Breastfeeding After A Cesarean

by KMom

Copyright © 1998-2002 KMom@Vireday.Com. All rights reserved.

Last updated: October-2002

DISCLAIMER: The information on this website is not intended and should not be construed as medical advice. Consult your health provider.

CONTENTS

Introduction

The cesarean rate in the United States skyrocketed in the 1980s until more than 1 in 5 births took place via cesarean.  After dropping somewhat in the 1990s, it has started to rise again.  It now is about 1 in 4 births, and will probably continue to have a very significant increase in the next few years.  Therefore, many women are having to cope with having a cesarean (and all the problems associated with it) just as they are also trying to care for their newborn children.  

One area which cesareans affect significantly is breastfeeding.  Research shows fewer women breastfeed their babies after having had a cesarean.  Stress tends to delay lactogenesis (the mature milk coming in), and routine protocols and medicines that surround cesareans tend to interfere with breastfeeding initiation and decrease supply.  

Breastfeeding advocates have long promoted the idea that women who have had a cesarean need EXTRA support and help to establish breastfeeding.  However, few hospitals routinely offer extra breastfeeding support to women who have had a difficult birth or who have had a cesarean.  In fact, many hospitals have protocols that actively interfere with breastfeeding under these conditions.  

This particular FAQ, therefore, is about breastfeeding after a c-section.  It examines the benefits of breastfeeding after a cesarean, how a cesarean can interfere with breastfeeding, strategies for increasing breastfeeding success, bonding issues after a difficult birth, and issues of grieving in women for whom breastfeeding does not work out.

Too often, women who have had a long difficult labor and/or a cesarean encounter breastfeeding difficulties.  Many of these difficulties could have been avoided or fixed much sooner had the women had better or more timely help.  For most women, breastfeeding difficulties are resolvable with timely help, emotional support, patience, and diligence.  Unfortunately, not all women receive timely help or emotional support after birth, and so breastfeeding does not last long for some.  For a few women, hormonal, genetic, or infant conditions may prevent them from  breastfeeding their babies fully.  Try as we might, breastfeeding does not always work out, and this can be a very difficult and painful situation.  

Women who have had an undesired cesarean and then encountered breastfeeding difficulties on top of that have a great deal of grief to deal with.  Yet problems breastfeeding after a cesarean do not have to be a life-long wound on their hearts.  Learning more information about this situation and hearing other women's stories can help women come to terms with their own grief and start the healing process.  

This FAQ has several goals.  First, it offers help to women who are presently struggling with breastfeeding problems after a cesarean, with information, links, and resources to help them overcome the difficulties they might be having.  It discusses how common hospital protocols can affect breastfeeding, ways to work with hospital staff to minimize problems like these, other factors that might be affecting breastfeeding or  supply, and resources they can call on for further help.  

Second, this FAQ offers help to women planning to breastfeed in future pregnancies, whether those births are by Vaginal Birth After Cesarean (VBAC), unplanned cesarean, or planned repeat cesarean.  If they know ahead of time the problems to watch for, they can develop a plan of action to prevent these problems from occurring, or a plan of action to get help if problems do occur.  Many women have found that they are able to breastfeed much more easily the second (or even third) time around with good resources and planning.

And third, this FAQ offers reassurance to women who have had trouble breastfeeding after past births.  It is important that women come to terms with past breastfeeding difficulties so that they can grieve the experience and find a measure of peace about it.  They need to read other women's stories so that they know they are not alone in this experience, and that many other women have walked this path before them. They need to understand the breastfeeding problems they may have encountered and why they may have occurred, to understand that they made the best decisions they could at the time with the information they had, and that past difficulties with breastfeeding does not have to mean future difficulties with it.  They also need to know that although breastfeeding is very important, breastfeeding alone does not define themselves or their relationship with their babies, whatever happens. The first and most important thing is mother love.

*Special Note:  This FAQ is long, and many people will not read it in a continuous fashion, or in one sitting.  Therefore, some information is repeated between sections, with apologies for the redundancy.

Benefits of Breastfeeding After a Cesarean

Breastfeeding offers many benefits to both infant and mother, but it is not within the scope of this FAQ to adequately cover all of the many benefits of breastfeeding in detail.  For further information about the benefits of breastfeeding, see www.promom.org, www.breastfeeding.com, or www.lalecheleague.org.  

Briefly, mothers who breastfeed lower their risk for reproductive cancers like breast cancer, ovarian cancer, etc., and may have less osteoporosis.  Infants receive superior nutrition and immunological protection that strongly lowers their rate of ear infections, gastrointestinal problems, allergies, and many other illnesses.  The longer the breastfeeding, the stronger the benefits to both mother and baby.

In addition, breastfeeding offers many benefits to the cesarean mother in particular.  These include faster uterine involution and quicker weight loss after birth.  Cesarean babies who are breastfed also receive significant benefits such as immunological protections, and prevention/minimization of hypoglycemia and jaundice problems.  Finally, the cesarean mother/baby duo often finds that breastfeeding is extremely healing emotionally after a difficult birth and can do much to help the pair bond under trying circumstances.  Many cesarean moms report that being able to breastfeed their child afterwards was one of the most healing things they were able to do for themselves.  

Faster Uterine Involution

After the baby is born, the uterus needs to start shrinking down in order to return to its normal size and state.  Breastfeeding stimulates uterine contractions and helps the uterus start shrinking more quickly and efficiently. Although the drugs most hospitals give will start this process, breastfeeding helps continue the process more naturally and efficiently.  

Negishi (1999) found that cesarean mothers tended to have larger uteri at one month postpartum than mothers who had had a vaginal birth, so uterine involution may be of special concern to women who have had cesareans.  They further found that by 3 months postpartum, mothers who were breastfeeding 80% or more per day had smaller uteri than those who were breastfeeding 2% or less per day.  So breastfeeding helps uterine involution strongly.  Since cesarean mothers may have more trouble with uterine involution, breastfeeding may be especially helpful in this group. 

Weight Loss

Many mothers find it difficult to return to the pre-pregnancy weight after birth, and anecdotally, this may be particularly true after a cesarean.  Restrictions on mobility, pain from the incision, anemia from blood loss, adhesions from the surgery, etc. may all combine to make a cesarean mother less active than one who has given birth vaginally, sometimes for significant lengths of time, which may affect postpartum weight loss.  

Research shows that breastfeeding helps women return to their pre-pregnancy weight levels faster than those who do not breastfeed.  Therefore, breastfeeding may be particularly helpful for losing pregnancy weight if a woman is having difficulty resuming her activity level after a cesarean. 

Immunological Protections for the Baby

Cesarean babies may be more at risk for infection for several reasons.  Babies born after the mother's waters had been broken for a long time are more at risk for infection.  Cesarean mothers also have higher rates of infection than moms who have had vaginal births, thus potentially exposing their babies to this infection as well.  Invasive procedures and equipment for the breathing problems common to cesarean babies may also further the risk for infection. And since cesarean babies stay in the hospital longer as their mothers recover, they are exposed to more germs and risk for infection, since recent research has shown that neonatal and maternity units are often home to some of the most virulent germs in the hospital.

Colostrum (the 'first milk') is extremely high in protective antibodies that help coat the baby's gastrointestinal system and protect it from harmful bacteria, and  it also contains substances that help 'kickstart' the baby's own immune system.  This helps protect the baby faster and more effectively than if the baby has to start its own immune systems without the mother's help.  Research has shown that colostrum is extremely important in reducing a child's risk for infections.  

As one doctor put it, "Breastfeeding is nature's first vaccine." Considering the possible infection risk many cesareans babies face, breastfeeding's immunological protections become especially important. 

Hypoglycemia

Because of the possibility of low blood sugar after a difficult birth, many hospitals routinely give a bottle of glucose water to cesarean babies, 'just in case.'  Unfortunately, this tends to cause a quick spike in blood sugar followed by a crash, and this unstable blood sugar can be a problem for the baby, causing a vicious cycle of treatment and re-treatment. 

Unless the hypoglycemia is really severe, a better treatment is nursing frequently.  The first milk a mother produces ('colostrum') has plenty of lactose to help raise the baby's blood sugar, but unlike glucose water, it also has a high amount of protein to help stabilize the blood sugar.  The long-term treatment for adults with low blood sugar is frequent doses of protein to help slow and stabilize the rise in blood sugar.  Nursing is the most like the usual treatment for adult hypoglycemia, plus it has the added benefits of all those immunological protections.  

Barring illness or extreme prematurity, babies who are nursed early and frequently generally have a more stable blood sugar than those given glucose water.  The Womanly Art of Breastfeeding states, "Nursing at least ten to twelve times per day is the best way to stabilize a baby's glucose levels."

Jaundice

Another common complication for newborns is physiological jaundice.  This is a normal process that occurs when the body breaks down extra red blood cells that are not needed for life outside of the womb. One of the byproducts of this is bilirubin, which can make the baby appear yellowish-orange if his liver does not process it efficiently.  In low levels, bilirubin is not harmful, but high levels may potentially be harmful.  

Jaundice is most common in premature babies, sick babies, babies of diabetic mothers, and when labor was induced or augmented artificially with pitocin.   Many of these babies end up with cesareans.  Thus jaundice is not an unusual finding in cesarean babies, not because of the cesarean itself but because of the conditions and drugs that tend to cause a higher cesarean rate.

Frequent nursing causes the baby to stool more frequently, and much of the bilirubin in the first days is eliminated through the baby's meconium (stool).  If the baby does not stool enough, the bilirubin is reabsorbed through the intestines.  Because the colostrum acts as a laxative, it helps the body process and excrete the extra bilirubin instead of re-absorbing it.  Thus breastfeeding frequently is one of the best ways to minimize jaundice. Research clearly shows that nursing 7 or more times a day significantly decreases the occurrence of jaundice (Yamauchi and Yamanouchi, 1990). 

Although in the past jaundice was often treated by giving bottles of glucose water to help "flush" out the jaundice, research has shown that this does not help and may actually increase jaundice. Nursing early and frequently and exposing the baby to indirect sunlight are the best treatments for normal physiological jaundice.  If extra help is needed, treatment with 'phototherapy' lights can also help lower bilirubin levels.  

Many babies that end up with cesareans may be at more risk for physiological jaundice.  Nursing is one of the best treatments for mild jaundice, and in conjunction with other therapies, can help even in more serious cases.  But the benefits are strongest when the baby is able to nurse as soon as possible after birth, and as frequently as possible in the first few days. 

Bonding

Bonding is often an issue after a cesarean.  Many mothers report feeling distant and detached from their cesarean babies.  In part, this may be because the mother is not able to actually "see" the baby emerging from her body, and is usually one of the last people to get to hold and snuggle baby for any real time.  Many women wonder if the baby handed to them is actually theirs.  Others are so preoccupied with physical pain, grogginess from drugs, and exhaustion that they find it hard to care about their children the way they thought they would. Some women experience anger at the baby for being 'too big' or 'turned the wrong way' or for going into distress.  After birth, some women report feeling like they were simply 'babysitting' their children for someone else, and this can cause real feelings of guilt. 

Breastfeeding can help restore the bond between mother and baby, healing the separation that has occurred.  Women often report that breastfeeding helped them reconnect with their babies in a way that nothing else did, helped them feel competent and whole again, and brought them emotionally closer to their babies. For many women, breastfeeding was the most healing thing in their lives after going through the cesarean.  

Breastfeeding is important for cesarean mothers and babies not only for physiological reasons, but for emotional ones too.  Unfortunately, too many hospitals do not place a priority on breastfeeding, or have routine protocols that actively interfere with breastfeeding.  

 

How a Cesarean Can Interfere with Breastfeeding

Breastfeeding is more difficult after a cesarean for many reasons.  These include maternal pain and fatigue, delayed access to baby, increased supplementary feedings, separation of mother and baby, blood loss causing anemia, mechanical problems in feeding, interference from medications, etc.  Fortunately, although these can place significant barriers in front of the cesarean mom, many women manage to go on and breastfeed their child anyhow, in spite of the difficulties. 

Maternal Pain, Stress, and Fatigue

Mothers who have had a cesarean tend to initiate breastfeeding less often than mothers who have had a vaginal birth.   Most women plan to at least 'try' to breastfeed, but after a cesarean, many change their minds as the physical toll of the cesarean saps their physical and emotional resources.  They may be groggy from drugs, woozy with pain, and exhausted from labor, surgery, and significant blood loss.  Suddenly breastfeeding may seem overwhelming and too much trouble, or they may be too 'out of it' to try very effectively.  In this situation, bottlefeeding often seems easier and more convenient.  

Stress clearly can affect people strongly, and women who have had a difficult labor and then an unexpected cesarean (or women who have a bad cesarean experience) may be especially susceptible to stress-related breastfeeding problems.  Dewey (2001) found that maternal stress interfered with the release of oxytocin, the hormone responsible for milk ejection reflex.  It also found that stressed newborns were more likely to be weak or too sleepy to latch and suckle effectively.  

Research clearly shows that after a cesarean, fewer women initiate breastfeeding at all, or give up within the first month.  DiMatteo (1996), Perez-Escamilla (1996), Samuels (1985), Weiderpass (1998),  Menghetti (1994), Ever-Hadani (1994), Mansbach (1991), and Dewey (2001)  all show that women who had a cesarean had lower breastfeeding rates.

Delayed Access to Baby

Nursing your baby as soon as possible after birth ensures the jumpstarting of hormonal processes designed to ensure milk supply, and aids in the physical recovery afterwards.   Studies show that the most critical issue for breastfeeding success after any birth is early and frequent breastfeeding (Asselin and Lawrence 1987, Sozmen 1992, Samuels 1985).   Research shows that breastfeeding works best if the first nursing takes place within the first hour after birth.  Unfortunately, even in vaginal births many hospitals are hard-pressed to meet this standard, but delays tend to be especially long after a cesarean.  

Although a few women are able to nurse their babies right on the table during surgery, most are told to wait until they are in the recovery room.  This means a delay of almost an hour, and sometimes more.   Although not ideal, this is not insurmountable.  But a few misguided hospitals still have the outdated practice that forbids breastfeeding even in the recovery room, so their babies must wait even longer to nurse for the first time.  In addition, many women are so groggy from drugs after the surgery that they are not able to nurse for many hours after that as well.  All of these delays can add up.   

Women who have a cesarean tend to receive their children much later than if they had had a vaginal birth, and in some places, the delay can be many hours.  Dasgupta (1997) found that although their hospital had adopted guidelines stipulating that cesarean babies should be nursed for the first time within at least 4-6 hours, not a single baby in their hospital was nursed within this time period.  

This delay in first nursing can cause critical differences in hormone levels (Nissen, 1996) and impact milk supply.  It also helps delay the appearance of mature milk (Chapman and Perez-Escamilla 1999, Vestermark 1991), putting the baby at risk for dehydration or excessive weight loss after birth, which often leads to supplementary formula.  All of this combines to undermine a woman's confidence and desire to breastfeed.  

Because breastfeeding is very much a function of supply and demand, early and frequent breastfeeding is EXTREMELY important for establishing breastfeeding.  Studies show that the more the first nursings are delayed, the higher the rate of problems (Mathur, 1993).  Similarly, frequent breastfeeding (every 2-3 hours or so) in the first day is VERY important in helping the mature milk to come in more quickly.  

The more feedings of colostrum (the early milk) that the baby receives, the more immunological protection the baby gets.  In addition, early and frequent breastfeeding can help lessen or treat a baby's tendency towards hypoglycemia and jaundice, problems common after birth scenarios that lead to cesarean.  So not only does early and frequent nursing promote earlier 'mature' milk and greater milk supply, it also is protective against many of the problems babies can face after difficult pregnancies or births.  

Supplementary Feedings

Many cesarean babies are given bottles of formula routinely (Vestermark 1991), which research clearly shows also lowers the rate and duration of successful breastfeeding (Samuels 1985, Hill 1997).  Blomquist (1994) found that, "Infants given a supplementary feeding had 4x the risk of not being breastfed at 3 months."  Cronenwett (1992) found that "30% of mothers whose babies received bottles in the hospital reported severe breastfeeding problems, as compared with 14% of those whose babies did not."

Chapman and Perez-Escamilla (1999) also found that exclusive formula-feeding before onset of lactation was a strong risk factor for delayed onset of lactation (mature milk coming in late), which can lead mothers to think they 'don't have enough milk' and stop breastfeeding.  Yet many hospitals still have policies requiring routine bottles, or nurses who aggressively insist that a postpartum bottle is necessary to 'prevent hypoglycemia' or 'test the baby's ability to suck and breathe at the same time.'  

Even pediatricians rarely understand just how much supplementary feedings can interfere with breastfeeding.  Freed (1995) studied over a thousand pediatricians and pediatric residents, and found that "Only 64% of practitioners and 52% of residents knew that supplementing during the first few weeks of life may cause breast-feeding failure." Thus the culture and traditions of hospitals and their personnel regularly promote supplementary feedings without recognition of just how harmful these can be.

When the mother's access to the baby is delayed, the baby is often given a pacifier to soothe it and keep it quiet in the meantime.  Even when 'only' a pacifier and no supplementary bottles are given, research shows that breastfeeding can still be affected. Righard and Alade (1997) studied the effect of pacifier use on breastfeeding duration.  They found that, "The breastfeeding rate at 4 months was 91% in the nonpacifier group and 44% in the pacifier group." The findings of Righard (1998) and Victora (1993) also support that pacifiers can interfere with breastfeeding.  So not only should routine supplementation be abolished, but routine pacifier use should also be avoided whenever possible. 

One circumstance that can sometimes necessitate supplementary feedings is when the baby loses a great deal of weight after birth and does not regain it quickly.  In some cases, this is truly worrisome and indicative of problems, but in other cases, it can be caused by the policies of the hospitals themselves. Many women are given IV fluids during birth, sometimes excessively, and especially so before epidural or spinal anesthesia.  Some of this may transfer into the baby and make him appear larger than normal at birth.

Henci Goer  (The Thinking Woman's Guide to a Better Birth) documents that this overload of fluids  "also result[s] in a transfer of water into the baby's tissues.  This extra fluid inflates the baby's birth weight and the subsequent weight loss after birth.  Doctors and others often gauge breastfeeding adequacy by how fast the baby regains her birth weight, so this misleading weight loss may lead a doctor or mother to mistakenly conclude that breastfeeding is inadequate" or that supplementary feedings are needed.  Because of this, many babies are given supplementary feedings that seem necessary at the time but which are actually caused by the interventions used on the mother.  

Although supplementary feedings should be avoided as much as possible, sometimes circumstances or medical conditions really do necessitate them.  If they must be done, research shows that doing them by non-bottle means preserves breastfeeding more often than if the baby is given a bottle.  Mathur (1993) found that 87% of babies who had 'prelacteal feeds' by spoon went on to total breastfeeding, while only 33% of babies who had prelacteal feeds by bottle went on to total breastfeeding.  So why aren't hospitals avoiding bottles when supplementation truly is needed? 

Many hospitals strongly resist non-bottle supplementation options because they are not aware of other options, are not trained or encouraged in other options, or are stuck in old, rigid protocols.  Many different types of non-bottle options are available, including syringes, cup feeding, finger feeding, eyedroppers, spoon feeding, supplementary nursing systems, etc.  Further information on these alternatives can be found below, and also online at www.breastfeeding.com, www.lalecheleague.org, and www.promom.org.   

Separation of Mother and Baby

Research shows that rooming in (having baby stay in the room with you instead of staying in the nursery) also increases breastfeeding rates.  This is probably because the baby nurses more often (stimulating milk supply) and gets less supplementation. Because some hospitals do not permit women who have had a cesarean to have their babies room in with them, this can negatively affect breastfeeding rates.  

For example, Mathur (1993) found that 68% of women whose babies were not separated from them practiced total breastfeeding, versus only 35% of women whose babies were separated from them.  Flores-Huerta and Cisneros-Silva (1997) found that 61% of those who had 'joint lodging' breastfed exclusively for the first month, while only 42% of those who did not room together breastfed exclusively in that time.  Samuels (1985) also found that keeping the infant in the room during the hospital stay encouraged breastfeeding rates.  Rooming in makes a difference!

Some nurses offer to take the baby to the nursery for the night in a well-meaning gesture to help the mother recover better. But Anderson (1989) found that women who roomed in with their babies used less pain medication and slept just as well as those whose babies went to the nursery.  In addition, the babies' blood pressures were lower, they cried less, and their vital signs stabilized more quickly.  

Anderson (1989) also noted that secretion of prolactin (an important hormone in milk supply) is 10x higher at night, and therefore nursing frequently at night "may be more important than daytime in the establishment of lactation."  Frequent nursing at night is much more likely if the baby rooms in than if it goes to the nursery, where the nurses may or may not call the mother for a feeding, and sometimes give surreptitious bottles. Although well-meaning, taking the baby to the nursery for the night for "respite" care often exacerbates problems with low milk supply.

Many women also report that sleeping with their babies in the hospital bed (once they are aware and responsible after anesthesia) makes life after a cesarean much easier.  It is easier to get the baby ready and into position when it's time to nurse, and they tend to nurse the baby more often and respond to its hunger cues more quickly when baby is right beside them.  As long as safety precautions are followed and the mother is not too drugged, sleeping with the baby after a cesarean can work very well.

Since frequent feedings are an important part of establishing milk supply in a timely manner, rooming in is an important part of helping cesarean mothers breastfeed  more easily, and sleeping with the baby in your arms can help even more.   

Anemia From Blood Loss

Research shows that women having a cesarean lose about twice the amount of blood as women having a vaginal birth.  If a woman experiences excessive blood loss during surgery, she may experience anemia afterwards, which can interfere with milk supply significantly (Willis and Livingstone, 1995).  Yet few doctors are aware that anemia can affect milk supply, and few check for it or treat it aggressively afterwards.  

More women may be anemic postpartum than doctors recognize.  Bodnar et al. (2001) found that 27% of women were anemic postpartum, and that the rate of anemia rose to 43% among non-Hispanic black women.  Yet much of this anemia goes unrecognized and untreated. 

Henly (1995) studied the relationship between anemia and insufficient milk syndrome in 630 first-time mothers.  They found that 22% of the mothers were anemic, and of the anemic women, about 20% reported symptoms of insufficient milk syndrome.  These mothers breastfed fully for a shorter period of time and weaned earlier as well. The authors summarized their study by saying, "This study suggests that anemia is associated with the development of insufficient milk, which in turn, is related to duration of full breastfeeding and to age at weaning."  

Women most at risk for anemia postpartum include those who were anemic prenatally; those whose babies were born by cesarean; those who experience a hemorrhage during or after birth; those with certain placental problems like placenta previa, accreta or abruption; women carrying multiples; those with a history of prior post-partum hemorrhage; those with uterine atony; and heavy women (because of extra blood vessels feeding extra tissue).  Bodnar (2001) found that minority women and women from low socioeconomic groups may also be at greatly increased risk for anemia.

Although surgeons and nursing staff should be on alert for anemia in all women post-surgery, sadly this is a condition that is often missed.  Even when it is caught, problems with breastfeeding are often not connected to it.  If you experience dizziness, weakness, fainting, or extreme fatigue after your cesarean, strongly request that your iron levels be checked.  Early treatment can prevent or minimize problems with milk supply and speed your recovery significantly.  Iron supplements (herbal or traditional) and modifying food intake to include more iron and folic acid can usually take care of the problem if it is caught early enough.

Mechanical Issues

Cesarean surgery also makes positioning the baby for nursing more painful.   The usual 'cradle' nursing position can be painful after a cesarean, since this places baby against an abdomen that has just been traumatized.   Placing a pillow over the incision may help cushion it sufficiently, but for some women even this places too much pressure on a tender area.  

Many nurses tell women to nurse lying down instead, which some cesarean moms do find to be easier.  However, others find this position quite difficult, especially when they have to turn over in bed in order to nurse on the other side.  Well-endowed women often find nursing while lying down especially challenging. 

The football hold is a great hold for post-cesarean nursing, as the baby is not against the incision at all, the mother can sit up (which makes controlling the baby's head and latch easier), and the mother can see to latch the baby on easier.  For more information on the football hold or any other nursing position, see the "help" videos at www.breastfeeding.com

However, some mothers even have difficulty using the football hold.  Simply put, a cesarean presents yet another level of physical challenge to the new and unfamiliar task of breastfeeding, and the pain factor can be a significant deterrent for many women. 

Type of Anesthesia

The type of anesthesia used for the cesarean can also influence breastfeeding rates.  Several studies (Lie and Juul 1988, Mathur 1993, and Albania et al, 1999) have found that breastfeeding rates are significantly higher after regional anesthesia (epidural or spinal) than after general anesthesia.  

This may due to a number of causes.  Albania et al. speculated that the difference was probably due to faster mother-baby bonding after regional anesthesia.  Since mothers who have general anesthesia tend to take longer to wake up and are often more groggy and 'out of it' afterwards, they may be less inclined to nurse, or to nurse right away. Many women who have experienced cesareans by general anesthesia also report feeling less connected to their babies, and may thus be less devoted to the idea of nursing.  Also, because of the delay in access after a general, many of these babies also receive supplementary feedings in the nursery before the mother gets them.  

There may also be physical influences on the baby and mother which may affect nursing.  General anesthesia tends to reach the baby strongly, and may depress his/her responses after birth for some time.  This may make the baby harder to rouse for nursing, resulting in baby getting nursed less often (creating less demand for the milk supply).  Drugs may also result in the baby being less effective at suckling, which would make his nursing less efficient too.   Regional anesthesia results in lower doses of the various drugs crossing the placenta to the baby, so although baby may still be affected, he may not be affected as strongly as after general anesthesia.

Whether the cesarean was scheduled or unplanned also may make a difference in 'delayed onset of lactogenesis.'  Chapman and Perez-Escamilla (1999) found that women who had scheduled cesareans experienced delayed lactogenesis (mature milk coming in later) at a much lower rate than women who had unscheduled or emergency cesareans.  This may reflect the type of anesthesia, the amount of medications the baby received, the amount of separation of mother and baby after the operation, or many other factors.

Inhibition of Newborn Suckling Responses by Medications

Although many women are told that pain medications (and particularly epidurals) do not reach or affect the baby, research shows that they do have some effect on babies, although authorities debate how significant these are.  The weakness of much of this research is that they often do not include unmedicated control groups, and rarely do they consider feeding ability as an outcome.  Thus, it is difficult to know how strongly babies really are affected by medications.

For years, lactation consultants have believed that pain medications affect the baby more than OBs and anesthesiologists believe they do.  In particular, they find that babies of highly medicated labors tend to have trouble getting started with nursing.  Walker (1997) states:

Staff nurses and lactation consultants have noted that many babies whose mothers receive labor analgesia, including epidurals, have difficulty performing a cluster of behaviors necessary for successfully initiating feedings at the breast.  They have difficulty latching to the breast, are unable to sustain sucking once latched on, have inefficient or uncoordinated sucking leading to little milk transfer and low intake, have difficulty arousing or staying awake, and exhibit poor cueing to feed.  Thus, these babies gain slowly or not at all, and many lose excessive amounts of weight during the first week following birth.  Mothers of these babies may present with sore nipples, low milk supply, secondary engorgement, plugged milk ducts, and blocked areas of the breast.  

Riordan et al. (2000) used a scoring system to evaluate the effect of medications on neonatal suckling in 129 vaginally-delivered babies.  Babies of medicated mothers scored lower in suckling effectiveness than babies of unmedicated mothers, and the scores were lowest in the group that received both epidurals and IV drugs.  The overall breastfeeding duration to 6 weeks postpartum was not significantly affected, but even so the authors concluded that:

Labor medications impair suckling in the early postpartum period.  Therefore, lactation consultants should be concerned that breastfeeding mothers who have received labor medications may become discouraged, especially if they are discharged before effective breastfeeding is established.  If mothers lack adequate support at home or did not receive follow-up care, babies with poor breastfeeding behaviors are at greater risk for dehydration, jaundice, and poor weight gain.

If these effects occur in babies that were born vaginally, what about the effects on babies who went through a long and highly medicated labor and then were exposed to even more drugs for a cesarean?  Only further research will tell for sure, but it is likely these babies are affected even more strongly.   

Righard and Alade (1990) found that sucking problems were more common in babies whose mothers had received Demerol.  Walker (1997) reviewed a series of studies to determine the effect of labor medications on critical neonatal breastfeeding behaviors and time to first 'successful' breastfeed.  She found that IV narcotic medications such as Demerol, Stadol, and Nubain did affect breastfeeding by depressing or delaying behaviors such as rooting and sucking. The longer the infants had been exposed to the medications, the more the feeding behaviors were affected, and generally speaking, the longer until the first 'successful' breastfeed.  She noted that every single study reviewed "demonstrated that maternal medication had some effect on the breastfeeding behavior of the baby."  

The effects of epidurals are harder to measure.  We do know that epidurals affect newborn behavior, especially in alertness and in disorganized  movements (Sepkoski 1992).  However, Walker's review found NO studies on epidurals that specifically mentioned breastfeeding as an outcome.  Of the studies that do measure behavioral effects of epidurals, designs of the studies do not permit adequate analysis of effect on components that might affect breastfeeding. The truth is no one has really studied the issue adequately, so no can say for sure that epidurals do or do not affect breastfeeding behaviors!  

Instead, epidural studies examine the behavior of the newborn on behavioral assessment scales, but even these studies have major weaknesses, according to Walker.  Most studies use dissimilar drugs and dosages and measure differing behaviors, so comparisons are difficult.  Very few include a non-medicated control group, and even fewer include assessments of infant behavior after 24 hours postpartum, let alone assessment of breastfeeding behaviors.   Walker urgently advocates for more well-controlled studies with these parameters. 

Walker did find 2 studies (Murray 1981 and Sepkoski 1992) which had unmedicated control groups and behavioral assessments for longer than 24 hours postpartum:

[Both studies] showed clear depression in motor abilities of medicated babies.  Both studies also showed medicated babies exhibited poor state control.  The developmental agenda for healthy term infants is that of increasing differentiation and control of states.  Medication may delay the process and interfere with the baby's ability to gain control over and modulate state changes in the first 24-48 hours.  Drug induced interference may account for the anecdotal descriptions of 'sleepy' babies (babies unable to exhibit enough state control to breastfeed effectively) and further prolong the period of state disorganization.

Walker further notes that the most common drugs used in epidurals are known to cross the placenta.  Bupivacaine "enters the maternal blood stream rapidly from the epidural space.  It then crosses the placenta so that a measurable concentration is present in the fetal circulation within 10 minutes of administration."   Narcotics (such as Fentanyl) that are commonly added also "show significant placental transfer."  In a few studies reviewed for her article, some infants were affected by labor medications for as long as a month after birth (Sepkoski 1992).  

A very recent article (published after the Walker article) compared the effect of 'caine family of drugs on newborn breastfeeding behaviors.  'Caine family drugs are the anesthetics typically used in epidurals; bupivacaine is the drug most frequently used.  In this small study, 10/10 (100%) of the babies of non-medicated mothers initiated instinctive breastfeeding behaviors and successfully self-attached and suckled.  The results were far different for the babies of the medicated mothers.

Only 2/6 (33%) of the babies who received a pudendal block (using mepivacaine) successfully self-attached and suckled, and only 3/12 (25%) of the group exposed to epidural bupivacaine, narcotic, or combo of these successfully self-attached and suckled.  Although the study is extremely small, it certainly seems to indicate that medication can affect instinctive breastfeeding behaviors.  (Read more about the study in the article by Henci Goer at www.parentsplace.com/expert/birthguru/articles/0,10335,243385_406529,00.html.)  

In summary, research clearly shows that IV narcotic pain meds can affect breastfeeding behaviors.  While the effect of epidurals on breastfeeding cannot be conclusively analyzed, it is likely that there is reason for concern.  This too, may be another reason why breastfeeding can be harder after a cesarean.  

Lactation Supply Inhibition Due to Medication

Some medications may inhibit milk production. For example, if a woman has had her labor induced or augmented with Pitocin, its anti-diuretic properties may inhibit milk production. This tendency towards fluid retention may make the mother's milk tend to come in late, may make the mother excessively engorged or have difficulty resolving the engorgement, and the baby may have a harder time latching on because of this engorgement.  

Certain specific labor or postpartum medications may also suppress breastfeeding. Hirose (1997) found that postoperative extradural buprenorphine decreased the amount of breastfeeding and infant weight gain for 11 days after a cesarean.  Although this study needs to be replicated, the authors suggested that extradural buprenorphine suppressed breastfeeding after cesareans.

Many women are given Duramorph in their epidurals during the cesarean to help with post-operative pain.  Duramorph and similar drugs are associated with a high incidence of itching (pruritis), and women are often given Benadryl or other antihistamines to lessen the itching.  Unfortunately, antihistamines tend to "dry you out" and may interfere with milk supply if given in high amounts, or may make the baby drowsy and less responsive to nursing.  

Many mothers report anecdotally that Magnesium Sulfate can interfere with establishment of breastfeeding.  Mag Sulfate is a medication used to help women with pre-eclampsia prevent seizures and other problems.  Most women report that its effects are most unpleasant, and the stress from being on this drug alone can probably interfere with breastfeeding.  

Many women are given diuretics after birth to help deal with significant swelling/edema.  Women who have had pre-eclampsia, women who have been induced with pitocin, and women who have had lots of extra IV fluids tend to have the worst problems with edema after the birth.  To help women get rid of these extra fluids, some doctors prescribe diuretics.  However, this can also interfere with breastfeeding supply.  

Birth control pills can also decrease milk supply.  Traditional estrogen-only pills are known to decrease milk supply significantly, yet many doctors remain unaware of this problem and prescribe them anyhow.  Combined estrogen/progestin 'mini-pills' can be safely used during breastfeeding by most women, but few doctors know that if these are prescribed too early postpartum, they can also inhibit milk supply.  Generally, it is safest to wait at least 6-8 weeks before starting the mini-pill, and even then a few women have noticed that it inhibits their milk supply (Breastfeeding Answer Book, 1997).  

It's clear that medications given during labor and birth can affect the baby's suckling response and feeding behaviors (see above), and it's also clear that medications given to the mother can also affect her milk supply.  

 

Breastfeeding Holds Useful After a Cesarean

As noted, positioning can be more difficult after a cesarean. There is no one hold that is best for everyone after a cesarean; each mother has to experiment to see what works best for her unique needs.  

Many women can still use the 'cradle' position after a cesarean by putting a pillow over their incision and putting baby on top of that pillow.  This position is the one most women use permanently for nursing, and although a bit awkward after a cesarean, can be done.   If this position feels fine to you and will be the position you use for nursing later, don't feel that you have to use a different nursing hold just because you've had a cesarean!  However, some women do find this position too difficult or painful after a cesarean and so choose other options. 

Some women nurse in a side-lying or lying-down position after a cesarean, due to either discomfort or to prevent a 'spinal headache.' This is the position some breastfeeding books recommend first after a cesarean.  A nurse or professional lactation consultant can help you use pillows to support your back and help position baby properly.  Illustrations on breastfeeding positions can be found online at www.breastfeeding.com/helpme/helpme_video.html.  

Women who are well-endowed or who find it difficult to nurse lying down usually find the football hold the best position for nursing after a cesarean.  In this position, the baby's body is held to one side of the woman, under her arm and supported by pillows. Be sure your hospital bed is cranked up to a comfortable angle---higher is better than lower. Use LOTS of pillows wedged between you and the bed railing to bring baby up to your breast level; never lean in to baby. In Kmom's personal opinion, this is the most comfortable of the nursing positions for after a cesarean, and should be promoted more in breastfeeding resources. 

The advantage of the 'football' hold is that it is easier to control the baby's head and latch, and easier to support a larger breast in this position.  It also takes the weight of the baby off of your incision and allows you to sit up comfortably while nursing (many women find it difficult to lie down fully after a cesarean).  It is also an excellent position for premature babies or when the mother is quite engorged.  A video demonstrating the 'football' hold can be found at www.breastfeeding.com/aaavideo/footballhold.avi or at the 'helpme' videos on this site.  

If you find these other positions impossible, some women have luck with the Aussie hold.  In this unusual hold, the mother lies flat on her back or slightly tilted.  She puts the baby on top of her body or with its legs slightly off to one side, with the baby's mouth at the mother's breast.  Be sure baby is able to breathe around your breast tissue. If necessary, gently depress the breast around his nose slightly to ensure that baby has ventilation. Babies' noses are flared and made just for this situation so he won't need much help, but with very large breasts this is occasionally needed.  Although it does not seem that this position would work very well from the description, some women find that this works better for them than the traditional 'lying down' position.

For more information on breastfeeding after a cesarean and illustrations of all these various nursing positions and others, read The Nursing Mother's Companion, The Womanly Art of Breastfeeding, or So That's What They're For! Breastfeeding Basics.  You can also find more information and illustrations online at www.promom.org or www.lalecheleague.org.   

 

Strategies for Increasing Breastfeeding Success

What if you must have a cesarean because it is medically necessary? Or if you are going for a vaginal birth but want to be prepared for a better breastfeeding experience in case a cesarean becomes necessary?  Does breastfeeding after a cesarean HAVE to be difficult?  What things can you do to help ensure breastfeeding goes well?

Even if you had a bad experience breastfeeding before, it doesn't have to happen that way again.  Research shows that most women who have had problems breastfeeding a prior child have a better breastfeeding experience with a subsequent child (Ingram 2001).  There are never any guarantees, of course, but chances are very good that things will be better this time.  Remember, this is a DIFFERENT CHILD, a DIFFERENT BIRTH, and a DIFFERENT EXPERIENCE.  Consciously choose to make as many things different this time as possible, and let those differences help you make a totally new experience this time.   

Here are some ideas that may help facilitate a smoother transition to breastfeeding. The main thing is to be as informed as possible about breastfeeding, nurse early and frequently, have lots of expert resources, get help quickly if needed, and make the best decisions you can at the time.   Then you can go forward, knowing that you did the very best you could do for your child and for yourself, whatever happens.

These ideas are drawn from the research cited above.  Some of them may work for you; others may not be appropriate in your situation.  As always, take what you need and leave the rest behind.  

Summary of the Research: Hints for Breastfeeding Success Go for a VBAC if possible; the hormones of labor will help breastfeeding get started sooner

It is apparent from the literature that delayed lactogenesis is common with cesareans.  In most cases, a VBAC is better for both mom and baby, and helps jumpstart the hormonal processes for lactation better than an elective cesarean.  Thus, if at all possible, choose a VBAC for your next birth.  However, if you do have a cesarean, it doesn't mean you cannot breastfeed!  Simply emphasize nursing as early and as frequently as possible afterwards in order to help speed up the process of the mature milk coming in, and to lessen the chances of supplements being needed due to hypoglycemia or jaundice. 

