Vanliga problem som ammande kvinnor stöter på
Låg mjölktillgång; platta och inverterade bröstvårtor
Vanliga problem som ammande kvinnor stöter på Amning är hur kvinnor har matat sina barn från tidernas begynnelse, så du bör förvänta dig att processen kommer att fortskrida utan händelser, eller hur? När allt kommer omkring verkar det bara rimligt att en kvinna som gör det positiva valet att amma sitt barn skulle kunna amma så länge hon vill. Den överraskande och nedslående sanningen är att amningsproblem förekommer, även bland kvinnor med de bästa avsikterna och den högsta motivationen att lyckas med att amma. Ibland involverar problem mammans bröst och bröstvårtor eller relaterar till hennes allmänna hälsa. Vid andra tillfällen involverar amningsproblem barnet eller påverkar barnets välbefinnande. Vissa problem beror på omständigheter utanför vår kontroll, medan andra är det direkta resultatet av bristande kunskap eller brist på självförtroende, felaktig teknik eller dåliga råd. De flesta problem som får kvinnor att avbryta amningen innan de hade velat uppstår inom de första veckorna, men ett amningsbesvär kan uppstå när som helst under amningen. Oavsett om amningsproblem börjar på sjukhuset eller uppstår månader senare, kan de vara källan till stor stress och hota långvarig amning.
Vikten av att få hjälp tidigt
Tidig upptäckt och behandling av ett amningsproblem ger den bästa chansen att svårigheten kan lösas framgångsrikt. Huvudbudskapet är:Få hjälp så snabbt som möjligt så att du kan lösa ditt problem innan det blir komplicerat av otillräcklig mjölk. Tyvärr utövar många hälso- och sjukvårdspersonal ett avvaktande tillvägagångssätt för amningsbesvär, i hopp om att eventuella svårigheter automatiskt kommer att rättas till mellan kontorsbesöken. Detta icke-ingripande tillvägagångssätt är förståeligt med tanke på hur lite utbildning de flesta vårdpersonal får om hantering av amningsproblem. Utan korrigerande åtgärder förvärras dock många problem av låg mjölk eller ett underviktigt barn, vilket förvärrar en dålig situation.
Varför amningsproblem lätt kompliceras av låg mjölktillgång
Amningssvårigheter kan orsaka fysiskt obehag, utmattning och frustration, såväl som spädbarns kräsenhet och dålig tillväxt hos spädbarn. Dessutom blir många amningsproblem lätt komplicerade av låg mjölktillgång. Ofta är besvär hos ammande kvinnor kopplade till ineffektiv eller sällsynt tömning av mjölk. Om mjölk inte tas bort från brösten regelbundet, ansamlas en kemisk hämmare i restmjölk och minskar ytterligare mjölkproduktion. Dessutom kan för högt tryck från tömd mjölk orsaka skador på de mjölkproducerande körtlarna. Mjölk kvar i bröstet verkar alltså för att minska ytterligare mjölkproduktion. Problem som försämrar mjölkavlägsnandet - sällsynta eller korta matningar, inverterade bröstvårtor, bröstinfektioner, ömma bröstvårtor, bröstsvamp - kan snabbt resultera i minskad mjölkproduktion.
Platta och inverterade bröstvårtor
En platt bröstvårta är en som inte kan fås att sticka ut med stimulering. En inverterad bröstvårta dras inåt istället för att bli upprätt när vårtgården komprimeras. Både platta och inverterade bröstvårtor kan göra det svårt för ett spädbarn att greppa bröstet korrekt. De är också mer benägna att få trauma från tidiga amningsinsatser, vilket kan resultera i smärtsamma sprickor och skadad hud. När platta eller inverterade bröstvårtor upptäcks prenatalt finns flera behandlingsalternativ tillgängliga för att dra ut bröstvårtorna. Den mest populära av dessa är att bära bröstskal, även känd som mjölkkoppar, över bröstvårtorna inuti mammabh:n. Dessa kupolformade enheter har en inre ring som bärs över bröstvårtan. När ett bröstskal är placerat över en platt eller omvänd bröstvårta, applicerar det ett konstant tryck vid basen av bröstvårtan vilket gör att det sticker ut genom den centrala öppningen.
