours before you notice significant improvement in terms of breast pain, fever, and body aches. Call your doctor if you aren't feeling much better within two days.
Drink plenty of fluids, especially if you have a fever. Fever markedly increases your fluid requirement and places you at risk for becoming dehydrated. Dehydration not only makes you feel worse, but it can reduce your milk supply. Normally, nursing mothers should drink an eight-ounce glass of water or nutritious beverage with every feeding. During an illness, you will need to drink additional fluids. If your appetite is diminished, at least try to consume liberal quantities of juice, soups, and gelatin. If your mouth feels dry or your urine is infrequent or dark, you are probably somewhat dehydrated.
You will probably require pain medication the first two days of your illness. Ask your doctor for a prescription if necessary. Ibuprofen is a good choice for over-the-counter pain medication, because only minimal amounts of this pain reliever are excreted into milk. Furthermore, the anti-inflammatory effects of ibuprofen help reduce the breast inflammation that accompanies mastitis. Rarely, prescription pain medication is necessary for a day or two. Fortunately, after twenty-four to forty-eight hours of antibiotic therapy, the breast discomfort usually improves dramatically.
Nurse more often, especially on the affected side, to keep your breasts well drained. Failure to remove milk from the breasts at regular intervals can make a woman more susceptible to a breast infection. Similarly, leaving the breasts full and engorged during a bout of mastitis makes it more difficult to cure the infection and increases the risk that a breast abscess will form. Although a woman with a breast infection should try to keep her breasts well drained, this can be difficult to do for several reasons. First, the pain of mastitis can make a woman postpone feedings or limit nursing on the infected side. Second, breast inflammation can interfere with normal milk flow, leading to swelling, firmness, and engorgement in one or more areas. So the very thing that's needed-effective milk removal-is more difficult than usual to accomplish. Try to nurse as often as possible. It will probably be more comfortable to start feedings on the good side until the let-down reflex is triggered. Once milk is flowing, move your baby to the infected breast until it is drained well.
If nursing your baby on the infected breast is extremely painful, or if you are having trouble getting milk to flow, it might be necessary for you to use a hospital-grade electric breast pump for a couple of days. Some mothers with mastitis find pumping to be more comfortable than nursing their baby. You can use the pump to regularly remove milk from the infected breast while continuing to nurse on the good side. Pumping will help improve emptying and maintain your milk supply in the infected breast until you are able to tolerate full breastfeeding again.
Consider requesting a prescription for synthetic oxytocin nasal spray if your milk isn't letting-down. When a woman has mastitis, her milk ejection reflex may not work as well. Not only does pain inhibit milk let-down, but the breast inflammation caused by mastitis also impedes milk flow. Some women report improved milk flow when they use synthetic oxytocin nasal spray before pumping or nursing. The potential benefits of the medication must be weighed against the expense. If the infected breast is very engorged and you cannot get milk to flow with the measures described on the preceding pages, then synthetic oxytocin is worth a try.
To prevent getting a recurrence of mastitis, search for and eliminate any risk factors that might be present. All too often, doctors treat mastitis solely by prescribing an antibiotic. Many women suffer recurrent bouts of the illness without ever figuring why they are at increased risk. In my opinion, searching for risk factors that predispose a woman to mastitis is an essential part of the treatment plan. In addition to the more common risk factors listed below, I have found that mastitis often follows some type of vigorous upper-body activity, such as jumping rope, scrubbing a floor, vacuuming, raking, mowing the lawn, rowing a boat, lifting and moving things, or doing jumping jacks. I suspect that vigorous upper-body exercise in women with heavy, milk-laden breasts causes leakage of milk into the breast tissues. Such leakage produces inflammation, which can progress to infection. While I'm not suggesting that a breastfeeding woman never exercise or attend an aerobics class, I do think she should only participate in such activities after first nursing and while wearing a good support bra. I have encountered some women who were plagued with recurrent bouts of mastitis that occurred in relation to vigorous upper-body exercise. Most of these women decided to discontinue the mastitis-provoking activities until they weaned their babies.