Utilize regional anesthesia instead of general anesthesia for the cesarean

As noted above, breastfeeding seems to go easier after regional anesthesia (epidural, spinal, or combined spinal epidural) rather than general anesthesia.  This is probably because the mother is able to nurse sooner, with better pain control, and is less 'out of it' from the drugs.  Also the baby is exposed to a lower dosage of drugs in regional anesthesia and thus may suckle more effectively than after general anesthesia.  Unless there is a true emergency where every second counts, women should have regional anesthesia for their cesareans. If you had trouble with an epidural last time, a spinal or combined spinal epidural is often a good alternative and offers much better coverage.  Discuss with your anesthesiologist your desire to sit up to breastfeed as soon as possible in recovery, and ask for ways to avoid a spinal headache or drug combinations that may cause problems.  Working with your providers to express your concerns and desires ahead of time often helps women have a better experience and avoid the problems that occurred previously.

Nurse as early as possible after the baby is delivered, especially before regional anesthesia wears off

Nurse as early after birth as possible.  Some women are able to breastfeed the baby right on the delivery table as the surgeons finish up their repairs, but most women nurse for the first time in the recovery room.  Nursing within the first hour after birth and frequently thereafter helps bring the mature milk in sooner and increases supply.  If possible, nurse the baby before the effects of the regional anesthesia wear off. You will be relatively alert and free of pain, which will help the first nursing go better than if you are worn out, in pain, or in need of sleep.  

Take pain medication as needed in order to be comfortable

After the regional anesthesia has worn off, don't hesitate to take enough pain medication to be comfortable.  You cannot nurse well or enjoy your baby if you are in pain from the surgery.  Take what pain relief that you need so that feeding and enjoying your baby will be your top priority.  The pain medication that you are given will be safe for your baby and will only be passed on in small amounts that won't affect baby very much.  Occasionally some women find that their babies are more affected by pain medication; these women must find a balance between getting enough  pain relief to function yet easing off the amount in order to make baby less lethargic. But most women find that it is best to take pain medication as needed, and that adequate pain relief helps them be more able to nurse frequently.  

Pursue regular, frequent feedings

Research shows that breastfeeding goes best if mother and baby nurse early and frequently in the first few days.  Experts note that babies do best when nursed at least 8-12 times in the first days.  Breastfeeding is very much a supply and demand process, and the best and simplest thing you can do is to nurse AT LEAST every 2-3 hours for the first several days to a week.  After that, use your baby's cues to help you know how often to nurse; about every 3 hours works well for most babies.  

Don't limit time on the breast

Many hospitals, even today, tell women that they do not need to breastfeed their babies more than about 5-10 minutes on each side.  This is poor advice.  Some babies nurse more efficiently than others, while some are sleepy at first and may take a long time to finish a feed.  Limiting time on the breast does NOT eliminate sore nipples, and can lead to low weight gain in babies.  Babies need to receive plenty of the fat-rich hindmilk (which  comes in the last part of a nursing session) in order to regain their birth weight more easily; limiting time on the breast also limits baby's weight gain.  Instead, be sure baby gets plenty of time nursing at each breast so that they get plenty of foremilk AND hindmilk.  Babies don't need to nurse constantly, but neither should they be artificially limited to small amounts of time.  Let your baby set its own feeding cues as long as it seems like they seem like they are getting enough.  If there is any doubt about baby's weight gain or whether there is sufficient intake, nurse frequently and don't limit time on the breast.  

Use relaxation tapes and guided imagery to help decrease stress and increase milk output

Dewey (2001) discusses a study where the use of of relaxation and guided imagery audiotapes before nursing helped nearly double the milk output of a group of pumping mothers of premature babies.   Holding preemies skin to skin also helps increase the mother's milk supply.  If you are having trouble with milk supply, take time to do relaxation exercises, get relaxation and guided imagery tapes if you can (some are available through www.lalecheleague.org), and hold your baby skin to skin as much as possible.  You can also ask a lactation consultant about herbs and/or medications to help increase milk supply.

Utilize the support of a professional lactation consultant to help with positioning and latch-on concerns 

If you are having trouble getting the baby latched on properly, finding a comfortable nursing position, or are experiencing lots of soreness, don't hesitate to call in a PROFESSIONAL lactation consultant.  They are experts at assessing the latch of a baby, the suck of a baby, and helping mothers find the best way possible to help their babies breastfeed.  Nurses on the hospital staff may say that they are trained in breastfeeding issues (and some genuinely are), but so much misinformation about breastfeeding is passed on in the medical and nursing professions that you never know if they really have been well-trained. Many give out well-intentioned but incorrect information. A professional lactation consultant with the initials "IBCLC" after their name has taken a standardized and carefully prepared course of learning, and has passed a rigorous exam in order to become board-certified. If in doubt, call the true experts, the IBCLCs.  

Avoid artificial nipples and unnecessary supplements as much as possible

Above all, avoid bottles if at all possible. Bottles are a quick way to breastfeeding problems, especially if used in the first few weeks of life. If you need to use them for working, they can be introduced later, but they can greatly complicate breastfeeding during the initial weeks. If supplementation becomes medically necessary, there are other methods that pose less interference with a baby's sucking mechanism, such as syringe, finger-feeding, flexible cups, etc. Although some babies can successfully switch from bottles to breast and back, many have difficulties with it.  Unfortunately, you cannot predict ahead of time which babies will have problems with nipple confusion and which will not. Therefore, it's best to try to avoid bottles if at all possible, and to use alternative methods should supplementation become necessary. 

The ' football' or 'clutch' hold is often more comfortable after a c-section

Although most breastfeeding guides suggest that women nurse lying down after a cesarean, many women find this quite uncomfortable or difficult to manage.  It can be an especially hard position for the well-endowed woman.  Although women should use whatever position they find most comfortable, many women do find that the 'football' hold ('clutch' hold )is the most position to nurse in immediately after a cesarean.  The key to using the football hold is to raise the head of the bed somewhat, and to put plenty of pillows beside you so that the level of the baby's mouth will be at your breast.  It is very important to bring the baby to YOU, instead of you leaning over to the baby.  Don't be afraid to use LOTS of pillows.

Room in with the baby to increase the breastfeeding success rate

As noted above, rooming in has been found to strongly increase the breastfeeding success rate.  When the baby rooms in with its mother, it gets more frequent nursing (and therefore more milk), and the mother's supply is stimulated more.  It is also less likely to receive a bottle if it is rooming in with the mother.  Most hospitals today recognize that rooming in is a good thing, but a few still discourage cesarean mothers from doing this.  Families may have to be assertive about keeping the baby in the room with them.

Have a family member (father or other relative) room in too

Having the father (or other family member) stay in the hospital room overnight can greatly ease the process of rooming in.  If the staff is resistant to the idea of a cesarean mother rooming in with her baby, then the presence of another adult can help reassure them that baby will be well taken care of.  In addition, the cesarean mother often needs a little extra help with the baby when it is time to get out of bed to go to the bathroom or walk around, and the father can help with diaper changes too.  When a woman has had major surgery and is taking care of a baby too, an extra pair of hands are important.  Having another family member room in should be done whenever possible.  

Sleep with the baby, which can greatly ease regular feedings

As long as the mother is not too groggy from drugs, she can keep the baby in bed with her as much as possible.  This makes feedings much easier, probably helps ensure more frequent feedings and better weight gain, and can help the mother and baby bond better.  Naturally, the mother should pay careful attention to safety concerns with the baby in bed with her, using the railings and the pillows as needed to keep a barrier to the edge, and keeping the baby in her arms as much as possible so she is always sure where the baby is.  If the mother is not feeling well enough or alert enough to have the baby in bed with her, the father (or other relative) can take the baby between nursings, and the baby can sleep with the father on the pullout couch. However, most women find that they are able to sleep with the baby very safely, and that it makes things much easier after a cesarean. Best of all, many women report that it speeds their emotional healing to have baby so close. 

Be sure your nutrition is excellent and that you are getting plenty of extra fluids

If you are breastfeeding, you will need to be sure that you are getting enough extra calories and fluids and such, so continuing to follow a pregnancy diet is generally a good idea. Do not try to diet right away (if at all, see discussion in Dieting and Pregnancy). You will probably find that breastfeeding, on its own, will promote some weight loss with very little effort, although this is not a sure thing for all women. However, restricting your food intake can affect your milk supply or make you run down, so you will want to be sure to continue to eat well and healthily. Emphasize iron and folic acid foods to help build back up your blood supply, and drink plenty of fluids so you are well-hydrated.  Some sources also recommend  extra vitamin C in order to help tissue healing.

Watch carefully for thrush (a yeast infection)  after a c-section

Thrush (a yeast infection of the baby's mouth and/or the mother's nipples) is a special concern after a c-section, due to the high amounts of antibiotics often given during and after surgery. If the mother tends towards glucose intolerance/insulin resistance and she consumes a lot of carbs, she may be particularly prone to developing thrush. Any pain, redness, burning/itching of the mother's nipples, or white patches seen in baby's mouth may indicate that thrush has developed and needs to be treated. Often, significant nipple soreness in the early weeks of nursing is actually due to undiagnosed thrush.  There are a number of options for treatment of the baby's mouth and the mother's nipples, but it is critical that both mother and baby be treated simultaneously, since it is very common for one to reinfect the other, making the process an ongoing and stubborn battle. The mother's bras should be laundered daily to prevent re-infection from that source as well.  For more information on treating thrush/yeast, see www.laleacheleague.org, www.promom.org, or www.breastfeeding.com.  

Also watch for infections in the "fold" under the belly near the incision, as a yeast infection there can easily transfer to the breasts through cross-contamination.  Use a blow-dryer on "cool" to help decrease the likelihood of infection, and be sure to stay away from simple carbs for a while. Taking "acidophilus" in your diet may also help.  Consult your doctor about other possible treatment options if yeast becomes a chronic problem.  For really stubborn and recurring yeast problems, some women report that a careful consultation with a naturopath can help. 

If experiencing problems, get expert help from a professional lactation consultant as soon as possible

If you have ANY problems with breastfeeding, be sure to consult a professional lactation consultant as soon as possible. Given the high occurrence of breastfeeding problems, women who have had cesareans should be receiving automatic consultations from lactation consultants, but unfortunately they often do not get this extra help. Breastfeeding presents so many benefits that it should be strongly promoted for all moms, but the reality is that help is often neglected, and many cesarean moms fall through the cracks.  If you have problems at ALL, get to a professional IBCLC as SOON as possible. Quick support is often the difference in whether breastfeeding works out or not.

 

Other Strategies for Success

Leave The Free Formula at the Hospital

Many doctors and hospitals routinely send free formula samples home with mom, which can be a difficult temptation to resist, especially in the mother's vulnerable postpartum state.  Cesarean mothers may be even more vulnerable to these samples.  Well-meaning family members may give the baby a bottle 'to give mom a break,' or the mom may be so exhausted and groggy from the surgery that she gives in to the temptation to use the formula.  Or if the baby has experienced  jaundice or low weight gain, the hospital may tell her to take the formula to help finish 'flushing out the jaundice' (see above) or to bolster the baby's weight gain. But these extra bottles can be a road straight to breastfeeding 'failure.'

Even pediatricians and new mom support groups often have free formula samples prominently on display. These free samples are unethical and a violation of World Health Organization Code, but they are still quite common. This kind of sabotage from health professionals is an outrage, but it does exist, and is insidious in its influence on breastfeeding.  Giving free samples to mothers who intend to breastfeed shortens the breastfeeding period markedly.  This affects babies' health long-term, and so is unethical and unconscionable.

Even simply having formula advertising in infant feeding information packs can lower the rate of breastfeeding.  One randomized, controlled trial (Howard 2000) found that the group exposed to formula advertisements had greater breastfeeding cessation rates in the first 2 weeks.  In particular, women with uncertain or short-term breastfeeding goals were the most affected.  The authors state unequivocally that "Formula promotion products should be eliminated from prenatal settings."  

Formula companies also routinely send unsolicited cases of free formula in the mail to pregnant women, especially if you sign up for one of their 'free' teddy bears or diaper bags (even when you note on the sign-up form that you plan to exclusively breastfeed). This isn't altruism!  They know that a breastfeeding child who has formula in the house is likely to wean more quickly, thus making the company more money in the long run.  Although it may seem like a gift to have these free formula samples 'just in case,' formula companies are good at marketing.  They know that a little product sample up front will mean greater profits later. And it's your baby's health that potentially pays the price.

New mothers who intend to breastfeed have to be very careful to avoid falling into these seductive marketing traps. The best strategy is to not sign up for promotional gifts, avoid formula promotional materials, and to leave the formula at the hospital so you are not even tempted to use it at home.  If you prefer, you can take the formula to your local food closet/shelter, or donate it to a friend who is already bottle-feeding. 

Of course, if you are truly struggling with nursing issues and a professional lactation consultant has recommended supplementing the baby, there is no reason to feel guilty about taking home the free samples of formula.  Although most cases of 'low milk supply' are iatrogenic (caused by medical mismanagement) and can be resolved through nursing alone, this is not always true.  Sometimes supplementation really is necessary and there are women who must combine nursing with supplementation.  

If you need to do this, then of course, formula can be a wonderful and life-saving product.  That is a different situation than deliberately sabotaging breastfeeding because of corporate greed.  When supplementation is truly necessary, free samples can be very helpful, judiciously used, and mothers should never be made to feel bad for taking advantage of them.  

But for the majority of women who are breastfeeding, it is best to leave the free formula samples at the hospital or give them away immediately.   They are a specific marketing tool designed to sabotage breastfeeding, and this strategy is all too successful.  If you have had breastfeeding difficulties in the past, you should be particularly careful to avoid taking these home with your next baby.  

Nutrition Issues

It is important to continue to pay attention to proper eating post-partum.  It is vital that a woman be well-fed and well-hydrated while her body goes through the difficult hormonal and physical changes postpartum, and while her body is attending to the amazing physical task of starting to breastfeed. 

Yet between the time period before and after a cesarean, most hospitals strongly restrict a woman's intake for several days.  This can further interfere with the body's ability to cope with postpartum changes and to start the lactation process efficiently. Many women complain of feeling starved, yet still being deprived of food their body desperately needs to start recovering well. 

The hospitals do have a legitimate concern for using this protocol.  Surgical anesthesia can affect the function of nearby organs, and the intestines tend to slow down (and can even be affected permanently sometimes).  To make sure a woman's intestines have started re-functioning properly after the surgery, hospitals often refuse to let a woman eat real food again until she has started to pass gas. The problem with this protocol is that if the woman has been in labor a long time at a hospital that forbids food during labor, there is no food to help make the gas.  Or the woman may have plenty of gas but the intestines are moving slowly from the surgery and with no new food the gas becomes trapped and painful.

Some hospitals are beginning to question this protocol now.  A recent study (Patolia 2001) found that women who ate earlier than traditional protocols did just as well as women who ate later.  They reported feeling better and less weak.  They also were ready to leave the hospital sooner.  Although breastfeeding was not a measured outcome in this study, it would be interesting to see if the delay in food intake plays a part in the delayed lactogenesis that many cesarean mothers experience, or if it negatively affects milk supply.  At the very least, most cesarean moms would feel better to be able to eat normally again sooner instead of later.

A woman who is breastfeeding needs as many or more calories in the first few weeks as she did when she was pregnant. In addition, some sources feel that women who have had a c-section need a slight increase in calories as well in order to help with recovery and healing. So be careful to be sure that your intake in the first weeks after birth is really adequate; sometimes women are so worn out from the surgery and new parenthood that they neglect their nutrition.  And this can definitely affect milk supply and slow down healing.

As during pregnancy, QUALITY is more important than quantity; keep your emphasis on plenty of fruits and veggies, plenty of protein, and other foods in moderation. It is also important to up your consumption of fluids (preferably WATER) during this time to help flush out any edema and keep up your fluid levels for breastfeeding.  You may also want to consider adding a vitamin C supplement to help promote tissue healing.

If you have been on a somewhat restricted-calorie regimen in the past (either before or during pregnancy), you need to be sure you are getting adequate intake for this post-partum period, even if you feel like you need to emphasize weight loss. La Leche League recommends that a woman who is breastfeeding consume at least 1800 calories minimum, and most women immediately post-partum need more like 2000+. So it is vitally important not to diet or to let others pressure you into limiting your intake during this very important period.  

Although research shows that women can start cutting back their calories modestly once their milk supply is well-established, this process should not begin until at least 4 (and preferably 6) weeks postpartum.  Milk supply in the first 2 months can be a delicate balance, so it's best not to throw in too many variables too early.   Increasing your exercise level won't hurt the baby and may help with weight loss, so if you are wanting to start working off that pregnancy weight gain, start with increased exercise first.  After 6-8 weeks or so, you can also start modestly cutting back on calories if you do it carefully.  Keep your emphasis on quality foods.  For more guidance on this subject, see the La Leche League book, Eat Well, Lose Weight While Breastfeeding.  

Even if you did not lose a lot of blood or experience significant anemia, you should emphasize iron foods in your diet, since you did have surgery and blood loss is involved. Foods that are great sources of iron include legumes, beef, dried fruit, eggs, liver, and particularly seeds such as pumpkin and sesame (try tahini butter).  Sea vegetables are also an excellent source, if you have access to them. Iron absorption is decreased if you eat your iron foods with milk or other sources of calcium; iron absorption is increased if you eat your iron foods with vitamin C foods such as oranges, strawberries, or broccoli. So pay attention to how you schedule your foods together as well as what you eat.

Excellent nutrition is an important part of every woman's postpartum journey; it is even more important for the cesarean mother.  Make sure you continue to emphasize great nutrition just as strongly as you did in pregnancy.  Remember that you are recovering from major surgery,  nourishing another little human being, and helping your body adjust to huge postpartum hormonal changes. Nutrition is VERY important for this transition.

Lactation Consultants and Peer Support Groups

As noted, one of the best things that mothers who are having breastfeeding difficulties can do is to get expert help.  Sometimes this help is available right in the hospital, but oftentimes women must look elsewhere for it. 

Support for breastfeeding in hospitals tends to be inconsistent, and expert training in lactation issues incomplete at best.  Even nurses that have taken extra training in lactation issues often are misinformed and can do more harm than good, especially if there are special concerns like a premature baby, an extremely well-endowed mother, flat or inverted nipples, etc.  Research also shows that even pediatricians (who ought to be experts in lactation) are woefully lacking in breastfeeding knowledge and give advice that leads to breastfeeding difficulties (Freed 1995). That's why, whenever possible, it is best to bring in the true experts, professional lactation consultants. 

But how can you know that the person you are consulting is really a breastfeeding expert?  Many hospitals have people who claim to be lactation experts and may even carry that title, but who are not fully trained in lactation issues and intervention techniques.  That's why it's important to look for a lactation consultant with the title, "Internationally Board Certified Lactation Consultant."  Lactation consultants with this extra training can be identified by the initials "IBCLC" after their names.  Some hospital LCs are board-certified (IBCLCs) and can be very helpful; sometimes women need to go outside the hospital to find an IBCLC.  Whomever you find, it is important that they be truly well-trained in lactation issues.

It is especially critical to enlist the help of an IBCLC when there are supply issues. If you think you don't have enough milk, be sure to see an IBCLC right away as there are many things to be done to help with this problem but quick intervention is critical to success. An LC will evaluate your baby's latch and suck, your positioning, and help evaluate the baby's hydration and weight gain patterns.   If supplementation is necessary, the LC will guide you so that it interferes as little as possible with breastfeeding and supply.  Interventions may include pumping to increase your milk supply, medications or herbal supplements to increase your milk supply, retraining your baby's suck, or help correcting the baby's latch and/or positioning.  (See below for more details.)

Another time it is important to see a lactation consultant right away is when you are experiencing significant soreness.  A bit of tenderness is not unusual at first, but should not be much nor last long.  Real soreness usually indicates a poor latch, a problem with the baby's suck, a plugged duct, mastitis, or thrush.  Again, a professional LC is needed to diagnose and evaluate the problem, and then to decide upon the proper treatment.

Although these are the most common reasons women need to see LCs, a consultation may be helpful in any situation where you experience difficulty with breastfeeding.  Although it is disconcerting to consider exposing your breasts and breastfeeding in front of a stranger, professional LCs can help eliminate so many of the common problems that derail many breastfeeding relationships that it is worth pursuing, even if you are particularly modest.  And really, after prenatal care and childbirth, modesty about breastfeeding in front of a professional LC seems redundant!

Many moms have reported delaying seeing an LC due to embarrassment, modesty, or reluctance to seek help, yet regretted delaying so long once they saw how much help they received. It is normal to feel strange about breastfeeding in front of a stranger, but don't let that stop you from getting needed help.  Your baby is depending on you, and you deserve to have a better nursing experience. 

Also remember that sometimes you may need to see more than one lactation consultant to get the right help, a new perspective, or to find the right mesh of personality styles.  Don't be afraid to try more than one LC if needed.  Another option for help is peer support through a breastfeeding support group.  If a professional lactation consultant is not available right away, then volunteer leaders from La Leche League or Nursing Mother's Counsel can fill in the gaps.  The advantage of these resources is that they are completely free and sometimes peer support from another mother is less threatening than going to yet another healthcare professional.  

However, do remember that these peer support organizations are staffed by volunteers, so the skills may vary from leader to leader, and the women are mothers themselves and may be too busy to offer the amount of support you need. Usually there is more than one chapter in an urban area so if you don't get the help and support you need from one leader, try calling another chapter.  Chances are one of them will suit you and be able to help. Also take full advantage of their library of breastfeeding and parenting books that can be checked out for free; many of these are extremely helpful.

Some people are hesitant about these organizations because they are afraid of 'breastfeeding militants,' but generally most mothers find that these groups really are invaluable. What you have to do is find a group that suits your attitudes and situation, then take the advice you need for yourself and leave the rest behind.  Don't deny yourself the benefits of these groups because you might not necessarily agree with all that they say. Because these are volunteer groups, their quality and leadership will vary greatly. If you do not find one to your liking at first, keep looking. All points in the breastfeeding spectrum are represented sooner or later in these groups, and eventually you will find one that suits your needs. 

In summary, do not rely on your doctor to help diagnose or rectify breastfeeding problems; they are often too unaggressive in their approach and they usually have little training in lactation. Hospital nurses can sometimes be very helpful, but on the other hand, sometimes perpetuate breastfeeding myths and may not be adequately trained either.  

You need a lactation specialist (preferably an IBCLC), and you need it as EARLY as possible. You need the eye of an experienced professional to identify potential problems that a less-trained person might misdiagnose, to detect the subtle and very technical problems that hospital nurses and doctors are not qualified to identify or treat, to evaluate whether your baby truly needs supplementation or not, and to help you work out a plan of treatment that meets the baby's needs for nourishment while still doing everything possible to preserve breastfeeding.  Don't let problems escalate by delaying treatment. 

Finally, peer support groups can be invaluable as well, especially for the breastfeeding mother experiencing problems.  The one-to-one support from other mothers who have 'been there, done that' can help women work through the difficult emotional issues that can accompany breastfeeding problems, and put into perspective the everyday ups and downs of a breastfeeding relationship.  Although these are volunteer groups and can vary in quality at times, most women find them an extremely valuable source of support and comfort during their breastfeeding years. 

 

Dealing with Special Situations

Cesarean moms can encounter a number of special situations that may complicate breastfeeding.  These can include hypoglycemia, jaundice, a sleepy baby, prematurity, need for supplementation, and 'failure to thrive' syndrome.  Also, although most mothers who have Poly Cystic Ovarian Syndrome (PCOS) breastfeed without problems, there is a small but significant percentage who have major breastfeeding supply problems.  

Because these situations can complicate breastfeeding after any birth (but especially after a cesarean), more information on these issues is presented here.  However, this is just general information about these situations; more thorough information on these subjects can be found on various breastfeeding websites online.  And as always, consult a medical professional (preferably one well-educated about lactation issues) about your own specific situation.

 

Hypoglycemia

As noted previously, the conditions that lead to cesareans can sometimes cause cesarean babies to have hypoglycemia issues.  Because of this, it is routine in many hospitals to automatically give a cesarean baby a bottle of glucose water or formula, usually before the mother is even out of surgery, and before discovering whether or not baby even has hypoglycemia issues.  Although sometimes supplementation truly is needed, most of the time routine supplementation is not necessary, and can even be harmful. It is often the first step on the way to breastfeeding 'failure.'  

Even when hypoglycemia is present, the best treatment is usually nursing.  As noted above, colostrum has plenty of lactose to help raise the baby's blood sugar, but more importantly it has lots of protein to help stabilize those blood sugars as well.  Protein and lactose together are important to help slow and stabilize the rise in blood sugar. With lactose or glucose alone, the baby's blood sugars tend to rise and then crash later, a fluctuation that can also be harmful.  

Unless hypoglycemia is severe, frequent nursing is usually sufficient to treat most cases, plus it has the added benefits of immunological protections.  The Womanly Art of Breastfeeding states, "Nursing at least ten to twelve times per day is the best way to stabilize a baby's glucose levels."

On the other hand, while it is clear that routine supplementation of cesarean babies is unnecessary, sometimes treatment for hypoglycemia can become necessary. However, just how aggressive surveillance and treatment should be will depend on the cause and circumstances of the case. 

Possible Causes of Hypoglycemia

Babies who have been through a long or stressful labor can sometimes have low blood sugar at birth, especially if they were deprived of oxygen at some point.  Although all babies with hypoglycemia need to be watched, most cases that result from moderate stress respond well to treatment and stabilize quickly.  For these babies, frequent nursings and close observation is sufficient treatment most of the time. If the baby is symptomatic, not nursing well, or does not respond to nursings, then supplementation may sometimes be necessary.  Usually, however, aggressive testing and routine supplementation is not necessary unless the baby's stress has been severe.

Another baby that is often aggressively supplemented is the macrosomic ('big') baby.  Although definitions vary, macrosomia is loosely defined as any baby at or over 9 lbs.  Because a percentage of macrosomic babies do experience hypoglycemia, many hospitals routinely require automatic testing and/or supplementation of babies over 9 lbs.  This is rarely necessary, as most of these cases respond well to early and frequent nursing, and simple observation is usually all that is required.

Extra-small babies ('Small for Gestational Age') may also experience higher rates of hypoglycemia, and often are supplemented too. These babies must be carefully watched because there is a potential for problems, and if the baby does not maintain a stable blood sugar level, supplementation may become necessary.  However, most SGA babies stabilize well if they are nursed early and frequently.  

Babies of diabetic mothers, on the other hand, need careful testing and observation because neonatal hypoglycemia is a real risk.  Because these babies tend to receive higher levels of blood sugar in utero, they respond by producing high levels of insulin.  After birth, the mother's blood sugar is taken away but the baby's insulin production takes a while to adjust, and thus unstable blood sugar is common.  This is most prevalent in babies of poorly controlled diabetics but can sometimes also occur even with well-controlled diabetes.  

In the past, most babies of diabetics were automatically given IV glucose and/or formula supplementation, but recent research has shown that many of these babies do very well on nursing alone, with careful monitoring.  So while some babies of diabetic mothers are going to need supplementation, automatic supplementation should be replaced by a more selective approach (Cordero 1998).  And even if a baby of a diabetic pregnancy needs supplementation, there is no reason it has to be given by bottle.  Nursing and non-bottle supplementation methods should be combined to help these babies stabilize their blood sugar while also stimulating the mother's milk supply and giving the baby those all-important antibody protections.   

Babies of mothers with gestational diabetes used to be treated exactly the same as those with overt diabetes, with extremely aggressive testing and supplementation protocols.  However, it is questionable whether this is truly necessary in most cases.  If the mother needed insulin, then careful testing is probably justified, and supplementation may sometimes become necessary.  If the mother did not need insulin and had excellent control, then routine testing may not be needed at all; careful observation and promotion of early and frequent nursing may be sufficient.  However, just how much testing and what protocols are important is subject to a great deal of debate, and standards will vary considerably from hospital to hospital.  (For more information about this, see the FAQ on GD and Breastfeeding.)

Premature babies often struggle to regulate their blood sugar, and supplementation often becomes truly necessary here.  A lot depends on just how premature the baby is, how well they are able to suckle (if at all), and whether there are other problems accompanying the prematurity.  There are too many variables in prematurity for any strict guidelines; consulting a board-certified lactation specialist is the best way to sort through all the information and know more reliably when supplementation is truly needed and when it is not.  Further resources on breastfeeding premature babies can be found at www.preemie-l.org

Babies who have an infection (or who are otherwise sick) often have hypoglycemia problems, and may have particular difficulty keeping their blood sugar steady.  Their blood sugar can shoot up and down like a roller coaster; keeping their levels steady can be very difficult.  This type of hypoglycemia is much harder to treat and often does necessitate supplementation, but should not rule out breastfeeding either.  Sick babies need the protective immunological elements in their mother's colostrum and milk the most, so supplements should never be used instead of breastmilk but in addition to it (preferably after nursing).  However, as with premature babies, even if supplementation does become necessary, it does not mean that it has to be done by bottle.  There are many other options that can help preserve breastfeeding (see below). 

Finally, while it is clear that automatic bottles after cesareans should be abolished, some hospitals still cling to this outdated protocol under the assumption that any baby born by cesarean is going to be stressed and have low blood sugar.  Parents need to assertively make it clear that NO routine bottles should be given to their babies, and frequently remind staff of this during and after the cesarean.  The father or support person can request that the baby stay in the O.R. while the surgery is completed (where they can watch for supplements), or they can follow baby to the nursery and reinforce the message that no supplements are to be used unless hypoglycemia is shown to be a legitimate concern.  

Diagnosis and Treatment Issues

If low blood sugar is suspected, then it is possible that the baby may indeed need supplementation.  However, it is important that this be DOCUMENTED WITH LAB TESTS.  Unless the baby is severely symptomatic or there is reason to suspect a serious problem, frequent nursing should be the only treatment to take place until lab results document that there is a problem.  Although there are occasional exceptions, early and frequent nursing should be the treatment of choice before routine supplementation.

Lab tests are important to document blood sugar levels because most portable glucometers do NOT accurately measure blood sugar in a newborn.  Unless the monitor has been specially calibrated for differences in neonatal blood, it consistently underestimates a newborn's blood sugar levels.  Yet even though this is stated on the brochures of many glucometers, some hospitals still continue to use regular glucometers, leading to babies being diagnosed and treated for 'hypoglycemia' that doesn't exist.  A regular glucometer can be used to rule out hypoglycemia, but it cannot be used to diagnose it. 

On the other hand, if glucometer results are extremely low, then lab tests will undoubtedly confirm hypoglycemia, and treatment should proceed immediately without waiting for lab results.  Even so, unless the hospital has a glucometer that is calibrated for neonatal blood, lab tests should still be run to find out the exact blood sugar levels of the baby.  Continuing treatment needs to be based on valid data.

At what point hypoglycemia should be diagnosed is a difficult question.  It depends on the circumstances. If the baby is ill, premature, or has some other special consideration, the guidelines used for diagnosis completely depend on the situation.  No guidelines can be presented here for scenarios of illness or prematurity because the cutoffs are so dependent on the situation. Consult a lactation consultant for guidelines specific to your situation.

However, if baby is born at term, is healthy, and has no other special concerns, then hypoglycemia diagnosis guidelines range between 30-40 mg/dl (divide by 18 for non-USA readings).  Some doctors use 40 mg/dl as a cutoff, most use 35 mg/dl as a cutoff, and a few use 30 mg/dl as a cutoff.  At this time, research does not make clear which diagnostic cutoff is most advantageous.

How seriously these results are treated varies too; in some hospitals, a level of 37 mg/dl is considered normal or 'borderline,' yet in others is considered seriously hypoglycemic. One hospital may require automatic supplementation with formula or glucose water at 37 mg/dl, yet another hospital may require nothing more than frequent breastfeeding, observation, and retesting in an hour or two.  Because opinions and requirements vary so much, no absolute guidelines can be set out, and each mother should consult a board-certified lactation consultant to discuss the implications of any specific situation they encounter.

Hypoglycemia Summary

Hypoglycemia is a potentially serious problem for a newborn if it is severe or if the blood sugar is unstable. If untreated, it can result in brain damage and other problems, and it is totally understandable that hospital personnel are concerned about it.  However, it is clear that routine supplementation protocols of the past are outdated and should be abandoned.  

In the normal term baby with no symptoms of hypoglycemia, automatic supplementation is not needed.  Nursing about every 2 hours is usually enough to prevent hypoglycemia.  In the baby at increased risk for hypoglycemia, more frequent nursing is indicated.  Supplementation is usually not necessary for most of these babies; careful observation and periodic testing is usually all that is needed.  However, babies that are symptomatic or born with special concerns like prematurity, illness, or maternal diabetes may need closer observation and more aggressive treatment.

If treatment is needed, it should be based on valid data (instead of on assumptions about risks, or on data from invalid sources), should take into account the specific circumstances of each unique situation, and should be based on the latest research instead of on tradition.  If supplementation does become necessary, preserving breastfeeding should still be an important priority, alternative methods should be used whenever possible, and frequent nursing should be among the treatment options utilized.  Whenever there are concerns about hypoglycemia, consultation with a PROFESSIONAL lactation consultant for treatment decisions is vital.  

 

Jaundice

Jaundice is another potential complication that can accompany difficult labors and cesareans.  Like hypoglycemia, the traditional treatment protocols for jaundice can interfere with establishment of breastfeeding, and sometimes even increase the jaundice.  Again, treatment should be based on the specifics of the case and recent research findings, not on traditional and outdated protocols.

Cause and Types of Jaundice

Jaundice occurs when the extra red blood cells baby uses in utero are broken down after birth.  A by-product of this process is bilirubin, which must be processed by the baby's liver.  If the baby's liver is a bit immature or there are a lot of extra red blood cells to be broken down, then this processing may not be very efficient.  Extra bilirubin that remains in the baby's body tends to make him turn yellowish. Although usually not serious, it has the potential to be dangerous if bilirubin reaches very high levels. 

There is more than one type of jaundice. Abnormal jaundice begins the first day or so after birth, and often is the result of incompatible blood types or other serious problems.  In this type of jaundice, the baby is seriously sick and will need many treatments, perhaps including blood transfusions.  This is not the kind of jaundice this FAQ discusses.  Consult your provider for specifics on this situation. 

Normal, physiological jaundice is the type of jaundice this FAQ is concerned with.  In this type, jaundice is a result of normal physiological processes, and treatment means simply helping the baby to get rid of the extra bilirubin in its system.  This is best accomplished by having the baby nurse early and frequently and by exposing it to light.

Some babies are particularly prone to physiological jaundice and this may make them sicker than most jaundiced babies.  Premature babies often have immature livers and so can have trouble clearing the bilirubin from their systems.  Sick babies may also have trouble because their systems are so overwhelmed that they have difficulty coping with normal processes.  Multiples often have a greater tendency towards jaundice, as do babies who have bruises resulting from the birth process.  Babies of diabetic moms are more prone to jaundice because hyperinsulinemia tends to result in the production of lots of extra red blood cells, which present a difficult load for the baby's liver to handle.  

Babies where the mother has been induced or augmented significantly with pitocin also tend towards jaundice; the drug labels on pitocin warn that jaundice is one of the possible complications frequently associated with pitocin.  Babies whose mothers receive a great deal of fluid by IV (such as during induction or epidurals) may also have higher rates of jaundice.  According to Henci Goer in The Thinking Woman's Guide to a Better Birth, high fluid rates by IV can cause the baby's red blood cells to swell and burst, thus increasing the load of bilirubin by-product for the baby's liver to deal with right away.  

Diagnosis and Treatment

The best prevention/treatment for jaundice is early and extremely frequent nursing. The colostrum or 'pre-milk' of the first few days acts as a major laxative and helps the baby pass its meconium (first stool) faster. When the liver breaks down the extra red blood cells and processes the bilirubin, it is excreted into the meconium. If the baby's meconium is not passed quickly, the bilirubin in the stools may be reabsorbed by the intestines and into the bloodstream, exacerbating jaundice levels. Thus it is in the baby's best interest to pass meconium as quickly as possible, and the strong laxative effect of colostrum is one of the best ways to promote this.

Sometimes doctors and nurses recommend supplemental glucose water to help 'flush out' the bilirubin, but this treatment is outdated. The most recent research indicates that glucose water can actually make the problem worse by delaying stooling.  Frequent nursing is the best remedy for normal 'physiological' jaundice. 

Unfortunately, many doctors and nurses are unaware of this new information and may still recommend supplements when none are required. These tend to fill up baby and make him less interested in nursing, thereby making the problem worse. The American Academy of Pediatrics now states unequivocally that "Supplementing nursing with water or dextrose [glucose] water does not lower the bilirubin level in jaundiced, healthy, breastfeeding infants."

It is important that the mother nurse the baby as SOON as possible after birth and thereafter as often as possible in the first days in order to help the baby finish clearing the meconium from its system. One study cited by the Breastfeeding Answer Book showed that a minimum of at least NINE feedings every 24 hours prevented jaundice from becoming exaggerated, and noted that the number of the breastfeedings on the first day was especially critical.  Another study (Yamauchi and Yamanouchi, 1990) found that the incidence of significant jaundice was 7.7% in babies nursed 7+ times in 24 hours, and 22.8% in babies nursed less than 7 times in 24 hours. Frequent nursing is very important in preventing jaundice.

A good rule of thumb is to nurse every 2-3 hours during the day, and every 3-4 hours or so at night in the first week. If the baby is sleepy (common with jaundice), it is important to rouse the baby for feeding anyhow. 'Switch nursing' (see below) or other techniques may help in this process. However, do be sure that the baby eventually gets plenty of uninterrupted time on each side in order to get enough of the rich 'hindmilk' as well, since this also helps stimulate bowel movements and get rid of bilirubin faster.  Hindmilk also lessens baby gas, and increases the baby's weight regain after birth.

Normal physiologic jaundice usually resolves itself within a week or two and has no aftereffects, as long as bilirubin levels do not reach dangerous levels. If bilirubin levels are somewhat raised and your doctor is concerned, increase nursing frequency strongly.  Also expose the baby to indirect sunlight frequently during the day. This is usually enough to resolve most cases of jaundice. 

If levels are more strongly raised, however, phototherapy may also be needed in addition to frequent nursing and indirect sunlight. Sometimes hospitals will tell you that this means you cannot nurse much.  But except for rare cases, breastfeeding should NOT be interrupted. An American Academy of Pediatrics bulletin states, "The AAP discourages the interruption of breastfeeding in healthy term newborns and encourages continued and frequent breastfeeding (at least eight to ten times every 24 hours)...if the baby receives phototherapy...there is no significant advantage in discontinuing nursing." Frequent nursing remains especially important during the phototherapy process, since dehydration is one of the potential side effects of this treatment.