När prenatal behandling inte är möjlig eller när problemet inte upptäcks förrän efter förlossningen, kan mammor behöva extra hjälp med att komma igång med amningen. Oavsett om dina platta eller inverterade bröstvårtor behandlades prenatalt eller inte, är det viktigaste du kan göra när ditt barn föds att få skicklig hjälp med korrekt amningsteknik och sakkunnig vägledning för att hjälpa ditt barn att fästa vid ditt bröst på rätt sätt.
Platta bröstvårtor kan variera från de som bara är något mindre utskjutande än normalt, till bröstvårtor som nästan inte går att särskilja från den omgivande vårtgården. Inverterade bröstvårtor sträcker sig från de med en liten central veck eller gropar till djupa centrala inversioner som stör spädbarns spärrning och förhindrar att mjölken flödar normalt. Beroende på egenskaperna hos just dina bröstvårtor, kan ditt barn ha möjlighet att haka på och dra ut dina bröstvårtor utan någon speciell behandling. Om ditt barn har problem med att greppa dina platta eller inverterade bröstvårtor kan du prova följande strategier:
- Komprimera försiktigt och rulla bröstvårtan mellan tummen och pekfingret i en minut för att försöka göra den mer upprätt innan du försöker ge ditt barn mat. Med tålamod och uthållighet kan din bebis förmodligen fästa vid ditt bröst och amma effektivt även om du har platta eller omvända bröstvårtor.
- Använd en bröstpump för att dra ut dina bröstvårtor omedelbart innan du ammar ditt barn. En elektrisk pump av sjukhusklass kan finnas tillgänglig på postpartumgolvet för din bekväma användning. Om en elektrisk pump inte finns tillgänglig kan en handpump användas för att skapa ett stadigt, skonsamt sug i cirka trettio sekunder.
- Om en bröstvårta är mer utskjutande än den andra, börja dina amningsförsök med den bröstvårtan. När ditt barn har lärt sig att amma från ena bröstet, kanske han bättre kan dra ut bröstvårtan på andra sidan. Du kan bygga vidare på denna första framgång när du erbjuder den svårare sidan.
- Bär bröstskal i cirka trettio minuter före varje matning för att hjälpa till att dra ut bröstvårtorna. Uppenbarligen måste enheterna tas bort före amning. Vissa kvinnor kan tolerera längre perioder av slitage, men överanvändning av bröstskal kan göra bröstvårtorna ömma genom att fånga upp fukt. De kan också orsaka igensatta kanaler genom att trycka mot svullna bröstvävnader när mjölk kommer in. (All läckande mjölk som samlas i skalen bör kasseras.)
- Om ditt barn inte har lärt sig att fästa väl vid båda brösten och amma effektivt inom tjugofyra timmar efter födseln, rekommenderar jag att du börjar regelbundet mjölka. Använd den mest effektiva pumpen du kan få, helst en elektrisk bröstpump av sjukhuskvalitet med ett dubbelt uppsamlingssystem. Pump dina bröst i cirka tio minuter efter varje matningsförsök. Pumpning tjänar flera syften. Det drar ut dina bröstvårtor med varje pumpcykel, och det ger effektiv dränering av dina bröst för att säkerställa att du fortsätter att producera en riklig mjölktillförsel. Genom att pumpa erhåller man också utpressad bröstmjölk som kan användas för att komplettera ditt barn tills hon lär sig att amma effektivt.
- Medan ditt barn lär sig att amma på rätt sätt, anser vissa experter att det är bättre att inte använda en flaska för att ge den extra mjölk som krävs. De hävdar att en preferens för flaskmatning lätt kan utvecklas hos spädbarn som inte har lärt sig att amma effektivt. Dessa förespråkare rekommenderar koppmatning eller en annan alternativ metod för att ge den extra mjölken. Andra amningsförespråkare insisterar på att användning av flaskor inte nödvändigtvis stör att lära sig amma, så länge som mammans mjölktillförsel hålls riklig genom frekvent pumpning och barnet vägleds i korrekt amningsteknik. När en bebis har problem med att lära sig amma på grund av platta eller inverterade bröstvårtor, föreslår jag att du tillfälligt undviker flaskmatning, om möjligt, och väljer en alternativ metod för att ge extra mjölk, åtminstone under den period du är på sjukhuset.