Factors That Predispose Women to Mastitis
- Infrequent or ineffective removal of milk from the breast
- Cracked or chronically sore nipples
- Fatigue, exhaustion
- Overabundant milk supply
- Trauma caused by infant, especially teething/biting
- Vigorous upper-body exercise
- A constrictive bra (especially underwire types)
Overabundant milk supply; refusal to nurse Overabundant Milk Supply
I have made so many references in this book to low milk supply that you might wonder whether anyone really produces excessive quantities of milk. While many more women seek help for too little milk than for too much milk, an overabundant supply is a frustrating problem for some women. Obviously Mother Nature prefers to closely match a woman's supply to her infant's need. The process of lactation is not efficient when a woman's body makes surplus milk that isn't needed by her infant. I don't know why some women produce extra, unwanted milk, while others fail to produce enough. Although low-milk problems often result from improper breastfeeding management, overabundant milk production is usually unrelated to a mother's breastfeeding practices.
I am convinced that women vary widely in their capacity to produce milk. In earlier times, some mothers with overabundant supplies sought employment as wet nurses. I suspect that an overabundant supply results from a triple combination:exceptional production capacity, a brisk and well-conditioned milk ejection reflex, and a superefficient nursing baby. While generally preferable to low milk, the problem can still be a source of frustration and discomfort for both mother and baby. Women with an overabundant milk supply often voice the following complaints:
- Breasts that easily become uncomfortably engorged
- Dramatic (sometimes painful) sensations of the milk ejection reflex
- Chronic leaking milk
- Repeated clogged ducts
- One or more breast infections
- Rapid weight loss due to the high metabolic demands of producing so much milk
- Choking and sputtering when milk lets down
- Excessive gas and abdominal discomfort from overeating
- Rapid weight gain
- Inability to enjoy "comfort nursing" since the baby obtains unwanted milk even when trying to nurse to sleep
- Frustration with breastfeeding that leads to early weaning or a nursing strike
Meanwhile, you can try some of the following strategies to help your baby enjoy nursings better, to prevent the risk of clogged ducts and mastitis, and to gradually reduce your milk production:
Position your baby so that his head and throat are higher than your nipple. By nursing "uphill," he will be better able to control your overly fast flow of milk. Use the football hold and lean back to elevate your baby's head. Or, try the cradle hold, with your baby elevated higher than usual, while you lean back in a recliner.
If your let-down is causing your baby to choke and/or cry, temporarily interrupt the feeding until your milk stops spraying. Then allow your baby to resume feeding after the milk flow has slowed.
The two key ways to reduce milk production are to remove less milk at each nursing and to remove milk at less-frequent intervals. To prolong the interval at which milk is removed, you can try nursing on only one breast at each feeding, alternating the breast you use. Using one breast at each nursing might also make feedings go more smoothly for your baby. After the initial rapid flow tapers, your baby may be able to comfortably handle the milk volume from a single breast. However, the unsuckled breast may be left uncomfortably full and place you at risk for mastitis. If you decide to use one breast, you probably will need to express sufficient milk from the opposite breast to relieve some of the pressure and keep you comfortable. Eventually, the milk supply should decrease.
Another way to modify feedings is to allow your baby to nurse from both breasts at each feeding, but to avoid emptying either side well. The first breast will be left softer than the second, but neither will be thoroughly drained. You'll want to nurse at the first breast for at least five to seven minutes after your milk lets-down to assure that your baby gets ample hindmilk. Once he switches to the second breast, some mixing of foremilk and hindmilk already will have occurred. What isn't desired is to have your baby take only the watery foremilk from each breast.
Some women with overabundant milk choose to obtain a hospital-grade electric breast pump so they can soften their breasts whenever the need arises. They simply freeze their excess milk for later use-perhaps after they return to work.
