Baby-led feeding

A day came in the first few weeks of breastfeeding when things clicked for us.  This happened after we discovered that he was fighting against our efforts to manually manipulate his mouth into the right place (see last post).  It occurred to me to look back at what I learned about nursing in the first hour after birth--about the "breast crawl" and ways that baby learns to latch on.

I rested his cheek against my breast like on a pillow, and he would do this kind of sweeping motion of raising and turning his head and opening his mouth very wide.  At that moment I could bring him in and latch him on.  With a little practice we got the timing and aim down, kind of like hitting a baseball, and this method worked almost every time.  I used this method for many weeks until we didn't need to focus so much on the perfect latch (next post: breastfeeding is easy!).

Unintended consequences

One of the key components of a good latch is a big, wide open baby mouth that takes in as much mama as possible.  Pain can occur when baby slips down on the breast and treats the nipple like a straw.

One way to combat this tendency for newborns to "slip" is to have a partner help manipulate baby's lower jaw into better position after he has latched on.  We used this technique at almost every feeding to reduce pain and improve latch for the first week or two of nursing, and it worked well at first.

But at some point, Daddy had more and more trouble pushing down on Elliott's jaw, and in fact, it seemed like Elliott was actually fighting him, causing the problem to be worse--MORE clamping down--rather than less.  I found an article on kellymom that seemed to suggest that jaw manipulation may have not only diminishing returns, but the unintended consequence of actually making the pain worse after awhile. 

Why?  Consider would happen if you approached your partner, or parent, or friend and tried to physically open his or her mouth.  Or even if you tried to push him or her gently backward?  No matter how trusting the relationship, he or she would probably automatically exert energy in the opposite direction of your pushing.  Indeed, Elliott and his dad were experiencing their first power struggle, and in between was the tender skin of my nipple.

Is there a lesson in this idea that could help with my original idea?  Yes.  Try to push his mouth closed, not open, during latching on, and benefit from the reverse effect.

Even better, could we somehow tap into Elliott's natural instincts to get that wide open mouth we needed?  Yes.  Next post.

Problem, duct-tape solution, unintended consequence, aha moment, learn, succeed, repeat.

Magical Fixes

Breastfeeding was difficult for me at first, each feeding a challenge, sometimes painful, sometimes a lengthy and drawn-out ordeal.  We made progress in fits and spurts, tackling problems along the way, often with duct-tape solutions or trying things that had failed before.  After we had wired up a complicated hack for a problem, and then gotten used to it, it was hard to imagine any other way to do it, like when you're sick and can't remember what it's like to feel well.  Then, the problem would suddenly, randomly disappear.  (Or some unintended  consequence would appear that then needed its own solution.  Next post.)

An example of a "magically disappearing breastfeeding problem" was our stop-gap solution to nipple damage from sub-optimal latch: the widely dreaded or widely admired "nipple shield."  This is a very thin silicone cover that separates you from the baby and encourages the wide-open mouth necessary for a good latch.  Many people warn against their use because there is some evidence that it can reduce milk supply, but they are lifesavers for people facing serious breastfeeding hurdles like me.

After about 3 days of nursing a newborn, I had a lot of soreness, so we tried the nipple shield, which seemed to help with the pain and create a better latch.  The shield had to be washed and dried between uses, made pliable by a hot-water bath before use, positioned and applied carefully and correctly, and not knocked away or manually removed by a clawing baby or one of the many hands attempting to wrangle him onto my breast.  But it worked, and my nipples got less sore, so we went through this crazy dance at each feeding, make OK by the fact that it was better than pumping and syringe feeding, the next best option.

Eventually it became a kind of mental crutch--I could not envision being brave enough to nurse skin to skin.  The "crutch" then attained a mental permanency and I resigned myself to the ritual.  And then, trying to start a feeding one day, with the baby clawing at my breast and writhing wildly in my arms, the shield was propelled to the floor.  Out of what could almost be described as anger, or at the very least,  extreme frustration, I ditched our crutch and stuck him on my breast with fortitude and he nursed, painlessly, just like we were old pros.

Why?  Did the shield "train" him how to latch?  Does the newborn need a week's training before muscle memory kicks in?  Did he just get bigger?  I will never know.

We go from struggling, struggling, making our way slowly up the stairwell, until someone points out there's an elevator and we're suddenly whisked upward by a dozen flights all at once.

Docking the space shuttle

The key to early breastfeeding success is the latch.  What is "the latch?"  It is the way the baby connects with your breast to feed, and it is way more than just putting his mouth on your nipple.