Engorgement Bröstförstörning efter förlossningen
Mängden bröstförstoringar efter förlossningen som kvinnor upplever är mycket varierande. Vissa kvinnor kan knappt se att deras mjölk har kommit in, medan andra har extraordinära svullnader i brösten, fasthet och obehag. Mängden översvällning påverkas troligen av hur ofta mjölken tas bort, antalet närvarande mjölkkörtlar, hastigheten med vilken hormoner faller efter förlossningen och andra individuella skillnader.
Amningsproblem relaterade till översvämning
För över femtio år sedan publicerade en känd brittisk läkare, Dr. Harold Waller, en insiktsfull artikel i den medicinska litteraturen som beskrev bidraget från allvarliga bröstförstoringar till olika amningsproblem. Han uppskattade att cirka 20 procent av förstagångsföderskorna upplevde mycket dramatiska bröstförstoringar och hade svårt att etablera mjölkflödet. Det var hans övertygelse att denna överdrivna översvämning, om den inte lindrades omedelbart, snart ledde till de problem som beskrivs nedan och var den främsta förklaringen till tidigt misslyckande med amning. Mina egna observationer matchar Dr Wallers slutsatser, och jag instämmer helhjärtat med hans hypotes. Enligt min åsikt representerar svår eller olindrad översvämning under den första veckan efter förlossningen den största enskilda fysiska orsaken till misslyckad amning . Allvarlig översvämning, om den inte lindras omedelbart, kan bidra till var och en av följande svårigheter:
Bröstsvullnad och fasthet kan göra bröstvårtan och den omgivande vårtgården svårare (absolut inte lättare!) att greppa. Som ett resultat kan ett spädbarn haka på sig felaktigt, bara ta spetsen på bröstvårtan, vilket får lite mjölk och orsaka obehag i bröstvårtan. Bebisar som har lärt sig att fästa korrekt under de första dagarna eller två när bröstvårtan och vårtgården är mjuka och böjliga kommer att vara bättre förberedda för att amma effektivt om överdriven översvämning inträffar senare. Tidigare, när nyblivna mödrar rutinmässigt förblev inlagda på sjukhus i flera dagar efter förlossningen, började riklig mjölkproduktion före utskrivningen, och sjuksköterskor var tillgängliga för att hjälpa kvinnor att placera sina barn på rätt sätt om översvämning fanns. Men i dag befinner sig de flesta kvinnor som hemma när deras mjölk kommer in, och de får röra sig igenom upplevelsen utan att få hjälp av sjukvårdspersonal. Ett tidigt uppföljningsbesök inom två dagar efter utskrivning från sjukhuset kan hjälpa till att identifiera spädbarn som har problem med låsning på grund av allvarlig översvämning.
Svullnad av huden på bröstvårtan och vårtgården under översvällning gör bröstvårtan mer mottaglig för trauma under försök att amma och bidrar till ömhet. Den resulterande skadan - ofta med sprickor, blåmärken eller skavsår på bröstvårtan - leder till ömhet i bröstvårtan, allt från mild till svår, som kan störa amningen. Därför går obekväma bröstförstoringar och smärtsamma bröstvårtor ofta hand i hand, vilket skapar vad en mamma kallade det "dubbla smällen" mot amning.