Where feasible, supermilk producers can collect and donate their surplus milk to a Donor Milk Bank. This is an option available in Denver since we have a large distributing Mothers' Milk Bank. Being able to provide extra milk for infants in need serves to reframe a woman's "problem" and turn it into a positive.
Note :As unlikely as it seems right now, you actually can go from too much to too little milk in only a few days. I have seen this happen a number of times when women started skipping nursings and leaving their breasts engorged. Remember, extra milk is preferable to insufficient milk!
Nursing Strike
Occasionally, a breastfed infant starts refusing to nurse without apparent explanation. Nursing strike is an apt term used to describe this sudden breastfeeding refusal. It occurs most commonly between four and seven months of age. In a typical case of nursing strike, a mother will report that when she offers her breast, her baby cries, arches his back, pulls away, and essentially rejects the breast. He may latch on for a few seconds, but does not suckle for any appreciable time. The baby usually accepts a bottle well and is content to bottle-feed. Faced with this frustrating behavior in her infant, it is not uncommon for a woman to give up nursing and explain that her baby "weaned himself." Other women are distressed at the prospect of not being able to continue breastfeeding and seek advice from their doctor or a breastfeeding counselor. With prompt intervention, nursing strikes can often be remedied, thus preserving the opportunity for a woman to continue to breastfeed.
At first consideration, a nursing strike appears to occur suddenly and without obvious reason. Upon more careful examination, however, I find that one or more contributing factors are usually present. Some infants begin their distressing behavior during the course of an upper-respiratory infection. A stuffy nose can create distress when a baby tries to breath while nursing. Or an ear infection can be more painful when a baby reclines to nurse. The refusal behavior sometimes coincides with teething and may be the result of discomfort while sucking. I'm also aware of a few instances of nursing strike that started after a teething infant bit his unsuspecting mother and caused her to shriek in surprise and pain-which, in turn, startled and upset the baby. A busy mother may find she has been hurrying feedings to get to other activities instead of permitting her infant leisurely nursings. Another baby may go on strike because he has been frustrated by an overabundant milk supply or an overactive milk ejection reflex. The common theme in these examples is some type of unpleasantness associated with breastfeeding.
While any number of reasons-recognized or overlooked-may contribute to a nursing strike, I have come to conclude that many cases also involve a gradually dwindling milk supply . After the early months of frequent, round-the-clock nursing, many mothers begin giving supplemental bottles and spending increased periods of time separated from their babies. A mother's milk supply may decline after her baby starts sleeping through the night, causing her breasts to go eight, ten, or twelve hours without emptying. At first a mother may not even be aware that her supply is less abundant or that her baby is becoming frustrated with the increased effort to obtain milk. Without consciously planning it, she actually may have started weaning, and her baby may decide to escalate the process abruptly through a nursing strike. Thus, I believe the common denominator of nursing strikes all too often is low milk supply. When diminished milk flow is coupled with a baby who has been exposed to the ease of bottle-feeding, abrupt refusal to nurse can result. Low milk volume and bottle use aren't always to blame, however. Other cases have been described in which the mother had an abundant milk supply and the baby was being fully breastfed.
If your baby is manifesting a nursing strike, seek consultation with a lactation consultant or other breastfeeding specialist. You also should let your baby's doctor know that your infant is experiencing this feeding problem. The physician will want to make sure that no illness is present to explain your baby's behavior and that the infant continues to receive sufficient nourishment during the period of breast refusal. Effective treatment of a nursing strike involves three key strategies:
1. First, try to get your baby to return to breastfeeding by attempting to nurse him in his sleep. Fortunately, most infants will cooperate, although some may cry upon awakening and finding themselves at the breast. Eventually, your baby may awaken and continue to nurse without protest. Some mothers have found that they could keep their child nursing by walking with the infant. Bottle-feeding should be avoided if at all possible. If your baby requires supplemental milk, several options are available for providing it without using bottles. If regular bottle-feeding is inevitable, try to have another caretaker give the bottle. If breastfeeding frustrates your baby because it does not satisfy his hunger, you may be able to woo him back to the breast beginning with "comfort nursing" after he has been given supplemental formula to curb his appetite.