Occasionally formula supplements are needed in addition to nursing when jaundice levels rise too high, the mother's access to the baby is limited, or milk supply is low or delayed. A need for formula supplements is unusual and should NOT be done routinely, but if it does become necessary, parents should not hesitate to do it.  However, supplements should be given by alternative feeding methods instead of a bottle (see below). 

The exact levels at which jaundice needs aggressive treatment are subject to great debate and sources differ; consult your provider. 'Hyperbilirubinemia' is generally diagnosed in healthy term babies at levels of >12 mg/dl; the most commonly seen recommendations in the past were to treat fairly aggressively at 15-20 mg/dl.  At present the guidelines usually seen are a bit higher, depending on the age and condition of the baby.  According to Kathleen Huggins in The Nursing Mother's Companion, "If the baby was born at term and is otherwise healthy, many doctors will not order treatment unless the bilirubin level is over 20 mg/dl.  Frequent breastfeeding may be all that is necessary."

It must be strongly emphasized that any cutoffs are HIGHLY dependent on a number of complex factors, and a parent or other layperson is not familiar enough with all of the intermingling factors to make treatment decisions. Be SURE to consult a breastfeeding professional and medical professional for advice on your particular scenario.  

For example, a premature or ill baby cannot tolerate bilirubin as well and needs treatment at much lower levels. A healthy term baby who is nursing well, getting indirect sunlight, and who is being watched carefully may be able to tolerate higher levels before further treatment is necessary. A great deal depends on the baby's age, its health, bilirubin levels, how fast the bilirubin level is going up, and whether it has peaked or is near peaking. In extremely rare cases, a blood transfusion may be needed to help bring down a baby's bilirubin count, but the advent of phototherapy and other proactive treatments has made this an extremely unusual last resort for normal physiological jaundice.

If your doctor is concerned about your baby's jaundice levels, it is important to clarify what the cause of the jaundice is (is it normal jaundice or abnormal jaundice?), what test results have been, the diagnostic criteria used for determining care decisions, and the factors influencing your doctor's concern (illness, prematurity, etc.). Then clarify what types of treatment are recommended and why.  Remember that a lot also depends on the provider's philosophy of treatment.  If in doubt, start the prescribed treatment and get a second opinion.   

As noted, sometimes mothers whose babies are receiving phototherapy are told that they cannot nurse, or are kept from nursing frequently.  Mothers must advocate strongly in this situation that nursing continue as frequently as possible; dehydration is a real risk of phototherapy, and the mother's milk supply depends on frequent stimulation in the early days.   Interruption of nursing time and unnecessary nursing restrictions during phototherapy are often the first step to nursing difficulties and low supply down the line.  

Express your strong desire to breastfeed your baby and request a consultation with a professional lactation consultant in order to work out a plan that will allow you to stay as close as possible to your baby and continue to breastfeed frequently during treatment. For an excellent in-depth discussion of jaundice and breastfeeding issues, see The Breastfeeding Answer Book (La Leche League, 1997).

Jaundice Summary

Early and frequent breastfeeding is the most effective way to prevent jaundice.  Some babies may be more prone to jaundice than others, and in these babies frequent breastfeeding becomes especially important, along with close observation.  If jaundice does develop, most cases do not need specialized treatment, just monitoring to be sure levels do not go too high. In some cases, phototherapy or formula supplements may be needed, but breastfeeding rarely needs to be interrupted. 

In the vast majority of cases, early and frequent breastfeeding along with regular exposure to indirect sunlight can prevent or minimize physiologic jaundice.  If a woman knows her baby is at particular risk for jaundice, she and her care provider should develop a plan beforehand to be as proactive as possible in order to prevent or minimize jaundice.

 

Sleepy Baby

One problem encountered by many c-section moms is a sleepy baby from medications given during labor and surgery. IV drugs such as Demerol, Stadol, Fentanyl, etc. are known to affect the baby in utero.  Epidural drugs also reach the baby but their effects on baby are less well understood (see above); in all likelihood, they affect baby temporarily too.  Sometimes you have to keep aggressively nursing the baby until these drugs work their way out of the baby's system.  Breastmilk is the best protection you can give baby in the meantime, but it may take some time for the drugs to clear the baby's system fully.

Jaundiced babies are also often sleepy. As noted above, the best treatment for jaundice is frequent nursing to help the baby pass its first stools, as well as exposure to indirect sunlight  If necessary, phototherapy is also helpful.  Sometimes mothers whose babies are receiving phototherapy are told that they cannot nurse, or are kept from nursing frequently. Interruption of nursing time and unnecessary nursing restrictions during treatment are often the first step to nursing difficulties and low supply down the line.  

Babies can also be sleepy from birth trauma, from newborn trauma like circumcision, or simply being in an area with too much stimulation.  Babies who are wrapped snugly in blankets also tend to sleep for longer periods of time, which is why nurses have learned to do this.  In addition, sometimes nurses surreptitiously give babies bottles of formula or glucose water without the mother's knowledge, and this can make the baby appear 'too sleepy to nurse' when in reality the baby is sleepy because it's just been fed.  Mothers must make it clear that NO bottles are to be given without their consent.  Rooming in (and going with the baby for any 'procedures' that need to be done at the nursery) are an important way to avoid surreptitious bottles.  It really does happen more than women think.  

Sleepy babies often do not nurse as frequently or as efficiently, resulting in less milk supply stimulation for mom and perhaps delaying the arrival of mom's mature milk. In normal unmedicated births, the mature milk usually comes in within 2-4 days. In medicated births, this can be longer. In medicated, traumatic births like many c-sections (and especially those with general anesthesia), mature milk is often delayed until 4-6 days. A baby is usually fine on just colostrum during this time if he is nursed frequently and suckles well, but a sleepy baby may not be nursing efficiently enough or often enough to avoid dehydration. It is important to carefully monitor the sleepy baby for signs of dehydration (see below).  

The most important thing to do if you have a sleepy baby is to nurse as frequently as possible (at least every 2 hours), waking baby up and stimulating him in order to get efficient sucking and longer nursing times. If he drowses during a feeding, keep waking him up and give him lots of time to complete the feeding.  It is important to be sure that the baby receives plenty of fat-rich hindmilk from an extended feeding in order to help increase his weight gain and prevent gassy colic (see below).  

Although it may seem unkind to wake a peacefully sleeping baby up every two hours, it is important to do so in the first days.  Demand feeding is fine as the baby gets older, but the sleepy baby needs mother-led feeding schedules for the first few days. Don't hesitate to wake the baby up for feeding EVERY TWO HOURS.  This is very important for the sleepy baby, especially if there are other medical concerns like jaundice.

Nursing books and websites have lots of hints for waking a sleepy baby to nurse, including:

It is important to watch baby's subtle cues for signs of wakefulness and hunger.  It is much easier to rouse a sleepy baby for nursing if he is in a 'light' stage of his sleep cycle than if he is in a 'deep' stage of the sleep cycle.  Signs of lighter sleep include REM sleep (eyes moving around under the closed lids), grimaces or changing facial expressions, lots of limb movement, and sucking motions with the mouth.  If you see these 'light' sleep signs, wake the baby for a full nursing session. This will be more successful than trying to wake baby from a deep sleep to nurse.  

Also watch for subtle hunger cues.  Crying is a late sign of hunger.  Watch carefully for more subtle signs of nursing readiness, such as mouthing the hand, rooting behaviors, restlessness, etc.  Be ready to put the baby to the breast quickly if you see subtle signs of nursing readiness. 

One piece of advice often give moms struggling with a sleepy baby is to "switch nurse."  In this, you wake the baby up frequently by switching from breast to breast often during the nursing period.   Although this can be helpful, you want to be sure he does get some extended time on at least one side eventually in a feeding so that he is getting lots of rich hindmilk as well as the initial foremilk.  Otherwise baby may experience a condition known as 'foremilk/hindmilk imbalance,' where baby gets the lactose-rich foremilk (which causes lots of gas) and misses out on the fat-rich hindmilk (which helps improve weight gain, helps the baby stool, and satisfies the baby's hunger more long-term). Signs of foremilk/hindmilk imbalance can include lots of gas, an unhappy baby, and frothy green stools.  

Dehydration is a legitimate medical concern with sleepy babies.  Many babies do not wake for frequent, regular feedings, and parents let them sleep, grateful for the extra sleep for themselves.  Even when they wake for feedings, sleepy babies often fall asleep during the feeding, leading the parents to cut the nursing session short, thus decreasing the baby's intake even more, especially of the fat-rich hindmilk.  This can become a vicious circle, especially with a placid baby that is lethargic or doesn't complain much.  

This is why nursing books strongly advise feeding newborns every 2 hours during the day and every 3 hours or so at night in the first few days, even if baby doesn't seem to want to nurse that often.  After the baby is gaining well, nursing effectively, and the mother's milk supply is well-established, a demand feeding schedule is an excellent idea.  But due to the prevalence of medications, jaundice, and other complications, it is better to err on the side of overly frequent nursing in the first few days, and especially so with a sleepy baby.  These babies really are at risk for dehydration and poor weight gain.

If a baby shows signs of dehydration or too much weight loss, then some supplementation may become necessary.  Signs of dehydration include dark urine/little urine, little stool output, lack of weight gain, sunken fontanels, dry mouth, listless baby, etc. If in doubt, consult an expert (preferably an IBCLC) to know if dehydration or weight loss is becoming a problem and what to do about it.  If supplementation becomes necessary, do not hesitate to use supplements!  However, bottles should be avoided if at all possible; supplements can be given via cup, eyedropper, fingerfeeding, spoon, supplemental nursing system, etc.  See below for more information.

 

Prematurity

A premature baby is one of the most difficult situations a mom who wants to nurse can face.  A great deal depends on the age of the baby, how much milk the mother is able to pump, the support of the staff for using pumped breastmilk before the baby is able to suckle, their willingness to use non-bottle methods of supplementation when needed, their openness to going straight to breastfeeding before bottlefeeding, and their belief in and support of breastfeeding in general.  

Because many premature babies are born by cesarean, many mothers face a doubly difficult situation---recovering from major surgery and dealing with a premature baby.  Both of these have major emotional and physical implications, and the combination of these two factors can be overwhelming for some women.  Add in the rigors of pumping and helping a preemie learn to suckle effectively, and it's no wonder that so few preemies receive human milk.  

Advantages of Breastmilk for the Preemie

Research clearly shows that breastfeeding offers significant advantages for the premature baby.  Preemies who have received breastmilk have significantly lower levels of necrotizing enterocolitis (Schanler 1999), have lower rates of (and less severe) infections, and have lower rates of sepsis/meningitis.  In fact, one study (Hylander 1998) found that breastfeeding cut the risk for infections and meningitis in HALF.    Since these types of infections are common and very serious in preemies, this is a very important advantage. 

Preemies fed human milk tend to gain weight slower at first, but research clearly shows they are healthier in the long run (Schanler 1999). They have better vision, lower blood pressure, and may also have lower rates of retinopathy of prematurity (Hylander 2001) and cerebral palsy.  They tend to have somewhat higher IQs (Lucas 1992) and perhaps better motor development later in life as well.

The mother's own pre-term milk is especially suited for a preemie's special needs.  It contains more of nutrients such as sodium, nitrogen, protein nitrogen, long-chain fatty acids, protein, iron, and chloride, and has more infection-fighting antibodies than the milk of mothers who give birth at term. These extra nutrients and immune factors stick around far longer than the baby's initial prematurity period; they may last for as long as six months in order to help the baby compensate for its extra early birth.   

A mother's pre-term milk also contains the enzyme 'lipase,' which helps the baby digest milk fat (an important source of energy for growth) more easily and efficiently, helping the baby grow better. It also has 'growth-modulators,' which help the digestive system adjust better to oral feedings. 

The medical literature supporting the benefits of mother's milk for premature infants is extensive, and only a brief synopsis is offered here.  A summary of the research of the benefits of breastmilk for premature babies can be found in The Breastfeeding Answer Book (La Leche League) and on the La Leche League website at www.lalecheleague.org/cbi/biospec.htm

The Challenges of Pumping

Very premature babies will not be able to suckle right away, but if possible their mothers should pump  (with a hospital-grade pump like a Medela Lactina) so that the baby can receive the protection of their milk by tube.  Pumping should begin as soon as possible after birth, and mothers should pump about 8x per day.  They should go no more than 3 hours between pumping sessions, and pump 2-3x at night if possible, since prolactin levels are highest at night and this is the time that is especially critical for establishing milk supply. 

It is also very important not to rush the pumping session.  The fat-rich hindmilk is produced later and it is the critical factor that can help baby gain better; therefore mothers should pump for at least 10-15 minutes per session (and more if needed). If the mother limits her pumping time too much, less of the hindmilk is present in the stored milk, and this can hinder weight gain.  In babies where weight gain is a particular issue, pumping specifically for the fat-rich hindmilk and feeding this hindmilk preferentially can significantly boost weight gain (see below).  

Getting the immunological protections of mother's milk into the baby's gut as soon as possible is vitally important; it may help prevent or minimize a lot of later problems like necrotizing enterocolitis.  Sometimes a fortifier is added to the mother's pumped breastmilk to give the baby even higher levels of nutrients like calcium and phosphorus, but nothing can protect the baby's immature systems as effectively as the immunological gold of breastmilk.  Therefore, whenever possible, it is vital that the preemie get as much breastmilk as possible, even when fortifiers are needed too.

Pumping can be a challenge for any mom, but it can be extra challenging for moms of preemies.  More information about pumping in general can be found at www.pumpingmoms.org/index.html, info about boosting supply at www.pumpingmoms.org/faq-boost.html, and specifics about pumping for premature infants at www.parentsplace.com/expert/lactation/qas/0,10338,239823_106347,00.html

Weight Gain Issues

One relative disadvantage of breastmilk is that preemies tend to gain less relative to formula.  If the NICU staff's only measurement of baby's progress and health is weight gain, then they tend to push formula.  But while weight gain can be important in a preemie, the whole picture must be taken into account, and the research is unequivocal that  breastfed preemies are healthier in the long run. For the most part, weight gain should not be the overruling concern for most preemies; it is important but not the ultimate marker of prematurity progress.  However, in cases where weight gain is a deep concern, breastmilk and formula may be combined (using a supplemental nurser or non-bottle methods if possible).  

Another option may be to aggressively pump hindmilk and feed this to the baby. During the first few minutes of nursing, babies get the lactose-rich 'foremilk,' which tends to be lower in fat and calories.  If allowed to nurse longer on the same breast, babies get the fat- and calorie-rich hindmilk.  This hindmilk is critical to weight gain and long-term growth in the baby.  Therefore, if the mother is able to pump so as to separate out the hindmilk from the foremilk and feed this hindmilk preferentially to the baby, the baby's weight gain may be substantially enhanced.  

Indeed, one study did find that feeding hindmilk to the preemie helped improve weight gain (Valentine, 1994).  It is important that the mother pump for substantial lengths of time on each side so as to access more of this hindmilk; some mothers rush their pumping in order to spend more time with baby, but may be inadvertently decreasing the amount of hindmilk her baby receives.  In The Nursing Mother's Companion, Kathleen Huggins describes this process:

Some premature babies need a more concentrated source of calories.  If this is the case with your baby, ask about feeding hind milk.  This is the fattier milk produced after the first few minutes of pumping.  To collect hind milk separately from foremilk, pump for about two minutes after the milk lets down, then stop pumping and switch collection bottles.  Pump again until the breast is completely drained.  Label the first bottle as foremilk, the second as hind milk. Provide the hindmilk for the baby's immediate needs, and freeze the foremilk for the future (for use during separations or for supplementation).  Feeding hind milk for a week or two can be very helpful in achieving a good weight gain in a preemie.  

It is also important to note that the milk delivery system (tubes etc.) can interfere with getting enough of the milk fat to the baby.  Milk fat tends to stick to the plastic tubing, so the longer the tubing used, the more fat that is lost.  Interestingly enough, shortening the tubing can help cut down on fat loss. Feeding the baby intermittently instead of continuously can also lessen fat loss.  If a syringe and pump are used for tube feeding, one study found that positioning the syringe upright decreased the fat loss from 48% to 8%!  (Breastfeeding Answer Book)

Kangaroo Care

As the baby gets older, suckling can begin in small steps.  This process is often not easy, and can take a long time. The first step may be simply kangaroo care----holding the baby skin to skin as often and as long as possible.  Often the mother's breasts will leak during this process and this will help the baby associate the smell of milk with its mother.  Another advantage to kangaroo care is that skin-to-skin contact increases the mother's milk production (Hurst 1997), and enhances the mother's capacity to synthesize specific factors to protect against the dangerous bacteria found in hospitals (and especially in NICUs).  

Another study (Bier 1996) found that simply holding the baby as often as possible skin to skin with the mother (not wrapped in a blanket and held against her clothes, but clad in only a diaper and placed between the mother's naked breasts then covered with a blanket) significantly improved the breastfeeding rate and duration.  Babies held skin-to-skin had higher oxygen saturation and half as many desaturation episodes; no differences were noted in temperature, heart rate or respiratory rate.  Mothers who held babies skin-to-skin had a more stable milk production, and breastfed their babies for longer periods.  90% of skin-to-skin moms continued to breastfeed for the duration of hospitalization (vs. 61% of standard contact moms), and 50% of skin-to-skin moms continued to breastfeed through 1 month after discharge (vs. 11% in the standard contact group).  So even as simple a difference as holding your baby directly against your skin instead of against your clothes can improve your milk supply and breastfeeding duration.  

Another step towards breastfeeding is getting the baby to associate sucking with being fed.  Most very low birthweight babies are fed at first via gavage tube (a tube that goes down directly to their stomach).  Some preemie websites recommend holding the baby in feeding position even with gavage feedings, and letting the baby suck on your little finger (pad side up) or a preemie pacifier while he is fed by gavage.  In this way, baby begins to associate feeding with sucking.  

One study found that babies allowed to suck while being fed by gavage/tubes gained weight faster and were discharged earlier (Field, 1982), but did not examine breastfeeding outcomes.  Because studies on preemie pacifier use do not examine whether it negatively affects breastfeeding (as it often does in term infants), it is probably preferable to let baby suck on a clean finger rather than a preemie pacifier, just in case, but more study is needed to clarify this issue.  

Preemie Response to Breastfeeding and Bottlefeeding

One misconception commonly held by NICU staff is that breastfeeding is more stressful for preemies than bottle-feeding.  Many mothers are told that babies must be bottlefed before they can be breastfed, and that the effort of breastfeeding 'uses up' all the calories babies get from breastmilk.  This is not true at all.  Several studies have actually found that breastfeeding is less stressful for preemies than bottlefeeding!

For example, Blaymore-Bier (1997) found that extremely low birth weight babies had higher oxygen saturation rates, higher temperatures, and were less likely to desaturate to <90% oxygen when breastfeeding compared to bottlefeeding.  Meier and Anderson (1987) also found that infants tolerated breastfeeding better, and the smaller the babies, the more pronounced the difference. Yet this myth that breastfeeding is harder on preemies is one that refuses to go away, and most preemie moms are still told this incorrect information.  

Many preemie moms are also erroneously told that preemies cannot breastfeed until the baby reaches a certain weight or gestational age, or that bottlefeeding must happen first to prove that baby can coordinate sucking and swallowing.  Yet Meier (1988) and Meier and Anderson (1987) were able to start babies nursing at just under 3 lbs. and about 32 weeks; the babies were able to suck and swallow regularly during breastfeeding but that when bottlefeeding was tried, their sucking and swallowing pattern was more disorganized.  The Breastfeeding Answer Book states that, "It appears that the ability to breastfeed develops well before the ability to bottle-feed." 

Yet despite the research showing that preemies find breastfeeding easier and less stressful than bottlefeeding and that the age when breastfeeding can start may be even earlier than thought, many NICUs persist in outdated policies. When Sidell and Froman (1994) surveyed 430 US NICU units, they found that gestational age and weight were still commonly used to determine when to start breastfeeding.  They also found that more than 93% of the nurses surveyed stated that standard protocol was to bottlefeed before breastfeeding. 

Another extremely persistent NICU myth is that preemies don't get nipple confusion.  This is not true; many preemies DO get nipple confusion, and because the sucking mechanism for bottles is totally different than it is for nursing, many learn the 'wrong' way of sucking when given bottles first and are unable to change over later.  If at all possible, it is important to avoid bottles for preemies, just as it is for full-term babies.  Yet the pressure for bottles in the NICU is very strong and hard to resist. 

Supplementation Alternatives to Bottles

There are viable alternatives to bottles for preemies; the choice is not just between bottles and nursing.  The following is a brief summary of some of the various supplementation choices available. 

Babies can continue to be fed via gavage tube between nursings.  Some doctors will agree to continue gavage feedings in between nursing until very close to the time of hospital discharge; this allows the baby the maximum chance to learn to breastfeed without bottle interference.

Cup feeding is the method that many African hospitals use (Armstrong 1987), and bottles for preemies are very rare there.  In that situation, cup feeding has been very successful; Newman (1990) found that nipple confusion was rare there as a result.  Other hospitals in England have tried cup feeding with great success (Lang 1994), and found that babies there were able to cup feed earlier than they were able to either breastfeed or bottlefeed.  In the English study, 81% of babies who had received supplements via cup feeding were fully breastfeeding at hospital discharge, vs. 63% who had received supplements by bottle. 

According to the review of this study in The Breastfeeding Answer Book, "The researchers noted that cup feeding requires little energy, gives the baby more control over milk intake than bottle-feeding, and involves tongue movements that are also important for successful breastfeeding.  During cup feedings, the premies were found to maintain satisfactory heart rate, breathing, and oxygen levels."  

To cup feed a preemie, you need to have a small flexible cup, like a medicine cup or even a Dixie cup.  (Medela, Ameda/Egnell and La Leche League sell a series of cups specially made for this purpose.)  You hold the baby as upright as possible (swaddled so his hands won't bump the cup), and use a bib or blanket to protect clothing.  You put a small amount into the cup (measure it so you will know how much baby is drinking), and if necessary, fill several cups ahead of time so that the feeding process can be continued smoothly and without interruption.  

Gently tilt the cup to the baby's lips.  Place the edge of the cup at the outer corners of the baby's upper lip and resting gently on the lower lip with the baby's tongue inside the cup. (Some babies reportedly prefer their tongue under the lip of the cup.)  Tilt the cup so the milk touches the baby's tongue. Don't move the cup during the feeding----the baby will lap the milk or sip it on his own rather than you pouring the milk into baby's mouth.  Let the baby swallow before offering more, and let the baby set the pace for feedings.  If he tires, don't force the issue.  

Some US hospitals have pioneered the use of cup feeding in the United States (Stine 1990).  Unfortunately, at this time, most NICUs in the U.S.A. view cup feeding as too difficult to do, impossible, or even 'risky' to try. However, there are some hospitals that are willing to try cup feeding, and with the help of a lactation consultant as advocate, others are learning to try it.  

You can find out more about cup feeding from www.mother-2-mother.com/cup_feeding.htm, www.askdrsears.com/html/2/T026000.asp, or the article by Dr. Jack Newman at www.breastfeeding.com.  There is a video of cup feeding available at www.breastfeeding.com/aaavideo/cup1.mov

Spoon Feeding is very similar to cup feeding, except that the baby is fed from a spoon instead of a cup.  No special equipment is needed; any clean and sterile spoon is suitable.  Follow the same directions as setting up for cup feeding, then bring the spoon to the baby's lips.  Gently tilt it so that it rests lightly on his lower lip when he opens up, with the milk just touching his lips. Tip the spoon slightly so that the milk flows into the baby's mouth.  Repeat as needed.  

As previously noted, Mathur (1993) found that 86.8% of the cesarean babies who received their first feeds by spoon kept on practicing total bfing, while only 33.3% who received first feedings by bottle did.  Although not specifically about preemies, this study does indicate that spoon feeding is a viable alternative to bottles, and The Breastfeeding Answer Book reports that it works well with preemies too. 

Eye Droppers and Feeding Syringes can also be used to feed preemies.  With eyedroppers, a soft plastic type is best because it is unbreakable.  With feeding syringes, peridontal or orthodontic syringes can be used in the same way; their advantage is that they hold more fluids.  Both eye droppers and feeding syringes are available in most drug stores; this is advantageous because the mother doesn't have to wait for special equipment to arrive.  

Again, prepare the baby the same way you would for cup feeding, holding him upright and swaddled.  Protect all clothing as sometimes spills happen in this process. Bring the eye dropper or syringe to the baby's mouth, and slowly drip in the milk.  It is important not to go too fast, so that the baby has a chance to swallow before more is given.  When the baby needs to pause, it is important that the person feeding the baby take a break too.  To avoid choking, keep the baby upright and give only small amounts at a time.   

One of the best alternatives to bottles for preemies is finger feeding.  This can work especially well as a transition to breastfeeding.  In finger feeding, a small tube (often a #5 French tube) is attached to a bottle of expressed breastmilk (or formula if necessary).  The tubing is then taped to the caregiver's finger, either to the pad or to the side.  If the baby cannot open his mouth very wide, then the caregiver can use the smaller fingers, but the idea is to use the largest finger possible so that baby learns to open its mouth very wide.  The caregiver's finger is then inserted into the baby's mouth, pad side up, and the baby sucks the milk/formula out of the tubing.  

Photos and information about finger feeding can be found online at several different websites, including www.promom.org/bf_info/Fingerfeed.htmwww.asac.ab.ca/BI_fall01/wbdw.html, www.deleons.com/breastfeed.htm, and www.preemie-l.org/bfaq.html.  There is a video of finger feeding available at the website,  www.breastfeeding.com/aaavideo/finger1.mov.  The Hazel Baker Finger Feeder can be bought at many sites, including www.medela.com/NewFiles/specialtyfdg.html

Finger feeding has numerous advantages over bottles.  It teaches the baby that sucking is rewarded with milk, it teaches the baby to open its mouth very wide, it won't cause nipple confusion, and the baby is not taught poor sucking habits.  The sucking mechanism with finger feeding is more like breastfeeding sucking, thus making a transfer to breastfeeding later on more likely.  In addition, any caregiver can finger feed; the mom does not have to be present 100% of the time.  Bottles can also be given by any caregiver, but they interfere with proper sucking technique, whereas finger feeding does not.  Dr. Jack Newman writes at www.breastfeeding.com/all_about/all_about_f_feed.html

Finger feeding is much more similar to breastfeeding than bottle feeding is. In order to finger feed, the baby must keep his tongue down and forward over the gums, the mouth wide open (the larger the finger used, the better), and the jaw forward. Furthermore, the motion of the tongue and jaw is similar to what the baby does while feeding at the breast. Finger feeding is best used to prepare the baby to take the breast.

Finger feeding helps prepare the baby for breastfeeding by learning the correct type of suck.  Eventually, when the baby is ready, he can be put to the breast.  At first the baby may just lick the nipple, mouth it, or take a couple of weak sucks and fall asleep. This is very normal initial breastfeeding behavior for preemies.  Some babies transition to full nursing quickly, but many babies take quite some time to learn to transition to the breast.  Don't get discouraged; this is not unusual.  Perseverance is important.  

Some women report that if they give the baby a minute or two of finger feeding first before switching to the breast, the baby latches on and suckles more efficiently.  This soothes the frantically hungry baby with immediate food, rewards the baby for suckling, and quickly switching from finger feeding-suckling to breastfeeding-suckling often eases the transition to suckling at the breast.  

One good option for long-term supplementation is a Nursing Supplementer.  This is a bag or bottle containing formula that hangs on a cord around the mother's neck, usually resting between her breasts.  A thin tube comes out from the container and is taped to the mother's breast.  The end of the tubing extends just beyond the end of the nipple. The baby is put to the breast and sucks on both the mother's breast (thus stimulating her supply) and the tube (thus getting supplementary formula).  It is the only method of supplementation that involves being fed at the mother's breast and stimulates her milk supply.  

A nursing supplementer rewards even relatively weak suckling, provides stimulation for the mother's milk supply, and provides supplements to be sure baby is being well-nourished.  It is designed in a way that when the baby learns to suckle more effectively, less supplement is taken, hopefully leading to weaning from the supplementer. However, not all babies are able to learn to breastfeed fully, and many will continue using the supplementer for many months.  

A nursing supplementer is best used for long-term supplementation instead of short-term needs.  It is a good alternative to bottles because it keeps the mother's supply stimulated, doesn't cause nipple confusion, and makes it less likely that the baby will come to prefer the bottle.  It works well for long-term supplementation of the premature or term baby.  It can also be used for re-lactating if a mother weans prematurely and then wants to go back to breastfeeding.  Adoptive mothers also have used it to successfully induce lactation or combine breastfeeding with supplements.  

Nursing supplementers come with different sized tubing, which can help control how fast the formula flows to baby.  Large tubing gives the fastest flow.  Breastfeeding books recommend starting with medium size tubing and then experimenting to see what works best for each mother-baby pair. Where the nursing supplement container is placed also makes a difference; the higher up on the mother's body it is, the faster the flow.  If the bottom of the container is above the mother's nipple, the supplement flows non-stop, which can be too much for many babies.  The lower the container is, the harder it is for baby to suck the supplement. As the baby learns to suckle more effectively, the mother can switch to a smaller tubing and change the position of the container on her chest.

It is extremely important that the baby be well-positioned at the breast, even though baby is getting more of its nutrition at first from the supplementer.  The baby must open wide and take in as much of the mother's areola as possible in order to help stimulate the mother's milk supply better, and to assure that the baby receives the most breastmilk possible.  This is a very important point that is often overlooked.

There are several different brands of nursing supplementers, including the Supplemental Nursing System (SNS) from www.medela.com, and the Lact-Aid from www.lact-aid.com.  Women who have used both often report that they prefer the Lact-Aid for long-term supplementation.  They report that it is faster to use, easier to conceal, more comfortable, easier to clean, and more conducive to proper suckling.  However, both are excellent products and valuable options.  For further discussion of this issue, see www.adoptionbreastfeeding.com/supplementers.asp

If the baby has very poor sucking or refuses the breast completely, the nursing supplementer can also be used for finger feeding as well.  Thus, the nursing supplementer is a versatile and valuable option for long-term supplementation needs.  For more information about lactation aids, see the FAQ at http://users.erols.com/cindyrn/5print.htm.  For photos, see www.fourfriends.com/abrw/Photo%20Album/album.htm.  For further information about lactation aids, see www.fourfriends.com/abrw/Articles/uala.htm

The Haberman Feeder is yet another supplementation option; it is a type of bottle that helps babies with extremely weak sucks.  This bottle was invented by Mandy Haberman, a British graphic designer whose baby was born with a congenital syndrome that include sucking problems and a cleft palate.  She designed a bottle that would be more like breastfeeding and would help babies with weak or ineffective sucks, such as babies with cleft lip/palate, Down Syndrome, congenital heart disease, neurological or genetic disorders, and premature babies. 

Haberman studied cineradiographs of suckling babies to better understand the mechanics of feeding.  She found that bottlefeeding involved primarily sucking, while breastfeeding primarily involved pumping actions on the areola with the baby's tongue and gums (suckling).  In breastfeeding, the baby must open very wide to take the mother's nipple and areola into his mouth.  The tongue then elongates the breast tissue and presses it up against his palate, while the tongue and jaw work rhythmically to stimulate milk production.  The baby swallows and takes a breath, then repeats the process.

In bottlefeeding the baby is trained to push its tongue forward to stop the flow of milk (so he doesn't get too much at once), just the opposite of what needs to happen during breastfeeding. He does not need to open his mouth wide to take in the mother's areola, so he tends to "nipple feed" with his lips tightly surrounding the firmer artificial nipple in the front of his mouth, and his jaws don't need to move to stimulate milk production.  

With the Haberman Feeder, the baby is encouraged to have mouth movements more like breastfeeding than like bottlefeeding.  Joan McCartney at www.widesmiles.org/outreach/ws322.html writes, "The unique design enables the feeder to be activated by tongue and gum pressure, imitating the mechanics involved in breastfeeding, rather than by sucking."   The result is thought to be closer to breastfeeding.

A one-way valve separates the nipple from the bottle, so there is a small reservoir for milk near the nipple, away from the rest of the bottle.  Because of this, milk will not flow backwards back into the bottle.  The end of the bottle's nipple is slit, making it easier for milk to come out with less suckling pressure, but a valve prevents the baby from being flooded with milk due to the easier flow.  You can see a picture of a Haberman Feeder at www.ciaccess.com/moebius/haberman.htm

The Haberman feeder is designed so that the baby does not get any milk unless the baby sucks, but even weak sucks are rewarded.  Thus it reinforces the baby's sucking efforts, and progressively trains the baby to suck more effectively.  Rotating the bottle's nipple in the baby's mouth helps control the rate of flow, which can help train the suck to be stronger. Air flow is also controlled so that babies swallow less air while feeding

An information FAQ about the Haberman Feeder at  www.breastfeedingbasics.com/html/haberman_hazelbaker.htm states, "The Haberman...allows many infants to develop an effective suck utilizing the tongue striping motion necessary for successful breastfeeding as well as neural development...the Haberman has been shown to improve muscle tone, awake cycles, and ability to retain sucks effectively in pre-term babies."

There is a "Mini-Haberman Feeder" available for use with premature babies. Its nipple is smaller and more suitable for the mouths of very low birthweight babies.  Information on this can be found at www.selfexpressions.com/habermanfeeder.html. Remember that the nipple and the valve need replacement about every 5-6 weeks of use in a Haberman feeder of any size, so it may be helpful to order extras of these.

A Haberman Feeder can be ordered through Medela and many other breastfeeding supply companies, including:

Breastfeeding Holds and Hints for Preemies

It may be especially difficult for a tiny preemie to latch on at first if the mother is very well-endowed and/or her breasts are very engorged.  Many women report that hand-expressing some milk (or pumping a little) ahead of time lessens engorgement and makes it easier for the baby to latch on. Expressing a little milk onto the babies lips also tends to remind him of what's coming and trigger feeding and sucking behaviors.  As noted above, finger feeding a little first and then switching to the breast also helps some babies transition better to breastfeeding.

The football hold may be especially advantageous to use with preemies as they learn how to nurse, as it makes it easier to control the breast, check the baby's latch, and keep a large or engorged breast from overwhelming the baby.  Preemies' heads also need more support than full-term babies' heads; the football hold offers extra support for a preemie's head and neck, and so is an excellent choice for that reason too.  Some sources report that the cross-cradle hold is very effective with preemies as well, while other sources discredit its usefulness.  Consult your lactation consultant for her opinion, and experiment to see what works best for you with positioning.  

The Importance of Time and Patience

Remember that the process of the baby learning to latch on properly can be a long and slow one in preemies, and it is important not to give up too soon.  Some babies learn to breastfeed in the hospital before going home, while others go home combining breastfeeding and supplementary methods.  Sometimes moms go home with the baby not yet breastfeeding, and once the baby reaches a certain level of development, the baby is able to latch on and nurse effectively.  Don't give up if baby is not yet breastfeeding when you take him home; breastfeeding CAN often still happen with time and patience!

Several stories of preemies learning to breastfeed in the hospital or at home can be found at www.lalecheleague.org/NB/NBpremature.html. Although not all moms are able to preserve breastfeeding in this difficult situation, many do.  Keep working at it if at all possible, but of course, each mother must judge for herself when to keep going and when it is time to stop.

If Breastfeeding Does Not Work Out

Sometimes full breastfeeding is not possible with a very premature baby.  Prematurity is one of the most difficult situations a nursing mom can face, and sometimes, even with the most dedicated mother and best hospital pumps, full breastfeeding will not occur.  This leaves the mother with several difficult choices to make.  Information on these choices can be found at http://members.aol.com/KBone91/pumping.html

Some women continue to put the baby to the breast but because of supply concerns or the baby's weak suck, they may use a supplementary nursing system while nursing in order to give the baby supplements.  This keeps the mother's supply more stimulated, helps her connect with her baby more intimately, but also makes sure the baby keeps up its weight gain and stays well-nourished.  Some women find supplemental nursing systems easy to use and not burdensome long-term, while others find it cumbersome and a barrier to emotional intimacy with their babies. 

Some women pump and give their breastmilk by bottle for many months. This way, the baby still receives the important nutritional and immunological protections of breastmilk, which is a tremendous advantage for the preemie.  Women who have done this report that having a number of different sets of extra flanges etc. eases the process, so that you don't have to wash up immediately every time you pump.  They also report that breast compression can sometimes help them increase the amount of milk pumped ( www.fourfriends.com/abrw/bc.htm). 

Many women are able to completely supply their baby's needs through pumping; however, keeping up a steady supply of milk can be challenging over the long run.  It is important to carefully work to keep up your supply if you choose this route.  Information on boosting supply can be found at www.pumpingmoms.org/faq-boost.html, http://users.erols.com/cindyrn/fenuhugg.htm, www.deleons.com/pumping_page.htm, and www.internetbabies.com/mobi/Articles/HerbalGalactagogues.asp.  Be sure to consult a lactation consultant about the use of any herbs or medicines for increasing milk supply and be watchful for any side effects (see below).

Some women with supply issues successfully combine breastfeeding, pumping and feeding expressed breastmilk, and formula supplements as needed.  Sometimes these supplements are given through bottles, sometimes through other measures such as cups or finger feeding.  This also offers baby the important gift of immunological protections, while still assuring that baby gets adequate nourishment and hydration.  

Other women end up deciding that pumping, partial breastfeeding with supplements, or supplementary nursing systems have become too stressful on their families and have chosen to wean and go to formula instead.  In this difficult situation, women must rest assured that they have given their baby everything they could have.  They should not beat themselves up emotionally if it becomes too stressful to continually nurse and pump and supplement. An excellent discussion of this difficult decision can be found at http://members.aol.com/KBone91/pumping3.html.  In addition, read the section below on Grieving Breastfeeding, and consider joining a support group such as MOBI (Mothers Overcoming Breastfeeding Issues).  

Sometimes breastfeeding a preemie does work out just fine, and sometimes, despite a woman's best efforts, it does not. There are so many variables that can influence the outcome of preemie breastfeeding that often women simply must do the best they can, proceed on faith, and go with the flow.  Don't judge your mothering abilities on whether or not you can nurse; prematurity can challenge even the most dedicated and experienced nursing moms.  Do the very best you can for your baby, but don't torture yourself if breastfeeding doesn't work out.  Remember that ANY amount of breastmilk that you did manage to give them is greatly beneficial, and that you did the best you could under very trying circumstances.  Concentrate instead on what you can give your baby---your love and emotional nurturing. This is the most important thing of all.  