Överdriven uppslukning leder till kvarvarande mjölk och förhöjt tryck i mjölkkanalerna som orsakar minskad mjölkproduktion. När trycket från svår översvämning stör mjölkflödet, kan kvarvarande mjölk i brösten minska ytterligare mjölkproduktion. Således kan en kvinna gå mycket snabbt från för mycket till för lite mjölk. Flaskmatande mödrar representerar ett vanligt exempel på hur snabbt obehindrad översvämning kan orsaka minskad mjölktillförsel. Flaskmatande mödrar intygar att extrem bröstfasthet och fyllighet avtar avsevärt inom cirka fyrtioåtta timmar, eftersom de mjölkproducerande körtlarna slutar fungera. Sålunda är översvämningsperioden en kritisk tidpunkt i början av amning, ofta gör-det-eller-bryt-det-perioden. Om mjölkflödet är lätt att etablera och brösten dräneras regelbundet, fortsätter full mjölkproduktion. Men om trycket i spända, trånga bröst inte kan avlastas och lite mjölk tas bort, kommer en kvinnas kropp att reagera som om hon matar på flaska. Inom några korta dagar kan en kvinna med obehaglig bröstsvamp drabbas av minskad mjölktillförsel. Det kan ta dagar, eller till och med veckor, av hängivna ansträngningar att återställa mjölkproduktionen till sin fulla kapacitet efter bara några dagar av tidiga svårigheter. Ibland kan effekten vara permanent. Obelastad bröstsvamp är mer än en tillfällig olägenhet eller ett obekvämt besvär. Det är ett mycket verkligt hot mot framgången med amning eftersom det är så skadligt för mjölkförsörjningen.
Allvarlig och olindrad bröstsvamp kan göra det svårt för barnet att få tillräckligt med mjölk under amning. Flera faktorer kan begränsa ett barns mjölkintag under överdriven översvämning. Inte bara försvåras korrekt spärrning när brösten är svullna och fasta, utan för högt tryck kan försämra mjölkflödet. En mamma kan kämpa vid matningstillfällen för att få sitt barn att fästa sig och dia bra, medan det hungriga barnet gråter av frustration över att inte kunna placera sin mun på rätt sätt på den spända vårtgården. Eller så kan en bebis till synes amma tillräckligt ofta, men ändå förbli undermatad eftersom hon inte effektivt kan extrahera mjölk under amningsförsök. Allt eftersom dagarna går kan ett barn gå ner mycket i vikt, bli sämre att amma effektivt, samtidigt som mjölkproduktionen snabbt minskar. Detta är en farlig kombination som alltför ofta följer på svår, olindrad bröstförtörning.
Behandling av engorgement
Matningsschema
Oavsett om översvämning kan förebyggas med frekventa matningar eller inte, håller jag definitivt med om att det förbättras genom frekvent, effektiv omvårdnad. När mjölken kommer in runt den tredje dagen, bör ett barn amma varannan till var tredje timme, minst åtta till tio gånger under tjugofyra timmar. Det är inte ovanligt att en bebis har ett längre sömnintervall (förhoppningsvis på natten!). Vanligtvis skulle jag tillåta en nyfödd en fem timmar lång sträcka utan matning under en tjugofyra timmars period, men om dina bröst är överfyllda, skulle jag inte låta detta enda längre intervall överstiga cirka 3 1/2 timme. Jag rekommenderar att du inte låter ditt barn använda napp under de första veckorna av amning, och detta gäller särskilt under översvämning. Det gör ingen nytta för din bebis att suga icke-näringsmässigt på en napp när dina fulla bröst behöver tömmas. Även om din bebis ammade för fyrtio minuter sedan, om hon visar några matningssignaler, lägg henne tillbaka till ditt bröst. Det är fullt möjligt att hennes senaste matning inte var särskilt effektiv och att hon fick lite mjölk. Nu vill hon försöka igen - och det borde hon! Att gå efter klockan ("Jösses, hon borde inte ha fått mat ännu") kommer sannolikt att förhindra att dina bröst får den stimulans och tömning de behöver och att ditt barn får all mjölk hon behöver.