2. Eliminate any unpleasantness associated with nursings and remedy any exacerbating factors. If your baby has a cold, nurse your infant after clearing the nasal passages with a bulb syringe. If you think an ear infection could be present, have your child checked and treated. Attempt to nurse in subdued, quiet surroundings to minimize distractions, and let your baby take all the time he wants. If discomfort from teething seems to be contributing to difficulty nursing, soothe your baby's gums with a cold teething ring.
3. Evaluate your milk supply and, if low, attempt to increase your milk production. Even if your supply was normal prior to the nursing strike, your milk can rapidly decrease if your baby refuses to nurse. Once the original problem is compounded by low milk, it will be even harder to get your baby back to breastfeeding. So, unless your infant immediately can be enticed to resume breastfeeding at the normal frequency and for a suitable duration, you will need to obtain an effective breast pump to maintain (and increase) your milk supply. While hand expression and manual pumps prove highly effective for some women, in general, I recommend an efficient hospital-grade electric pump to regularly empty your breasts and keep your milk production up until your baby is nursing well once again.
Pumping can create a potential dilemma since you can't predict when your baby might be willing to cooperate and nurse. It's possible you will finish emptying your breasts with the pump just when your baby acts like he might be willing to breastfeed. On the other hand, if you leave your breasts unemptied while waiting expectantly for your baby to suckle, your milk supply may dwindle. I would advise putting your baby to breast every couple of hours (preferably with the infant asleep or drowsy at first). Then, you should pump both breasts immediately after your nurs-ing attempt to assure they are well drained.
With sufficient reassurance, a strong commitment to nursing, and the temporary discontinuation of bottle-feeding, a nursing strike often can be overcome. Increasing your milk if it is low and nursing your baby in his sleep are your best strategies.
Medications; infant allergies Maternal Medications and Breastfeeding
FamilyEducation Editor's Note: For the American Academy of Pediatrics' latest guidelines on medication safety for breastfeeding women (effective September 2013), click here. Many medications can be taken while breastfeeding, but always check with your doctor, who will likely consult a drug-safety database called LactMed for the most recent studies and information on medications for nursing women. Some of the information in the section below may change over time as new drugs and studies come out.
Nursing mothers naturally are concerned about the potential dangers of medications they take being transmitted to their babies through their breast milk. In fact, all drugs are excreted to some degree in breast milk, and medications should not be taken indiscriminately by nursing mothers. Many factors have an influence on the amount of drug that will be transferred into milk, including the dosage amount and dosing schedule, how the drug is taken (e.g., oral versus by injection), the physical and chemical properties of the drug, the amount of breast milk the baby drinks, how often the baby is fed, and how long the drug is needed. Fortunately, most medications taken by breastfeeding women are safe for nursing infants, because the amount of drug present in breast milk usually is minimal.
However, lack of information about drug excretion into breast milk frequently has resulted in misconceptions and exaggerations about the risks to the infant. Often, nursing mothers are mistakenly advised to wean their infants when the medication prescribed for them actually would have been compatible with breastfeeding. Or, a mother may decide not to take a medication she needs because she is worried that it could have a harmful effect on her baby.
Some drugs may cause temporary side effects in infants when they are passed into breast milk. One study examined adverse reactions in more than eight hundred infants who were breastfed by women taking medications. Although no major adverse effects requiring medical attention occurred in any of the infants, about 10 percent of women reported minor adverse reactions in their infants. Here are the most common reactions according to drug category:antibiotics caused diarrhea; prescription pain medication caused drowsiness; antihistamines caused irritability; and sedatives, antidepressants, and antiseizure medications caused drowsiness. In all cases, the benefits of breastfeeding were felt to outweigh the temporary, minor effects of a maternal medication on the infant.