A really thorough description of all the issues in breastfeeding a premature baby is far beyond the scope of this FAQ.  For further information about breastfeeding a premature baby, see: 

 

Need for Supplementation

Sometimes, a baby truly does need supplementation.  Our devotion to breastfeeding must not cloud the fact that sometimes, supplementing IS needed and can be life-saving.  But how can you tell if your baby truly needs supplementation?  And if your baby needs to be supplemented, how can you do this in a way that will interfere with breastfeeding in the most minimal way?  

The first step is to try to determine whether or not supplementation is truly needed.  Take time to review the situation and any special circumstances; don't supplement automatically.  Consult a professional lactation consultant (IBCLC).  These are the professionals truly trained to know when supplementation is necessary.  They will work with your baby's doctors to work out the best plan for meeting your baby's needs while still trying to preserve breastfeeding as well.  

The following are some general considerations on when supplementation may not be necessary and when it may indeed be needed. However, these are only considerations; they are not strict guidelines and not medical advice. It is important to emphasize that supplementation decisions should only be made in consultation with lactation consultants and your baby's doctors; the issues involved can be complex. 

When Supplementation May Not Be Necessary

As noted previously, supplementation should never be routine for any condition; it should be based on a documented medical need.  Ask for lab tests to show the need for supplementation whenever possible (barring an emergency).  Then seek an expert opinion of a professional lactation consultant to confirm this need.  Oftentimes, the standards that are used to diagnose and treat conditions like hypoglycemia and jaundice are open to interpretation, and it may help to review the standards and variations of interpretation with an impartial observer.  See the sections on hypoglycemia and jaundice above for further information.

Many women assume that if a baby cries even after nursing, he is still hungry and needs supplementation.  Actually, babies cry for many reasons; perhaps the baby is crying to tell you that something else is wrong.  Don't assume crying is only about hunger. Sometimes the baby cries simply because he is uncomfortable or because he wants to be nearer to you.  Check thoroughly for other reasons and resist the temptation to supplement unless the baby is showing signs of truly needing it. 

Don't assume that if your milk 'comes in late' (later than day 2 or 3) that the baby must be supplemented.  Because mature milk can sometimes take extra time to 'come in' after a cesarean, women may be told that they must supplement in the meantime.  Many doctors and nurses are not aware that is common for the milk to take longer to come in after a cesarean, and so they may start jumping to conclusions about "low milk supply" and recommend supplementation.  

Colostrum (the first 'milk', a golden or clear substance produced in the first days after birth)  is so highly concentrated that not much is needed to sustain the baby. You will not produce great quantities of colostrum, but what is there packs tremendous nutritional and immunological punch.  It is the ideal first food for baby.  It has plenty of protein and energy concentrated into a few small drops, is baby's first immunization, is full of antibody protections, helps protect baby's intestines against harmful bacteria, helps baby produce his first meconium stool, and is easily digestible. These benefits are vitally important for baby's protection; any supplements reduce the amount of these protections.  Therefore, supplements should be added only if absolutely necessary.

Many women see how little colostrum they produce and panic that this is not enough for baby to survive on, or worry that they will not make enough milk to satisfy the baby.  Rest assured that colostrum production is small because it is so highly concentrated, and that this does not indicate what your production will be once your mature milk comes in. You will produce plenty of milk eventually.  

In the meantime, the small amount of colostrum is part of nature's design to promote breastfeeding.  These small amounts of colostrum ensure that baby wants to nurse quite often in the first few days.  This frequent stimulation helps ensure a greater milk supply later on for the mother, reduces engorgement for the mother when the milk does come in, and ensures the baby gets more frequent doses of the important immunological protections in colostrum.  Supplements fill the baby up and make him want to nurse less often, thus decreasing the mother's supply and giving the baby less protection immunologically.

Because colostrum is produced in smaller amounts, nursing the baby very frequently during the first few days is extra important. Nursing 8-12x per day is usually enough to sustain the baby until the mature milk comes in, as long as the mother has unrestricted access to her baby and does not limit time on the breast. 

Dehydration is a potential concern if the mature milk does not come in within a few days, but a great deal depends on how often the baby is nursing, how the baby's weight is doing, and whether the baby has symptoms of problems.  Each situation must be judged on its own individual circumstances; a professional lactation consultant can help you decide if supplementation is needed.

Remember that nature designed baby to get frequent, small, powerful doses of colostrum for a few days after birth; this is the system that evolved over millions of years to become the one that is safest and most efficient for baby.  Unneeded supplements tamper with this system and interfere with the intended chain of events. Unless circumstances clearly show the baby is in need of supplements, this is not something to tamper with lightly. 

When Supplementation May Be Necessary

However, there are times when supplementation can become necessary.  In some situations, supplementation can be life-saving.  The ultimate goal is the health and well-being of the baby, so of course if the baby truly needs a supplement we must not hesitate to give it. 

It is important to watch for signs of dehydration in the baby when the mature milk takes a long time coming in, if the mother and baby are unable to nurse frequently, or if there is reason to believe that the mother's supply may be affected.  Usually, nursing every 2-3 hours in the day (and every 3-4 hours at night) is enough to keep a baby well-hydrated and in good shape, but if it is not possible to nurse that often or if low supply is an issue, dehydration can occur. 

If the baby becomes truly dehydrated, he is at risk for many problems and must be treated.  Symptoms of dehydration include:

These are signs of serious problems that need to be treated immediately.  Sometimes nursing more often can rectify the situation; at other times, supplements become necessary.  If in doubt, consult an IBCLC lactation consultant to know if dehydration is a problem and what to do about it.   

If the baby is losing too much weight, this can be another sign that he needs supplementation.  However, this can be complicated by the fact that babies' birth weights are often inflated by the excessive amounts of I.V. fluids that are given to the mother during labor and birth.  When this  transient fluid is lost, it looks like the baby has lost an excessive amount of weight and 'needs' supplementation.  

As quoted previously, Henci Goer  (The Thinking Woman's Guide to a Better Birth) documents that this overload of fluids  "also result[s] in a transfer of water into the baby's tissues.  This extra fluid inflates the baby's birth weight and the subsequent weight loss after birth.  Doctors and others often gauge breastfeeding adequacy by how fast the baby regains her birth weight, so this misleading weight loss may lead a doctor or mother to mistakenly conclude that breastfeeding is inadequate" or that supplementary feedings are needed. 

It is not always easy to tell when a baby is truly losing too much weight after birth; this is another situation where the evaluation of a neutral breastfeeding expert can help clarify the baby's true condition and needs.  Sometimes a small amount of supplementation is enough to 'tide over' a baby until the mother's milk supply increases or the baby learns to nurse more efficiently.

Sometimes a baby has a problem learning to suck well and may need a supplement while he learns to nurse.  If the baby is "tongue-tied" (a problem with the frenulum on the bottom of the tongue), has an extremely high and arched palate, or is unable to coordinate sucking and tongue motions very well, he will tend to not nurse very well and not regain his weight after birth.  This situation needs evaluation by a professional lactation consultant (IBCLC) to determine what the exact problem is.  Often there are things that can be done to help the baby learn to suckle more efficiently. It is vital that an IBCLC lactation consultant be seen as SOON AS POSSIBLE in this situation so that supplementation is minimal and the baby learns new habits quickly.   

Another situation that may justify supplementation is if the baby's condition is unclear (there are possibly troubling symptoms) and you cannot see an expert right away to know for sure how serious the problems may be. Although the best choice is to get advice from an IBCLC lactation consultant, not all hospitals have these readily available.  Until an IBCLC can be called in to help evaluate the situation, if the baby has symptoms that may indicate a real problem, it may be better to err on the side of caution and give a supplement. However, this does not have to mean giving a bottle!

Bottles should be avoided if at all possible, because the sucking mechanism for bottles is completely different than the sucking mechanism for nursing.  In bottlefeeding, a baby's role is basically sucking.  In breastfeeding, a baby's role is basically "pumping" the mother's areola to produce the milk.  In other words, the baby's tongue motions plus the pressure from its tongue and gums "pumps" the areola, producing milk.  In bottlefeeding, none of these tongue motions are needed, and the baby's tongue basically pushes forward to stop the flow of the milk from the single hole in the end of the artificial nipple when baby needs a rest.   

Because the tongue movements are totally opposite, many babies have difficulty switching between breastfeeding and bottlefeeding.  Also, a baby must open his mouth very wide for nursing at the breast properly, whereas he needs to only open his mouth a little to suck on a bottle nipple.  This often means that babies given bottles try to 'nipple-feed' when breastfeeding---instead of opening the mouth wide to encompass the mother's areola, the baby sucks on the nipple only.  This creates tremendous soreness for the mother and leads to baby not getting very much milk because the mother's areola is not stimulated.

Although many nurses will tell you that 'nipple confusion' doesn't exist and bottles won't interfere with breastfeeding, research clearly shows that it does (Samuels 1985, Hill 1997, Blomquist 1994, Cronenwett 1992). Many nurses will also tell you that the only way to supplement is with a bottle, but there are actually many alternatives.  Many U.S. nurses have not been trained to be familiar with non-bottle supplementation techniques, but outside the U.S., these alternate methods are more common.  

Alternative Methods of Supplementation

There are many ways to supplement a baby without using a bottle.  These include a syringe, eye dropper, spoon feeding, supplemental nursing systems, cup feeding, finger feeding, or supplemental nursing systems.  There are also special bottles for certain situations that may be less confusing to a newborn.  

The following section briefly summarizes some of the alternative supplementation options to bottles.  Much of this information was covered above in the section on nursing a premature baby and is repeated here for readers who may not read this FAQ in a continuous fashion.  Readers may wish to skip ahead if they are already familiar with the material.

Spoon Feeding, Eye Droppers, and Syringes

Mathur (1993) found that spoon-feeding instead of bottlefeeding improved the long-term breastfeeding rate.  In the study, 86.8% of those who received their first feeds by spoon were still practicing total breastfeeding, while only 33.3% who received first feedings by bottle were still nursing.  

Spoon Feeding is very similar to cup feeding, except that the baby is fed from a spoon instead of a cup.  No special equipment is needed; any clean and sterile spoon is suitable.  Follow the same directions as setting up for cup feeding, then bring the spoon to the baby's lips.  Gently tilt it so that it rests lightly on his lower lip when he opens up, with the milk just touching his lips. Tip the spoon slightly so that the milk flows into the baby's mouth.  Repeat as needed.  

Eye droppers are another way to get baby extra nourishment, and a syringe can also be used, although there is less research available on these methods. With eyedroppers, a soft plastic type is best because it is unbreakable.  With feeding syringes, peridontal or orthodontic syringes can be used in the same way; their advantage is that they hold more fluids.  Both eye droppers and feeding syringes are available in most drug stores; this is advantageous because the mother doesn't have to wait for special equipment to arrive.  

Again, prepare the baby the same way you would for cup feeding, holding him upright and swaddled.  Protect all clothing as sometimes spills happen in this process. Bring the eye dropper or syringe to the baby's mouth, and slowly drip in the milk.  It is important not to go too fast, so that the baby has a chance to swallow before more is given.  When the baby needs to pause, it is important that the person feeding the baby take a break too.  To avoid choking, keep the baby upright and give only small amounts at a time.  

Cup Feeding

Cup feeding is a bit more familiar to most NICU nurses than spoon feeding, eye dropper or syringe feedings.  In studies of several African and English hospitals, researchers found that cup feeding preemies resulted in less nipple confusion and higher breastfeeding rates than bottlefeeding.  Lang (1994) found that 81% of babies who had received supplements via cup feeding were fully breastfeeding at hospital discharge, vs. 63% who had received supplements by bottle.  

To cup feed, you need to have a small flexible cup, like a medicine cup or even a Dixie cup.  Medela, Ameda/Egnell and La Leche League make a series of cups specially made for this purpose.  Hold the baby as upright as possible (swaddled so his hands won't bump the cup), and use a bib or blanket to protect clothing.  Put a small amount into the cup (measure it so you will know how much baby is drinking), and if necessary, fill several cups ahead of time so that the feeding process can be continued smoothly and without interruption.  

Gently tilt the cup to the baby's lips.  Place the edge of the cup at the outer corners of the baby's upper lip and resting gently on the lower lip with the baby's tongue inside the cup. (Some babies reportedly prefer their tongue under the lip of the cup.)  Tilt the cup so the milk touches the baby's tongue. Don't move the cup during the feeding----the baby will lap the milk or sip it on his own rather than you pouring the milk into baby's mouth.  Let the baby swallow before offering more, and let the baby set the pace for feedings.  If he tires, don't force the issue.  

Some US hospitals have pioneered the use of cup feeding in the United States (Stine 1990).  Unfortunately, at this time, most NICUs in the U.S.A. view cup feeding as too difficult to do, impossible, or even 'risky' to try. However, there are some hospitals that are willing to try cup feeding, and with the help of a lactation consultant as advocate, others are learning to try it.  You can find out more about cup feeding from www.mother-2-mother.com/cup_feeding.htm, www.askdrsears.com/html/2/T026000.asp, or the article by Dr. Jack Newman at www.breastfeeding.com.  There is a video of cup feeding available at www.breastfeeding.com/aaavideo/cup1.mov

Finger Feeding

Another alternative to bottles is finger feeding. This works especially well as a transition to breastfeeding.  

A small tube (often a #5 French tube) is attached to a bottle of expressed breastmilk or formula.  The tubing is then taped to the caregiver's largest finger, either to the pad or to the side.  If the baby cannot open his mouth very wide, then the caregiver can use the smaller fingers, but the idea is to use the largest finger possible so that baby learns to open its mouth very wide.  The caregiver's finger is then inserted into the baby's mouth, pad side up, and the baby sucks the milk/formula out of the tubing. This is more like breastfeeding sucking than bottle feeding sucking, and many babies do very well on this regimen (Kurokawa, 1994). 

Photos and information about finger feeding can be found online at several different websites, including www.promom.org/bf_info/Fingerfeed.htmwww.asac.ab.ca/BI_fall01/wbdw.html, www.deleons.com/breastfeed.html, and www.preemie-l.org/bfaq.html.  There is a video of finger feeding available at www.breastfeeding.com/aaavideo/finger1.mov. The Hazel Baker Finger Feeder can be bought at many sites, including www.medela.com/NewFiles/specialtyfdg.html

Finger feeding has numerous advantages over bottles.  It teaches the baby that sucking is rewarded with milk, it teaches the baby to open its mouth very wide, it won't cause nipple confusion, and the baby is not taught poor sucking habits.  The sucking mechanism with finger feeding is more like breastfeeding sucking.  In addition, any caregiver can finger feed; the mom does not have to be present 100% of the time.  Bottles can also be given by any caregiver, but they interfere with proper sucking te chnique, whereas finger feeding does not.  Dr. Jack Newman writes at www.breastfeeding.com/all_about/all_about_f_feed.html

Finger feeding is much more similar to breastfeeding than bottle feeding is. In order to finger feed, the baby must keep his tongue down and forward over the gums, the mouth wide open (the larger the finger used, the better), and the jaw forward. Furthermore, the motion of the tongue and jaw is similar to what the baby does while feeding at the breast. Finger feeding is best used to prepare the baby to take the breast.

Finger feeding helps prepare the baby for breastfeeding by learning the correct type of suck.  Eventually, when the baby is ready, he can be put to the breast.  Some babies transition to full nursing quickly, but many babies take quite some time to learn to transition to the breast.  Don't get discouraged; this is not unusual.  Perseverance is important.  

Some women report that if they give the baby a minute or two of finger feeding first before switching to the breast, the baby latches on and suckles more efficiently.  This soothes the frantically hungry baby with immediate food, rewards the baby for suckling, and quickly switching from finger feeding-suckling to breastfeeding-suckling often eases the transition to suckling at the breast.  

Supplemental Nursing Systems

In some cases, a supplementary nursing device such as a "Lact-Aid" or "Supplemental Nursing System" can provide baby with the nourishment he needs while still preserving breastfeeding and stimulating supply.  This can be ideal for many cases where long-term supplementation is needed.  It is the only method of supplementation that involves being fed at the mother's breast and stimulates her milk supply.  

This is a bag or bottle containing formula that hangs on a cord around the mother's neck, usually resting between her breasts.  A thin tube comes out from the container and is taped to the mother's breast.  The end of the tubing extends just beyond the end of the nipple. The baby is put to the breast and sucks on both the mother's breast (thus stimulating her supply) and the tube (thus getting supplementary formula).  

As The Breastfeeding Answer Book summarizes:

When a baby swallows, the natural response is to suck.  A nursing supplementer--a device that allows the baby to receive supplements through a tube taped to the mother's breast---is designed to stimulate this natural response to help improve a baby's suck while providing needed supplement...A nursing supplementer may help a baby learn to suck more effectively because the extra milk he gets from the supplementer stimulates him to swallow and consequently suck more often.  As the baby's suck becomes more vigorous, he will receive more milk from the breast and further stimulate the mother's milk supply.  As the baby begins to take more milk from the breast he automatically takes less from the supplementer.  The mother can gauge her baby's progress in part by how much of the supplement is left after nursings...The nursing supplementer allows the whole feeding time to be spent at the breast, while bottles and other alternative feeding methods are used after nursings.  

A nursing supplementer rewards even relatively weak suckling, provides stimulation for the mother's milk supply, and provides supplements to be sure baby is being well-nourished.  It is designed in a way that when the baby learns to suckle more effectively, less supplement is taken, hopefully leading to weaning from the supplementer. However, not all babies are able to learn to breastfeed fully, and many will continue using the supplementer for many months.  

A nursing supplementer is best used for long-term supplementation instead of short-term needs.  It is a good alternative to bottles because it keeps the mother's supply stimulated, doesn't cause nipple confusion, and makes it less likely that the baby will come to prefer the bottle.  It works well for long-term supplementation of the premature baby.  It can also be used for re-lactating if a mother weans prematurely and then wants to go back to breastfeeding.  Adoptive mothers also have used it to successfully induce lactation or combine breastfeeding with supplements.  

Nursing supplementers come with different sized tubing, which can help control how fast the formula flows to baby.  Large tubing gives the fastest flow.  Breastfeeding books recommend starting with medium size tubing and then experimenting to see what works best for each mother-baby pair. Where the nursing supplement container is placed also makes a difference; the higher up on the mother's body it is, the faster the flow.  If the bottom of the container is above the mother's nipple, the supplement flows non-stop, which can be too much for many babies.  The lower the container is, the harder it is for baby to suck the supplement. As the baby learns to suckle more effectively, the mother can switch to a smaller tubing and change the position of the container on her chest.

It is extremely important that the baby be well-positioned at the breast, even though baby is getting more of its nutrition at first from the supplementer.  The baby must open wide and take in as much of the mother's areola as possible in order to help stimulate the mother's milk supply better, and to assure that the baby receives the most breastmilk possible.  This is a very important point that is often overlooked when using supplementers.

There are several different brands of nursing supplementers, including the Supplemental Nursing System (SNS) from www.medela.com, and the Lact-Aid from www.lact-aid.com.  Women who have used both often report that they prefer the Lact-Aid for long-term supplementation.  They report that it is faster to use, easier to conceal, more comfortable, easier to clean, and more conducive to proper suckling.  However, both are excellent products and valuable options.  For further discussion of this issue, see www.adoptionbreastfeeding.com/supplementers.asp

If the baby has very poor sucking or refuses the breast completely, the nursing supplementer can also be used for finger feeding as well.  Thus, the nursing supplementer is a versatile and valuable option for long-term supplementation needs.  For more information about lactation aids, see the FAQ at http://users.erols.com/cindyrn/5print.htm.  For photos, see www.fourfriends.com/abrw/Photo%20Album/album.htm.  For further information about lactation aids, see www.fourfriends.com/abrw/Articles/uala.htm

Haberman Feeder

Babies who have problems with weak sucks may be helped by a special device such as a Haberman Feeder. In this special type of bottle, the baby is rewarded for even very weak sucking efforts.  

This bottle was invented by Mandy Haberman, a British graphic designer whose baby was born with a congenital syndrome that include sucking problems and a cleft palate.  She designed a bottle that would be more like breastfeeding and would help babies with weak or ineffective sucks, such as babies with cleft lip/palate, Down Syndrome, congenital heart disease, neurological or genetic disorders, and premature babies. 

Haberman studied cineradiographs of suckling babies to better understand the mechanics of feeding.  She found that bottlefeeding involved primarily sucking, while breastfeeding primarily involved pumping actions on the areola with the baby's tongue and gums (suckling).  In breastfeeding, the baby must open very wide to take the mother's nipple and areola into his mouth.  The tongue then elongates the breast tissue and presses it up against his palate, while the tongue and jaw work rhythmically to stimulate milk production.  The baby swallows and takes a breath, then repeats the process.

In bottlefeeding the baby is trained to push its tongue forward to stop the flow of milk (so he doesn't get too much at once), just the opposite of what needs to happen during breastfeeding. He does not need to open his mouth wide to take in the mother's areola, so he tends to "nipple feed" with his lips tightly surrounding the firmer artificial nipple in the front of his mouth, and his jaws don't need to move to stimulate milk production.  

With the Haberman Feeder, the baby is encouraged to have mouth movements more like breastfeeding than like bottlefeeding.  Joan McCartney at www.widesmiles.org/outreach/ws322.html writes, "The unique design enables the feeder to be activated by tongue and gum pressure, imitating the mechanics involved in breastfeeding, rather than by sucking."   The result is thought to be closer to breastfeeding.

A one-way valve separates the nipple from the bottle, so there is a small reservoir for milk near the nipple, away from the rest of the bottle.  Because of this, milk will not flow backwards back into the bottle.  The end of the bottle's nipple is slit, making it easier for milk to come out with less suckling pressure, but a valve prevents the baby from being flooded with milk due to the easier flow.  You can see a picture of a Haberman Feeder at www.ciaccess.com/moebius/haberman.htm

The Haberman feeder is designed so that the baby does not get any milk unless the baby sucks, but even weak sucks are rewarded.  Thus it reinforces the baby's sucking efforts, and progressively trains the baby to suck more effectively.  Rotating the bottle's nipple in the baby's mouth helps control the rate of flow, which can help train the suck to be stronger. Air flow is also controlled so that babies swallow less air while feeding

An information FAQ about the Haberman Feeder at  www.breastfeedingbasics.com/html/haberman_hazelbaker.htm states, "The Haberman...allows many infants to develop an effective suck utilizing the tongue striping motion necessary for successful breastfeeding as well as neural development...the Haberman has been shown to improve muscle tone, awake cycles, and ability to retain sucks effectively in pre-term babies."

There is a "Mini-Haberman Feeder" available for use with premature babies. Its nipple is smaller and more suitable for the mouths of very low birthweight babies.  Information on this can be found at www.selfexpressions.com/habermanfeeder.html. Remember that the nipple and the valve need replacement about every 5-6 weeks of use in a Haberman feeder of any size, so it may be helpful to order extras of these.

A Haberman Feeder can be ordered through Medela and many other breastfeeding supply companies, including:

Conclusion

If supplementation must be done, it is best to do it in such a way that preserves breastfeeding as much as possible.  Whenever possible, NURSE BEFORE ANY SUPPLEMENTATION. Your milk is dependent on the supply and demand principle.  If you are not receiving regular stimulation, your breasts will down-regulate production and supply will go down.  Furthermore, baby will suckle more strongly and effectively prior to supplementation, and will receive a higher amount of immunological protections than he would from half-hearted suckling after supplementation.  Therefore, it's to your great advantage to always nurse first and then give any supplementation.

Furthermore, some authorities suggest supplementing 2-5 times per day, rather than after every nursing.  In other words, nurse first, then offer a few ounces of supplement in some feedings, but in other feedings, nurse longer, skip the supplement altogether, and then give a larger amount at the next feeding.  By doing this, the baby will not learn to expect supplementary feedings after every nursing.  

It is important to keep up your own supply, even when supplementing.  Use a hospital-grade pump (i.e. Medela Lactina) to help stimulate milk production, not a cheap pump that is less effective.  Remember that double-pumping produces a greater milk yield and stimulates prolactin levels more effectively (Breastfeeding Answer Book).  If you can, double pump whenever possible. Alternatively, you can pump one side while nursing the baby on the other side and/or use breast compression ( www.fourfriends.com/abrw/bc.htm) to help pump more productively.

You may also want to investigate using herbs to increase your supply. Some women find herbs a significant help and some do not; because herbs are medicine too, it is important to consult an expert before using them.  See a professional board-certified lactation consultant about the proper use of herbs before trying any. There are also pharmacological medications that can increase milk supply, but some of these can have severe side effects in some women and must be carefully supervised.  

More information about galactagogues (herbs and medications for increasing milk supply) can be found at the following sites:

If the baby has become nipple confused due to bottle supplementation, this can often be remedied with time, great patience, and careful guidance from an expert lactation consultant.  There are women who have had babies who were unable to nurse and fed by bottle for many months, but were eventually able to learn (or re-learn) the ability to nurse. Many adoptive mothers have found that they were able to teach their older adopted infants to nurse, even after many months of bottles ( www.adoptivebreastfeeding.com and www.fourfriends.com/abrw/).  The process is not easy, but it is not hopeless.  It is certainly worth trying, given the superior health benefits associated with breastfeeding.  

If the baby is not succeeding in breastfeeding because of a weak suck, this can also sometimes be remedied.  However, careful guidance from an IBCLC or neurodevelopmental therapist (NDT) trained in helping retrain a baby's suck is vital, and the baby must be carefully monitored to be sure he stays well-nourished and hydrated.  See the following section on "Failure to Thrive" syndrome for further information.  

If supplementation does become medically necessary, by all means do so, knowing that this is what your baby needs. You can also take comfort from the fact that many times, with help, a breastfeeding relationship CAN be preserved, even in spite of substantial supplementation.  Once the baby is doing better, the supplements can eventually be decreased until they can be discontinued altogether.  

Although breastfeeding does not always work out in these situations, supplementation does not have to be the end of breastfeeding.  Sometimes it is a necessary middle step to getting  baby back on track to breastfeeding.  Sometimes, when done judiciously, it is the factor that gives breastfeeding a second chance. Although it is hard for many mothers to see supplementation in a positive light, sometimes it really can be a helpful tool, both for baby's overall health and in re-establishing breastfeeding.  Use it judiciously.

 

Failure to Thrive Syndrome

When the baby has difficulty gaining weight despite many chances to feed, health professionals get worried, and for good reason.  Dehydration and too much weight loss are major concerns for babies that are not feeding well.  However, just how much weight loss is normal, how slow weight gain concerns should be handled, and when to supplement are matters of great controversy.  It is beyond the scope of this FAQ to cover this subject as it deserves; only a few basics will be covered here.  Please be sure to see a nursing book and a lactation consultant for more information and guidance specific to your situation.   

The biggest dilemma facing a mother in this predicament is trying to determine how much intervention is truly necessary and what the proper treatment should be.  Unfortunately, women often receive conflicting information from different sources.  Many medical personnel have been trained to automatically give a bottle of formula at even the vaguest sign of concern, and this is often the first step to weaning.  On the other hand, sometimes supplementation really is medically necessary, yet some breastfeeding resources may make you feel guilty for even considering it.  So how is a mother to know what to do? 

Get Expert Help

If you are having major supply and failure-to-thrive issues, be sure to consult a professional lactation consultant (IBCLC).  The source of the problem may be the baby (inefficient suck, tongue-tied, high palate, etc.), or it may be due to low milk supply (caused by hormonal imbalances, lack of breast growth in pregnancy, drugs that suppress lactation, anemia or retained placental fragment, hypothyroidism, etc.), or it may simply be due to medical mismanagement (unneeded bottles, pacifiers, mother-baby separation, infrequent nursing, etc.).  

You need professional evaluation in order to determine the causes and possible solutions to breastfeeding problems.  Too many personnel with inadequate training are trying to give women breastfeeding instruction, and they often cause more harm than good.  Seeing a professional is critical to your breastfeeding efforts and for your baby's safety. 

A professional lactation consultant can watch the baby nursing and evaluate his suck, check your positioning, check baby's mouth and tongue for abnormalities, evaluate your breastfeeding history, calculate your milk supply and nursing efficiency, advise you on your choices to change things, etc.  She can also advise you on when supplementation is needed, danger signs in the baby to watch for, how to supplement with non-bottle methods, herbal and pharmacological drugs to increase milk supply, etc. A good professional lactation consultant (LC) will work with your pediatrician and help coordinate care decisions.  

Professional lactation consultants have the initials IBCLC after their names to show that they are International Board-Certified Lactation Consultants.  To find an IBCLC in your area, go to www.breastfeeding.com, click on the map of the United States, then click on your state to find a list of IBCLCs in your area.  Or check the directory at www.ilca.org

Slow Gainers Vs. Failure To Thrive

One of the most important first steps is to determine whether baby is just gaining slowly or whether the baby is truly in trouble.  Many babies have been labeled 'failure to thrive' who were just slow gainers, but sometimes babies who were truly having difficulties and need supplementation have been dismissed as simply 'slow gainers.'  It is an extremely important distinction to make!  This is one of those things that is very complex to determine and needs evaluation by a professional lactation consultant. 

Most often, medical mismanagement is to blame for slow weight gain and changing a few basic things will help baby and keep the breastfeeding relationship intact.  On the other hand, a small percentage really do have long-term milk supply and/or sucking issues.  True 'failure to thrive' cases may need to combine breastfeeding with supplements; some women may choose to use formula exclusively to end the hassle of pumping and supplementing if it all becomes too overwhelming. 

The first step is to determine the accuracy of baby's weight.  Although scales are supposed to be standardized, they rarely are, and even an adult's weight can vary dramatically from one scale to another at times.  Furthermore, what the person has eaten, what clothes she is wearing, and the time of day can also cause significant changes in weight as well.   Because babies are so small, these seemingly small discrepancies can appear to be huge changes proportionally.  

So whenever possible, babies should be weighed ON THE SAME SCALE, and preferably without clothing (or similar clothing every time).  In this way, the baby's true gain or loss can be measured accurately.  Many medical personnel dismiss this as unimportant, but  treatment decisions must  be based on VALID data!  Some mothers have found that paying attention to the scale makes a critical difference at times, so be sure to check on this first.

The second step is to determine whether the baby is nursing often enough and long enough.  Many women are kept from their babies for extended time periods, are told that baby only needs to nurse every 3-4 hours, or told that they should only nurse 5-10 minutes on each side to prevent soreness. All of these problems can affect a baby's weight gain.  

Think about it.  If the baby is only being nursed every 4 hours, then he is receiving about half as many calories as one who is being nursed every 2 hours, and his mother's milk supply is receiving half the stimulation. This difference can be crucial in a baby who is struggling to regain his birth weight, or whose weight gain is lower than usual.   

Yamauchi and Yamanouchi (1990) followed two groups of newborns from birth on.  As summarized in The Breastfeeding Answer Book

"[They] found that on their third day of life the milk intake of the babies who nursed six or fewer times per day was only about 54% of that of the babies who nursed seven to eleven times per day.  The babies who nursed more frequently also lost less weight initially and began regaining their birth weight more quickly.  The difference in intake continued to be significant through the fifth day of life, when the group nursing less frequently consumed 83% of the milk consumed by the more frequently nursing group." 

A newborn needs to nurse at least 8-12 times every 24 hours (preferably 10-12 times per day in the first few days).   The Breastfeeding Answer Book recommends that women worried about infant weight gain nurse their babies AT LEAST every 1.5-2 hours during the day and every 3 hours at night.  To do this, many women find it most effective to go to bed with their infants and do nothing but nurse and sleep for a few days, leaving all other concerns to others.  

Frequent nighttime nursing may be especially important.  Anderson (1989) states that secretion of prolactin (an important hormone in milk supply) is 10x higher at night, and therefore nursing frequently at night "may be more important than daytime in the establishment of lactation."  If the hospital takes the baby for the night 'to give the mother some rest,' they may be adding to low milk supply issues.  Although it is important for the mother to get a stretch of some uninterrupted sleep in the night, nursing every 3 hours at night for a while can help increase milk supply substantially. 

Another important question is how long the baby is nursing on each breast.  Many hospitals tell women that baby will get all he needs in the first 5 minutes or so of nursing, and often recommend limiting nursing to 5-10 minutes on each side 'in order to prevent soreness.' Limiting nursing will NOT prevent soreness, but it will prevent baby from getting much of the fat-rich milk produced at the end of nursing ('hindmilk'), which is where most of the calories are.  If the baby is nursing only 5 minutes on each side, then he is getting substantially fewer calories and fat than the baby who is nursing 20 minutes on each side.  No wonder the weight gain is lower!  

A few babies are able to nurse very efficiently and quickly in shorter nursing periods; babies don't always have to nurse 20 minutes or more every time.  If their weight gain is fine and they are producing plenty of wet diapers and stools, then how long the baby nurses is not a concern.  But most babies do best if they are able to nurse for at least 10-20 minutes per side, and this is particularly important in the slow-gaining baby. Therefore, if your baby's weight gain or hydration is a concern, try to nurse every 1.5-2 hours, and aim for at least 20 minutes per side, if possible.  Don't be afraid to let the baby nurse even longer than that; 20-45 minutes per side is also fine.  

So the common hospital practices of long separations from the mother (which lessens the mother's milk supply), taking the baby to the nursery for the night, and advice to nurse 5-10 minutes on each side every 3-4 hours can lead susceptible babies to have low weight gain.  Often, when these mothers strongly increase their nursing frequency and length, these babies plump right up and do just fine.  

That's why some breastfeeding resources don't treat the idea of 'low milk supply' or 'slow-gaining babies' as seriously as they should.  Oftentimes it is a problem that is created by the medical professionals or mistaken practices, and often it is easily fixable by just having the baby nurse longer and more frequently.  However, this is not always true.

Failure to Thrive Babies

Some mothers nurse frequently, let the baby nurse as long as he wants, and do everything 'right,' yet still have weight gain and/or supply problems.  These are the true 'failure to thrive' cases.  These babies must have close supervision and follow-up to be sure that dehydration does not become a problem, and to be sure that baby's growth and development is not affected.  These babies often need formula supplementation, and sometimes may even need special 'pre-digested' formulas so that the proteins are more easily tolerated.

If the baby becomes truly dehydrated, he is at risk for many problems and must be treated.  Symptoms of dehydration include:

For exact guidelines on whether a baby is wetting enough diapers or gaining enough weight, consult an IBCLC and the baby's pediatrician for further information.  And of course, if you observe any of the above symptoms in your baby, be sure to consult a medical professional.  Doctors and lactation consultants should co-manage cases of slow-gaining babies for optimal outcomes.   

If the baby is clearly not getting enough milk, then supplementation is required.  Unfortunately, there is a vast gray area between the baby who is simply gaining a little slower than usual and the baby who is clearly malnourished.  Most babies fall somewhere between these two extremes and it can be difficult to know what course of action is best for them.  In these cases, some supplementation may be needed while the true cause of the problem is being discovered.  

According to The Breastfeeding Answer Book, providers are most concerned when they find a baby who is still losing weight after 10 days, does not regain its birth weight by 2-3 weeks, loses more than 10% of its birth weight by 7-14 days, has little growth in head circumference and length, and looks dehydrated and malnourished.  A baby with these symptoms is in very serious shape and needs immediate attention and supplementation.  

In some cases, the cause of a "failure to thrive" baby can be certain chronic diseases. For example, slow weight gain is often an early sign of a baby with cystic fibrosis. Other problems can include anatomical abnormalities, heart defects, malabsorption problems, gastrointestinal problems, endocrinologic diseases, etc. If a baby consistently fails to do well and seems very ill, these conditions should be considered and ruled out.  

Assuming the baby has no other contributing medical conditions, the main question that must be answered is whether the problem lies with low milk supply in the mother, poor suckling abilities in the baby, or a combination of both.   Only when this question is answered will the mother know what the best course of action is in her situation.

Low milk supply in the mother is most often caused by infrequent breastfeeding, medical mismanagement, and/or insufficient stimulation of the mother's breasts (as with delayed nursing or a poor latch-on by the baby). Therefore, a careful consultation with a lactation consultant is always the first step, since these factors are so common and are usually easily treatable.

Other significant factors can include untreated physical causes such as maternal hemorrhage, anemia, and retained placental fragments.  Treatment for these conditions are usually very effective and often cure a problematic milk supply.  Unfortunately, despite its frequent occurrence, anemia is often not tested for in post-cesarean mothers.  Large mothers may be at particular risk of anemia after a cesarean.  If you bled a lot during the cesarean, or if you suspect anemia because of symptoms of weakness, fatigue, dizziness, etc., be sure to request a test for anemia.  If you are having prolonged bleeding after the birth, you can also ask about a retained placental fragment, which is another classic cause of low milk supply.

Certain medications such as birth control pills can also impede milk supply.  Even the "mini-pill," which is supposed to be breastfeeding-friendly, can affect milk supply if started too soon postpartum, and may affect milk supply in a few women no matter when it is started.  Birth control pills of any type are best avoided until at least 6-8 weeks postpartum, and estrogen-only pills are best avoided until at least 6 months postpartum (or completely if possible).  

Other medications can also affect milk supply.  The Breastfeeding Answer Book states that certain medications for conditions such as asthma, allergies, depression, hypertension, insomnia, migraines, autoimmune diseases, and heart problems can all affect milk supply as well.  Antihistamines (often given for itching after regional anesthesia) and diuretics in particular can reduce milk supply.  If you are concerned about a particular medicine that you are taking, be sure to consult your provider and an IBCLC.  You can also consult some of the breastfeeding and medications resources listed in the Resources section, including CARE Northwest, Dr. Hale's website, and La Leche League.  

Hormonal imbalances can also cause low milk supply in the mother.  Low thyroid levels are known to impact milk supply, and childbirth can disrupt thyroid levels in some women.  Even women who have never had low thyroid levels before can suddenly develop hypothyroidism after birth.  Therefore it is important to test thyroid levels in women with low milk supply, although many doctors are reluctant to do this.  Be sure to test both  thyroid levels and Thyroid Stimulating Hormone (TSH) levels; some women have "subclinical" hypothyroidism where the thyroid levels are normal but TSH levels are high.  If hypothyroidism is diagnosed, medication is perfectly safe for the baby; it is simply replacing what the body should already be producing.  Prompt diagnosis, however, is vital.

Another hormonal imbalance that can cause low milk supply occurs in some women with Poly Cystic Ovarian Syndrome (PCOS; see below).  Although research is just beginning to emerge on this, some women with PCOS experience difficulties with low milk supply.   No one knows for sure why some women with PCOS are able to breastfeed without any problems while others experience great difficulty, but this is a common cause of breastfeeding supply problems.