Korrekt positionering vid bröstet
Att gå igenom rörelser av frekventa matningar gör föga nytta om barnet är felaktigt placerat för att amma. Faktum är att det kan göra saker värre genom att orsaka ömma bröstvårtor som stör efterföljande matningar. Du kan behöva använda en bröstpump (se nedan) eller handuttryck för att ta bort lite mjölk innan du spänner på ditt barn. Att ta ut lite mjölk först mjukar upp bröstvårtan och areola-området och gör det lättare för ditt barn att greppa. Om du börjar få lite mjölk att droppa från bröstvårtan hjälper det också att locka ditt barn att haka på. Genom att kupa ditt bröst i C-hållet, med fingrarna långt bakom vårtgården, kan du behöva trycka ihop tummen och pekfingret försiktigt för att göra bröstvårtan och den omgivande vårtgården lättare att greppa. Se till att ditt barn tar en stor munfull bröst. Hennes läppar ska flänsas ut, inte krökas in.
Kyl och värme
Enkla åtgärder som applicering av kyla och värme kan hjälpa till att lindra obehag i brösten och förbättra mjölkflödet. Förkylningsterapi erkänns alltmer för sitt värde för att minska inflammation och smärta. Traditionella isförpackningar, kyliga kompresser eller kommersiella kylförpackningar - även påsar med frysta grönsaker! - kan appliceras på de överfyllda brösten i femton till tjugo minuter åt gången för att minska blodstockning och vävnadssvullnad. Detta kommer att minska det inre trycket i bröstet och hjälpa mjölken att flytta genom kanalerna till bröstvårtornas öppningar.
Många kvinnor intygar att deras bröst börjar droppa mjölk när de står under en varm dusch. Denna observation har lett till den utbredda rekommendationen att applicera fuktig värme på överfyllda bröst, särskilt före matning för att öka cirkulationen till bröstet och föra hormonet oxytocin för att hjälpa till att utlösa mjölkminskning. Att slå in brösten i varma, våta tvättlappar eller handdukar i tio till tjugo minuter känns inte bara bra utan kan också börja droppa mjölk. Kommersiella varmförpackningar finns tillgängliga från en bröstpumpstillverkare. Dessa förpackningar kan återanvändas genom att värma dem i mikrovågsugnen. Var försiktig så att du inte bränner de redan sträckta, skadade bröstvävnaderna, särskilt i det känsliga bröstvårtområdet. Prova både värme- och kylapplikationer för att hitta vilken som ger dig mest lättnad från obehag och som hjälper bäst att förbättra ditt mjölkflöde och minska brösttäppa. Du kan varva dessa behandlingar på ett sätt som är mest effektivt för dig.
Kålblad
I århundraden har kål använts i många länder som ett folkmedel mot en mängd olika åkommor. Alla typer av medicinska tillämpningar har föreslagits för kål, inklusive att äta den rå eller lätt tillagad, dricka färsk kåljuice eller applicera ett rått kålbladsgrötomslag. Under de senaste åren har ett antal amningsexperter föreslagit att inpackning av överfyllda bröst i kålblad ger snabb, effektiv lindring av obehag och underlättar mjölkflödet. Många kvinnor vittnar om fördelarna med denna behandling, men det saknas fortfarande vetenskapliga bevis för att bekräfta huruvida sådan terapi verkligen är effektiv för bröstförstoring. Huskuren används enligt följande:
- Nergott sköljda och torkade, kylda eller rumstempererade, spröda, gröna kålblad förbereds genom att ta bort den stora ådern innan bladen appliceras över det eller de överfyllda brösten. Bladen kan antingen bäras inuti bh:n eller som kompresser täckta av en sval handduk. Hål kan skäras i bladen vid behov så att bröstvårtorna kan hållas torra. Kålbladskompresserna får ligga på plats i cirka tjugo minuter, eller tills de vissnat, då kan de ersättas med färska blad. De flesta kvinnor rapporterar betydande lättnad inom åtta timmar. Fortsatt applicering upp till arton timmar har rekommenderats för mödrar som behövde avvänjas abrupt eller för kraftigt översvämmade flaskmatande mödrar som ville torka upp helt.
- Ansökningarna bör avbrytas så snart det önskade resultatet erhålls; överbehandling påstås minska mjölktillgången. Utövare som använder kålblad rapporterar att kvinnor vanligtvis bara behöver en eller två appliceringar för att etablera ett bra mjölkflöde.