A few drugs that are necessary to protect a mother's health are too toxic for breastfed babies. Included among those that are considered incompatible with breastfeeding are cancer chemotherapy medications, drugs that suppress the immune system, and lithium, used to treat bipolar disease (although some women have breastfed while taking lithium, without apparent harm to their infants). Other drugs, such as some antidepressants, may also be of concern.
In the past, many prescription drugs were said to be unsafe for nursing mothers simply because little information was available about how much of the drugs entered the breast milk. As medical knowledge about the topic has increased, many drugs that were previously considered to be contraindicated during breastfeeding are now considered to be compatible with nursing. Because knowledge about drug excretion in breast milk changes so rapidly, it is a good idea to get a second opinion whenever you are advised that breastfeeding is not possible with a certain medication. Ask the physician prescribing the drug, as well as your baby's doctor, before concluding that weaning is necessary. Often pharmacists, especially those at drug information centers, have the most up-to-date information. The Drug Information Service sponsored by the University of California at San Diego will answer inquiries from the public about medication use during breastfeeding. If the drug being prescribed poses a risk to nursing babies, the pharmacist might be able to suggest a safer alternative. The American Academy of Pediatrics (AAP) publishes and regularly updates an excellent reference for health professionals about the transfer of drugs and chemicals into human milk. Ask your doctor if he or she has a copy of the latest version of this AAP publication. Other helpful guidelines for breastfeeding women requiring medications are outlined below.
- Whenever your doctor prescribes a medicine for you, ask whether it is safe for breastfeeding. Whenever you are taking a drug, notify your baby's doctor and observe your infant carefully for possible side effects. Report these to your baby's doctor at once.
- Take only necessary and effective medications. When choosing over-the-counter drugs, avoid multi-ingredient medications to treat minor symptoms.
- When feasible, it is generally preferable to take a medication right after nursing your baby. For most drugs, the peak concentration in breast milk will usually be reached between feedings if the medication is taken right after nursing.
- When once-daily medications are prescribed, the dose can be taken just prior to your baby's longest sleep interval at night. Most long-acting drugs, however, will maintain a fairly constant level without identifiable peaks.
- If you are nursing and must take a medication that is believed to pose a risk to your infant (such as a radioactive compound), you can temporarily interrupt breastfeeding without permanently weaning. A rental electric breast pump can be used to express your milk at regular intervals and maintain your supply until you have completed the course of therapy and can safely nurse once again.
- When you have advance knowledge of the need to take a medication (e.g., for elective surgery), you can pump extra milk and freeze it prior to beginning your course of therapy. Your baby can be fed the stored breast milk while nursing is interrupted. Of course, you will have to pump and discard your milk while taking the drug that is unsafe for breastfeeding.
Some Drugs That Should Not Be Taken During Breastfeeding*
- Cancer chemotherapy drugs
- Drugs that suppress the immune system
- Lithium
- All illicit drugs
- Radioactive drugs (usually taken for diagnostic scans)
- Acetaminophen
- Antibiotics (most)
- Antihistamines (most)
- Antiseizure medications (most)
- Blood pressure medications (many)
- Blood thinners (most)
- Diuretics (most)
- Ibuprofen
- Insulin
- Over-the-counter medications (most)
- Pain medications (most)
- Prednisone
- Thyroid replacement hormone
- Antianxiety medications, such as Valium
- Antidepressants, such as Prozac, Zoloft
- Antipsychotic medications, such as Thorazine
- A few antibiotics, including chloramphenicol and ciprofloxacin
While true allergy to mother's milk has never been proved, some breastfed infants react adversely to certain foods consumed by their nursing mothers. Mothers of these babies typically report that their infant becomes fussy three to six hours after the mother has eaten an offending food. It usually takes one to four hours for allergic components of foods to appear in mother's milk. A baby may react within minutes after nursing, but usually within two to four hours. The reaction can continue as long as the offending substance remains in the mother's system and continues to enter her milk. This can be three to four days or longer after eating certain foods.