If inverted nipples are causing a problem with latch-on and thus impacting milk supply, lactation consultants can help. If you have inverted nipples, it is important to have expert help as soon after birth as possible; don't wait to get help. Positioning is critical; some women have found that the football hold helps them get a better latch-on with inverted nipples.  Avoiding engorgement through the use of early and frequent breastfeeding is particularly important, as engorgement makes latching on to inverted nipples more difficult. It is also important that the baby opens his mouth very wide in this situation, so that he closes his gum farther back on the breast and stimulates the milk sinuses under the areola. 

Some women find that working with the nipple just before a feeding can help.  Some women use a breast pump or manual stimulation shortly before a feeding, or hand express a little bit of milk first to bring out the nipple.  Pulling back slightly on the breast tissue to help the nipple protrude a bit more may also help during latching-on, or even during the feeding.  Dribbling a little milk onto baby's lips during the latching process may help the baby open wider and be more interested in latching on.  Further information about breastfeeding with inverted nipples can be found online at www.breastfeed-essentials.com/invertednipples.html, www.breastfeedingbasics.com/html/flat_inverted.htm

Some resources recommend special devices to help draw out the nipple, while others do not.  Research does not seem to support that special devices help women with inverted nipples, but some anecdotal evidence suggests that special devices can help some women.  Information about products that may sometimes help with nipple inversion can be found at  www.snj.com/maternal/, and www.avent.co.uk (the Nipplette, a device for severely inverted nipples).

Some mothers fear that if they had problems with milk supply in one pregnancy that they are doomed to have similar problems in the future.  Because many milk supply issues are caused by medical mismanagement or untreated physical factors, milk supply can often be improved in subsequent pregnancies. In fact, one study (Ingram 2001) found that women produced about 31% more milk with their second child, and that women with the lowest milk outputs in their first pregnancy showed the greatest increases in milk production with the second baby.   So don't assume that if you had problems with the first baby that you will automatically have problems with the second.  It's possible it may happen again, but in many women it does not.  

The baby is the other side of the equation in a potential "failure to thrive" situation.  If the baby is not able to suckle effectively, it cannot get all the milk it needs to sustain itself.  Many babies initially have poor latches after birth, especially when their mothers have been medicated or there has been separation from the mother (Righard and Alade, 1990).   If the baby is sleepy from jaundice or medication, its ability to suck effectively may be diminished.  This may lead to a vicious circle of supplementation, incorrect suckling, more supplementation, etc.  

Some babies may refuse the breast because they have been traumatized by aggressive suctioning or other medical procedures at birth. Finger feeding can sometimes help these babies learn to transition to the breast,  and lactation consultants may have other techniques that can help.  Other babies are back archers, and may be triggered to arch away from the breast when held in the traditional cradle hold.  These babies may be helped by changing the way the baby is held or by using the football hold, making sure that the baby is flexed at the hips so the feet do not touch that back of the chair and trigger the arching reflex.

Babies who nurse frequently and for long periods yet do not have good weight gain often have problems with their latch.  Babies who do not suck effectively cannot build up their mothers' supply enough to meet their needs.  These babies may only be getting a little bit of milk from the breast because they are not stimulating additional let-downs from the mother.  Nor are they getting the fat-rich hindmilk from the latter part of feedings, so weight gain is inhibited.  Thus these babies may "nurse all the time" yet due to their poor suck may actually not be receiving much milk at all.

A mother who has consistently sore nipples often has a baby with a poor latch as well. Some babies "nipple feed;" that is, they take in only the nipple instead of the nipple plus the areola.  If they do this, they are not stimulating additional let-downs from the mother, they are traumatizing the nipple, and they are not getting much milk at all from the breast.  Babies who have been supplemented with bottles often "nipple feed," because this is the type of sucking that is involved in bottle-feeding.  This is why it is so important to avoid supplements if not needed, and to use non-bottle methods if supplements really are needed.  

Frequent bouts of mastitis (breast infection) may also indicate poor positioning and poor latch-on because the breast is not being emptied efficiently or evenly. If the mother has sore nipples, sore breasts, or mastitis, it is vital that the baby's positioning and latch be checked by an IBCLC.  Often small changes in positioning and latch can make a big difference in comfort levels, and can help baby get milk more efficiently.  

Thrush (a yeast infection) can also affect the baby's ability or willingness to nurse because it makes the baby's mouth sore.  The classic sign of thrush is small white patches on the baby's mouth or tongue.  The mother's nipples are usually also infected and can be quite sore as well.  Thrush is common after a cesarean because the antibiotics used during surgery can upset the balance of beneficial flora in the body.  Thrush can be treated through diet and medication, but careful hygiene measures are also important so that re-infection does not occur.

Babies who have a very poor suck often have dimpling of the cheeks or make clicking sounds during nursing.  This shows that the suction is being broken and/or the tongue is not being used properly.  Not being able to hear or see the baby swallowing very often is another sign that a baby may be having major sucking problems.  There should also be a "wiggle" at the junction of the baby's ears and temples to indicate that the baby is using his tongue, gum, and jaws to help "milk" the breast properly.  Babies who are not sucking effectively may not have this "wiggle" of the jaws.

Some babies will push the breast out of their mouths with their tongues (a "tongue-thrust" problem).  This is common with babies who have received bottles, were born early, or have a short frenulum (tongue tie, or shortened tissue on the bottom of the tongue where it connects to the floor of the mouth). Babies who are tongue thrusters can have their sucks retrained with the help of a lactation consultant; positioning the baby so that he is nursing "sitting up" may also help the tongue-thruster.  Babies who have a short frenulum can have it clipped, which usually greatly improves their latch.  

Some babies have poor muscle tone causing the weak suck, and so the breast keeps coming out of the baby's mouth or milk leaks out while nursing. Some sources suggest that stimulating the baby's lips before breastfeeding can help.  Circling the baby's lips with the finger 3 times in one direction and then 3 times in the opposite direction may stimulate the baby to get a better seal on the breast.  Different nursing holds may also help some babies suck more effectively.  In particular, the football hold or the cross-cradle hold may help some babies with weak sucks do better because the mother's hand keeps an even and constant pressure on the back of the baby's head.  

Careful attention to latch-on and positioning is also vital for the baby with poor muscle tone.  Be sure that baby opens his mouth wide enough before latching on; some women have luck with pulling down gently on the baby's chin as he opens his mouth., and/or supporting the baby's chin while he nurses.  Also be sure that the baby is pulled in very close to the mother as he latches on.  This gets more breast into baby's mouth and stimulates sucking better.  

If supplements are needed, a nursing supplementer is often an excellent choice because the baby does not have to suck hard in order to receive supplements, yet as the baby's suck improves, it can be adjusted to make it harder for the baby to suck.  The mother receives breast stimulation at the same time the baby receives its needed supplements, and this helps maintain her milk supply while baby learns to suck more effectively.  Some sources also believe a Haberman Feeder can help babies with weak sucks learn to suck more effectively, while others do not favor it for babies learning to breastfeed.  

Full coverage of infant sucking problems is far beyond the scope of this FAQ.  If you suspect that your baby has a weak suck or similar problem, it is VITAL that you see an IBCLC for help. Many are familiar with techniques for "re-training" a baby's suck.  Sometimes they will refer a parent out to a neurodevelopmental therapist (NDT), who is a physical therapist with special training in working with infant muscle and motor problems.  See the Breastfeeding Resources section below for contact information to help find an IBCLC or NDT.

Retraining a baby with a weak or problem suck is not easy but it IS possible.  Many babies with sucking problems do learn more effective sucking, and do go on to full breastfeeding later on.  Other babies may never learn to fully overcome weak sucks, or may become hopelessly nipple confused if too many supplementary bottles are given.  Early and timely help is very important if there is a concern about a baby's suck.  

Conclusion

In summary, there are several main differences between babies are slow to gain and babies who are truly "failure to thrive."  Slow gainers nurse fairly often, have a sufficient suck, have enough wet diapers, have pale urine, normal development, and babies are alert and responsive.  Mothers experience the feeling of let-down and their breasts feel less full after a feeding.  These babies have slow weight gain but it is mostly consistent. These babies often simply need to nurse longer and more frequently.

On the other hand, "failure to thrive" babies tend to be unresponsive, have poor muscle tone and strength, cry weakly, have few wet diapers with concentrated-looking urine and infrequent stools, have poor skin resiliency, and "just don't look right." These babies are in dire need of help and definitely need supplementation.  

In between these two extremes are the majority of slow-gaining babies.  Most of the time, slow weight gain is caused by simple medical mismanagement or infrequent nursing.  However, at other times, a baby may truly be in need of supplementation due to the mother's low milk supply, a baby's physical condition, a baby's poor latch-on or weak sucking, etc.  Only an IBCLC and doctor can evaluate your child's condition properly to discover what the problem is and what the best solution for the problem may be.  

Chiropractic and Cranial Sacral Therapy

One option that some lactation professionals are beginning to utilize is Chiropractic treatment and/or Cranial Sacral Therapy (CST).  This has helped many babies who were having trouble nursing well or who had problems with their suck.  Many "slow gain/failure-to-thrive" babies have been helped into more effective breastfeeding techniques after treatment.  Because "failure-to-thrive" can be caused by many different problems, chiropractic care and CST will not help every case, but it probably can help some of them.  

The theory is that the mechanical processes of birth and the forceful ways that many OBs manipulate babies during the birth can be harmful.  The head, neck, and spine may be twisted and pulled, often quite forcefully, and this may affect the baby's bones and nervous system.  This effect may show up in unexpected ways.  These babies often exhibit problems such as long-lasting colic, frequent waking, chronic ear infections, elimination problems, and nursing difficulties.  

Some chiropractors believe that if the bones of the baby's head and neck are not moving freely, then pressure can be placed on the nerves that deal with suckling.  This interference with proper nerve function can affect nursing efficiency and comfort in some babies.  The baby's tongue may not be able to make the proper motions or work as efficiently as it should, the baby's suck may be weak or uncoordinated, the baby may be diagnosed as having a 'high palate,' or the baby may find the nursing position physically uncomfortable for its head.  "Freeing up" these bones can relieve pressure on the nerve, enabling babies to suckle more effectively and comfortably.  It often helps babies sleep for longer stretches of time as well.

In one very small case series, Hewitt (1999) found that spinal adjustment and/or CST helped babies with dysfunctional nursing resolve their nursing difficulties, and the mothers also reported improved sleeping patterns as well.  Other practitioners have reported similar results (see www.icpa4kids.com/articles/july01.htm).  Many lactation consultants have begun working with chiropractic/CST practitioners on a regular basis, and anecdotally report great success rates with it.  

Unfortunately, data is limited and mostly based on small case series or anecdotal reports.  Formal 'gold-standard' research is lacking at this point, which makes it difficult to prove conclusively whether chiropractic and CST can help with some nursing difficulties.  As a result, many lactation consultants are unfamiliar with chiropractic and CST as possible treatments, and so remain unaware of its potential assistance.  Therefore, many babies who might be helped by CST and chiropractic go untreated.  However, this treatment shows significant promise for certain types of nursing difficulties; hopefully as research accumulates, its potential benefits will become more well-known, and more lactation consultants will consider it.  

Although the idea of 'freeing up the head bones' or manipulating a newborn sounds strange or even risky, chiropractic and CST can be very gentle when done by a well-trained practitioner.  In CST, the pressure on the baby is no more than the weight of a nickel on the skin, and the movements extremely subtle.  In fact, most people who watch CST being done comment that it looks like nothing is happening.  It looks like the practitioner is simply putting his/her hands on different parts of the baby's head and resting them there.  

Although the type of chiropractic adjustments done on a newborn are usually extremely gentle, it is very important to find a chiropractor who is well-trained in pediatric chiropractic care.  Try to find one who has had graduate training in pediatric chiropractics, and who also is trained in CST if possible. You can contact www.chiropractic.org or www.icpa4kids.com for a list of pediatric chiropractors in your area (be sure to call their 800 numbers as well as looking on their websites, as many additional names are available that are not always listed on the websites).  

Cranial Sacral Therapy is done most often by chiropractors, but other professionals like massage therapists, physical therapists, and even some doctors are trained in it.  You can find a list of practitioners who are trained in CST by consulting www.upledger.com, or calling your local pediatric chiropractors and finding out which ones are trained in CST.  Again, it's best to find a chiropractor who specializes in children and has extra training in pediatric chiropractics and CST, if possible. 

Chiropractic and CST is also effective for treating colic (see below), chronic ear infections, frequent waking, constipation/elimination problems, some cases of gastric reflux, birth injuries, and other problems as well as nursing difficulties.  Although research done in the traditional medical model is lamentably lacking for most chiropractic techniques, anecdotal evidence and small case series studies do suggest that it can be helpful.  It is another possible tool to try when these types of difficulties occur.  

True Low Milk Supply Issues

Sometimes there are women who just have low milk supply, and the baby needs supplementation in order to thrive or even survive.  Often there are choices to help maintain some breastfeeding in this situation, such as using a supplemental nursing system, using alternative methods for supplementing, or combining nursing and bottles of formula.  

A supplemental nursing system is one of the better choices when chronic low milk supply is an issue.  The baby receives the formula supplements it needs in order to be healthy, but receives them through a tube taped to the breast while nursing.  In this way, the mother's supply is stimulated as much as possible, and much more than would occur with pumping alone.  The baby does not get nipple-confusion, receives the intensive nurturing of nursing at the breast, associates feeding with breastfeeding, and still receives some breastmilk with its valuable immunological protections.  

There are women who have used supplemental nursing systems long-term in order to help their babies receive more breastmilk while still getting the formula supplements they need.  Two main supplemental nursing systems are generally available in the United States: Medela's Supplemental Nursing System (SNS, available at www.medela.com), and Lact-Aid (available from www.lact-aid.com).   Women who have tried both seem to report preferring the Lact-Aid more often, although both are valuable and helpful products.  (For more information, see above.)

Some women have babies who are easily able to switch between nursing and bottles.  In this situation, the mother nurses the baby FIRST, giving the baby those valuable immunological protections, and stimulating her own milk supply as much as possible.  Afterwards, the mother gives the baby a bottle of formula as needed to keep up the baby's weight gain and hydration.  It is vitally important that the mother NURSE FIRST and give the bottle afterwards, and during any separation from the baby, she should also pump regularly.  As noted above, it may be helpful to supplement with bottles only at certain nursings during the day instead of at all of them, depending on the needs of the baby and the amount of milk the mother supplies.  Consult an IBCLC for guidance on your particular situation.  

Some women's babies become so nipple confused or have such difficulties with their sucks that they never do learn how to nurse.  In this situation, many women pump long-term and feed their babies their breastmilk by bottles, supplementing with formula as needed.  One such story is told by Beth Warden at www.asac.ab.ca/BI_fall01/wbfdw.html. Although not easy, some women are able to feed breastmilk by bottles long-term.  Their amazing dedication enables their babies to still receive the benefits of breastmilk, even though nursing itself did not work out. 

Some women find that, with perseverance, the baby is able to learn how to latch on properly and breastfeed, even after being fully bottlefed for many months.  Some lactation consultants don't believe that nipple confusion is permanent, and that with time, LOTS of patience, and constant reinforcement of proper latch, many babies CAN still learn to breastfeed properly despite being bottlefed long-term.  This may be especially true of preemies as they get older.  Of course, it doesn't always work out, but it may be worth considering trying breastfeeding again, even if you have given it up as hopeless. Some babies DO catch on eventually, given time, careful instruction, and lots of patience. 

It is important to keep up your own supply, whether pumping fully or supplementing.  Use a hospital-grade pump (i.e. Medela Lactina) to help stimulate milk production, not a cheap pump that is less effective.  Remember that double-pumping produces a greater milk yield and stimulates prolactin levels more effectively (Breastfeeding Answer Book).  If you can, double pump whenever possible. Alternatively, you can pump one side while nursing the baby on the other side and/or use breast compression ( www.fourfriends.com/abrw/bc.htm) to help pump more productively.  Many moms have also reported that it is easier to pump frequently if they own extra sets of flanges, etc., which enables them to wash less often.  

The important point is that ANY amount of breastmilk that baby gets is important and it is greatly beneficial to keep this up as long as possible.  Some women are able to maintain this effort for a longer period by utilizing supply enhancement drugs and herbs. Some women find these things a significant help and some do not.  If this option is considered, it is important that a medical professional ALWAYS be consulted during this process as some milk supply drugs can have substantial and severe side-effects in some women.  While herbs have a great deal of favorable anecdotal evidence and seem quite safe, they are still medications of a sort and should always be done in consultation with a medical professional.  See both an IBCLC and a general physician.  

More information about galactagogues (herbs and medications for increasing milk supply) can be found at the following sites:

For some women with supply concerns, the answer is to redefine what breastfeeding success means to them.  Instead of focusing on being able to fully supply all the baby's needs with breastmilk alone, some women find it's better to focus on getting as much breastmilk to the baby as possible, on sustaining partial breastfeeding for as long as possible, on being okay with using supplements as needed while still focusing on the breastmilk that baby is receiving, and on feeling at peace when the time comes to move on from breastfeeding, knowing that they worked very hard to see that their baby got as much breastmilk as possible under the circumstances.  

Deciding to Wean

Sometimes mothers work themselves into a frazzle trying to keep up breastfeeding.  Some women report a "love-hate" relationship with their supplementary nursing devices and their pumps, and sometimes it all can get to be too much hassle.  Supplementary devices can be very frustrating to use sometimes, and a strict pumping schedule can sometimes leave no time for the mother to relax and just be with her baby.  All of this can be very hard on a mother's relationship with her baby.

While it is important to give your baby as much breastmilk as you can, it is also important to have a happy relationship with your child.  If you have tried lots of things and are really stressed trying to keep up with all the requirements, one option may be to decide to stop nursing, or to gradually decrease nursing/pumping while increasing formula.  Sometimes moms just need to know that they did great no matter how it turns out, that they worked extremely hard and did the best they could, and that it can be okay to stop, too.  

A healthy child and a healthy mother/child relationship is the top priority.  Although breastmilk is the most optimal food for baby, many babies do all right on formula.  The goal of nursing the baby should not supercede the health and sanity of both mom and baby.  Sometimes the sane thing to do is to wean, or to find the combination of breastfeeding and supplementing that works for YOU.  

One online resource is available for those who are struggling with milk supply, pumping, and other breastfeeding issues. MOBI (Mothers Overcoming Breastfeeding Issues) offers excellent support for women who are struggling with breastfeeding, and supports equally those women who elect to continue with breastfeeding as well as those who elect to wean because of the stress of pumping and supplementation. A web page with more information can be found at www.internetbabies.com/mobi/.   This is an excellent resource, and Kmom highly recommends it.  

 

PCOS and Breastfeeding

Although no one has documented exact numbers, some lactation consultants have observed that some women with PCOS (Poly Cystic Ovarian Syndrome) have trouble breastfeeding and need to partially or fully supplement.  Although most women with PCOS are able to breastfeed fully (and up to 20% even overproduce milk due to very high prolactin levels), there are some women with PCOS who must partially or fully supplement, despite doing their utmost to nurse.  This is NOT a failure of these women to be proactive about breastfeeding; it is a physiological imbalance!

No one understands why some women with PCOS are able to breastfeed without problems and yet others cannot; a best guess is that since PCOS may be a group of related syndromes instead of one well-defined disease, time and research will probably find that the cause of these women's PCOS is somewhat different (and thus manifests itself differently). Thus, some women with PCOS are able to breastfeed easily and others have significant difficulties.  Unfortunately, nearly all research into PCOS in the past has covered reproductive issues only; PCOS researchers are generally very uninterested in lactation issues. 

In the lactation research community, there is beginning to be some acknowledgement of the problem (Marasco 2000), but by and large, most of the information remains anecdotal and speculative. Some women are beginning to experiment with herbs, hormones, or insulin-sensitizing agents to try and treat milk supply issues, but formal data on the safety of this approach is not readily available yet.  Therefore, help for this difficult problem at this time is significantly lacking.

PCOS mothers should be strongly encouraged to breastfeed, since most of them do so successfully and it has so many potential benefits for children.  Some research indicates that children who are breastfed may develop type 2 diabetes at a lower rate than formula-fed babies.  This may be because babies tend to demonstrate less insulin resistance in response to breastmilk than to formula.  Since babies of mothers with PCOS may also be at risk for insulin resistance and diabetes, these are potentially important findings.  Furthermore, some research also indicates that women with gestational diabetes who breastfeed improve their 'good' cholesterol levels and have better blood sugar results as well (see the FAQ on GD and Breastfeeding for further information and references).  Thus, breastfeeding may be especially beneficial in women with PCOS and should be strongly pursued. 

However, women with PCOS should be extremely well-educated and proactive about breastfeeding, and receive careful help and monitoring from lactation experts. They should not give up easily since many women experience transient breastfeeding problems after birth, and these difficulties may indeed be able to be resolved fairly easily.  They should not approach breastfeeding feeling like they are going to "fail;" remember that MOST women with PCOS are able to breastfeed.  They should instead be extremely proactive about breastfeeding ahead of time, and be ready to get help if it is needed.  

Even in those women whose supply problems are long-lasting and not easily resolved, many women who cannot fully breastfeed their babies are able to partially supply their needs.  Remember that any amount of breastmilk a baby gets is greatly beneficial for its antibodies and protective immunity properties.  Therefore, every mother with PCOS should always try to breastfeed, and should do her utmost to give as much breastmilk to her baby as possible.  

For some women with supply concerns, the answer is to redefine what breastfeeding success means to them.  Instead of focusing on being able to fully supply all the baby's needs with breastmilk alone, some women find it's better to focus on getting as much breastmilk to the baby as possible, on sustaining partial breastfeeding for as long as possible, on being okay with using supplements as needed while still focusing on the breastmilk that baby is receiving, and on feeling at peace when the time comes to move on from breastfeeding, knowing that they worked very hard to see that their baby got as much breastmilk as possible under the circumstances.  

Infants of PCOS moms with milk supply issues should be monitored carefully both in and out of hospital. A visit by a home-care nurse or regular visits to a lactation clinic can help monitor for dehydration, hypoglycemia, jaundice, and 'failure to thrive' syndrome. If supplementation becomes necessary, medical personnel need to make every effort to do it in such a way that it does not interfere with breastfeeding (avoiding bottles if possible), and to help the woman feel empowered to continue partial breastfeeding for as long as possible.

How long to sustain this must be left up to the mother involved; it is not always an easy process and the benefit to baby must be balanced against the stress that is placed on the mother and baby. Kmom would encourage these mothers to nurse their babies as much as they can, for as long as they can, but if the process becomes too stressful, each mother must be encouraged to do what is best for the mother-child pair as a unit. In some cases, this may include weaning if the process becomes too stressful. 

Support for this agonizing decision must be offered freely and without reserve; these moms should never be made to feel guilty. Options and support for continuing should be made available, but if the mother decides not to because of the tremendous stress involved in both nursing and supplementing, that decision must be respected.  And of course, as noted above, women who are struggling with breastfeeding issues can find support online through Mothers Overcoming Breastfeeding Issues, www.internetbabies.com/mobi

 

Breastfeeding and Bonding After a Difficult Birth

Some mothers who experience traumatic births have difficulty bonding with their babies at first. This is the darkest secret that many women have in their feelings about their births, and one many women feel terribly guilty about, yet the truth is that it is not unusual.  Many cesarean moms have felt this and worked through it.

Why do some women have difficulty bonding with their babies after a difficult birth? Sometimes women  consciously blame the baby for the experience, but usually they just have difficulty connecting with the infant at first after an overwhelming experience, or are too pre-occupied with the trauma of what has happened to them to be able to open their hearts fully. Often, the high rates of post-partum depression surrounding cesareans and difficult births impede the bonding process.  It doesn't mean that these mothers don't love their babies or are 'bad' mothers, just that what has happened to them is overwhelming and difficult to deal with.  It can take time to fully integrate a difficult birth, and sometimes this means a delay in bonding with the baby.

Since most cesarean  moms do not get to see the baby emerging from their bodies, the baby may seem unreal or as if it's the wrong baby at first.  Sometimes mothers feel as if they are 'just the babysitter' instead of the 'real' mother, or they lack confidence in their mothering abilities and instincts.  Some feel alienated from the baby, or even actively angry at the baby.  Some women simply are so overwhelmed with fatigue and pain that they have trouble reaching out to the baby.  

Deep down, a woman who is not close to her baby at first usually feels great guilt, but it's important to point out that these scenarios are quite common.  A difficult birth or a difficult start to breastfeeding really can cause bonding difficulties, and this is totally understandable.  This state does not persist forever, and most moms who have trouble bonding eventually experience a breakthrough and bond just fine-----but they may mourn forever the time lost to them. Sometimes the process takes days, sometimes weeks or months, but usually at some point, the mother finds the opportunity to 'fall in love' with her baby after all.

On the other hand, some women who experience traumatic births bond fiercely and immediately with their children. Trauma and difficulty do not always impede bonding; sometimes it has just the opposite effect. These women are often intensely connected with their children, and the level of bonding can be quite fierce. The trauma in these cases only helps to focus the mother's attention on her child, and the effect may be so strong that other concerns may drop away. Long-term recovery here may involve relaxing enough to loosen vigilance and include others within their tight world. Sometimes, fierce bonding and concentration on the baby can be the way a mother avoids dealing with her difficult birth, or the intensity of the bond may be in opposite proportion to the trauma of the birth or the length of separation from the child.  Either is a perfectly legitimate response to a challenging situation. 

Although it's dangerous to over-generalize, it does seem that women who are able to breastfeed successfully tend to experience less severe levels of Post-Partum Depression and quicker bonding after a traumatic birth, while those who find breastfeeding difficult or who give up may find it more severe (Laufer, 1990). This may be related to hormone levels (since women who do not or cannot breastfeed tend to 'crash' more quickly), or it may simply be emotional.  Whatever the cause, the feelings are real and must be honored. 

And of course it must be noted that while some women who experience breastfeeding difficulties have bonding issues with their children, not all do.  Some are able to bond just fine anyhow.  And not all women who are able to breastfeed easily bond well with their children either.  There are no absolutes here, but many women do seem to report that breastfeeding progress can really impact their relationship with their babies, and especially so after a cesarean.

Breastfeeding and Bonding Problems: A Double Burden of Grief

When women are able to breastfeed successfully after a cesarean, they often find that they are able to 'reconnect' with their baby through this experience, to firmly cement their missed bonding, and to feel like finally, their bodies "were able to do something right."  Many cesarean moms report that breastfeeding was a source of significant emotional healing after their cesarean.  They realized that breastfeeding is something only they could do for the baby, and that this can help heal their wounded self-esteem and re-establish their image of themselves as mothers.

Unfortunately, women who are not able to breastfeed long-term after a cesarean have a double burden of grief to deal with.  They may be disappointed over the birth, in pain from the cesarean, and feeling uncertain in their femininity or 'motherliness' because of the cesarean.  Adding trouble with breastfeeding issues may exponentially increase the anguish and their self-doubt about themselves as mothers, and all this grief may impact their ability to bond with their babies.  

Nancy Wainer, author of Silent Knife (the first book about VBACs), offers a periodic workshop on healing and grieving births.  She points out that normal childbirth in and of itself already involves so many changes and so many losses that it alone can be hard to deal with.  Loss of privacy, loss of time alone with the spouse, career changes or modifications, loss of free time, less ability to be spontaneous, less time to yourself, less time for hobbies and other interests, etc.----all of these are real losses that women with a completely normal birth and postpartum course experience.  

In cesarean moms, on top of all the normal upheavals that go with every birth, add in the grief and uncertainty of a difficult labor, the agony of a difficult birth experience, and the pain of major surgery.  Combine in the fear and conflicting emotions of having a cesarean, then pile on top the stress of breastfeeding problems after the birth, the pressure to supplement, the doubting of your ability to sustain your baby, and the criticisms and pressure from others about breastfeeding.  It's enough to deeply stress even the most sane and balanced woman!  

If bonding is also an issue, the grief and guilt and self-blame can be unrelenting.  Sometimes it's the straw that seems like it will break the camel's back.  Yet the situation is not unfixable.  With love and help, a woman can learn to grieve, heal, and fully integrate even the most difficult birthing or breastfeeding experience, and no matter how much time has passed, can re-strengthen the bonds with their children.  It is NEVER too late to start.  

Nurturing the Bonding Process

It's vitally important to emphasize that all women can of course can still bond with their baby, even if they have had a rough start to the process.  With a little time, healing, and help, most women eventually do reconnect with their babies just fine.  But to start the recovery, first it's important to look back and acknowledge just how stressful a time you've been through, how many pressures and difficult situations you've faced, and to give yourself credit for going through them.  

If you were a doula or just helping out a friend who had this experience, you would be able to step back with compassion for their situation, appreciate just how hard a time that person had been through, and give them credit for everything they'd done along the way.  But we are always most judgmental about our own actions.  So the first step to healing is to give yourself the compassion and understanding and credit that you would be giving to anybody else in the same situation.  

It's also important to realize that when a mother has difficulty bonding with her infant, she most likely has other overwhelming issues to deal with.  Starting to work through these issues is a very important step to bonding with the baby, and should be the central point of any recovery process.  Sometimes counseling to address other life issues is needed in order to get to the bottom of bonding issues.  

Many women may have issues such as career conflicts, ambivalence about motherhood, self-esteem concerns, family conflicts, lack of confidence in their mothering abilities, etc.  These issues often benefit from short-term counseling or support groups for new mothers.

Many women who have long-term difficulty bonding with their babies are actually reacting to difficulties from earlier in their lives, especially issues such as past abuse, abandonment, or addiction. They may have issues from their own births, their early childhoods, or with their own parents. Many women find that their own life issues come to the fore again when they become parents, and it is often a tremendous opportunity for healing.  They often find that therapy is extremely helpful in healing past wounds and in preventing the pain from extending to new generations. 

In some women, underlying hormonal imbalances need to be addressed, and if necessary, medications utilized.  Women who have had a past history of depression are the most likely to have a true biochemical imbalance that needs treating before real emotional healing can also take place.  Although sometimes women are told that they must wean in order to take medications such as these, the latest research seems to indicate that many of these medications are compatible with breastfeeding.  For further information about breastfeeding and medications, consult Dr. Hale's website at  http://neonatal.ttuhsc.edu/lact/.  

A greatly under-recognized source of post-partum depression is also grief over traumatic or unsatisfying births, and also over breastfeeding outcomes.  Therefore, whenever a mother has difficulty bonding with her baby, she should seek an impartial listening ear that can help her work through her birth and breastfeeding experiences, to help her work through the very real grief of these issues.  This, in turn, should help her attach to her baby more firmly and lovingly.

Seeing a counselor trained in dealing specifically with birth issues is extremely important, since many traditional therapists are not trained in birth issues and may minimize or disregard a woman's feelings about birth.  A well-trained therapist who is familiar with counseling techniques for birth issues can help women understand the life issues that are behind the feelings of trauma.  In time, they can help women learn to separate the baby from the birth outcome, an important part of the bonding process.  

Another thing that greatly helps women start to process their birth and bonding issues is to join a group that offers support after difficult births.  The International Cesarean Awareness Network (ICAN) is a group that helps women recover from difficult birth experiences.  They have many chapters all over the country where women can go to get personalized support in a group setting; meetings are free.  They also have an online group that offers support to women in their own homes.  For more information about ICAN, see www.ican-online.org.   

If seeing a therapist is not practical, there are also books that are helpful emotionally after a difficult birth.  These include Rebounding From Childbirth by Lynn Madsen, and Birth As a Healing Experience by Lois Halzell Freedman.  In addition, there are exercises and ideas for healing on this website in the FAQ on Emotional Recovery After Cesarean.  

There are many other basic techniques that can help babies and mothers start to bond.  One that helps many women is to go to bed with their babies and just stay there for several days. To do this, they should arrange for help with household tasks or older children to help eliminate stress and distractions.  If the father or other relatives are not available, hire a postpartum doula.  Further information about postpartum doulas can be found online at www.birthworks.org, www.dona.com, and from other doula organizations.  

If women are breastfeeding, going to bed with the baby is an excellent way to increase supply as well as work on bonding.  Even if a woman is not breastfeeding, going to bed with the baby for an extended period is an excellent way to decrease stress and catch up on missed sleep, which can tend to exacerbate bonding issues.  Concentrating only on feeding, changing, and snuggling the baby often helps women open their hearts to their babies in a new and permanent way. In addition to counseling, it can radically change a woman's feelings about her baby.

If it simply isn't possible to go to bed with the baby for several days, try carrying the baby in a sling with you as much as possible during the day.  Babies strongly need to be close to their mothers, and often feel more secure and less fussy if carried a lot.  They will connect with you better if you hold them frequently, closely, and securely.  Many women find that this is difficult at first, but eventually helps them break through the emotional barriers and bond with their children more thoroughly.  

Another thing that helps many women is to take time to stop and really look at and notice her baby.  She should eliminate all distractions and just sit with her baby, talking to and observing him.   She needs to notice all the unique things about him, appreciate the soft fuzziness of his sweet head, count his little toes, observe the folds of his legs and arms, the roundness of his beautiful tummy, and the sweetness of his gaze.  Sometimes women are so overwhelmed with recovery, with learning to take care of the baby and the stresses of lack of sleep, that they forget to take time and just 'be' with their baby.  Set aside some time every day to just admire and tickle and snuggle your baby, free from all other stresses and cares.  Make a 'date' to get acquainted with your baby every day, and let yourself start to fall in love. 

Dealing With Colic

Sometimes baby is colicky and his constant crying impedes the mother's ability to bond. Colicky babies are difficult for ANYONE to deal with; dealing with colic on top of birth, breastfeeding, and bonding issues can be almost overwhelming.  In these cases, it's no wonder the mother finds it difficult to bond!  One option in this situation is to consider alternative therapies such as Cranial Sacral Therapy (CST) or pediatric chiropractic treatment to help resolve the colic.  

Chiropractors believe that in some births, the baby's head bones and/or spine are somewhat traumatized during the birth process, from fetal malpositions, from forceps/vacuum extractors, or from the manipulations doctors use as the baby is born.  They believe that this can cause the baby's head bones, neck, and/or spine to get stuck ('subluxated,' or not moving freely), thus placing stress on the nerves in the area.  This can make the baby uncomfortable and in some cases, colicky.  Pediatric chiropractics and CST are techniques of very gently freeing the bones and restoring optimal nerve function, which often makes the baby more comfortable. It may also even help them to nurse better.

In one study on colic, a Danish randomized controlled trial compared the use of spinal manipulation to the use of dimethicone (similar to Mylicon, often recommended by doctors) for colic.  They found that manipulation did significantly better at helping colic symptoms (Wiberg, 1999).  Klougart 1989 and Nillson 1985 also found that chiropractic can help alleviate colic.  And as noted above, Hewitt (1999) found that chiropractic and CST was helpful in resolving many cases of nursing problems.  Thus, if the mother is having difficulty bonding with baby because of colic or 'failure to thrive' nursing issues, she may want to explore CST or chiropractic therapies as a way to help the baby through the colic so that they can get on with the business of bonding.  

Summary

Although society generally does not like to acknowledge it, many people have difficulty bonding with their babies at first.  This seems to be particularly true if the birth was a difficult one, if breastfeeding is difficult, if the mother has pressing emotional issues to deal with, or if the baby is colicky and difficult.  

Our stereotyped image is that once we look into our baby's eyes, we will fall deeply and irrationally in love with him.  In reality, other factors often get in the way of this process.  This does not make the person a "bad mother," it simply makes them human.  Pregnancy, birth, and parenting is a HUGE and often overwhelming experience, and it is not unusual for people to experience mixed feelings about parts of the process.  

However, people who have had difficulty bonding with their baby at first HAVE gone on to bond very well with them later.  Troubles with initial bonding is NOT a life sentence.  Taking the time to proactively address the bonding problem is very important to working through it.  

Although some women are able to work through bonding issues on their own, outside help or support can be very helpful in resolving bonding issues.  The mother needs a "safe place" to explore her issues, a place where she can be as weepy or as angry or as ambivalent as necessary without feeling judged, and she needs an objective ear to help her figure out how best to deal with the situation. With help and support, women can process and grieve their births and find a safe space emotionally where they can fall in love with their babies again. Bonding problems are not unusual after a difficult birth, but they can be overcome.

 

Grieving Breastfeeding

Mothers who experienced great difficulty in breastfeeding, who had to supplement extensively, or who were not able to breastfeed often feel great guilt, frustration, or anger. Like a traumatic or disappointing birth, this also needs grieving and processing. 

The reasons for breastfeeding difficulties may vary widely. Some experience breastfeeding problems because of a lack of support, preparation, or medical mismanagement. Others may have undiagnosed transient physical causes that caused their breastfeeding difficulties.  Still others may hormonal imbalances that interfere with breastfeeding supply.  

The baby, too, can be a factor when breastfeeding does not work out.  Some babies have physical problems that make it difficult to latch on well, or have undergone extensive medical procedures that may interfere with a good latch.  Some babies have a poor suck due to prematurity, neurological problems, or excessive manipulation during the birth, and some babies have developed permanent nipple confusion due to extra bottles given to them.  Sometimes these problems can be helped, but sometimes they cannot.  Either way, they too must be grieved.  

Breastfeeding problems with one child do not have to mean breastfeeding problems in the future.  Most of the time, with time, education, and hindsight, women who had breastfeeding difficulties can look back and point to factors that interfered with breastfeeding last time, factors that can be changed next time. These women are quite likely to be able to succeed at breastfeeding again with another child, given adequate information, care, and support.  Even so, they still need to grieve and vent about their difficult experience this time.

Although most breastfeeding 'failure' after cesareans is due to medical mismanagement, it is important to note that there are some  women who are not able to breastfeed fully because of supply issues, even when extremely well-prepared and supported. These dedicated women do everything possible to ensure success, get plenty of timely professional help, pump religiously and take medications to increase supply, etc., yet are never able to produce enough milk to fully sustain their child. 

No one knows exactly how many are truly unable to breastfeed since medical mismanagement is so common, but. there is a very small percentage of women whose breasts hardly change during pregnancy and who get very little milk, and there is a slightly larger group who get some milk but not enough to fully support feeding their baby without supplementation. This is probably hormonal (as in PCOS, as noted above), but no one quite understands what happens in these cases.

A women who is unable to breastfeed, whatever the cause, has to grieve that loss too.  For some women, this grief is easily  managed, but for others it can be devastating.  Whatever course your grieving takes, honor it.  Don't minimize or gloss over it, and don't let others minimize it either.  It does matter, it is a 'big deal,' and you have every right to be upset.  Take time to fully grieve the loss of breastfeeding and the breastfeeding relationship with your child.