Många kvinnor är ovilliga att pumpa eller ta ut mjölk under översvämning av rädsla för att de kan stimulera för mycket mjölk och förvärra tillståndet. Men översvällning är mer ett problem med dåligt mjölkflöde än överdriven mjölkproduktion. Att ta bort mjölk är väsentligt för att minska trycket i brösten och backupen av mjölk som så småningom kan minska mjölktillförseln. Förbättring av mjölkflödet från brösten gör det lättare för barnet att få mjölk när det ammar. Eftersom situationen så ofta förvärras av spädbarns svårigheter att amma, kan en bröstpump vara enormt hjälpsam för att hantera översvämning. Ett brett utbud av pumpar är tillgängliga, allt från billiga handpumpar till sjukhusklassade elektriska pumpar. Jag rekommenderar starkt att du skaffar en elektrisk pump av sjukhusklass med en dubbel uppsamlingssats som kan tömma båda brösten samtidigt om dina bröst blir kraftigt uppsvällda. Eftersom obehindrad översvämning kan vara så plågsamt och dess snabba lösning är så avgörande för fortsatt framgång, kommer du att vilja ha det mest bekväma, bekväma och effektiva sättet att tömma dina bröst. Om ditt barn inte ammar bra eller om dina bröst fortfarande är obehagligt fyllda efter amning, pumpa efter matningen för att pressa ut eventuell kvarvarande mjölk och minska bröstets fasthet. Tio till femton minuters pumpning med en elektrisk pump räcker vanligtvis vid ett pass. Längre pumptider kan skada bröstvårtor och svullna bröstvävnader. För svår översvämning får vissa kvinnor bättre resultat genom att pumpa ett bröst i taget istället för båda brösten. Använd din fria hand för att försiktigt massera ditt bröst medan du pumpar. Konstant tryck som appliceras på områden med fasthet börjar ofta mjölken att flöda, åtminstone kortvarigt. När mjölkflödet upphör, byt till det motsatta bröstet. Massera och pumpa på andra sidan så länge du får resultat. Byt sedan igen när mjölkflödet upphör. Efter femton till tjugo minuter av total ansträngning, vänta en timme eller två innan du försöker igen.
Avkoppling
Gör ditt bästa för att slappna av och visualisera hur din mjölk flödar. Att vara orolig och spänd kommer sannolikt bara att hämma din mjölkutkastningsreflex. Spela lugnande musik eller träna avslappningstekniker som Lamaze-andning. Be din partner ge dig en nackmassage eller ryggmassage. Sträck ut armarna ovanför huvudet och för dem långsamt ner till sidorna. Upprepa denna "flygande ängel"-övning flera gånger. Många kvinnor tycker att det hjälper deras mjölk att sjunka.
Syntetisk oxitocin nässpray
Hormonet din kropp gör för att utlösa din mjölkutstötningsreflex och få din mjölk att flöda kallas oxytocin. En syntetisk form av detta hormon marknadsfördes tidigare som en nässpray känd som Syntocinon (Sandoz Laboratories). Läkemedlet ordinerades till ammande kvinnor för att hjälpa till att utlösa deras nedgångsreflex och främja mjölkflödet när mjölkutkastningsreflexen ansågs vara hämmad. Syntetiskt oxytocin ordinerades ibland till mödrar till för tidigt födda barn och anställda mödrar som behövde hjälp med att konditionera sin mjölkutdrivningsreflex när de använde en bröstpump. Läkemedlet rekommenderades också för att lindra allvarliga bröstförstoringar genom att utlösa mjölkutkastningsreflexen och stimulera mjölkflödet. Syntocinon marknadsförs tyvärr inte längre. Däremot kan en blandningsfarmaceut bereda ett likvärdigt läkemedel med recept från en läkare. En blandningsfarmaceut är en farmaceut som gör skräddarsydda mediciner från grunden. International Academy of Compounding Pharmacists erbjuder en remisstjänst för patienter för att hjälpa dem att hitta en farmaceut inom en radie på femtio mil från deras postnummer (se Resurslista, sidan 451). Om andra åtgärder för att lindra översvämning inte har hjälpt, fråga din läkare om syntetisk oxytocinnässpray kan vara värt att prova i ditt fall.