In  our case, it felt a lot like docking the shuttle at the international space station, except you only have control over the station.  The shuttle has a brain of its own, and it is a person named Elliott. 

Components of my good latch:

• intense, driving motivation to breastfeed
• four adult hands
• three human brains
• plan of action written out prior to birth by lactation consultant (LC)
• great support team and medical providers at birth
• no medications during labor
• smooth, problem-free delivery
• healthy, hungry baby with a big open mouth
• hospital that supports skin to skin, feeding within first 20 minutes, and rooming in
• LC available the first night
• another written prescription for action by LC before leaving hospital
• baby's dad who would  not let me settle for an imperfect latch

Elliott, Day 1

That the nurses and LC could see on my chart the breastfeeding prescription--which included strategies to avoid soreness--meant that everyone around me was prepared to help.  The first day and a half I let the baby nurse and nurse and tried a few times to latch him myself.  It felt OK.  His mouth was huge.  Edema wasn't a problem since I had received no IV fluids and no medications. The nurses said, "That latch looks perfect.  Textbook."

It wasn't until I got to meet with the LC who prescribed my breastfeeding strategy, Suzanne, on Day 2 just before we were discharged that I realized I was on a course to repeat my mistakes.  She said,  "On a scale of 1-10, what is your pain level?"

I said, "Maybe two or three."

She said, "It needs to be zero.  Take him off and try again."

When breastfeeding hurts, the latch is not good enough, and breakdown of nipples begins, leading to more pain and more breakdown.  This is the cycle I got trapped in with Sam.  Suzanne was taking no prisoners this time.  She wrote another plan for us before sending us home.  We took pictures and videos of the right way to do it.  At home, Max emulated her helping hands and rigorous standards.  He insisted on zero-pain latch.

Our life was a jumble of nipple shields, pillows, tylenol, breast pump parts, ice packs, cabbage leaves, waterproof pads, and used tissues.  But we made it.  We nursed.

Lactation Consultations by Skype

In a previous thread on increasing breastfeeding rates, one commenter remarked about the first days of breastfeeding: "It's usually those hours you need someone that no one is available."   I remember one evening calling my birth hospital in desperation.  A caring nurse spent time on the phone with me, though all she could offer was general advice and emotional support.  This helped, but it would have been wonderful to have a lactation consultant to speak to.

A company called Milkalicious is offering lactation consultation appointments by Skype.  The cost is $45 per hour, and a check of their availability showed same-day appointments.  I'm sure LCing by computer can't compare to having an expert with you in person (I remember mine moving things around to try to guide us), but having that kind of resource could at least provide some strategies and support to new moms.

There is also a National Breastfeeding Helpline: 800-994-9662.  La Leche League-trained Breastfeeding Information Specialists can answer "basic breastfeeding questions."  Unfortunately, it's not a 24-hour hotline.  The US government also offers an "Easy Guide to Breastfeeding."  Online support forums can also be a support system, though the advice is usually from other moms, not trained professionals.

It's those times when we are forced to make hard choices about newborn baby feeding that have far-reaching effects for both baby and mom.  If every new mom left the birthplace with a contact of a trained support person available around the clock, we would have a better chance of working through those difficult moments and coming out the other side as nursing moms.

Supply

The second biggest reason moms choose to formula-feed is not being able to tell if the baby is getting enough milk, according to the same article (Arora, 2000) that cited fathers' feelings as the biggest reason (see February's post on Dads).  "Mothers should be educated about assessing the adequacy of milk supply by listening for an audible swallow, noting urine production by the number of diapers changed per day, and by recording weight gain at well-child visits."  Easy enough?  Not really, even if you're informed.

Imagine: you are in your first week of trying to breastfeed your new baby. Of course, you can't see the milk, and you have yet to learn your baby's feeding cues. Your newborn, like many, is very sleepy, and often falls asleep at the breast, leaving you wondering whether he is full or just got tired of trying to extract nonexistent milk.  You are counting pee diapers; but premium diapers feel so dry--does that really count as a pee?  He screams for food 45 minutes after a feeding, causing you to question whether he got enough at the last feeding.   At his well-baby visit, he comes in at the 30th percentile for weight (based on averages of both breastfed AND formula-fed babies).  The pediatrician says it's fine, but you are definitely concerned now that he isn't getting enough milk.  In a moment of panic, you feed him some formula.  The formula brings you a sense of relief because now you are certain your baby is getting the calories he needs.  It's comforting to view and measure the feeds.  Formula supplementing becomes part of your routine.  Meanwhile, your body is adjusting its supply to the milk demanded by the baby.  Since the baby, sated by formula, demands less, your body makes less.  Concerned still, you supplement a little more.  Eventually, it begins to feel like nursing is just for comfort, and maybe, you stop.