It can also be very informative to examine more closely what symbolism breastfeeding carries in your life. This may be the key to understanding and moving through your grief.  For example, to some women not being able to breastfeed calls into play other issues in life such as a lack of self-confidence in their bodies, their sense of femininity, their competency as mothers, or body image issues. Exploring these issues may be key to truly working through and healing your grief over breastfeeding.

Women who have infertility issues do have higher rates of breastfeeding difficulties.  Infertility plus a cesarean plus breastfeeding problems may be a devastating combination blow to the self-esteem.  Breastfeeding problems may hit directly on their deepest fears that their bodies "just don't work right," and "can't be trusted."  It may also impact deeply their concept of their own womanhood and femininity.  

Other mothers may find that breastfeeding problems reactivates body image problems they have experienced in their lives, and they may find themselves terribly angry with their own bodies again. Still other moms may feel that not being able to breastfeed confirms their fears that they will not be good mothers, that they were never meant to be mothers, or that their love will be inadequate for their children.  They may unjustly feel guilty that their children are deprived of the experience of nursing, of the immunological protection of breastfeeding, and they may wrongly equate the ability to breastfeed with the ability to emotionally nurture their child.  

Women who are grieving breastfeeding go through the same stages of grief as people do after any major loss---denial, anger, bargaining, depression, and acceptance.  Of these, anger and depression seem to be the strongest.  Many women are deeply angry that their bodies 'just don't work right,' or that 'everything happens to me.'  Many are deeply saddened when they see other women nursing and are depressed over their inability to share in this experience.  Other women may be angry with themselves that they didn't resist the bottles, that they didn't fight for breastfeeding more, or that they 'gave in too easily.'  

Ultimately women have to accept that this thing has happened to them, that it was difficult and painful, and come to understand that they just did the best they could at the time and that's all anyone can ever do.  If they had medical mismanagement, they have to remember that they were taught to trust everything the doctors/nurses say as gospel, that this attitude is difficult to overcome, and that they made the best decisions that they could at the time with the information that they had.  Finding a way to self-forgiveness is an important part of healing for many women.  

For women who gave up because of separation, pain, grogginess, sore nipples, etc., they need to understand that breastfeeding under such challenges IS tough, that sometimes it can be too much to deal with, and that it's okay not to have been Superwoman.  Sometimes even the toughest person gives up, and sometimes it can be the better part of valor to do so.  You made the best decision that you could for yourself at the time.  Honor and respect that.

For women who were not able to breastfeed despite doing everything 'right,' they have to understand that THEY DID THE VERY BEST THEY COULD.  Sometimes life isn't fair and things don't work out perfectly.  They have to give themselves full credit for every bit of effort they put in, and know that this effort was not wasted, even if breastfeeding didn't work out.  They have to realize that this was simply a matter of physiological imbalances, and something that was beyond their control.

Many women spend a lot of time pumping and supplementing and doing everything they could to preserve breastfeeding, only to give up eventually because it becomes too stressful.  Even though they know that the stress was outweighing the benefits, many mothers have lingering sorrow over having given up.  

But it's important for women to realize that the benefit to baby must be balanced against the stress that is placed on the mother. Of course it is important for mothers to nurse their babies as much as they can for as long as they can, but each mother must be encouraged to do what is best for the mother-child pair as a unit, and sometimes this may mean weaning. Sometimes the baby needs the mommy sane and happy more than he needs breastmilk.  If you eventually gave up breastfeeding or pumping because it became too stressful, understand that you made the decision that you had to, and that nurturing your baby emotionally is always more important than its feeding method.  

Remember also to give yourself credit for everything that you DID do.  Many women who cannot fully breastfeed their babies are able to partially supply their needs, and women for whom breastfeeding did not work out still managed to get some breastmilk into their babies.  Any amount of breastmilk a baby gets is greatly beneficial for its antibodies and protective immunological properties, and these protections last for months even after breastfeeding ceases.  

Give credit where credit is due; acknowledge the efforts that you did make, the benefits that your baby did get, and the angst you put yourself through for the sake of your baby's health. Forgive yourself for not being able to do everything you wanted to do, realize how much is beyond your control, and give yourself full credit for all you did do.  Every bit is beneficial.  

Not being able to breastfeed fully doesn't make you a 'bad' mother, nor does it mean that you 'cannot bond' with your children.  Being a mother is much more than simply breastfeeding.  As one mother of a preemie put it, "There is more to motherhood than what goes in, how it gets there, and where it comes from."  Give yourself credit for the full scope of your mothering, and in time you will find a way beyond this pain.

Finding Closure

One online resource for working through breastfeeding grief is MOBI (Mothers Overcoming Breastfeeding Issues). This is a group of mothers who have experienced (or are experiencing) breastfeeding problems.  It provides information and support about breastfeeding issues (including support from professional lactation consultants) for those who wish to continue breastfeeding efforts, while also providing support for women who have decided that the process is too stressful and that weaning is necessary. It is a great place to vent your anger and mourn your losses.  A web page with more information can be found at www.internetbabies.com/mobi/, and an article specifically about Breastfeeding Grief is also on this site at www.internetbabies.com/mobi/Articles/BreastfeedingGrief.asp. This website is an excellent resource, and Kmom highly recommends it.  

Many women also find it useful to sit down and journal about their breastfeeding grief.  Don't just think about these issues; the healing comes from actually taking the time and effort to write about them. Getting out all the anger and grief on paper can vent it safely, and often new insights come through the process of writing.  Feel free to rail at the world, at the medical personnel who weren't supportive of you or of breastfeeding, at the ignorance of breastfeeding issues in the world, at your friends and family if they weren't supportive of breastfeeding, at the people who made you feel guilty if you were ready to stop, at the breastfeeding activists who think that anybody can breastfeed if they just try hard enough, at whomever or whatever you are angry with.  

Then take time to explore why this grief resonates so deeply with you.  Does it reflect your fears of failure?  Is it really about self-esteem issues?  Does it activate body image issues or feelings of not being able to trust your body?  Does it activate issues about competence at mothering? How does this experience reflect the larger issues of your life?  Is this experience an opportunity to work towards healing of these life issues?   

Many women find that the process of journaling about their anger and grief helps work through and release it. Other women find comfort and closure through creating mourning rituals.  They may decide to write letters to the medical personnel that mistreated or misadvised them, and then take these letters and the journal writing and burn them ceremonially.  They may create a ceremony to work through and release the anger, or to symbolize moving on from that grief and into new learning.  However they do it, for some women, journaling or ceremonies can be an excellent way to find closure to this grief.  

Grieving breastfeeding means mourning the loss of one part of your mothering, then finding new ways of mothering instead to fill that need.  It means honoring the efforts and accomplishments you did have, realizing that some things were beyond your control, and that you did the very best you could at the time.  It means exploring what breastfeeding means to you symbolically and how this may be connected to other issues in your life, so that you can use the pain of not being able to breastfeed to heal other areas of your life and enhance your own personal growth.   

Although not being able to breastfeed may always be a sorrow to you, with time and work you will be able to place that breastfeeding experience in context. You are the most important person in your baby's life, and that is true whether or not baby is breastfed. Your baby will love you, no matter what. Breastfeeding is a wonderful and healthy thing, but it does not have to define your relationship with your child.

Find a way to deal with the trauma in your own way, accept your response as normal and human, and in time you will move beyond the pain and into healing and closure.  Mourn the loss of the breastfeeding relationship, but remember that there is more to the mother-child relationship than breastfeeding. Don't let breastfeeding be the primary definition of your relationship with your child.  Realize that even if you cannot nurture your child with breastmilk, you can nurture him in so many other ways that are even more important. Give yourself credit for the full scope of your mothering, and in time you will find a way beyond this pain. 

 

Conclusion

Having a cesarean can be a difficult experience, emotionally and physically.  The sheer physical impact of trying to recover from major surgery while taking care of a newborn baby is often overwhelming, and the emotional impact can be devastating as well.  In the context of this overwhelming experience and the medical protocols that often accompany surgical birth, breastfeeding can often get overlooked or pushed aside as unimportant.

Research clearly shows that breastfeeding initiation rates are lower after a cesarean, and that there is also a significant drop-out rate in the first month after a cesarean.  Many factors contribute to this lower breastfeeding rate, including the mother's fatigue, pain, and stress levels; type of anesthesia used in the cesarean; routine separation of mother and baby after a cesarean; delayed first nursing and less-frequent later feedings; increased supplementation of cesarean babies; use of bottles/pacifiers/artificial nipples with babies instead of alternatives; labor medication interference with baby's sucking mechanism; intrapartum and postpartum medication interfering with mother's milk supply; postpartum anemia affecting milk supply; and the significant mechanical difficulties of trying to manage nursing after major surgery.

Medical mismanagement and misinformation are clearly the most common sources of problems in establishing breastfeeding.  Outdated policies and lack of quality instruction about breastfeeding issues make it difficult to establish breastfeeding in many hospitals.  In 1990, Yamauchi and Yamanouchi concluded, "Our study suggests that many of the neonatal clinical problems related to breast-feeding are iatrogenic and could be ameliorated by education of mothers and nurses and by changes in hospital practices related to breast-feeding." 

The good news is that this means that most women who had difficulty with breastfeeding after a prior birth will be able to have a more positive experience with subsequent births, especially if they are well-educated and proactive about breastfeeding. It does not guarantee it, but it happens in many cases (see the stories below).  Having had one difficult experience with breastfeeding doesn't mean it will always happen that way.

Breastfeeding can be the source for additional trauma after a cesarean, or it can be a source of great emotional healing. A great deal depends on how initiation of breastfeeding goes, how much support the woman is given for breastfeeding, physical factors around the birth and recovery, and the importance a woman places on breastfeeding in her life.  

Emotional support for women after birth is sorely lacking, even for those who end up with a relatively normal birth experience. For those women who endure a traumatic labor, c-section, and then who also have trouble breastfeeding, the emotional devastation can be particularly difficult. Yet there may be little support and even blame from medical personnel and family. These women's difficulties need to be acknowledged and supported. 

Breastfeeding presents so many benefits that it should be strongly promoted and supported for all moms, but the reality is that active information and support for it is minimal in some hospitals, and particularly so for cesarean moms.  Despite this, if women are able to breastfeed successfully after a cesarean, they often find that they are more able to 'reconnect' with their baby through this experience, to firmly cement their missed bonding, and to feel like finally, their bodies were able to 'do something right'.   Many cesarean moms report that breastfeeding was a source of significant emotional healing after their cesarean. 

Unfortunately, in far too many cases, medical mismanagement sabotages the breastfeeding relationship of many women after a cesarean.  This can affect the bonding they feel with their babies, and make them feel like 'failures' as mothers.  They are NOT failures, of course, but sometimes they may feel that way. 

However, the picture painted should not be too gloomy.  In spite of all the obstacles, many women who give birth by cesarean DO still manage to preserve breastfeeding.  A few studies have even found that in some hospitals, cesarean mothers nurse at a similar rate as mothers who had vaginal births.  Janke (1988) found that despite later first nursings, a high occurrence of general anesthesia, and increased dissatisfaction with their births, cesarean mothers managed to breastfeed about as often as mothers who had a vaginal birth.  The single most important variable associated with successful breastfeeding was found to be the degree of commitment reported by the mother.  

This finding was echoed by another study (Kearney 1990), which also found that despite later first nursings and less satisfaction with the birth experience, cesarean birth was not related to breastfeeding duration.  The authors speculated, "The high level of commitment to breastfeeding in this sample may have overcome the effect of perinatal events."  And anecdotal reports indicate that women who experienced traumatic births or c-sections yet were fortunate enough to be able to preserve breastfeeding report the experience of breastfeeding to be one of their best acts of self-healing.  

This is not to say that one need only have the burning desire to breastfeed in order to succeed, or that if a woman is not able to preserve her breastfeeding relationship it was because she was not committed enough.  Of course not!  There are women who have had the highest level of commitment, had the best help, done everything 'right,' and still were not able to preserve breastfeeding.  Sometimes the medical sabotage of the hospitals overcome even the most dedicated mother, and sometimes there are physiological factors that are just beyond our control.  When this happens, we have to mourn the very real loss of breastfeeding, honor our lost dreams, forgive ourselves, and move on as we are able. 

It is important to fully grieve all the losses involved with birth, including those involved with breastfeeding.  Find the emotional supports and groups that understand what you've been through, who will listen to your grief and disappointment, who can give you valuable information and help, and who can help you move on afterwards.   Women who have a hard time establishing breastfeeding or who were not able to breastfeed their children at all can go on to emotional healing.  

Looking To The Future

For those women who know they are having a cesarean soon or who face the possibility of a repeat cesarean, rest assured that many cesarean mothers are able to breastfeed and are able to nurse long-term. If you are well-educated about breastfeeding, are aware of the potential pitfalls in hospital protocols, are very proactive about nursing early and often, and access expert help in a timely way, chances are that you too will be able to breastfeed long-term.   

If you have had a negative breastfeeding experience in the past, please be reassured that often, you can forge successful breastfeeding relationships with future children. Past problems with breastfeeding can often be prevented in future births, and many women who experienced trouble with low milk supplies in the past do go on to produce more milk in future births (Ingram 2001).  Although there are never any guarantees that breastfeeding will go perfectly next time, look at all the women's stories below where nursing went poorly the first time but was just fine with later children.  For many women, a prior negative experience with breastfeeding can be transformed into a positive one with future children. 

There may be a few women for whom breastfeeding will always be difficult due to hormonal or unexplained physical reasons.  Even then, partial breastfeeding is still worth pursuing in order to get as many valuable immunological protections to the child as possible.  Even if you cannot provide 100% of your child's nutritional needs, ANY amount of breastmilk you can give him is valuable, for however long you choose to pursue it.  If you suspect you may be part of this group, reframe your definition of breastfeeding success.  Concentrate on what you DO provide for your child, make peace with using supplements and nursing aids, and congratulate yourself for every single drop your child does get.  Define your own success, and concentrate on the positive.

Breastfeeding is ideal and we should do everything possible to support and promote it, but it is not the totality of parenting.  Do everything you can to get your baby as much breastmilk as possible, but don't let that be the only focus of your relationship with your child. Mothering is multi-dimensional; it is more than just about how a child is fed.  Realize that even if you cannot nurture your child with as much breastmilk as you'd like, you can give him as much as is possible, and you can nurture him in so many other ways too. Your baby will love you, regardless of how much breastmilk he gets.  You are the most important person in your baby's life, and your mother's love will shine through and overcome, no matter what difficulties it faces.

 

Women's Stories

Below are real-life stories of women's experiences breastfeeding after a cesarean.  Stories of all types are represented, from those who had no trouble at all, those who had great difficulties but who were able to preserve breastfeeding, and those who were not able to preserve breastfeeding.  The stories are separated into categories of those where breastfeeding did not work out and those where breastfeeding did work out so that women who are still working through breastfeeding issues can screen the stories they read if they wish.

These stories are presented in hopes that they will inform, reassure, and/or comfort other women who may have had similar issues  breastfeeding after a cesarean.  No judgments on any person's decisions or experiences are intended or should be inferred.  All stories are protected by copyright and none may be reprinted without the express permission of both Kmom and the mother involved.  

Breastfeeding Stories That Did Not Work Out

Alpha's Story (delayed milk, positioning problems, pumping, incision pain, weaning)

My experience with bfing after my c/s was horrible. My milk came in on the 5th day, but my son stopped trying to nurse on the 4th day. From that day forward, we struggled. Since the standard cradling wasn't working, I tried other holds. I tried the football hold without success. It turned out to be somewhat awkward for me to get him into the position, and the extra struggling hurt my incision. I tried the side-lying position, not realizing the stress on my incision would be torture. I even tried hovering my breast over his mouth while he was on the changing table, but that was also too hard on my incision. Between his angry refusals and my incision pain, we didn't get very far. 

I pumped for 6 weeks before finally giving up. If I had just had refusal and latch problems, I think we and a good lactation consultant could have worked through it; but I also had incision pain to deal with, and I think the two things together are what sank breastfeeding for me.

Before my c/s, I believed that if you want to breastfeed, you can. I expected to breastfeed for at least a year. I never expected a c/s and never thought much about the fact that it can interfere with breastfeeding plans. You can believe I've thought about it plenty since I experienced breastfeeding failure! Next time, I'm going to try for a VBAC, I'm going to line up a lactation consultant before the birth, and I'm going to be mentally prepared for the challenge should I end up with another c/s.

Susan's Story  (sleepy baby, supplementation, pumping, weaning, PCOS diagnosis, pumping with 2nd child, then bfing)

My husband took [my son] to the nursery while they finished the c-section and took me to recovery. My parents came in about that time and I got to see them in recovery. I was smiling and talking. Just in a total high over the whole thing (drug induced, I'm sure). My husband came back and told me he was 8 lbs. 6 oz and 20 3/4". When I got moved to my room, which was across from the nursery, they parked me in front of his bed and the nurse held him up for me to see. He had his eyes open. But, I didn't get to hold him until he was about 5 hours old. That is one of the things that I regret the most.

I was in the hospital for 4 days. I had him with me practically the whole time. My husband spent every minute with us except to go home and shower and then my parents would be there. I was never alone because they wouldn't let me have the baby by myself. My baby wanted to sleep all the time. He wasn't interested in eating. I couldn't get him to latch on. My pediatrician said not to worry about it, that lots of babies don't eat the first few days and to just let him sleep. He'll get hungry by the time my milk comes in. To try when he's awake, but not to force it. 

The nurses were badgering me. They said I had to feed him or I was hurting him. They said I was going to make him sick and it would be my fault. They insisted that I give him formula so I wouldn't hurt him. They bullied me into that a few times. But, then I would tell the pediatrician and he would say to not do that. I would argue with the nurses and they got real mad at me. They made comments about how if I can't breastfeed that I'd better give him formula. Or breastfeeding is great, if you can do it. I had no encouragement at all. I couldn't get him to latch so I would ask for help. The first nurse they sent pinched my nipple so hard it made me cry. None of the nurses could get him to latch.

Then they started having excuses for taking him into the nursery. Checkup or baths, whatever they could come up with. I had no choice in the matter. I would tell them to bring him back as soon as they were done and they wouldn't. We'd end up having to have my husband or someone go down and get him. They'd bring him and he'd be asleep and demand that I wake him up to feed him. I wouldn't do it, I stood my ground. There were many hateful things being said to me by those nurses about it. Then the last night there was one nice nurse in the nursery and she came to get him for his bath. I tricked her and asked when the last time he had a bottle. And I found out they had been feeding them all along.

I got my pediatrician involved. He had meetings with the nursery supervisor. It was to have stopped. Then they had him in there for a test and my Mom caught them about to feed him and stopped it. That was when I crashed. My husband was at home getting ready to bring us home later that day. I was crying uncontrollably. They finished the test and we got the results and my husband got there and we packed up and left. That was on a Friday. I felt my milk coming in on Saturday, but nothing would come out. I knew I had to pump since I couldn't get the baby to latch or my milk would go away. I gave him some formula that weekend so he wouldn't dehydrate. 

On Monday I called my pediatrician and he referred me to a lactation consultant. She was my godsend. She got me started with the pump and Fenugreek and all the crap that goes with these problems. But I tried for 2 months of excruciating breastfeeding for 45 min, pumping for 20, feeding the pumped milk. Washing nipple shields, breast pump and bottles. We tried all kinds of techniques. At 2 months I broke down and gave up. There had just been too many nights where I had been crying that I couldn't do it anymore. I've had the hardest time with overcoming this....[My story shows] that a bad hospital experience with breastfeeding can lead to really serious problems.

[I was eventually] diagnosed with PCOS and went through the typical PCOS problems breastfeeding my 2nd baby, as well as some really difficult suck/swallow/breathe and latch problems (clampdown bite).  [We also went through] something called sensory integration disorder, which is starting to be recognized by the lactation community.  Oh yes, and reflux.  I can't believe I made it with him!...We did end up nursing for 12 months. I wanted to go longer but he was ready to stop and I let him.  I did pump for him for about 4.5 months [in the beginning] and then got him back on the breast after his oral/motor problems had improved enough that he could latch on properly.  It was a trial nursing with all the problems we had.  I think the only way we made it thru is that he really loved nursing. 

[Kmom note: Susan started MOBI, Mothers Overcoming Breastfeeding Issues, www.internetbabies.com/mobi/, as a result of the difficulties she went through with breastfeeding her children.  She describes it below.]

MOBI is amazing.  I started it with just 4 of us and it has grown to a membership that stays consistently over 200.  It originally was us just grieving the loss of the breastfeeding relationship, and moved into looking at why and then how to avoid it in future children.  Well then, the whole thing took off and now we have quite a mix of people!  Now it's full of people working thru difficult situations and everyone cheering them on or giving them a shoulder to cry on.  We have lactation consultants, all sorts of peer counselors, herbalists, etc.  It's really an amazing thing that took a life of its own.  The women there are just remarkable!

Tracywag's Story (nursed 1st child; 2nd child born by emergency c/s, infection, antibiotics, thrush, failure to thrive, weaning)

Note: Tracy's full stories can be read in the BBW Birth Stories section on MalpositionsHer first baby was born vaginally and nursed for 9 months.  Her second baby was born by emergency c/s due to a cord prolapse, and breastfeeding became very difficult due to multiple factors like bottles, thrush, and failure to thrive issues.  

The cord had prolapsed, cutting off all circulation to the baby. There was meconium staining, an indication of fetal distress.  My midwife ordered the surgeon paged and the theater prepared.  The midwife calmly explained that she was sorry, but a surgical delivery was the only option right now.  The other nurse found the heartbeat and I finally breathed again.  At that point I didn't care if they took her out with a fork.  My midwife prepped me while the nurse took my husband to dress for surgery.  

The surgical theater was buzzing with people and machines.  I was strapped onto a board, crucifixion style.  I had a very hard time breathing in that position and said so...I lost consciousness for a little while, but remember them removing my baby.  Her umbilical cord had a true knot in it, and it was wound tightly around her neck.  They all commented on how big she was.  I listened for what seemed like an eternity.  Finally, after the longest minutes of my life, I heard her cry.  It was 6 p.m.

They finally let my husband in, and after a few more moments brought the baby over for me to see.  I immediately became ill, and they took her away.  I was in recovery for several hours, a little room that doubled as a janitor's closet.  I kept asking to go to my room, to see my baby.  My family had all left.  I was told the baby's blood sugars were low, and they had given her a bottle of formula.  When I finally got to hold her, it was after ten p.m.  She had no interest in nursing, no interest in anything.  I felt like I was holding someone else's baby.  

I tried to clear away some of the mental fog I was in.  I made myself get up, walk, and shower.  I wanted my baby with me (I was supposed to be rooming in), and retrieved her from the nurses on more than one occasion.  She wasn't eating well, so I requested the lactation consultant.  "Breastfeed Only" was all over her charts, as was "rooming in with mom."  Despite this, they consistently took her at 11 p.m. to the nursery for ped. checks, and didn't return her.  I was told they'd return her when she woke to eat, her chart said she woke and they fed her a bottle.  I mentioned this to the lactation consultant; she smiled and said they would never give a breastfed baby a bottle.  I handed her photographs.  

The hospital provided me with a breast pump, but not a convenient place to plug it in.  Meanwhile, I had acquired a roommate---a loud mother of three with lots of local relatives who was happily bottle-feeding her vaginally-born son.  There were never less than 5 people in this 8x10 room with two hospital beds and two chairs.  I was bleeding from many places simultaneously, trying to maintain some sort of dignity while sorting out my emotions over the birth, all with a perpetual audience and Jerry Springer shouting obscenities in the background.  The nurse took the pump away for a lady next door to use and never returned it.  I gave up trying to nurse until I got home.

Once we were released things went much more smoothly. I still had the impression that this was someone else's child.  Once a day, then twice, she'd manage to nurse.  Every two to three hours I pumped.  I was moving around fairly well, and even went on a few walks.  My toddler seemed to be adjusting okay, and the baby slept like a dream.  Eight days after the birth, my incision burst open, dramatically, in public.  Since I wasn't feeling ill or running a fever, the midwife said I could wait until morning to come in.  They cultured the incision, pried it open and forced some more fluid out.  The student nurse was in shock at the amount.  The culture tested positive for Strep, e. coli, and another bacteria I had never heard of.  They put me on very strong antibiotics (Cipro).  Then the real fun began.

The baby started to fuss about nursing, about taking bottles and about taking her pacifier.  She also started having very loose, strong-smelling stools.  I began a gastrointestinal episode that lasted 11 weeks.  I took the baby to the doctor, and expressed concern about her eating.  I discovered that no only hadn't she gained any weight, she'd lost it.  I was advised to stop all breastmilk.  The antibiotic I was taking was causing her problems.  I alternated taking her in for weight checks with going in myself for wound irrigation, every day for a month.  Every time I went out in public, the fluid would burst again.  It didn't take much to convince me to stay home. 

After a week on formula, the baby still wasn't gaining.  She now had thrush, again from the antibiotics, that caused her mouth to be so painful she stopped eating.  The first two rounds of anti-fungal didn't help her, so we went to another, stronger medicine that worked, but gave her diarrhea again.  After five weeks, she was finally back at her birth weight.  I continued to have weeping from my incision, as it hadn't healed yet, and the midwife ordered me home from work for another 3 weeks.  My own gastrointestinal distress progressed to the point of painful bleeding.  Vaginal bleeding problems weren't relieved until I was put on hormone therapy 12 weeks after the birth.  I would hide in the bathroom and cry as often as I could.  

I spoke with the midwife on several occasions about postpartum depression.  She gave me the name of some resources, but didn't feel I needed medication at this time.  She felt my depression was a normal response to the circumstances.

Shannon's Story (long-term antibiotics, post-partum depression;  breastfed 2nd child with help from LLL and nurses)

My first was not a good experience. I had an infection during labor and this was one of the reasons they did my c/s. I had to be on antibiotics for almost 4 months post partum because of the infection as well as having an infection in my incision afterwards. 

Shortly after my c/s I was given an antibiotic which was prescribed by the OB who did my c/s. My husband had gone to grab a bite to eat and I asked the nurse to bring me my baby to breastfeed. She in turn said that with the antibiotic I was given I would not be able to breastfeed. I was devastated; they saw my charts, they knew that I wanted to breastfeed. 

For the next two days we got a lot of conflicting views on whether we could breastfeed or not. We had a friend who is a GP,  my husband called her to ask her opinion. We found out from her that this particular antibiotic had been studied just recently and this particular study found that it was safe to use while breastfeeding. However, some women who had taken it had found that it either decreased their milk supply or stopped it from coming in all together. If I remember correctly it was something like 3-5% that this would happen to. I don't know if I would put myself in that 3-5% group or not. 

There were a number of factors that prevented a good breastfeeding relationship with my daughter. The c/s to start off with was very traumatic for me, the doctors were horrible, then the incident with the antibiotic. The nurses all thought I was putting on an act about how bad I felt. I was just under so much stress that how could my milk possibly come in? It was the worst experience I have ever gone through.  I believe part of my post-partum depression was due to my c/s but also due to me feeling like I failed as a mother.  Breastfeeding was very important to me, even more important than the actual birth.  I felt like a complete failure.  

My second daughter was also born by c/s but our breastfeeding relationship went great. I went to La Leche League when I was about 26 weeks along and they were so supportive of what I gone through. The leader of the LLL came up to the hospital the day after I gave birth to see if I needed any help. I can't thank her enough for doing that for me. The nurses were a great help. They could sense when I was getting discouraged and would encourage me to keep trying, that it would work out fine. 

We had a wonderful year of breastfeeding but to my sadness she weaned herself when she was about 13 months. I was not ready to give it up but I respected that she did not need it anymore.  [From my experiences]  I learned that doctors and nurses do not know everything and that you should get advice from someone who has more training or has gone through what you are going through.  La Leche League is a great resource and they have so much experience and knowledge in the subject of breastfeeding.  I wish that I knew about LLL when my first daughter was born.  I am sure the outcome would have been totally different.  

Sally's Story (infrequent feeding, maternal dehydration, low milk supply, pumping/supplementing, weaning; nursed 2nd baby)

My 1st son was born by c/s after 17 hours of labour. I was induced first with 2 doses of prostaglandin gel and then with Pitocin after 12 hours of labour. I had an epidural, EFM, AROM, catheter etc, etc and then the inevitable c/s after my son went into severe distress. I fed my son as soon as I returned to my room from recovery as his blood sugars were low and the pediatrician wanted him fed asap. I can't recall any trouble with attachment ( though the nurses did all that, I was too tired and still numb from the chest down) and he nursed well from the start. I do not know if he was given formula to supplement in the nursery, but wouldn't have consented if I did.  I had the usual sore nipples etc for a week or so, but apart from that it was plain sailing. My ultimate failure was not in this case really due to the c/s itself, but to my own ignorance of what led to successful breastfeeding. I made my son go 4 hours between feeds because I knew he could & wouldn't feed him any sooner than 3 hours & then only when I was desperate. I didn't drink anywhere near enough fluid either. 

We had no trouble till he was 11 weeks old when my previously well settled baby began to cry constantly. I asked a lot of people for advice and received a lot of it & most of it conflicting. Only one person felt that my milk supply was probably low. I was told that since my baby slept 12 hours at night he was getting enough to eat. I later found out the 12 hours at night was more to do with utter exhaustion than a full belly.  When it got to the point where my son was lethargic and unwell, I took him to the doctor, who told me he was fine & there was nothing to worry about. Well, I was still worried so I took him to the Baby Health Clinic, where the nurse took one look at him and told me my poor little baby was starving. The situation by that time was so severe that I had no choice but to go out & buy a bottle & formula, take them to my mum's( which was just 2 mins. away) and make him up a bottle. He drank the whole thing and fell instantly to sleep. 

There followed 6 weeks of frequent feeding, complementing with a bottle & expressing after every feed. By the time I finished this cycle it was time to start again. After a lot of tears and some pretty major depression & feelings of ultimate failure as a mother I switched him to a bottle and he had his last ever breastfeed at 4 months.

After this I was determined to succeed next time and armed myself with the required knowledge beforehand.  My 2nd son was born by c/s on the 8th May 2001. After spontaneous labour, getting to 6 cm on my own, I consented to an epidural, which was followed by an internal monitor, AROM, catheter, IV, maternal starvation etc, etc. After 36 hours another c/s for FTP was the inevitable result.  

This time breastfeeding was not so easy initially. This baby was very mucousy and disinterested in feeding. He had trouble attaching as he was very drowsy & difficult to wake & once attached would fall asleep almost instantly and fall off again. The nurses would hand express me (could hardly move to do it myself) and give my colostrum via a syringe to my baby. What little he did take he would vomit up again along with a lot of mucous. It was at least 24 hours before he had what I felt was a successful feed and probably longer before he was no longer so drowsy. My memory gets a bit vague as to times. I was in hospital for 7 days while we worked on problems with attachment.

This baby is now 9 months old and still breastfed. This time I feed on demand, even if he only fed 20 minutes ago! I still drink a bottle of water at each feed & take my multivitamins. Ultimately this time if I hadn't been so determined I might never have left hospital still breastfeeding.

Misha's Story (sleepy baby, supplementation, pain, weaning; breast reduction, nursed 2 later babies with supplementation)

I should preface my story by saying that my mom was a "radical" 70s La Leche League member and I was raised watching my brothers breastfeed. No bottle would ever cross my children's lips. After my first child was born by c/s, I did get to nurse her 3 hrs. postpartum. She was very tired (from the drugs, I assume), but we did alright that first time. As my stay in the hospital dragged on (4 days altogether) she became more and more sleepy and would not latch on properly. After a couple of days, Atilla the Nurse told me I "better get her to eat" or they'd give her formula. They did end up coercing us into it and brought a syringe full of formula, which I cried through feeding to my daughter. Finally, the night before we went home, an angel of a nurse sat down w/ me and worked w/ us till I could get her latched on correctly.

Once we got home, my milk came in about the 5th night. But my daughter's sleepiness remained, and she would go 4-6 hrs. during the day w/o waking up to eat. We did not know this wasn't normal, and no one had told us the pain drugs I was taking would do this to her. Even when I called my doctor, he did tell us we had to wake her up to eat more often, but said she was a kind of baby they call "willing to starve" - in essence blaming *her*, rather than saying, well the c/s and pain meds have probably messed up your supply and her ability to stay awake. My memory grows quite fuzzy after that point. Somewhere between age 1 wk. and one month old, she became very fussy (once she got sober from the pain drugs is my guess) and finally after several exasperating evenings of endless nursing, we broke down and took out that nice little can of formula we'd received in that cute little diaper bag from the hospital. She guzzled that bottle like she was starving, and my heart broke. I continued to nurse her, but the slippery slope had begun, and by 3 months she was completely weaned to the bottle.

I was under a lot of pressure from my in-laws (who had bottlefed) to "just give her a d*** bottle already!" I also struggled nearly the whole time I breastfed w/ cracked, bleeding, scabby nipples/areolas. It was horribly painful to breastfeed, and probably led to more bottles and a reduced supply. This was no doubt a result of a less-than-optimal latch. I know now these are correctable problems - don't speak to the in-laws until breastfeeding is well-established, and get an LC to observe your latch.

In retrospect, I can see that I had some baby blues, and for whatever reason, did not seek out breastfeeding help, even though my mother begged me to and even had a LLL leader call me. (When I explained the nonstop nursing and my daughter seeming like she was starving, this leader told me to go out and get some time away and leave baby w/ daddy! Through more extensive experience w/ LLL, I now know that this is NOT the norm to get a leader who would give such bad advice, they are wonderful for the most part, but that's too little too late for my first child.) 

I bore a lot of guilt over this experience, but my story does have a happy "ending" (or perhaps should say, continuation).  Despite having breast reduction surgery when my first baby was 6 months old, I have nursed my subsequent 2 children w/ supplementation, my son for 17 months, and my 17 month old daughter is still nursing. Though that can never replace what my daughter and I lost, it has removed some of the sting, set a great example for her, and reiterated 100% my devotion to breastfeeding as the best way to feed and nurture my babies.

Jenny's Story (milk came in late, supplementing, pumping, trouble bonding, weaning; nursed second baby successfully)

I had a cesarean section with my son in 1995. It was a planned natural childbirth in hospital with a CNM practice which had been completely supportive of my wishes for no routine monitoring or exams, no IV. My labor started in the evening and continued for the next 30 hours, so I was without sleep for almost 50 hours. My pushing stage was difficult; the CNMs did not suggest anything to help me besides pitocin or vacuum extraction. After I basically ran out of time as per their protocols, they pushed pitocin on me and then claimed fetal distress necessitated a cesarean. We believed our son was in danger. I had general anesthesia despite asking twice why I had to have a general. Only later did we realize that we were completely lied to, as the cesarean took 90 minutes to begin after we were informed our son was in danger. Also the surgeon's records noted a diagnosis of CPD, and made no mention whatsoever of fetal distress.

My postpartum experience was one long nightmare. I knew as soon as I woke up from the surgery that something just wasn't right. I was completely traumatized by the unexpected "failure" of my body. I did not really feel as if my son was my own. He didn't look like what I expected; I hadn't seen him born. I was in so much pain; I just wanted to sleep and wanted them to take him away where I didn't have to deal with him. I did breastfeed, or tried to, but found it almost impossible to sleep in the hospital. The less I slept the more my anxiety about caring for my son and not being able to sleep increased until I was basically unable to sleep. My milk had not come in by day three (which of course is not unusual) and I was told that I should supplement (again of course bad advice). The "lactation consultant" at the hospital sighed when observing the pump on my breast. Clearly I was not producing enough. Of course I felt like a failure all over again.

Once released from the hospital I still could not sleep. I was on overdrive, anxious, and so keyed up I never could relax enough to sleep or let down milk. My son got enough milk to keep him from dehydrating but his diapers were not really wet unless we gave him some formula.  After two weeks of this, and a trip to the emergency room because I had become suicidal I was told I could not breastfeed due to having to take antidepressants. I quit nursing having experienced only *one* letdown.

I do believe the cesarean almost completely caused my inability to nurse my son. Granted I would have been anxious about caring for my son even without the c/s; however, not seeing him born and the physical suffering I underwent totally severed any connection between us. It took months for me to develop a maternal relationship with him. And of course my trauma basically caused me to be in shock. I know that it would have been different without the c/s because with my daughter I had a VBAC and I have been successfully nursing her for over 18 months now. I have never had even one round of thrush or mastitis. My milk came in with her at three days and I let down plenty of it to her!

What a difference a normal birth makes. And the VBAC was not without difficulties but there was just no comparison.

 

Breastfeeding Stories That Did Work Out

Annette's Stories  (3 c/s, urged to supplement, 'routine' bottle with 3rd baby, some latch problems but easy bfing stories)

1) After my first labor and emergency C/S, I did not wake fully from general anesthesia until my son was over an hour old. I first nursed him at about 4 hours old. I had waited till all the nurses and relatives left because I was embarrassed to expose my breasts (and try this new thing that I feared I would probably be bad at) with anyone else watching. I tried what the hospital LC had taught at a pre-natal class. He latched on within several seconds and nursed well for 10 minutes. I tried him on the other side and he nursed for about 2 minutes. Just before he finished a nurse came in to "help me get started breastfeeding" and was very surprised that I'd done it on my own. She said it looked perfect and 12 minutes was a wonderful amount of time.

While we were in the hospital I kept asking the nurses to bring him to me as soon as they finished anything they were taking him for, and to be sure and bring him immediately to be nursed if he cried or seemed hungry. But they would neglect to return him to my room for hours at a time. Several times I went looking for him and found him crying hard. I kept putting the pacifier they provided into the drawer of his bassinet cart, but they kept getting it out again and giving it to him. Yet he nursed frequently and well and had no nipple confusion.

My milk came in on the third day (as we were being discharged) and I got so engorged my areolas were numb. A nurse manually expressed and then mechanically pumped my milk until the engorgement got down to where the baby could latch on. I nursed him frequently and had no problems. He was colicky until he was 4 months old, but we enjoyed nursing anyway for his first 5 1/2 months.

2) After my 2nd C/S, for which I had an epidural, I first nursed my baby at about 1 hour old. I was very surprised and glad that no one wanted to teach me how to nurse, as they had a year earlier with my first baby. Her second night of life she nursed every 90 minutes all night long. I had kept her in my room for the night over the objections of the nurses. When they saw how often she was nursing they encouraged me even more strenuously, over and over, to let them bottlefeed her in the nursery so I could get some sleep. Finally one of them said, "You must be a natural mother." This baby nursed until she was 9 months old.