Försenad omvårdnad; mjölkfel; ömma bröstvårtor Engorgement bortom postpartumperioden
Även om bröstsvamp utgör det största problemet under den första veckan efter förlossningen, kan det återkomma när mjölkavlägsnandet försenas. Även med väletablerad amning kan obehaglig fyllighet och fasthet uppstå när brösten inte töms regelbundet. Att tillåta brösten att bli markant uppsvällda riskerar den ammande mamman för flera komplikationer. För det första kan hennes utbud minska som ett resultat av kvarvarande mjölk och övertryck på mjölkkörtlarna. För det andra är en kvinna mer benägen att få en bröstinfektion när hennes bröst inte töms ordentligt. Här är några vanliga scenarier som kan leda till skadlig bröstsvamp efter den första veckan efter förlossningen.
- En mamma bestämmer sig för att hoppa över några amningar för att vila sina ömma bröstvårtor och upplever att hennes bröst blir hårda och ömma.
- En mamma återvänder till jobbet åtta veckor efter förlossningen och pumpar inte sina bröst under arbetsdagen. Vid middagstid är hon obehagligt mätt och börjar läcka mjölk (se kapitel 8 för råd om hur man framgångsrikt kan kombinera amning och sysselsättning).
- En mamma lämnar sin tre veckor gamla nyfödda hos sin syster medan hon gör några ärenden och upptäcker att hon är borta längre än hon förväntat sig. Hennes syster matar en flaska formel till barnet i mammans frånvaro. När mamma äntligen kommer hem är hennes bröst ordentligt uppsvällda, men hennes bebis sover gott med full mage och vill inte amma.
- En helt ammad tvåmånadersbarn som tidigare ammade en eller två gånger varje natt börjar nu sova igenom till morgonen. Mamman vaknar med obehagligt hårda, fylliga bröst.
Laktogenesfel:Mjölk kom aldrig in
Vissa kvinnor drabbas av extrem översvämning och andra faller i den motsatta änden av spektrumet, vilket gör att de tvivlar på om deras mjölk har kommit in. Ibland försenas laktogenes, uppkomsten av riklig mjölkproduktion två till fem dagar efter förlossningen, bland kvinnor som har komplikationer av förlossningen och förlossningen. Sällan stöter jag på kvinnor vars mjölk knappt kommer in alls. Ofta har dessa kvinnor medicinska problem som högt blodtryck, infektion eller anemi. Andra har upplevt extrem känslomässig oro. I fall av djup fysisk eller psykisk stress kan en mammas kropp misslyckas med att laktera fullt ut för att bevara moderns hälsa. Eftersom amning är den enda elektiva process som en mammas kropp utför, förvånar det mig inte särskilt att mjölkproduktionen ibland hämmas när en mamma är mycket sjuk. Ibland, när en mammas egna hälsoproblem löser sig, ökar hennes mjölktillgång stadigt om hon fortsätter att amma.
Om du tvivlar på att din mjölk har kommit in senast den fjärde dagen efter förlossningen, skulle jag råda dig att kontrollera din bebis för att vara säker på att hon inte har gått ner i vikt. Din läkare, en amningskonsulent eller en sjuksköterska med erfarenhet av att hjälpa ammande mödrar bör kunna avgöra om din mjölkproduktion har ökat normalt eller inte. Om din mjölk inte har kommit in rikligt fyra dagar efter förlossningen, bör du börja pumpa efter varje amning för att garantera att dina bröst får tillräcklig stimulans och tömning för att öka din mjölk. Enbart ditt barns sug ger kanske inte tillräcklig stimulans för att öka din mjölktillförsel. Att använda en elektrisk hyrpump av sjukhusklass efter amning kan bidra till att öka mjölkproduktionen. I sällsynta fall misslyckas en kvinna att producera tillräckligt med mjölk utan egen förskyllan, vilket gör det nödvändigt för hennes spädbarn att få regelbundna tillskott av formel.