It's a vicious cycle.  And maybe you never had a supply problem at all!  It is easy to understand how this can happen, given how powerful the need is for a new mother to nourish her baby.   Of course, supply problems can be and are real in many cases, but the treatment for low supply is more nursing, not less.  In yet another situation, the combo of support and information is the key: knowing the signs of a well-fed baby AND having someone there to coach you along saying, "He's eating well, and you're doing great."


Arora, S.; McJunkin, C.; Wehrer, J.; Kuhn, P. “Major Factors Influencing Breastfeeding Rates: Mother’s Perception of Father’s Attitude and Milk Supply.” From the Family Medicine Department and the Research Center, Hamot Medical Center, Erie, Pennsylvania. 2000.

BFF: My pump & me.

A few stars aligned for us to be able to bottle-feed breast milk. First, before Sam was born, I received a very generous gift of a Medela Pump in Style double electric breast pump from my step mom who said simply, “You’ll want a nice one.”  Second, Max was home during Sam’s first weeks and helped me immeasurably by taking care of the baby while I pumped and encouraging me to keep going.  Third, at work, there is a private place to pump, a dedicated refrigerator, and a culture that accepts breastfeeding.  Finally, I found an online community where I discovered I did not invent exclusively pumping.

At first, I pumped 7 or 8 times a day for about 20 minutes each. By 5 weeks, I was in much less pain and the engorgement had eased, so I dropped to 6 pumps a day, 10 minutes each. Now at 5 months, I am down to 4 pumps, without getting up in the middle of night to pump. It takes me about an hour a day to get 35-40 oz. of milk, a bit more than Sam eats.

The benefits of exclusively pumping are that Sam gets human milk, best for his health; it might be healthier for me too; I quickly returned to pre-pregnancy weight; other people can feed Sam; we can observe how much he eats; it’s free (or only the cost of the extra calories I eat); I get to bond with my baby while feeding without being in terrible pain; and I got to donate breast milk to another baby.  The detriments are that we wash a lot of plastic parts for the pump and bottles every day; I have to drag the pump and parts around and tuck myself away at certain parts of the day; some benefits of breast milk may be lost when it is stored and fed at another time; I have to buy bottles and milk storage bags; and we have to bring milk and bottles with us when we’re away from home. 

There are moments when it seems totally ludicrous to be attached to the pump.  For example, in the middle of one night when I was up pumping and Max was up at the same time feeding Sam, it all seemed especially kooky.  I was sad at those moments that I couldn't breastfeed. 

I tried nursing again when Sam was about three months old.  The pain returned and after a few feedings, and things just didn’t feel right. I called off the experiment.  We had our system, and it worked for us.

Dads

A 2000 study of new moms in Pennsylvania showed that the primary reason for initiating bottle-feeding over breastfeeding was the mother’s perception of the father’s preference (Arora, 2000).  Dads’ education and interest in baby feeding naturally have a big impact on the decision to breastfeed and the success of the breastfeeding effort.  It can be direct: a knowledgeable dad can play a direct role in baby feeding, such as by observing and assisting with latching positions.  It can be indirect too: a supportive dad gives encouragement and anticipates needs (Tohotoa, 2009), like taking care of housework or holding the baby while mom showers or rests. Another highlight of the 2009 Tohotoa study was that “fathers participating in the study all wanted to be involved with parenting and parenthood, but many of them felt they were unprepared and lacked the relevant information to be effective in their parenting role.” If we could do a better job of educating fathers, moms could be more empowered in baby feeding. 

I would never have gotten as far as I did with nursing if it weren’t for Sam’s dad, Max.  The two of us together agreed while I was pregnant to breastfeed, based on evidence that breast milk is healthier for the baby. During the two weeks we spent trying to breastfeed, he was extremely supportive.  He sat in on sessions with the lactation consultant and reminded me of her advice during feeding sessions.  He provided physical support, arranging the baby, pillows, and even Sam’s jaw and lips, helping get the job done, around the clock.    Moreover, he provided critical emotional support, listening patiently to my outpourings about how much pain I was in, how awful I felt, how desperately I wanted to feed my baby. And when we thought we would need to switch to formula, he supported that too.  Later, when I started pumping full-time, he continued to encourage me and took care of Sam while I pumped.  He deserves a big chunk of the credit for us eventually finding a system that worked. 