Common Offending Foods in the Mother's Diet
The most common foods that provoke allergic reactions in nursing in-fants include milk and other dairy products, wheat, eggs, peanuts, soy, fish, corn, and citrus. Often the food (or foods) the baby reacts to is something the mother eats daily or something she ate frequently during her pregnancy, such as orange juice or a peanut butter sandwich.
Typical Infant Symptoms of Allergy
Common allergic symptoms seen in breastfed babies include skin rashes, red cheeks, vomiting, diarrhea, runny nose, cough or congestion, fussiness, and "colic." Breastfed babies who are fussy due to allergies to foods in the mother's diet tend to be adequately nourished, or even overweight, rather than underweight. As a result of their frequent fussiness and apparent discomfort, their mothers may try to nurse more often and can end up overfeeding their babies.
Not all adverse reactions to foods the mother ingests are true allergies. Babies can be sensitive to foods in other ways than an allergic reaction. For example, babies might be extra fussy and irritable if their mothers consume too many caffeinated drinks, or they can become gassy due to broccoli, onions, or cabbage in the mother's diet. These unfavorable reactions are not true allergic reactions.
Keeping a Food/Behavior Diary
If you think your baby is reacting to something in your diet, discuss this with your child's doctor. You also should start keeping a meticulous food/behavior diary. Record on this daily log what and when you eat, when you nurse your infant, and the time and type of problem behavior observed in your baby. A sample food/behavior diary is available at the here. While you are keeping a record, simplify your meals. Try to eat only three food items at a meal. Avoid multiple seasonings and multiple ingredient dishes. By scanning your daily diary, you should be able to track the relationship, if any, between your baby's symptoms and specific foods you eat.
Eliminate Offending Foods
Don't get overzealous and go on a drastic elimination diet. Instead, be a sleuth as you review your diary to determine the most likely offending foods. This kind of detective work often pays off. Usually, only a few foods in your diet cause a problem for your baby. Completely eliminate the one or two most likely offensive foods for at least four to five days-preferably a week. That should be long enough to get the food entirely out of your system. At the end of a week, rechallenge with the particular food to see if your baby's symptoms reappear. Far too many women arbitrarily eliminate foods in hopes of reducing colicky behavior in their baby. I've met breastfeeding women who have restricted their intake to only half a dozen foods in a desperate attempt to improve their baby's symptoms. A drastic elimination diet is only likely to reduce your milk supply and make you feel like a martyr. Women who eliminate major food groups, such as dairy products, from their diets should receive nutrition counseling from a registered dietitian or their physician. Such women may require appropriate supplements to replace essential nutrients in the eliminated foods.
Prevention of Allergies in At-risk Infants
Infants at high risk for allergic disease include those who have a parent, sibling, or other close relative with food allergies, asthma, or eczema. Prolonged exclusive breastfeeding has been shown to reduce the likelihood of allergic symptoms in these at-risk infants. Breastfeeding is especially protective if the mother also eliminates the most common allergenic foods mentioned earlier from her diet during pregnancy and as long as she is nursing. Mothers of potentially allergic babies should also rotate their foods, avoiding eating any single food on a daily basis. Try to resist cravings and avoid eating large quantities of one food. You might be able to eat a small amount of an offending food every three or four days, but not every day. Once your baby starts solid foods, discuss with her doctor the plan for introducing new foods, especially allergenic ones like milk, egg, wheat, peanut butter, corn, citrus, and shellfish. If you have a strong family history of allergic disease or believe your baby displays allergic-type symptoms, I suggest you seek consultation with a pediatric allergist or an environmental medicine specialist. Allergic disease can be a chronic, frustrating problem-even a life-threatening one if anaphylaxis (severe allergic reaction with shock and airway obstruction) occurs.