Ömma bröstvårtor
Amning ska vara en trevlig och bekväm upplevelse efter den första veckan. Jag är förvånad över hur många mammor som accepterar ömma bröstvårtor som en oundviklig, obehaglig del av amningen som exceptionella kvinnor måste utstå. Mina kollegor och jag utvärderade över trehundra förstagångsföderskor fyra till åtta dagar efter förlossningen och fann att 13 procent upplevde bröstvårtsmärtor så allvarliga att det fick dem att frukta matningar. Det är mer än en av tio ammande kvinnor för vilka smärta var en stor nackdel med amning. De flesta av dessa kvinnor antog att en ammande mamma måste vara stoiker för att lyckas med att amma. Detta är helt enkelt inte sant. Även om de flesta kvinnor upplever lindriga bröstvårtor i början av amningen under de första dagarna av amningen, är svår eller ihållande smärta i bröstvårtan inte en normal del av amning. Allvarliga besvär är nästan alltid kopplade till felaktig amningsteknik och kräver utvärdering och behandling, när de förekommer.
Konsekvenser av ömma bröstvårtor
Ömma bröstvårtor är mer än bara ett besvär. Detta klagomål är en viktig orsak till tidigt avbrytande av amning. De flesta kvinnor som väljer att amma föreställer sig att amning kommer att innebära avslappnade, givande interaktioner med sitt barn. Matningsrelaterad smärta krossar snart den lugna bilden av en nöjd ammande mamma och hennes nöjda bebis. Smärta kan driva en störande kil mellan en ny ammande mamma och hennes ammande spädbarn. Jag minns den uppriktigt sorgliga vädjan från en avskräckt mamma med utsökt smärtsamma bröstvårtor som bönföll sin oskyldiga bebis:"Snälla, vakna inte upp och behöver mig."
Smärta i bröstvårtan kan inte bara störa relationen mellan mor och barn utan kan också leda till otillräcklig mjölk och försämrad spädbarns tillväxt. Du kanske undrar hur moderns obehag kan relateras till ett spädbarns näringsintag. Faktum är att den vanligaste orsaken till svåra eller ihållande ömma bröstvårtor är felaktig placering av barnets mun på moderns bröst. Om barnet inte tar tag i hela bröstvårtan och tillräckligt med omgivande vårtgård, kommer smärta att uppstå och barnet kommer inte att extrahera mjölk särskilt effektivt. Om hon upprepade gånger misslyckas med att tömma brösten väl, kommer den efterföljande mjölkproduktionen att minska.
Andra orsaker till att ömma bröstvårtor kan predisponera en kvinna för otillräcklig mjölk inkluderar begränsad matning och nedsatt mjölkminskning. Kvinnor som fruktar matning är benägna att hoppa över, skjuta upp eller begränsa ammande, vilket kan leda till minskad mjölktillgång. Dessutom kan smärta och andra skadliga stimuli försämra mjölkutstötningsreflexen, vilket minskar mjölkflödet vid smärtsamma matningar. Du kan förstå att en kombination av faktorer är på väg att göra minskad mjölktillgång till en vanlig komplikation av kronisk bröstvårtsmärta. Så småningom kan ihållande ömma bröstvårtor leda till otillräcklig viktökning hos spädbarn. En ond cirkel kan uppstå, eftersom en frenetisk, hungrig bebis kan amma oberäkneligt och producera ännu mer bröstvårtstrauma.
Tidig ömhet i bröstvårtan
Tidiga lindriga obehag i bröstvårtan är ofta närvarande på andra dagen av amningen och förbättras när din mjölk börjar komma in rikligt. Besvären är störst i början av matningen och varar sällan under hela en amning. Markant förbättring märks vanligtvis med början runt den femte dagen. Ingen specifik behandling krävs vanligtvis, och du bör förvänta dig att amningen är bekväm efter den första veckan efter att ha börjat.
Sore Nipples Caused by Improper Infant Latch-on or Incorrect Sucking
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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