He told me recently that he never really understood exactly how I felt.  I tried to explain the pain and resulting emotional torment as presenting your arm, once every two hours, to have a cigarette put out on it--for the first few times, you can endure it, but eventually you begin to feel beaten down, depressed, intimidated.  I think he understood the analogy, but the truth is that real empathy can only come from other women who have been through it.  (More on support from other women later.)  Nonetheless, he was a full partner in every way he could be, and my son and I are lucky to have him.

1.      Tohotoa, J.; Maycock, B.; Hauck, Y. L.; Howat, P.; Burns, S; Binns, C. W. “Dads make a difference: an exploratory study of paternal support for breastfeeding in Perth, Western Australia.” International Breastfeeding Journal 2009, 4:15.

2.     Arora, S.; McJunkin, C.; Wehrer, J.; Kuhn, P. “Major Factors Influencing Breastfeeding Rates: Mother’s Perception of Father’s Attitude and Milk Supply.” From the Family Medicine Department and the Research Center, Hamot Medical Center, Erie, Pennsylvania. 2000.

My baby-feeding story, abridged

Day 1

The focus of pregnancy for many women is childbirth, as it was for me.  I read the books, took the classes, imagined all the possible scenarios through which my child could be born. I felt that if I could get through childbirth, I could get through anything.  Parenthood, including breastfeeding, was a bridge I would cross when I got there, but felt sure that with a good partner and support system, it would be manageable.

My son’s birth was much like I expected: it was one day of the worst pain of my life, and then he was there, Samuel Sleigh, strong and healthy, with dark, observant eyes.

After he was born late in the evening, I held him skin to skin.  My doula, my nurses, and my husband Max kept encouraging me to place him at my breast, but I thought he would make his own way there, the way newborns did in the birth videos we watched in childbirth classes.  I thought it was only a matter of time and he would be suckling away, a hungry little baby.  Finally, I maneuvered him to help him get started.  He got mouth in the right place but would not suck.  He only fell asleep over and over again.  So, we let him sleep, and we slept.

Sam, Day 1

Day 2

The next day, my milk came in. The nurses were a bit surprised, as this normally does not happen until day 3 or 4.  I took it as a good sign; I was excited because I knew then I could feed my baby as soon as he was ready--no worries about lack of milk.

But all that day, Sam slept, and when we managed to rouse him and get him to my breast, he still would not suck.  The pediatrician and nurses assured me that this was not cause for alarm and that he would nurse soon.

Day 3

On day 3, the hospital’s lactation consultant, Suzanne, visited me.  She showed me how to manually express milk to entice the baby to nurse. She put on a latex glove and gently touched the roof of his mouth with her pinky.  He did not suck, which puzzled her.

She suggested I try a breast pump to get some colostrum—the early, nutrient rich milk--for Sam.  The nurses introduced me to a Medela hospital-grade pump and showed me how to use it.  I marveled at the few drops of yellow liquid, amazed yet again by my own body. 

The nurses mixed that tiny bit of food with some sugar water and fed it to my baby with a tiny plastic cup.  Watching this I felt sad, already feeling that I’d failed somehow.

Day 4

The next day, the pain started.  I thought now that I was starting to heal from the birth, I would feel better all around soon.  But trying again and again to nurse made my nipples tender and sore, and the fullness had escalated to engorgement.  My breasts were hard to the touch, the skin stretched and shiny.  

Early that morning though, with the help of a nurse and in just the right position, Sam nursed.  It was a tiny victory, the first in a series of battles to come.

Suzanne returned and examined me.  She said the engorgement was made worse by a case of edema, or water retention from the IV fluids I received during labor.  This also made it harder for Sam to latch—like trying to suck on an over-inflated balloon.  We kept nursing though, and I breathed through the pain.

On day 4, we took Sam home.  We were on our own, away from Suzanne and the caring nurses at the hospital.

Days 5-7

The first few days at home were like a dream, the three of us waking and sleeping at odd hours, not eating real meals, not leaving the house.  I made a home on the couch where I napped and tried again and again to feed the baby.  He would latch, then fall away, and latch again a short while later, each time more painful than the last.  It made my toes curl.  I would get into the shower afterward and cry.  I called the nurses at the hospital, but all they could tell me was that it would get easier soon.