*List is not inclusive
Colic; excessive crying; overactive let-down; GER Colicky Behavior in Breastfed Infants
Few things are more distressing to parents than the sound of their own baby crying. Mother Nature intended it this way, to guarantee that well-meaning parents would promptly respond to their baby's needs. Fortunately, by trial and error and good intentions, most parents soon learn to read their baby's cues and thus manage to keep crying to a minimum. Since human milk is the ideal infant food and is so readily digestible, breastfeeding parents often assume that their babies automatically will be content most of the time. But babies have a wide range of temperaments and differing needs. Some are naturally easy and predictable, while others are extrasensitive and more difficult in general. Babies cry an average of one and a half to four hours a day in the first six weeks of life, but any crying can feel like too much when it exceeds a parent's threshold for coping.
Colic is a vague term that describes excessive crying in an otherwise healthy baby for no apparent reason during the first three months of life. No specific cause or treatment has been identified, and parents are typically advised to use comfort measures to cope with the excessive crying until their baby outgrows the problem. Often, a baby is labeled as being "colicky" (crying without an explanation) when the infant, in fact, has a reason for crying that hasn't been recognized. If your breastfed baby cries excessively without an obvious explanation, consider the following possibilities:
Hunger
When a breastfed baby cries a great deal, the first thing to consider is the possibility of hunger. Neither the number of nursings nor the length of feedings can provide absolute assurance that your baby has gotten enough milk. Many breastfeeding mothers automatically assume that their baby can't be hungry because "I just fed him." But having nursed recently doesn't guarantee that your baby isn't still hungry. Sometimes babies nurse without having latched on correctly or without sucking properly. Sometimes the milk doesn't let-down briskly or a woman doesn't produce enough milk to satisfy the baby. Thus, an infant might "go through the motions" of nursing without actually getting a full feeding.
If your baby cries excessively and you can't figure out why, start with a weight check to be sure he is gaining at an appropriate rate. Don't settle for telephone advice about your baby's "colicky" behavior unless your infant has been weighed within the last week. Time and time again, we have evaluated a breastfed infant referred to the Lactation Program for "colic" only to find that the baby was very underweight and had been crying due to hunger. In the early months of life, you should expect your baby's height and weight percentiles to be proportionate. If your baby's weight is dropping percentiles, his crying might be due to hunger. Crying due to hunger is usually accompanied by vigorous sucking on a finger, fist, or pacifier and promptly responds to feeding.
Reaction to Maternally Ingested Foods
Allergies and other adverse reactions to maternally ingested foods can produce colicky behavior in breastfed infants as previously described. In addition to fussiness, these babies often have skin rashes, vomiting, diarrhea, congestion, or other symptoms. Irritable, allergic infants often are overweight, since they are put to breast frequently in an attempt to console them. They may become fussy minutes after nursing or a couple of hours later. Frequently, a family history of food sensitivities can be elicited.
Overactive Let-Down Reflex
As previously noted, some women are blessed with an abundant milk supply and a brisk let-down. Their breasts work like precision machines when it comes to feeding time. As soon as the milk ejection reflex is triggered, milk pours from their nipple openings so fast that it's all their baby can do to handle the flow without choking. It's a little like drinking from a fire hydrant, and some babies find it too much of a good thing. As they gulp and sputter their way through a feeding, they may get overwhelmed. Some infants pull off the breast and cry in frustration until the milk stops spraying. Others make valiant attempts to get through a feeding, but end up swallowing excessive amounts of air. This can cause uncomfortable gas and lead to unexplained crying during or after feedings.
If an overactive let-down is causing your baby distress, try expressing some milk before feeding, and put your baby to the breast after milk flow tapers to a manageable level. Or, you can interrupt nursing for a minute or two once the let-down is triggered and wait for the milk to stop spraying. Babies of mothers with overgenerous milk supplies often do better nursing from one breast at a feeding instead of both breasts. This way, they get more hindmilk and a gradually decreasing flow rate.