3) After my 3rd labor and emergency C/S I woke from general anesthesia before the baby was an hour old and nursed her a few minutes later. That night when she was taken to the nursery for a bath and check of her vital signs, she was given a bottle of glucose water for a "suck test." I was very upset when I found out, since I had ordered no bottles and had not been informed that such a test would be done. The staff insisted that the suck test was mandatory for all babies, even those breastfeeding exclusively. I was glad that she had no nipple confusion. During her first few weeks at home she developed a poor latch, not getting much if any of the areola in her mouth. I had sore nipples for weeks until I managed to correct her latch. She would never take anything but my milk from my breasts. She started sucking two fingers at 2 1/2 months, but other than that she nursed exclusively until I introduced solids at nearly 8 months. She continued nursing until I weaned her at 14 1/2 months.

MY MESSAGE is that C/S doesn't have to doom breastfeeding to failure or other problems. It can work out fine and be a saving grace of a bad beginning experience with a new baby. Don't get discouraged about breastfeeding just by hearing that you will have a C/S or by having had a C/S.

Note:  Annette went on to have a VBAC after 3 Cesareans.  Her story can be found on this site in the VBA2+C Stories FAQ.

Natalie's Story (macrosomia, weight loss, delayed milk, medical misadvice, frequent nursing, breastfeeding success)

My son was born after a very long posterior labor followed by an *emergency* cesarean section. He was 10lbs 2oz. I had never thought about not nursing him, and so in the recovery room he was placed at my breast. I was not conscious enough to latch him on, so others helped, and he nursed for a while, then we had to switch sides. That was the most painful thing in my life, even worse than the epidural failing during the cesarean. But I did it. Gregory nursed and was happy. 

Unfortunately, Gregory lost a bit of weight (a lb. total) during the first 3 days, and the nurses pushed me to supplement. Somehow I  knew that that was a bad idea, and so I nursed him every time he was awake. One evening he nursed for 3 hours straight! When we left the hospital 5 days after the birth my milk had just started to come in, and I never got engorged as Greg was nursing every hour. Thus continued a successful nursing relationship until Greg weaned himself at 12.5 months. Gregory has never tasted a drop of formula. 

The most important thing I learned was to trust my body, that is was able to nourish my son and that my son needed to eat frequently, and that that is normal! I also learned that nurses don't know everything and am sure if I had supplemented that we would not have continued nursing for long. 

Anne-Marie's Story (NICU, separation, pumping, tube feeding, flat nipples, breastfeeding success)

My son was born by emergency c/s for brow presentation at term +3 after prolonged ruptured membranes.  He weighed 9 lb. 1oz. On delivery he had a stridor (noisy breathing) and they thought the fluid they took from his lungs was infected (after tests it was shown not to be the case). He was taken to special care. I saw him the next day; he was in an incubator, on oxygen and had i/v antibiotics too. I wanted to b/f and was encouraged/shown how to use the breast pump so he could be tube fed. I wasn't really given much info on how often I should do this so the next day I was told they needed more milk and it had to be every 3 hours. My routine for the first few days was get up - breast pump, see baby, breakfast, see baby, breast pump, eat, etc day and night.

After investigation they found out that he had a condition (self-correcting) called tracheomalacia (narrowing of the voice box). After two days or so he was put into a normal cot and off the oxygen and iv but still on a monitor/tube fed. At the stage I could start trying to b/f. Initially I was trying to establish feeding and one of the special care nurses said my nipples were a bit flat; I tried using the pumpy/syringy things but that didn't help. She said that this was partly because DS was no longer sucky/hungry enough to suck them out. She then suggested nipple shields which worked a treat. I was able to start feeding one out of 3 feeds progressing to all feeds by the time DS was 5 days old.

Once feeding was fully established we went home still using nipple shields. I gradually weaned DS off these after about 2 weeks and continued to b/f until he was about 6 months.  Anyway I don't know if my successful b/f was made easier or harder because of my son going into SCBU or because of the section or not; I'm not sure if a normal midwife would have recommended nipple shields but it did work for me.

Tonya J's Story (baby with cleft lip, formula, rooming in, positioning issues, breastfeeding success)

My c/section came after 24 hours of labor, an episiotomy, vacuum suction, and a lot of drugs. On top of that, my son was born with a cleft lip that was not diagnosed before his birth. After the surgery, I fell asleep for 4 hours.

When I woke up, a nurse was feeding him formula in my room. This was despite my explicit line in my birth plan that he was to be exclusively breastfed. (The rest of the birth plan was out the window, why not this too?)

I was determined to breastfeed my baby. The birth had been so contrary to my expectations that I was going to MAKE this part happen. The cleft lip also presented a potential problem for his latching on. The formula feeding nurse showed me how to prop him up on pillows and lay on my side to nurse. This didn't work at all, but with the fresh incision, it was all I could do. 

The hospital had rooming in, and I basically kept my son with me 24/7. This was probably a big factor in our breastfeeding success. My milk came in on day four, as I was being discharged from the hospital. 

Once I got home, I tried the football hold to nurse. It worked well on one side, but not the other. I tried using a Boppy pillow, which was somewhat of a pain as well. Finally, I just grit my teeth, threw the pillow aside and nursed him in the cradle position. While it hurt for awhile, it was the perfect position for us.

The most important lessons I learned: rooming in is key. Also, don't let setbacks (like an unexpected c/section or facial deformity) deter you from pursuing your goal with determination. It would have been very easy to succumb to formula feeding, but this was one thing they weren't going to take from me!

Denise's Story (well-endowed, football hold, no problems breastfeeding after c/s)

My name is Denise. I was 353lbs when I delivered my daughter via c-section on November 4, 2001. The c-section was awful and I'm still not recovered from the emotional pain that I have suffered from that experience. On the other hand, my breastfeeding experience is wonderful!! I was able to breastfeed my daughter immediately after c-section, (within one hour from delivery) and I truly feel that this was the key to our success. She latched on like she had been breastfeeding for 6 months and continues to eat well even now. She is currently 3 months old, weighs 15 1/2 lbs and is 24 inches long. She is totally breastfed with no supplementation. 

I truly believe that God only gives us what we can handle and that is why my daughter has been such a great baby. I don't think I could have handled yet another disappointment with her birth. Breastfeeding her was very important to me. Actually she slept through the night (9 hours) the first night I brought her home and has continued to sleep through the night since that time!! (I know...I am VERY blessed!!)

I did want to mention one thing on the side of being a large size woman and breastfeeding. There are some differences. Women who are large generally have large breasts. This can make breastfeeding challenging in positioning the infant. I find that even now, I like to breastfeed Alexandra in the "football hold" best of all. It allows me to see her, and keep my rather pendulous breasts away from her nose. Women who aren't as large or who do not have such large breasts are able to feed their baby in the cradle hold with much greater ease. Granted when there is a will there is a way, so yes I do nurse my baby in the cradle hold and also feed her while I am lying down, but I always have to hold my breast with one of my hands so that I am not closing off her nostrils with my breast.

[Kmom Side Note: There is a FAQ on Breastfeeding When Well-Endowed on this site, which discusses these very same issues.]

Stephanie's Story (premature baby, bottle feeding, pumping, medical misadvice, breastfeeding anyhow)

[Back Story: Stephanie developed pre-eclampsia, was put in the hospital where she received a lot of magnesium sulfate, was induced (which didn't work), and ultimately had a cesarean.  Her baby was premature, which made trying to establish bfing that much harder.]

I heard babies crying in the other rooms and I ached for my own baby. Sleep was impossible. A nurse gave me a breast pump. I asked her how to use it and she had no idea. She told me to call a lactation consultant. I figured it out on my own. I saved the colostrum and milk for Hannah. That was all I could do for her. The next afternoon, Dr R finally came to see me and after much pleading on my part, she discharged me early. On our way to the other hospital to see Hannah, I found myself getting a little afraid. I am not sure why. I think I was afraid of what I would see. When we got up to the neonatal unit, I walked slowly and hesitantly over to Hannah's incubator. That was enough for me. My baby was in a cage. I broke down crying and told DH I wanted her out of there. She was 3 lbs 8 oz. 17 1/2 inches long. I couldn't believe how small she was. Her rib cage was defined and could be seen protruding through her skin. She had no fat on her body. My poor baby looked like an alien. 

I couldn't help feeling that I failed her somehow. I felt responsible. The idiot nurse taking care of Hannah made me wait a half hour to hold her. {It wasn't her feeding time yet!} When I finally held Hannah in my arms for the first time, I couldn't believe it! That feeling is a feeling our mortal tongue does not even have a word to describe. She was so tiny and so skinny and so perfect. I couldn't stop staring at her and holding her and kissing her. She had a tube in her nose because she was refusing to eat. So, I took out my bottle of colostrum that I had saved up and fed that to her. She drank the entire thing while I sang to her! The doctor was amazed! She just needed her Mama. 

Leaving the hospital that night was torture. I didn't like the nurse and there were other babies that she had to look after. I was frustrated and felt so helpless. She acted like Hannah was her baby and that I was only the mom and didn't know anything. When we got out to the car, Jeff held me while I sobbed. I felt like we were abandoning her. 

The nurses at the hospital I stayed at were no help at all with the breastfeeding. The nurses didn't even know how to use a breast pump. The nurses at the NICU wouldn't even LET me try to breastfeed until Hannah was taking all of her feedings through a bottle first! Dumb! I was pretty miffed at the nurses because I knew that their whole thinking was backwards. 

One lady who had a c-section at the same weeks of pregnancy as me {34 wks} had her baby in the NICU also because she was pre-term {the baby had no problems at all. Even her weight was good- 5 1/2 lbs.} But, they took her to the NICU for a day of "observation". That poor little baby was there for four weeks because she wouldn't bottlefeed! The woman and I spent every day together talking about our problems with nursing our babies. They wouldn't let her take her baby home until she would bottle feed all of her feedings! She was so distraught! This poor baby wanted to nurse, not bottle feed! But, of course, if she was nursing, the nurses couldn't tell how many ounces she was getting! Give me a break! I get mad just remembering this poor woman's nightmare! She would nurse the baby and the baby would have no problems and nurse like a champ! But, because the "protocols" are that the baby has to bottlefeed first before she can be discharged, she stayed there for a whole month! Whenever they tried to bottlefeed her, she would always refuse and so they would put a feeding tube in her nose! She hated that! Meanwhile, the mother was pumping like crazy but her milk was not coming in because of the effects of the mag sulfate that she had been on FOR AN ENTIRE WEEK and because she wasn't "allowed" to nurse her baby! No wonder so many women do not breastfeed in our country! The lack of support is ludicrous!

When I did finally breastfeed her in the NICU, one of the nurses came over and held Hannah's head in a weird position and Hannah fell asleep after just a few minutes {even though she was latching on!} When she did fall asleep, the nurse told me that it would be better if I didn't push the breastfeeding thing too much because she was so little that it could exhaust her and she would lose too many precious calories! Plus, she said that my breasts were so huge and her head was so tiny that I could suffocate her without knowing it! { You can tell this nurse was very enlightened!} 

Surprisingly, though, Dr R was wonderful about me nursing her. At my two postpartum check-ups, she always asked me how the nursing was going and to make sure I kept trying to give her breast milk because it is so important for her! She told me that breast milk is so perfect- especially for premature babies. She said that my breastmilk had extra fat and protein and calories that were especially produced for the age and weight that Hannah was born at. 

The rest of the week, my mom and grandma took turns driving me to the hospital. I would stay all day and Jeff would come meet me there for dinner after he got off work. Then, we would stay with Hannah and bathe her and change her and feed her. We usually left around 1 or 2 am. Every night it got harder and harder to leave. We were blessed, though. Hannah was doing beautifully and gaining weight rapidly! She was the healthiest baby in the NICU and sadly, the only one that was being fed Momma's milk. I was still pumping like crazy. I was tired, exhausted, it hurt to sit, to walk, to laugh, to cry, and to cough. Everyone told me to stay at home and rest. But I couldn't. My baby needed me. 

We tried breastfeeding her in the NICU {much to the dismay of the doctors and nurses who told me I couldn't do it}. My breasts were way bigger than her tiny head. I was worried that maybe they were right. We brought Hannah home from the hospital when she was ten days old. She weighed 4 lbs. 2oz. We were relieved and scared to death that she was finally released to our constant care. I was scared about what kind of mother I was going to be. 

For the first four weeks, I worked diligently at breastfeeding. It was so much harder than I thought. With engorgement, clogged milk ducts, thrush, and mastitis, breastfeeding was even that much more complicated. Not to mention the fact that Hannah had to learn to wean from the bottle to the breast and my milk supply was so enormous that it took awhile for us to be in sync. But everything is working better now. No bottles. No pumping. {My freezer is so full of milk right now that we have a good year supply!} Hannah nurses beautifully. I almost gave up last week but Jeff came over and helped calm Hannah down and told me that I could do it. He told me it would work out eventually, that it just takes a little time. What a wonderful husband. I could never do this without his support. He was right. 

I feel as if my body is finally doing something right for Hannah. Something that no one else can do for her but me. It is so relaxing and wonderful. I love it and I am going to breastfeed for as long as Hannah wants to. Maybe that will make up for the time that we were apart. I believe I will always be trying to make up for that. I can't believe our nightmare is finally over.

Sallete's Story (NICU, latch difficulties, bleeding, lactation consultant help, breastfeeding success)

My son Collin (who is four now) was a c-section for fetal distress and FTP.  I was two weeks overdue and there was an attempted induction which didn't work.  What we discovered as he was born is that there was NO amniotic fluid and I hadn't seemed to rupture or been leaking any before or during labor; [it was] very strange.  

When Collin was born he wasn't breathing well; he had inhaled amniotic fluid. There was meconium too but no inhalation.  He was whisked away to the NICU after I saw him for about 2 minutes and hooked to oxygen under a tent.  He was born at 1:22 p.m. but I didn't see him until about 7:00 p.m. and he was still under an oxygen tent, etc.  The neonatologist had come into recovery and let me know how Collin was doing and asked if I was going to breastfeed.  I said yes and so Collin was given an IV rather than any formula or bottle, etc.  I was very grateful for this as I knew the problems with nipple confusion.  

Finally around 1 a.m. I couldn't sleep.  All I could think about was my little man down there all alone.  I called the NICU and they had just put him on room air.  The first thing that I did when I went to see him was to pick him up and put him on my chest and I felt instant relief.  I hadn't been able to do anything for him all that time but I knew that I could comfort him and breastfeed.  He was so eager to feed he would latch right onto the end of my nipple and I was inexperienced (the book really didn't prepare me for the reality) and couldn't figure out initially how to get him off and relatched.  It took a little while.  I had a strong strong desire to breastfeed because I felt like I had failed at giving birth and I wanted to do "something right" for him.  I stayed down there most of the night with him dozing in the wheelchair and holding him on my chest and trying to feed.  

We continued to have difficulties with the latch.  I would have to pull him off and try to get him to relatch or wait for him to take the rest of the nipple in his mouth which somehow he figured out he needed to do but wouldn't do right away.  By the next day my nipples were raw and bleeding and I was feeling pretty emotional.  We continued to struggle through the next day and night.  It hadn't occurred to me to tell anyone I was having problems.  We were so consumed with Collin because first they thought he might have a blood clotting disorder because his platelets were off, then they thought he had a heart problem, then he developed an infection and needed several types of antibiotics, some of which had potentially severe side effects (i.e. hearing loss).  

On the second day one of the nurses saw me wince when Collin latched on and saw that I was developing sores on both nipples.  She immediately sent for the LC.  She very matter of factly came in and positioned Collin and kind of squeezed my breast with my nipple in the right position and latched him on for me.  I felt embarrassed but also almost immediately was able to see what I had been doing wrong.  She also showed me how to get him unlatched pretty quickly when he latched incorrectly.  So breastfeeding immediately began going better as far as Collin was concerned but for me it was extremely painful because of the sores and my incision.  I had difficulty getting comfortable.  

On the fourth day I was discharged and Collin was still in the NICU.  I refused to leave the hospital so they let me stay in a little room they have with a cot.  And I can remember laying there and the nurse brought Collin in and left, and I could not sit up because I had been laying completely flat on the cot with one pillow (DH was working) and he was screaming.  I finally got to sitting up after much struggle and discomfort and I start trying to get him to latch and he starts on the end of the nipple again.  The pain was excruciating and it all just seemed tooooo much and I burst out crying.  I was crying because I felt inadequate as a woman because I didn't give birth vaginally, because I didn't automatically know how to breastfeed my child, because I was fat and couldn't lay down on my side to feed him because my stomach would flop to the side and that hurt my incision, and because I had bleeding scabs on both breasts and it HURT!

I called my sister in another time zone (my mother is deceased) in the middle of the night because I remembered her telling me that breastfeeding could be difficult and make you a little sore at first.  I just sobbed to her on the phone, "How long is this going to last?" She said, "Hang in there for two weeks and you will feel so much better.  Just hang in there."  SO I gritted my teeth and kept at it and actually my nipples felt better in about 3-4 days and once I was able to take Collin home (after a week), mentally I started feeling better too.  

Being able to breastfeed made me feel like a successful mom and like I could do for him what no one else could, and that I helped to make him better.  It healed some of the guilt I had about his birth and difficult first weeks.  I went on to breastfeed Collin and his two younger siblings [both born by VBAC] for about 10 months each and found it to be the most rewarding experience of being a mom!

Chaya's Story (infrequent nursing, breastfeeding success)

"Well, I think we need to think about a c-section at this point," my OB said to me.  After pushing unsuccessfully for over 5 hours, I was in no state of mind to argue.  And just like that, I became a statistic; I became one of four women in the US to have their babies by cesarean section.  I felt devastated.  How could this happen to me?  What was wrong with my body that I couldn't push my baby out like a normal woman can?  

Forty-five minutes later, I was sitting in the recovery room with my new baby girl.  I did not birth this baby, what was I supposed to do with her?  I had always imagined that I would push her out and then she would be laid on my chest and she would just squirm up and know what to do.  As I held my daughter, Sarah, for the first time, I felt like a stranger.  Since I was not actively involved with her birth, somehow I did not quite feel like I was really her mother.  Obviously it did not help that I was drugged up on many narcotics for the pain.

Well, I knew I was supposed to breastfeed her, so I asked the nurse for some guidance.  She helped Sarah latch on for the first time.  She nursed well but after about 2 minutes, she was quickly fast asleep. She was then whisked off to check into the nursery and I was moved to my room.  When Sarah woke up the next morning, they brought her to me and left me alone with her.  It was quite difficult to figure out how to get her latched on, especially since it was painful for me to adjust my position.  

Luckily, I did succeed to nurse her.  I felt relieved.  I was her mother even though I didn't birth her.  I was able to nourish her with the most perfect substance for her.  I was able to give her something that no one else in the world could give her.  It was an amazing feeling....

......that lasted 2 minutes after which she dropped off and fell fast asleep.  I couldn't wake her up!  The nurses told me I needed to nurse her for 20 minutes on each breast!  Here she only nurses for 2 minutes on one side and there was no way I could wake her up.  I tried not to lose heart.  I knew there was a learning curve for both of us.  However, by the third day in the hospital, Sarah had still not improved.  She continued to nurse for only 2 to 3 minutes on one side very 3 or 4 hours.  The hospital guide to breastfeeding said that I needed to get to 20 minutes.  What was I doing wrong?  The nurses warned me that she wasn't getting enough milk.  I didn't know what to do. 

Exasperated, I called my sister who successfully nursed her baby.  She calmed me down and assured me that I was doing everything right.  She said that I just needed to pay attention to Sarah's needs and check her diapers.  When I finally left the hospital, my sister came to help me out and she took me to a La Leche League meeting.  Finally I felt validated.  I was finally able to really believe in myself and my ability to take care of Sarah.  I was told that every baby was different.  Sarah turned out to be a really efficient nurser and was able to meet her needs very quickly and didn't need the usual 20 minutes on each side, like some babies do.  

As I was reassured more and Sarah continued to gain weight, I started to feel more confident.  While I will always feel sad that I was not able to push her out on my own, I feel grateful that I was able to successfully nurse her.  It was important for my identity as her mother.  While she felt like a stranger when they first brought her to me, nursing helped me quickly bond to her, knowing that I was giving her something that only her mother could provide.  

Stacey's Story (medical misadvice, breastfeeding anyhow)

While pregnant, I read EVERYTHING I could find on breastfeeding.  Everything.  I looked at Internet stuff, I asked people I knew about breastfeeding, and I went to a La Leche League meeting.  I knew that I wanted to breastfeed my baby.  

(As a side note, I didn't do this for cesarean sections, and I would have to say that this is surely why I ended up with one.  I said at the time when I 'found out' and now, if I had read as much on cesarean as I did on breastfeeding, I wouldn't have had a cesarean.)

Given what I had read, I knew my baby should nurse in the half hour following delivery, and should room with me, and should not, for any reason, be given to the nurses to care for.  Here in France, bottle feeding is the norm, and if the baby is in the nursery, it is a given that she will get a bottle from the nurses who just don't feel the need to bring her back to feed.  

When it was clear I would have a cesarean, I told my DH to watch Emily and not let her out of his sight (which he did!!!).  I was taken to the baby nursery during my recovery period, about 45 minutes after delivery, and she latched on immediately.  (I have to say that Emily has never had any breastfeeding problems, and I am incredibly lucky for that!) What was weird was that when she was given to me to feed, she was completely clothed, even a hat!  It was strange to be mostly clothed myself, feeding this clothed little human.  

Although it was clear that Emily and I would have no difficulty with breastfeeding, the medical staff did.  The day after Emily was born, the pediatrician informed me that "such a large baby would never survive on colostrum."  (Emily was 4 kilos, about 9 lbs.) I looked at her, didn't respond emotionally, and said, "We'll see."  On day two, Emily had already started regaining her weight.  So, the pediatrician didn't say anything, not even "Ooops, guess I was wrong about that!"

The morning of day 3, the pediatrician announced that it was unlikely that my milk would come in, so we should start giving Emily bottles.  Again, I looked her in the eye and said, "We'll see."  I knew that milk might come in day three, or might wait until day five.  I also knew Emily would survive on colostrum so I didn't worry.  The evening of day 3, my breasts were spraying milk everywhere.  Emily enjoyed the new milk a lot, and drank tons that night and the next day.  I never really suffered from engorgement, thanks to her.

At Emily's one-month visit, I expressed concern about milk supply and working, and asked if she would prescribe a pump for me so insurance would pay.  She said that if my supply seemed low, to just give her a bottle.  I knew for sure this pediatrician was not the one for me (wonder what took me so long!).  

As I said, fortunately I had really read up on breastfeeding and the potential pitfalls.  Any comment form the pediatrician or anyone else fell on deaf ears.  I later asked this pediatrician why the stupid advice on colostrum and the milk coming in.  She said that although I was right, they usually said this to new mothers who had had difficult births so they wouldn't feel bad if they failed.  I asked her why they didn't just give the right advice to start with to help, but she couldn't answer that question.  

From what I have learned in my experience, I would tell anyone, c/s or not, difficult birth or not, to have confidence in yourself about breastfeeding.  Don't listen to anyone, get a couple of really good books and memorize them, and if necessary find a good lactation consultant.  But go with your gut and do the best you can.  You won't regret it.

Heather 3's Story (supplementation, cup feeding, pumping, Haberman feeder, breastfeeding)

[Backstory:  Heather developed HELLP syndrome at about week 38.  She was induced and ended with a cesarean.]

On day four in the hospital, the nurse came in the middle of the night and told me I needed to start supplementing the baby with formula.  Although she was a great latcher, my milk had not come in and my daughter had lost more than 10% of her body weight.  I gave her that bottle in the middle of the night and called my lactation consultant friend in tears the next morning.  She came and we started feeding my daughter formula from a spoon or small cup.  I also started pumping very small amounts of milk after feedings.

After we came home I tried just breastfeeding but she again lost weight.  The lactation consultant hooked us up with a Haberman Feeder, a special nipple that requires the baby to suck the nipple like at the breast and with variable flow.  I fed her at the breast during the day and then from dinnertime on, supplemented her after each feeding with formula.  I was determined that I would breastfeed this baby!  

Between 2-3 months we were able to exclusively breastfeed with a combination of pumping and the herb fenugreek.  When I went back to work my supply decreased but we have worked on building it back up.  She receives 4-8 ounces of formula per day and the rest breastmilk, either at the breast or expressed.  I found a good sitter close to home and work and am able to go home each day at lunch to feed her.  It has been exhausting but I am convinced it is the best thing for both of us!

Bonnie A's Story  (medical mismanagement, separation, pumping and bottlefeeding, back-arching baby, breastfeeding anyhow)

After doing her PKU 4 times (they kept saying they weren't getting enough blood), shooting her up with Vitamin K and Hepatitis B vaccine, weighing her (9 lbs 8 oz) and generally torturing her, some lady brought my daughter to my bed. Not my husband, not my family, but some lady who talked too fast and acted like the God of my baby...all in a very nice way. She held my baby girl in front of me for what seemed like eons, while I struggled with everything in me to keep my eyes open and seem alert...the drugs were overpowering. 

When she finally let me have the baby, she said I was too drugged to hold her and I would have to try nursing lying down because of my swollen belly and my "large size". They messed with my bed, moved me over, propped me up on pillows, and took my gown off to my waist. Then they put little Nataliť down beside me and she told me to move my arms out of the way. She took my breast in one hand and my little baby's brand new head in the other, and tried to force us together. I was humiliated and I remember just looking away once she told me to move my arms out of the way. Nataliť cried. She wouldn't be peaceful, and she certainly would not just let me hold or bond with my baby. Unfortunately, all the activity made me vomit - I knew it was coming and warned them just in time to get the baby off my lap and a little bowl in front of me. I heaved and vomited about 20 times. It was awful. 

They tried again. Nataliť showed no interest in eating and after she was manipulated and shoved into my breast enough times, she was inconsolable and the lady lifted her out of my bed and I don't remember what happened after that. I was told I could not hold her because of the drugs, that I could drop her. I just wanted to close my eyes and wake up in another world where this was not happening. The rest of the night was a blur.

The next day was a blur of having more than one person calling themselves "lactation specialists" come in my room, and proceed to try and instruct me in the complex art of breastfeeding. I would hesitantly take off my gown, and they would take my baby in one hand and my breast in the other, and get in a pulling match with Nataliť. My little one was a back-archer from the start, and strong as a horse. She would throw her head back and resist the pushing until she shook with the effort, screaming hysterically. They would be pulling my breast, rolling my nipple painfully and manipulating us to no end. I gritted my teeth and finally told one of them it hurt when she was tugging at my nipple, and was shocked when she said that it "couldn't hurt" and that she "had to"! At no point was I allowed to simply hold my own baby and try to feed her on my own. 

I began to feel like a failure. I cried whenever I moved it hurt so badly. I could feel the catheter and was not able to sit up at all because of the pain it caused in my urethra. One of the "specialists" told me if I could not sit up in the bed, there was no way Nataliť could try and nurse. So I cried and brought the bed up as high as I could. Of course, then the pushing match would start again. I was told over and over to please just keep my hands out of the way. I have no idea how someone could be expected to succeed in this position. I was mad at how hard they were forcing Nataliť. She became instantly hysterical whenever they tried. They would eventually sigh and give up, put her in her crib, squalling, and go off to find a bottle of formula. Then they would cup feed it to her at my insistence; I knew she should not have artificial nipple if she couldn't nurse. She would slurp it down, burp, and peacefully go back to sleep.

Since she wouldn't nurse, they rolled in a pump and instructed me how to start pumping my breasts so that my milk would come in. All the focus was on my milk. I would pump and pump, and get a few cc's of colostrum from each breast. Instead of feeding it to Nataliť, they would wash it down the sink and give her formula. When the shift changed and I got a really nice nurse, I asked her if I could please feed it to Nataliť. She was kind and helped me feed her the little bit I got during her shift. The formula made Nataliť spit up a lot. I know now that new babies do not need near as much food as they were forcing down her. No wonder she showed no interest in nursing! She was not hungry.

The Dr. had come that morning and mercifully told them to stop the Mag Sulfate. He also prescribed Lasix, which I knew was a strong diuretic. He did say the catheter had to stay in though, which disappointed me. During this day the nurses and "specialists" started becoming concerned about Nataliť's whistling while breathing. She had a real wheezy sound to her breath, especially when upset but also when resting. They brought up a specialist from Pediatrics who said she was OK once he checked her over. Later in the day, she was wheezing much worse so I asked them to take a look. The nurse was very concerned and told me they had decided to take her down to the intensive care nursery for testing. She assured me it would not be long, and she would let me know what was happening. I didn't want to part from Nataliť, since I had finally gotten to hold her, but I also wanted her to be OK.

Hours later, no word on Nataliť. My husband had been gone for hours and the nurses had changed shifts. He came back once in a dither because they wanted to give her a bottle and a pacifier and he knew I didn't want that. I said NO! And he said it was for some kind of test. I said NO...they could tell me what kind of test but otherwise no. He left. The new nurse knew nothing of my daughter and I asked her to please find out. My husband stopped in once to tell me everything was OK and they had run tests and she was fine. 

It was evening by now. My family was gone, my husband was gone, and my baby had been gone for almost 10 hours! I had to pump, and when I did I began to cry as I knew my baby was missing the precious colostrum my body was making to give her immunities. I called the nurse and asked her about my baby. She didn't know. She did give me a number for the nursery. I called and was told the nurse in charge of my baby was busy and I would have to call back in half an hour. I began to cry. The harder I cried, the more I thought. The more I thought, the harder I cried. Where was my baby? Was she OK? How was she eating without me? Formula? By some miracle, my sister had decided to bring some blankets from her car up to my husband; she came back and found me a dripping, crying mess. I called the nursery again, and they told me she was already on her way up to me. I calmed down. My sister decided to wait with me. The clock ticked. Over 40 minutes passed. When I told her about how long they had had Nataliť and what had happened, she went out to find out what was up. She came back to tell me that Nataliť had indeed been moved up to my floor, but to the nursery there. They had her hooked up to all sorts of monitors and told me that I could not see her because she could not be brought to me, and I could not get out of bed because of my catheter. I went ballistic. 

My sister left again and told them that I was going to flip out if I could not see my baby. She must have moved heaven and earth, because they unhooked Nataliť from all of her monitors and brought her to my room. This horribly mean, huge woman with an inch of makeup on named J---- was her nurse and would not hand her to me. She held her in front of me and lectured me on how many babies they had to take care of more important than mine, and that she didn't have time to cater to my wants to see my baby, and that she was their responsibility until the head Nurse Practitioner signed off on her. 

I lost it - I told her not to be rude to me and to please just let me hold my baby. She said, "I am TRYING not to be rude to you. You have to understand that we are busy. We have babies much more important than yours, with much worse problems." Blah blah blah. I didn't even hear her mouth talking after that. I went off. I said, "This is MY baby. You have had her for 10 hours. You did not even tell me she was OK, or what was wrong, or if I wanted to feed her. Someone took her from my room with an assurance they would be right back, and now you are telling me she is your responsibility. She is MINE. You can't just take her." I was sobbing uncontrollably. She tried to argue with me and raise her voice. My nurse, my husband, my sister, and this woman were all crowded into my tiny room, looking at me. She was still holding my baby! I said, "Just give me my baby," over and over. After much lecturing about how I only had 5 minutes, she handed me Nataliť. I just buried my head in her and took deep breaths. 

The 5 minutes was no joke and she was back to take her quarry. I asked how long until I could have Nataliť back. She said the head Nurse Practitioner came on at 10, and she would evaluate her then. She haughtily said that Nataliť would probably be released, but no guarantees. I told her I would wait until 10:30 before I started calling and asking. My loss of control had made its mark though; her pride was stepped on. She was not going to be doing me any favors. I waited with my sister, a lifesaver, and we made lists of questions to ask and what we would do. We called my doula and a friend who used to work at the hospital for advice. At 10:15, there was a knock and K--, the head Nurse Practitioner, had come to see me. She was nice but extremely patronizing. I apologized for losing it with her nurse, and tried to outline my frustration coherently. She said she had come to see me that afternoon, but that I was sleeping. This made me mad...they woke me every hour for blood pressure and temperature checks anyway! 

She also defended herself that everything had been explained to my husband.  I was baffled at their ignorance; my husband is obviously foreign and has heavily accented English and no knowledge of medical terms. She said they had no idea (right!). She in turn explained to me that Nataliť's esophagus was weak; that the cartilage rings had not hardened fully. She said that she was getting plenty of oxygen, the tests showed, and so she would release her to me when she got back to the nursery. She said the condition was somewhat common, and not dangerous because the esophagus was not closing completely. She also said her little nasal passages were swollen from all the aspirations. Apparently, they had aspirated her a 3rd time in the nursery for fluid her lungs. She was having a hard time breathing. The "test" with the bottle was to see if she could both breathe and suck at the same time; basically, to check and see if her nursing problem was physiological.

The huge, horrid nurse brought Nataliť back to me about an hour later. It was almost midnight by now. She triumphantly told me that I could have her in my room, but only on the condition of "supervised feedings." I was surprised and asked what this meant. And she said, every 2 hours she would come and "supervise" while I tried to nurse Nataliť. I asked her why, and she said that they were concerned that Nataliť would starve without enough food, because I didn't want her to have a bottle or formula. I was shocked.  I agreed, though, because all I wanted was to hold my baby. I took her out of her bassinet and laid her on my chest and dozed while looking at her sleep. I was completely on my guard for whoever wanted to steal her away again! That mean nurse did indeed come to "supervise" her feeding. I apologized to her for my outburst in an attempt to smooth her ruffled feathers if we had to get along in the middle of the night, and she had the power to take my baby away from me. She eventually warmed up a little and tried to "help" me feed Nataliť by trying nipple shields and this odd syringe and tube contraption that fed formula into the nipple shield so the baby would supposedly get the idea to latch on. Nothing worked, of course. I was very quiet and listened while she went on to tell me she had not had enough milk for her son and had to supplement with formula, and it was no big deal, and she had no idea what the lactation people were so worked up about anyway. She told me that giving a bottle or formula was fine, and would not cause any of that "nipple confusion" nonsense they were so worried about. She was very opinionated about it.

I finally just gave up. They broke me. I was running on only a few hours of drug-induced sleep, had been medicated within an inch of my life, was in severe pain from my section (I cannot take narcotics so I requested only 800mg of Ibuprofen), and felt rejected by my own baby and totally inadequate for not being able to figure out how to breastfeed my child. So, I let the nurse bottle feed my little Nataliť. And thus began my resolve to get the hell out of that hospital. I kept pumping my breasts anyway, in hopes that maybe when I got in the privacy of my own home I could do it. I had no idea just how bad letting her have a bottle was. 

[I finally eventually got the Foley catheter out and was able to take a shower. The next day, a]  nicer lactation consultant came that day, and she brought me a bottle of sterile water to mix with the colostrum I pumped to feed Nataliť. I never fed her formula again! They moved me to the 12th floor that day and I think they sort of forgot about their "monitoring" of my feeding, so I kept feeding her only my colostrum and water. I fed it to her in the bottle when they were looking, and in the cup when they were not. I was largely ignored once they moved me to the 12th floor, because I was no longer considered "high risk".

That night I was awake most of the night. I held Nataliť all night and plotted my way out of that place. It felt like jail. By 12 the next day, I was signed out...after about 6 lectures and 20 signatures, I was free. All I wanted was OUT, where I could get to know this precious little baby I hardly knew but already loved. It took them almost an hour to find the "large" wheelchair.  I just kept asking. I had this feeling of urgency...I was so afraid they would find some reason or other to keep me or Nataliť there.

The next few days were tumultuous and difficult. I had a severe bladder infection from the catheter and it hurt like heck every time I peed. I had to call the Dr. for antibiotics. Fun, more meds. Nataliť would not nurse any more at home than in the hospital, so I pumped constantly and was nauseated from the Ibuprofen. My mother was a godsend and cooked for me, made sure I got my meds, patted my head when I cried (which was a lot) and cared for Nataliť. She changed her and brought her to my bed for feedings. I could still barely walk. We tried breastfeeding almost every time but she would try to latch on, then rear back and cry wildly and gasp. I was afraid she couldn't breathe. I would then feed her my milk, which came in the day I escaped the hospital, from a bottle. I was over-engorged and my breasts were dripping constantly...it was painful, miserable, and sad because I didn't know why I couldn't feed my own baby. I began to get discouraged after a few days and was weeping over the thought of having to switch to formula. I considered pumping and bottle feeding, but I was so miserable and it didn't seem practical.

I followed my sister's advice and decided to make a final last-ditch effort and call her friend, who was a lactation consultant, post-partum doula, and general baby expert. After my previous experience with "experts", I didn't expect much. But I had met this woman before and liked her very much so I decided to do it. She agreed to meet with me. We had been emailing for a day or two, and her responses were so helpful, I knew that this was it: if she could not help me, it was over. My mom taxied us out to her office about 45 minutes away on a miserable pouring rain day. But once in her office, she handed me a nipple shield. I looked at it dubiously. She told me how to put it on (something the hospital staff never did, they just shoved it at me) and she took my baby from me and checked out her mouth, tongue and nose. She declared her perfect and then showed me how to hold her. She explained that back-arching babies have to have their arms and legs spread in order to "open up" to nursing. She showed
me how to hold her. With one try, Nataliť latched on and nursed without stopping for 20 minutes. I think I smiled the entire time. My mom and I were exclaiming over and over, "Look at her, look at her!" She was nursing like she knew all along. Well of course she did!

I was struck with gratitude for this wonderful woman who saved my relationship with my baby and made me realize that it was not my baby or I who was defective, but the people at the hospital! Imagine, in about 4 minutes our whole world was righted. Why couldn't someone at the hospital simply shown me how to hold her instead of telling me to keep my hands away? Was a back-arching baby so rare? I doubt it. I grinned all the way home and our lives changed forever that instant. I began to heal, and Nataliť was calmed. 

I love my daughter more than anything in this world and would do it all again for her. I am just so deeply sorry her start in life was so abrupt, so tragic, and so stressful. I wish I could take it all back and be more knowledgeable, healthier, and have been able to save her from nurses, probing, bottles, formula, separation, and everything else. I pray every day that she feels secure and loved.  And I am eternally grateful to the woman who made it possible for me to nurse my baby.

 

Breastfeeding Resources

Websites and Organizations

The Breastfeeding Advocacy Page (www.promom.org)

Extensive discussion and documentation on the many benefits of breastmilk. Excellent resource, with many medical references and studies examined. One of Kmom's favorites!