I would work myself up for a feeding, and with Max maneuvering Sam’s tiny little mouth, nurse him through the excruciating pain.  I began to dread feedings.  I started to feel afraid of my hungry baby.  My nipples were broken and cracked like a boxer’s knuckles, and the engorgement persisted.  I was feeding him, but I wasn’t sure how much longer I could stand the pain.  It was a rollercoaster of emotions.  A disastrous one would follow a successful feeding.  It wasn’t getting better.

Days 8-10

On day 8 I went back to the hospital for a consult with Suzanne.  She suggested I try pumping with my Medela double electric pump for 24-48 hours to let my nipples heal, and cup- or syringe-feeding Sam the milk.  She also suggested heat to get the milk flowing followed by cabbage leaves and ice for the engorgement.  She demonstrated putting downward pressure on Sam’s lower jaw and flipping out his lip for proper positioning.  I also got two prescription ointments, “gelpads” for sore nipples, and a bit of silicone called a “nipple sheild.”  It seemed an arsenal, and I felt hopeful.

Newborns need to eat every 2 hours.  That meant 30 minutes of heat, then pumping for 20 minutes, then applying medicine, then lying with ice packs and cabbage leaves pressed to my chest for an hour, while feeding the baby the pumped milk.  This involved tricking him into sucking on a finger while sneaking the milk into his mouth on the side with a large plastic syringe. (We were warned of “nipple confusion” in which a baby rejects the breast after being introduced to a bottle too early.) He seemed confused and overwhelmed, milk overflowing from his mouth, and I felt awful for doing it.  This was our routine, around the clock.  I barely ate or slept for 2 days.

On day 9, my damaged nipples had begun to heal, but since everyone had told me that the pump isn’t as efficient as the baby, I felt I had to start nursing again to ease engorgement.  The searing pain in my nipples began anew.  Not so much as a cotton shirt could touch them without stinging.

Sometime in this week Sam developed a new habit of flailing wildly when hungry, making nursing even more difficult.  Each feeding became an upheaval in our house, with baby and Mommy crying and Daddy assisting as best he could. My doula and family members said, “It will get easier, just hang in there.”  I began to wonder how we would cope, and started thinking about giving up on breastfeeding. I was facing failure. At this point I became undeniably depressed. I was afraid I would be unable to do the only thing I cared about then: feeding my baby.

Days 11-13

By late in Sam’s second week of life, the pain was nearly unbearable.  We researched infant formulas, unsettled by the long ingredient lists.  I began to mourn breastfeeding, gradually accepting potential failure.  I didn’t know how much more I could handle, physically and emotionally.  I was afraid it was affecting my ability to bond with my son.  I began to feel intimidated by him.

The day before he turned 2 weeks, early in the morning hours, I stopped nursing, pumped breast milk, and fed Sam with a bottle. We had just had an awful late-night feeding, with howling baby and weeping mommy. This is just not working, Max and I said to each other.  We were giving up.

That day, I felt a sense of relief for the first time since first trying to nurse.  The depression lifted.  It wasn’t what we’d hoped for, but we had a feeding solution.  I would gradually stop pumping and Sam would be one of the many healthy, happy, formula-fed babies of the world.

Week 3

Then, during the week after I stopped nursing, something happened: the Medela pump started to work.  I kept pumping at regular intervals, and gradually the engorgement eased. The pump was much gentler on my body.  There seemed to be plenty of milk, and the baby slurped hungrily at his bottle.  Gradually, the pain subsided. We didn’t need the formula after all. I thought I had accidentally invented a new baby-feeding solution.  But as it turns out, I was not the only new mom to exclusively bottle-feed breast milk. 

This is how I came to feed Sam breast milk from a bottle, exclusively.

Prologue

How did it happen that the hardest thing I would ever do would be to feed my child? Was it a shock because I was unprepared? Because everything else went so smoothly? Or does every new mom run the physical and emotional gauntlet of trying to meet the nutritional needs of her baby?

When I was pregnant, I read a few books about pregnancy, childbirth, and babies. All said that breastfeeding is best for both mom and baby for dozens of reasons, and most went on to explain the choice between breastfeeding and formula feeding. But what choice? Who would actively choose what is NOT best for her baby?

But according to the CDC, only 19% of new moms in 2008 were still breastfeeding after 12 months.

What else is at work here? Why do new moms not breastfeed? In the four months since my son was born, I discovered, there are too many to count—and you only need one.