Gastroesophageal Reflux (GER)
The circular muscle that separates the stomach and the esophagus (food pipe) is loose in young infants, so that stomach contents can easily enter the esophagus during or after feedings and be spit up. This condition is known as reflux or gastroesophageal reflux (GER). Reflux is more likely to occur when a baby is lying on his back with a full tummy. Thus, it is not uncommon for a baby to spit up while lying supine for a diaper change after a feeding. In mild cases of reflux, the baby may spit up a lot, but acts content and gains weight appropriately. Usually, by eight to ten months of age, when babies have learned to sit up well and spend more time in a semiupright position, the frequency of spitting decreases.
In a few infants, GER represents a serious problem rather than a benign condition. These babies may be chronically fussy due to the irritation of acid stomach contents in their esophagus, producing heartburn symptoms. Babies with serious reflux often become distressed and irritable during feedings. They may pull away from the breast, cry, arch, act uncomfortable, and refuse to keep nursing even though plenty of milk remains. Occasionally, reflux is severe enough to impede proper growth and cause choking, coughing, pneumonia, or hoarseness.
If your baby has symptoms that sound like reflux, notify her physician. Generally, babies with GER do better with frequent, smaller feedings that avoid overdistension of the stomach. Spitting up can be reduced by frequent burping during feedings and by positioning the baby upright after nursings. Sometimes medication is prescribed to help the stomach empty more rapidly or to reduce the amount of stomach acids. Rarely surgery becomes necessary to remedy the problem.
Infant Colic
Colic, described earlier, occurs in an estimated 10 to 15 percent of all infants, and it is one of the most difficult and frustrating things for new parents to handle. Crying attributed to colic typically is intermittent and intense, often coming in sudden attacks and lasting an hour or more at a time. There usually is a pattern to the crying, which escalates in the evenings, when parents are most depleted and least able to cope with stress. No definite cause of colic has been found, although common theories include a sensitive temperament, an immature digestive system, and excessive intestinal gas. Colic usually peaks around four to six weeks of age and subsides by three months. It occurs in both breastfed and formula-fed infants. Colicky babies are otherwise healthy, well fed, alert and active, appear happy between crying spells, and show no long-term effects of colic.
Colic is not a telephone diagnosis. If your infant cries excessively without explanation, it is essential that your pediatrician examine him and confirm that no medical problem exists (see below). Other parents have found the following strategies to be helpful in reducing infant crying:
- A baby's cry is a distress signal, and crying babies need to be held and comforted. Holding doesn't reinforce crying any more than feeding reinforces hunger. Responding quickly to a baby's crying doesn't "spoil" the infant. Rather, promptly attending to a crying baby teaches the infant to trust her caretakers. This trust relationship becomes the foundation for communication.
- Gentle rhythmic motion, such as rocking or swinging, and soothing words or repetitive singing will tend to diminish crying. Steady rhythmic sound, like running the vacuum or fan in the next room, may also settle a crying baby.
- Swaddling a distraught infant in a blanket or cuddling him snugly and providing close physical contact will help him feel secure and may diminish crying. A front-pack, carrier, or sling will allow you to hold your infant for long periods without restricting your activities.
- Avoid vigorous bouncing, jiggling, or jostling, crowds, loud noises, or other boisterous activities that may further upset your baby. When your baby starts to fuss, take him into a quiet room with subdued lighting and minimal stimulation.
- Place your baby across your lap tummy-down and pat her back or carry her facedown on your forearm with her legs draped over either side of your elbow. Pat her back with your other hand while walking, rocking side to side, or squatting and standing.
- Try a car ride. Secure your baby in his car seat and go for a short drive. The motion and motor usually lull the baby to sleep. Another strategy is to push your baby around the block in his stroller until he falls asleep.
- Arrange to take a break when you are feeling especially tense and anxious. Just getting outside and walking around your neighborhood or running a short errand while someone else stays with the baby can renew your perspective. Your baby's crying will not seem nearly as nerve-racking to a relief caretaker.
- Take consolation in the knowledge that other parents have survived colic too. Try to remember the crying is no one's fault, the condition is self-limiting, and your baby is otherwise healthy. Never shake an infant, as violent shaking can cause severe brain injury and even death!
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