Breastfeeding.Com (www.breastfeeding.com/helpme/)

Superb site devoted to helping mothers nurse. Usual advocacy information, but its best value lies in its extensive photos of babies nursing in various positions, even video clips of how to do the various positions (including the much-neglected football hold!). Extensive photography of nursing babies, including twins, tandem nursing (toddler and newborn), multiethnic nursing mothers, etc., plus lots of beautiful artwork of nursing mothers from ancient to modern art.

The Breastfeeding Helpline (900) 448-7475, ext. 55 ($1.99 per minute/avg 5 minutes; some sources list ext. 65 instead)

Recorded information available, counselors available during certain hours (La Leche League Service) .

CARE NW (Care and Advice on Reproductive Exposures) 1-900-225-CARE ($3 first minute, $2 for each additional)

This *INVALUABLE* service provides information on the effects of drugs and other exposures on the developing fetus and during lactation. If you are not sure about the safety of a certain drug or chemical exposure during pregnancy or during breastfeeding, they will research it for you. They often have access to more complete information than your physician. Their services were formerly available only to residents of the Pacific Northwest, USA, but they have now opened up to service elsewhere through the use of the 900 number.

Hale's Medications and Mother's Milk (http://neonatal.ttuhsc.edu/lact/)

THE most reliable source for up-to-date information about medications while nursing is this book. It is updated every year; every medical library and pediatrician should have it. Unfortunately, not all do. A smaller version of the book is available at the website plus information about the full book. If you really need to access this book, call a large local hospital and ask for the medical librarian. If they do not have this book ask if they can borrow it from another hospital or library. If not, they can probably photocopy the page of the medication in question for you and mail it to your local hospital. Most hospitals do this for free, but some may charge a small amount. If you cannot find a hospital with this book, La Leche League ( www.lalecheleague.org ) has it for sale now.  

La Leche League International 1-800-LA-LECHE 1-847-519-7730 (http://www.lalecheleague.org/ )

Excellent resource for information/support for nursing. Call to find the nearest meeting, to get in contact with a volunteer leader for questions, or to get a referral to a good lactation consultant. Also check out the web site! The best time to start attending meetings is BEFORE you deliver. Some women are afraid LLL is too radical for them; most do not find it so, but quality depends on the local leadership. However, the philosophy is "take what you need and leave the rest behind," so if you don't agree with something, ignore that recommendation. Truly an exceptional resource. Also offers many fine pamphlets on nursing-related topics/concerns.

Nursing Mother's Counsel  ( www.nursingmothers.org

An organization of one-to-one support, similar to La Leche League in some ways.  The website will have information on the counselor nearest you.  

Lactnet Archives  (http://library.ummed.edu/lsv/archives/lactnet.html)

Archives of past discussions of bfing topics on mailing lists for lactation consultants.  A good way to research a particular bfing topic and get a wide variety of opinions and ideas.  A bit clunky to use, but lots of valuable information onsite, so well worth going to.

International Lactation Consultant Association (ILCA) (919-861-5577, www.ilca.org

Organization of professional lactation consultants who have passed and taken their boards to become board-certified lactation consultants.  To find a professional lactation consultant in your area, consult the national registry at www.iblce.org/registr2.html (919-861-5577).  Or go to www.breastfeeding.com and click on the map of the USA, click on your state, and get a list of IBCLCs in your general area.

Medela, Inc. Breastfeeding Tips and Products 1-800-TELL-YOU (835-5968) (www.medela.com )

Call for Breastfeeding Advice Booklet that gives hints on breastfeeding, as well as offers several Medela products. Offers many supplemental nursing aids, including the Haberman Feeder, the Hazel Baker Finger Feeder, the Supplemental Nursing System, several different types of cups for cup feeding, etc.  

Lact-Aid International, Inc.  (423-744-9090, www.lact-aid.com

A nursing system that helps moms build up supply while still letting baby receive any needed supplements.  A bag containing the supplements goes around the neck.  A tube comes out of the bag and is taped onto the mom's nipple, so that baby can suckle to stimulate mom's supply while simultaneously receiving supplements as needed.

Nursing Mother's Association of Australia (http://home.vicnet.net.au/~nmaa )

A La Leche League-type organization for Australia; anecdotal reports Kmom has heard have been very positive. Contact them for support for nursing or for consultation if you encounter problems.

Pumping Moms' Website ( www.pumpingmoms.org )

Website with support groups, information, and advice for women who use pumping to supply breastmilk for their infants.  This includes moms who work outside the home, and moms who must pump because of medical reasons like a premature infant or a cleft-affected baby.  

parent-l mailing list (parent-l-request@uts.edu.au )

An extensive, high-volume mailing list designed to support breastfeeding and parenting the nursing child. There is an emphasis on extended breastfeeding and attachment parenting. To subscribe to the single message mode simply send a message with 'subscribe' in the body of the message.

Rx List (www.rxlist.com )

Provides free comprehensive information about 4000 commonly prescribed drugs. However, if this list is like the Physician's Desk Reference, it is overly conservative because of liability fears, and may list certain drugs as incompatible with nursing when under certain circumstances they might be ok. Use this list as an adjunct resource but not as your sole resource when researching drugs and lactation.

Breastfeeding After a Breast Reduction ( www.bfar.com )

Information about breastfeeding after having a breast reduction operation. La Leche League now carries a book written by some of the BFAR members about breastfeeding after a reduction, too.

MOBI - Mothers Overcoming Breastfeeding Issues  (www.internetbabies.com/mobi/)

Excellent resource for mothers having difficulty breastfeeding.  Open and non-judgmental, it supports women in whatever choice they end up making. If the mother wants to continue breastfeeding, it offers lots of information and support for that, and if the mother wants to stop because it is just too stressful, there is support there also for that.  Lots of emotional support for women to work through grieving issues about bfing problems, too.   

Neurodevelopmental Treatment Association  (312-321-5151, 401 N. Michigan Avenue, Chicago, IL 60611-4267)

Physical therapists who are specially trained in assessing and treating infant feeding problems, especially sucking problems.  

Breastfeeding Online: Articles, Advice and Encouragement ( http://users.erols.com/cindyrn)

Set of articles by Dr. Jack Newman, an expert on breastfeeding issues.  Articles on many various subjects, including finger feeding, cup feeding, jaundice, and many other issues.  Many articles by other people as well on galactagogues (herbs and medicines for increasing milk production), using a lactation aid, adoptive breastfeeding, and many others.  Excellent resource.

 

Nursing Books

These are the best nursing books, in Kmom's opinion; Your Mileage May Vary! You can find these books through:

The Nursing Mother's Companion, Kathleen Huggins, 4th Revised Edition, c. 1999.

By far the easiest-to-use and most practical of nursing guides. Pack this one in your hospital bag! Especially useful is the quick-reference Survival Guide for the First Weeks--much easier to use for trouble-shooting if you have any questions. 

The Womanly Art of Breastfeeding, La Leche League International, 6th Revised Edition, c. 1997.

Classic text on breastfeeding, very well-done. The section on medical benefits of breastfeeding is superb---a must-read.  Some topics are not as well-addressed, however, and some women find it very preachy---YMMV.  Still, an excellent resource.

So That's What They're For! Breastfeeding Basics. Janet Tamaro, c. 1996.

A more humorous approach to breastfeeding, but still full of useful information. A great book to get if you are not sure whether you want to nurse or not, or if you think you should but are not really crazy about the idea. Good for spouses too. Good book, but don't make it your only nursing manual; use it in tandem with another nursing manual like Nursing Mother's Companion or Womanly Art of Breastfeeding. 

 

References

Cesareans Affect Breastfeeding Rates

Perez-Escamilla, R et al. The Association Between Cesarean Delivery and Breast-Feeding Outcomes among Mexican Women. Am J Public Health. June 1996. 86(6):832-836.

This study examined the impact of cesarean delivery on the initiation and duration of breastfeeding among 2517 Mexican women. Multivariate Logistic Regression was used to determine the odds ratio of cesarean mothers not initiating breastfeeding (odds ratio=.64) or for breastfeeding less than one month (odds ratio=.58). If c/s mothers were able to successfully initiate bfing and nurse for at least a month, a c-section delivery was not found to be related to the overall duration of bfing. C-section was found to be a very significant factor in impacting breastfeeding rates. "It is desirable to provide additional breast-feeding support during the early postpartum period to women who deliver via cesarean sections."

Weiderpass, E et al.  Incidence and Duration of Breast-Feeding by Type of Delivery: A Longitudinal Study in Southeastern of Brazil.  Rev Saude Publica.  June 1998.  32(3):225-31.  [from abstract]

665 children born in SE Brazil were studied for the first 3 months of life through home visits.  Bfing during was similar among babies born by vaginal delivery or emergency cesarean.  However, babies born by elective cesarean had 3x the risk for stopping bfing in the first month of life.  The increased risk did not persist into the third month of life, indicating that cesarean women are at increased risk of not initiating bfing or of abandoning it prematurely, but that those who persisted beyond a month were able to breastfeed long-term.

Menghetti, E et al. The Nutrition of the Nursing Mother in Light of a Study of 200 New Mothers.  Minerva Pediatr.  Jul-Aug 1994. 46(7-8):331-4. [from abstract]

200 new mothers who breastfed their babies were followed over 2 months, and their diet monitored.  72% of mothers who gave birth vaginally were still bfing after2 months, but only 28% of those who gave birth by cesarean were still bfing at 2 months.  The translation in the abstract is confusing; it looks like it is saying that the cesarean mother sees the baby and puts it to the breast "before it is 3-4 days old."  It appears that they are pointing out that delay in access may be part of the reason for lower bfing rates among cesarean mothers.

Vestermark, V et al.  Influence of the Mode of Delivery on Initiation of Breastfeeding.  Eur J Obstet Gynecol Reprod Biol.  January 1991.  38(1):33-8.  [from abstract]

370 mothers of singleton babies were compared for initiation and prevalence of breastfeeding after discharge from the hospital.  Babies delivered by vacuum extraction or by cesarean section started suckling later, were given more formula in the first 4 days, were breastfed less often at night, and the mother's milk came in later.  However, once the mother was discharged, the prevalence of breastfeeding was not affected.  

Ever-Hadani, P et al. Breast Feeding in Israel: Maternal Factors Associated with Choice and Duration.  J Epidemiol Community Health.  June 1994.  48(3):281-5.  [from abstract]

Surveyed 8486 women about breastfeeding history of first child after giving birth to the second child. Failure to start breastfeeding was strongly predicted by cesarean delivery, as well as infant's birth weight, maternal smoking habits, and mother being a non-immigrant.  

Mansbach, IK et al.  Onset and Duration of Breast Feeding Among Israeli Mothers: Relationships with Smoking and Type of Delivery.  Soc Sci Med.  1991.  33(12):1391-7.  [from abstract]

Studied 190 mothers of first-born, 6 month-old infants to examine the mechanisms that affect onset and duration of bfing.  Even when controlling for educational level, cesarean mothers are less likely to begin breastfeeding.  However, once begun, mode of delivery is not significant.  Emphasizes the importance of reaching out to cesarean moms to help them initiate bfing while still in the hospital.  

DiMatteo, MR et al.  Cesarean Childbirth and Psychosocial Outcomes: A Meta-Analysis.  Health Psychol.  July 1996.  15(4):303-14.  

A meta-analysis examines the results of many different studies to see if there are trends and how strong these associations are.  This literature review examined the difference between vaginal and cesarean birth on 23 psychosocial outcomes of birth.  It found that cesarean mothers, as a group, expressed less satisfaction with the birth (both short-term and long-term), were less likely ever to breastfeed, had a longer time to first interaction with their babies, had less positive reactions to them after birth, and interacted less with them at home.  

Nissen, E et al.  Different Patterns of Oxytocin, Prolactin But Not Cortisol Release During Breastfeeding in Women Delivered By Caesarean Section or by the Vaginal Route.  Early Hum Dev.  July 1996.  45(-2):103-18. [from abstract] 

Authors studied whether hormonal patterns differ by mode of birth.  17 mothers who had an 'emergency' cesarean and 20 mothers with a normal vaginal birth had blood samples taken on day 2.  Researchers examined the number of oxytocin pulses, and the levels of prolactin and cortisol.  Vaginal birth moms had significantly more pulses of oxytocin than the cesarean moms, and had more of a rise in prolactin levels as well.  After analysis, the strongest variables related to the release pattern of oxytocin were mode of delivery (vag. vs. c/s) and infant's age at first nursing.  This study may shed some light on why milk may come in a bit later in some cesarean mothers.

Kearney, MH et al.  Cesarean Delivery and Breastfeeding Outcomes.  Birth. June 1990.  17(2):97-103.  

Unlike most other studies, this study of 121 first-time moms did not find that cesarean delivery affected bfing rates.  Cesarean moms did have a later first breastfeeding and were less satisfied with their birth experience, but in this sample it did not affect bfing rates significantly.  The authors speculate that "the high level of commitment to breastfeeding in this sample may have overcome the effect of perinatal events."

Janke, JR.  Breastfeeding Duration Following Cesarean and Vaginal Births.  Journal of Nurse-Midwifery.  July-August 1988.  33(4):159-64.  

Another study like Kearney's that found that despite later feedings and less satisfactory birth experiences, the breastfeeding rate between c/s and vaginal birth groups was not significantly different.  (It was somewhat less in the cesarean group but this difference did not rise to statistical significance.)  "Among the cesarean birth women, the only variable found to be associated with successful breastfeeding was the degree of commitment reported by the mother in the hospital...The greater the commitment, the more likely the woman would still be breastfeeding at 6 weeks."  However, do note that the study's population was largely white, married, middle class or more, and at least high-school grads.  Many had had prior experience with breastfeeding as well.  This may also have influenced the degree of breastfeeding success as well. 

Delay In First Nursing After Cesarean

Dasgupta, A et al.  Breast Feeding Practices in a Teaching Hospital of Calcutta Before and After the Adoption of BFHI (Baby Friendly Hospital Initiative).  J Indian Med Assoc. June 1997.  95(6):169-71, 195.  [from abstract]

Two groups of 102 mothers were compared before and after the intro of the Baby Friendly Hospital Initiative, which among other things, suggested guidelines for time to first breastfeeding after birth. Of the vaginal births, only 14.3% were given their first nursing within the ideal time of half an hour after birth.  Of the cesarean births, NOT A SINGLE BABY was given their first nursing within the stipulated time period of 4-6 hours.  Authors note that overall the BFHI has helped reduce the time gap between birth and first nursing in all types of delivery, and reduced non-nursing feedings (i.e. bottles of formula or glucose water), but that there is still progress to be made.  [Kmom's Note: There is no need in most cases for a cesarean baby to wait even 4-6 hours to be nursed.  Most can nurse within an hour or two, at most. Although striving to reach these guidelines is improving care and breastfeeding rates somewhat, these 'ideals' do not necessarily represent the most optimal timelines.] 

Chapman, DJ and Perez-Escamilla, R. Identification of Risk Factors for Delayed Onset of Lactation. Journal of the American Dietetic Association.  April 1999.  99(4):450-4.  

Studied 192 women after they gave birth to a healthy, term singleton baby, and analyzed risk factors for delayed onset of lactation (delay in mature milk coming in).  Risk factors that were significant included white/Hispanic ethnicity, heavy/obese body build, unscheduled cesarean delivery, vaginal delivery with a prolonged stage 2 labor, infant birth weight less than 8 lbs, and exclusive formula feeding before onset of lactation.    The 'heavy/obese' body build factor may actually instead be a marker for Poly Cystic Ovarian Syndrome, which is often accompanies by obesity, and can affect milk supply in some women with PCOS.  Or it may be a marker for a higher cesarean rate (with correspondingly higher blood loss rate and anemia that may affect milk supply).  

Sozmen, M.  Effects of Early Suckling of Cesarean-Born Babies on Lactation.  Biol Neonate.  1992.  62(1):67-8. [from abstract]

20 cesarean mothers who suckled their infants early were compared to 20 cesarean mothers who suckled late and provided supplementary foods to their babies.  The colostrum and milk-ejection periods of the early-suckled group were significantly better than the group that was suckled late.  "The results show that the chance of infants born by cesarean section of being fed by maternal milk could be increased by early and regular suckling of the maternal milk."  

*Also see Mathur et al., 1993, and Samuels et al., 1985 below

Importance of Early and Frequent Nursing

Yamauchi, Y and Yamanouchi, H.  Breast-feeding Frequency During the First 24 Hours After Birth in Full-Term Neonates.  Pediatrics. 1990.  86:171-75.  

"One study that followed two groups of newborns from birth found that on their third day of life the milk intake of the babies who nursed six or fewer times per day was only about 54% of that of the babies who nursed seven to eleven times per day.  The babies who nursed more frequently also lost less weight initially and began regaining their birth weight more quickly.  The difference in intake continued to be significant through the fifth day of life, when the group nursing less frequently consumed 83% of the milk consumed by the more frequently nursing group."  (summary from The Breastfeeding Answer Book.)  

The study also notes that there was a strong dose-response relationship between breastfeeding frequency and bilirubin (jaundice) levels.  The incidence of significant jaundice was 7.7% in babies nursed 7+ times in 24 hours, and 22.8% in babies nursed less than 7 times in 24 hours.  Frequent nursing also increased early milk production (as noted above) and increased infant weight gain during the first week.  The authors conclude, "Our study suggests that many of the neonatal clinical problems related to breast-feeding are iatrogenic and could be ameliorated by education of mothers and nurses and by changes in hospital practices related to breast-feeding."

*Also see Samuels et al., 1985 below, and Sozmen 1992 above.  

Breastfeeding and Pacifiers

Righard, L and Alade, MO. Breastfeeding and the Use of Pacifiers. Birth. June 1997. 24(2):116-120.

82 exclusively breastfeeding mother-infant pairs were followed up for 4 months to study the effect of pacifier use on breastfeeding duration. "The breastfeeding rate at 4 months was 91% in the nonpacifier group and 44% in the pacifier group (p = 0.03). An incorrect superficial nipple-sucking technique at the breast from the start combined with pacifier use resulted in early weaning in most cases. To promote successful breastfeeding and to reduce nursing problems, an incorrect sucking technique should be prevented or corrected, and the use of pacifiers should be avoided or restricted."

Righard, L.  Are Breastfeeding Problems Related to Incorrect Breastfeeding Technique and the Use of Pacifiers and Bottles?  Birth.  March 1998.  25(1):40-4.

52 mother-infant pairs with bfing problems were referred to a nursing clinic in Sweden; 40 pairs without bfing problems served as a control group.  Most nursing problems were caused by incorrect sucking technique.  Less women continued to bf if the infant was already used to bottle-feeding.  "Pacifier use was more common in conjunction with breastfeeding problems and in cases with a faulty superficial nipple-sucking technique."  

Victora, CG et al.  Use of Pacifiers and Breastfeeding Duration.  Lancet.  February 13, 1993.  341(8842):404-6.  

354 infants in Brazil were followed to evaluate the impact of pacifier use on early weaning.  "Among 24 children still breastfed at 1 month, the risk that a child would be weaned at an age between 1 and 24 months was higher in pacifier users than in non-users (hazard ratio 3.0...).  The association remained even after adjustment for the child's age, sex, birthweight, socioeconomic status, and age at introduction of bottlefeeding."

Formula and Supplementation Lowers Breastfeeding Rates

Blomquist, HK, et al. Supplementary Feeding in the Maternity Ward Shortens the Duration of Breast Feeding. Acta Paediatr. November 1994. 83(11):1122-1126.

Compared the breastfeeding rate at 3 months postpartum for 521 babies born in a certain maternity unit. Analyzed a number of factors, including supplementary feedings (mother's milk, donor milk, or formula), to see how they related to 'long-term' breastfeeding rates at 3 months. Using a multiple logistic regression analysis, found that infants given a supplementary feeding had 4x the risk of not being breastfed at 3 months. Other risks also included maternal age <25 years, maternal smoking, and an initial weight loss of 10% or more (who would be likely to be supplemented). "Thus the administration of supplementary donor's milk or formula during the early neonatal period was associated with an increased risk of a short duration for breast feeding, even after adjustment for a number of potential confounders."

Samuels, SE et al.  Incidence and Duration of Breast-Feeding in a Health Maintenance Organization Population.  Am J Clin Nutr.  Sept. 1985.  42(3):504-10.

Studied 632 women delivering between May and August of 1980 in a heterogeneous HMO population.  Found that cesarean deliveries discouraged breastfeeding, as did receiving formula in the hospital.  Formula supplementation in the hospital was associated with a shorter breastfeeding period.  Nursing immediately after delivery and keeping the infant in the room during the hospital stay encouraged breastfeeding.  

Cronenwett, L et al. Single Daily Bottle Use in the Early Weeks Postpartum and Breastfeeding Outcomes. Pediatrics. 1992. 990(5):760-66.

Found that "30% of mothers whose babies received bottles in the hospital reported severe breastfeeding problems, as compared with 14% of those whose babies did not."

Hill, PD et al.  Does Early Supplementation Affect Long-Term Breastfeeding? Clin Pediatr (Phila).  June 1997.  36(6):345-50.  

Women who intended to breastfeed were followed for 20 weeks postpartum (or until they weaned their babies).  Bfing rates were compared between those in each group who were supplementing with manufactured formula in week 2 and those who were not.  Two different sample groups were followed.  As expected, those whose infants exclusively received human milk only breastfed for a longer period of time than those who were supplemented with formula.  In sample one, bfing rates were 63%  vs. 28%; in sample two, bfing rates were 58% vs. 24%.   The two groups had no other significant differences and were not different in their intended duration of bfing.  The authors conclude, "Early introduction of supplemental bottles of artificial milks is associated with a decrease in the amount of human milk the infant receives as well as with early weaning."

Freed, GL et al. Pediatrician Involvement in Breast-Feeding Promotion: A National Study of Residents and Practitioners. Pediatrics. September 1995. 96(3 Pt 1):490-494.

"This study was designed to assess pediatricians' knowledge, attitudes, training, and activities related to breast-feeding promotion" through the use of a random survey mailing to pediatricians and pediatric residents (over a thousand responded). "Their clinical knowledge and experience did not suggest a high degree of competency." For example, a number were not aware of breastfeeding's protective effect against ear infections, and many recommended inappropriate breastfeeding termination or formula supplementation. "Only 64% of practitioners and 52% of residents knew that supplementing during the first few weeks of life may cause breast-feeding failure." For both groups, prior personal breastfeeding experience (themselves or their spouses) was a major determinant of knowledge and activity. "Residents reported that the breast-feeding instruction provided during training was primarily in lecture format, with limited clinical opportunities to practice skills needed to assist breast-feeding mothers...These results indicate that residency training does not adequately prepare pediatricians for their role in breast-feeding promotion. Improvements in residency training and innovative continuing education programs should be implemented to help pediatricians meet the needs of their breast-feeding patients."

Howard, C et al.  Office Prenatal Formula Advertising and Its Effect on Breast-Feeding Patterns.  Obstet Gynecol.  February 2000.  95(2):296-303.  [from abstract]

Randomized, controlled trial of 547 women exposed to either infant feeding materials produced by formula companies (with ads), or breastfeeding promotional materials without formula ads.  While breastfeeding initiation rates and duration after 2 weeks were not affected, women in the formula ads group were more likely to cease bfing before hospital discharge (5.8x risk) and before 2 weeks (1.9x risk).  Women with uncertain or short-term goals about bfing were especially effected.  The authors conclude, "Educational materials about infant feeding should support unequivocally breast-feeding as optimal nutrition for infants; formula promotion products should be eliminated from prenatal settings."

*Also see Mathur et al, 1993, below

Rooming-In and Breastfeeding

Flores-Huerta, S and Cisneros-Silva, I.  Mother-Infant Rooming-In and Exclusive Breast Feeding.  Salud Publica Mex.  March-April 1997.  39(2):110-6.  

178 healthy mother-child pairs with term pregnancy were studied.  90 pairs used rooming-in ("joint lodging") and 88 pairs did not.  In the first month, exclusive breastfeeding was 61% in the rooming-in group and 42% of the non rooming-in group.  Mode of birth in this study did not make a difference; the only variable which significantly influenced exclusive breastfeeding rates was rooming-in.

Mathur, GP et al.  Breastfeeding in Babies Delivered by Cesarean Section.  Indian Pediatr.  November 1993.  30(11):1285-90.

100 mothers having a cesarean were studied regarding what factors affected the establishment of breastfeeding during their stay in the hospital.  65.7% of women who had an elective cesarean were breastfeeding exclusively vs. 53.8% or women who had an emergency cesarean. 62.8% of women who had a spinal for their cesarean were breastfeeding, vs. only 28.6% of women who had had a general.   All those women who had nursed their babies within 12 hours of the surgery were practicing total bfing, but it's shocking to note that only 9/100 women were able to nurse their babies within 12 hours of surgery!  Very poor rate.  Only 5.8% of mothers who started nursing after 96 hours (4 days) were still bfing.   86.8% of those who received their first feeds by spoon were still practicing total bfing, while only 33.3% who received first feedings by bottle were still nursing.  Finally, rooming in helped breastfeeding; 68.1% were still on total breastfeeding, vs. 35.5% of those separated from their mothers. The authors note, "Early initiation of breastfeeding has highly significant correlation with establishment of breastfeeding, while separation of babies from mothers discourages breastfeeding."

Anderson, GC.  Risk in Mother-Infant Separation Post-Birth. Image: Journal of Nursing Scholarship.  Winter 1989.  21(4):196-99.  [As reported in Midwifery Today, Special Breastfeeding Supplement, 1994.]

The author, a Florida nursing professor, reviews rooming-in benefits and studies, and discusses the limited ways rooming-in is implemented in this country.  She notes that studies show that women who room in with their babies use less pain medication and sleep just as well as those whose babies are in the nursery.  She notes that prolactin secretion is 10x higher in the nighttime, and therefore nursing at night "may be more important than daytime in the establishment of lactation."  Babies who roomed in with their mothers started and cried less than those in the nursery, their vital signs stabilized more quickly, they had lower blood pressures.  In addition, they had better sucks, and got more milk at first feeding.  

*Also see Samuels et al., 1985, above 

Anemia

Willis, CE and V. Livingstone. Infant Insufficient Milk Syndrome Associated with Maternal Postpartum Hemorrhage. Journal of Human Lactation. June 1995. 11(2):123-126.

Examines a possible association between insufficient milk syndrome and maternal postpartum hemorrhage. 10 consecutive cases associated with hemorrhage were examined; all of the babies were 'failing to thrive'. 6 of the 10 mothers experienced a significant drop in hemoglobin, and 2 of the 10 experienced very large drops in blood pressure at times (can be a cause of fainting). 5 infants experienced dehydration and elevated sodium levels. "These data serve to heighten awareness of insufficient milk syndrome as a potential consequence of postpartum hemorrhage. Early postpartum review of all breastfeeding mothers and infants is strongly encouraged."

Henly, SJ et al.  Anemia and Insufficient Milk in First-Time Mothers.  Birth.  June 1995.  22(2):86-92.  

Studied the relationship between anemia (postpartum hemoglobin <10 g/dL) and insufficient milk syndrome in 630 first-time mothers.  22%  of mothers were classified as anemic, but no information was available about treatment of the anemia.  Of the anemic women, almost 20% reported symptoms of insufficient milk syndrome.  Anemic mothers had more symptoms of insufficient milk, had a shorter period of full breastfeeding, and weaned at an earlier age.  Their reasons for weaning were related more to milk supply than to other reasons.  "This study suggests that anemia is associated with the development of insufficient milk, which in turn, is related to duration of full breastfeeding and to age at weaning."  

Bodnar, LM et al.  High Prevalence of Postpartum Anemia Among Low-Income Women in the United States.  American Journal of Obstetrics and Gynecology.  August 2001.  185(2):438-43.  

Retrospective cohort analysis of 59,428 women in the WIC program in 12 states.  Prevalence of postpartum anemia was 27%, rising to as high as 43% in non-Hispanic black women (note: the study states 43% and 48%  in different spots, so Kmom used the lower number just in case).   Prenatal anemia was the strongest predictor of postpartum anemia (2.7x risk); maternal obesity, multiple births, and not breast-feeding also predicted postpartum anemia.  Anemia rates are also high among low socio-economic groups and minorities.  "The high prevalence of post partum anemia among low-income women highlights the importance of anemia screening at 4 to 6 weeks post partum."  Trouble is, delaying screening until 4 to 6 weeks postpartum may cause breastfeeding failure that cannot easily be fixed!  In Kmom's opinion, doctors should be watching for it much earlier than that.

Stress and Breastfeeding

Dewey, K.  Maternal and Fetal Stress are Associated with Impaired Lactogenesis in Humans.  The Journal of Nutrition.  November 2001.  131(11):3012S-5S.  

Reviews the research literature on the effects of stress on lactogenesis.  Found that "Maternal stress seems to interfere with the release of oxytocin, the hormone that is responsible for the milk ejection reflex," and also that "A newborn who experienced stress during labor and delivery may be too weak or too sleepy to latch on and suckle effectively at the breast."   Cites several studies that show that unscheduled cesarean section and/or long duration of labor were major risk factors for delayed lactogenesis.  Also cites one study where the use of relaxation and guided imagery audiotapes before nursing helped nearly double the milk output of a group of pumping mothers of premature babies.  Points out the need for extra expert help in establishing bfing after a difficult birth; unfortunately, many hospitals do not routinely make this a priority.  "Mothers who experience high levels of stress should receive additional lactation guidance during the first week or two postpartum."  

Pain Medications, Anesthesia, and Breastfeeding

Lie, B and Juul, J.  Effect of Epidural vs. General Anesthesia on Breastfeeding.  Acta Obstet Gynecol Scand.  1988.  67(3):207-9. 

28 women who had delivered by cesarean with either general anesthesia or epidurals were examined.  "A significantly higher breastfeeding frequency and longer breastfeeding periods were found after epidural analgesia than after general anesthesia."  

Albani, A et al.  The Effect on Breastfeeding Rate of Regional Anesthesia Technique for Cesarean and Vaginal Childbirth.  Minerva Anestesiol.  September 1999.  65(9):625-30.  

355 cesarean deliveries where the mother had stated that she wanted to breastfeed were examined.  Analysis showed that more mothers who had regional anesthesia (epidural or spinal) breastfed than those who received general anesthesia for their cesareans (95% vs. 85.5%). "Regional anesthesia seems to be advantageous for breastfeeding after cesarean section, probably because of a faster neonatal-maternal bonding if compared with general anesthesia." 

Riordan, J et al.  The Effect of Labor Pain Relief Medication on Neonatal Suckling and Breastfeeding Duration.  Journal of Human Lactation.  February 2000.  16(1):7-12.  

This study is one of the first to specifically study the effect of labor pain meds on newborn suckling behaviors instead of simple neurological measures. 129 mother-baby dyads who had delivered vaginally were divided into 4 groups (unmedicated, epidural, intravenous drugs, and epidural plus IV drugs).  Each baby was evaluated using the IBFAT scoring measure of the effectiveness of neonatal suckling.  Babies of medicated mothers scored lower overall than babies of unmedicated mothers, but overall duration to 6 weeks postpartum was not significantly affected by pain meds.  IBFAT scores were lowest in the group that received both epidurals and IV meds.

"Labor medications impair suckling in the early postpartum period.  Therefore, lactation consultants should be concerned that breastfeeding mothers who have received labor medications may become discouraged, especially if they are discharged before effective breastfeeding is established.  If mothers lack adequate support at home or did not receive follow-up care, babies with poor breastfeeding behaviors are at greater risk for dehydration, jaundice, and poor weight gain." 

Hirose, M et al.  Extradural Buprenorphine Suppresses Breast Feeding After Caesarean Section. Br J Anaesth.  July 1997.  79(1):120-1.  [from abstract]

Authors investigated the effect of postoperative extradural buprenorphine on breastfeeding after a cesarean. They checked the amount of breastfeeding and infant weight gain for 11 days after a cesarean in patients with and without this medication.  Both measures decreased significantly.  "We suggest that extradural buprenorphine suppressed breast feeding after Caesarean section."

Walker, M.  Do Labor Medications Affect Breastfeeding?  Journal of Human Lactation.  1997.  13(2):131-7. 

Review of a series of studies to determine the effect of labor medications on critical neonatal breastfeeding behaviors and time to first 'successful' breastfeed.  IV narcotic medications such as Demerol, Stadol, and Nubain did affect breastfeeding by depressing or delaying behaviors such as rooting and sucking. The longer the infants had been exposed to the medications, the more the feeding behaviors were affected and the longer until the first 'successful' breastfeed.  She noted that every single study reviewed "demonstrated that maternal medication had some effect on the breastfeeding behavior of the baby."  

The effects of epidurals are harder to measure.  Walker's review found NO studies on epidurals that specifically mentioned breastfeeding as an outcome.  Of the studies that do measure behavioral effects of epidurals, designs of the studies do not permit adequate analysis of affect on components that might affect breastfeeding.  Instead, epidural studies examine the behavior of the newborn on behavioral assessment scales, but even these studies use dissimilar drugs and dosages and measure differing behaviors, so comparisons are difficult.  Very few include a non-medicated control group, and even fewer include assessments of infant behavior after 24 hours postpartum.

Walker's review did find 2 studies (Murray 1981 and Sepkoski 1992) which fit these parameters.  Both studies "showed clear depression in motor abilities of medicated babies.  Both studies also showed medicated babies exhibited poor state control.  The developmental agenda for healthy term infants is that of increasing differentiation and control of states.  Medication may delay the process and interfere with the baby's ability to gain control over and modulate state changes in the first 24-48 hours.  Drug induced interference may account for the anecdotal descriptions of 'sleepy' babies (babies unable to exhibit enough state control to breastfeed effectively) and further prolong the period of state disorganization."  

Walker further notes that the most common drugs used in epidurals are known to cross the placenta.  Bupivacaine "enters the maternal blood stream rapidly from the epidural space.  It then crosses the placenta so that a measurable concentration is present in the fetal circulation within 10 minutes of administration."   Narcotics (such as Fentanyl) that are commonly added also "show significant placental transfer."  In a few studies reviewed for her article, some infants were affected by labor medications for as long as a month after birth.  Walker urgently calls for more research that focuses on the effects of epidurals on breastfeeding behaviors in particular.

Ransjo-Arvidson, A et al.  Maternal Analgesia During Labor Disturbs Newborn Behavior: Effects on Breastfeeding, Temperature, and Crying.  Birth.  28(1):5-12.  As discussed by Henci Goer at www.parentsplace.com/expert/birthguru/articles/0,10335,243385_406529,00.html

In this very small study, babies were placed on their mothers' chest after birth.  They were videotaped for the first 2 hours after birth, and then the videotapes were analyzed for instinctive breastfeeding behaviors, successful self-attachment, and successful suckling.  The viewers analyzing the videos were blinded to which group the infants belonged.  

Of the babies whose mothers were completely unmedicated, 10/10 (100%) of the babies successfully self-attached and suckled.  Of the babies in the pudendal block group (mepivacaine injected into the vaginal walls), only 2/6 (33%) successfully self-attached and suckled.  Moreover, one of these was helped by the mother. Of the babies exposed to narcotics, bupivacaine through epidural, or some combo of narcotic, pudendal block, and epidural block, only 3/12 (25%) successfully self-attached and suckled.  One of these was not properly latched onto the nipple.  

Furthermore, the babies of medicated mothers cried substantially more on the tapes, and ran significantly higher temperatures (possibly from crying).  This can be a problem for weight gain after birth because it uses up more calories.  Although this study is small and data with bigger numbers and more uniform medication exposure is needed, it does seem to indicate that medications can affect instinctual breastfeeding behaviors.  

Righard, L and Alade, M.  Effects of Delivery Room Routines on Success of First Breast-Feed.  Lancet.  1990.  336:1105-07.

Found that sucking problems were more common among babies whose mothers had received Demerol.  They also "found that in addition to the effects of labor medication, separating mother and baby before the first nursing also resulted in sucking problems when mother and baby were reunited to nurse, even though the separation was only about twenty minutes long.  Of the babies who had unmedicated births with no separation from mother, 16 out of 17 breastfed well.  Of the babies who had unmedicated births and were taken from mother for about twenty minutes for weighing and measuring, only seven out of 15 babies breastfed well.  Of the babies who had medicated births and were briefly separated from mother, none of the 19 babies breastfed well at the first nursing."  (summary from The Breastfeeding Answer Book.)  

Sepkoski, C et al. The Effects of Maternal Epidural Anesthesia on Neonatal Behavior During the First Month.  Dev Med Child Neurol.  1992.  34:1072-80.  

"Found that babies whose mothers had received epidurals were less alert, less able to orient themselves, and had less organized movements than babies whose mothers gave birth without medication and that these differences were measurable during the babies' entire first month."  (summary from The Breastfeeding Answer Book.)  

Uterine Involution and Breastfeeding

Negishi, H et al.  Changes in Uterine Size After Vaginal Delivery and Cesarean Section Determined by Vaginal Sonography in the Puerperium.  Arch Gynecol Obstet.  November 1999.  263(1-2):13-16.  [from abstract]

This study evaluated 'uterine morphological changes' for 3 months postpartum after vaginal birth and cesarean section, and also in relationship to breastfeeding status.  They found that uterine size after delivery was related at first to cesarean vs. vaginal birth, but that uterine size at 3 months was more related to breastfeeding rates. In other words, breastfeeding helped reduce uterine size (uterine involution) significantly, especially long-term.   

Psychological Impact of Breastfeeding

Laufer, AB. Breastfeeding. Toward Resolution of the Unsatisfying Birth Experience. Journal of Nurse-Midwifery. January 1990. 35(1):42-45.

"The act of birth and the way it is managed have great meaning for many women. What may appear to professionals as a routine or unremarkable delivery may be perceived by the mother as humiliating, mutilating, or dehumanizing. If the mother has an extremely negative perception of her birth experience, she will suffer a loss of self-esteem, and it is more likely that she will have trouble taking on the maternal role. A successful breastfeeding experience builds up a mothers' confidence and self esteem and facilitates acquisition of the maternal role."

Breastfeeding and Special Circumstances

Cordero, L et al. Management of Infants of Diabetic Mothers. Arch Pediatr Adolesc Med. March 1998. 152(3):249-254.

Examined the clinical outcome of infants born to mothers with gd and mothers with pre-existing type one diabetes. Experimented with routine care and normal feedings for these babies (vs. the usual hospital policy of automatic admission to the NICU for observation, testing, and supplementation). Found that most gd babies assigned to routine care did fine.  Breastfed babies had fewer routine care failures that resulted in the baby having to be admitted to the NICU. States that "breastfeeding among women with GDM and IDDM should be encouraged" but does note that many of the routine policies in the past for babies of diabetic mothers (extended admission to the NICU, lapse time to the first breastfeeding, lack of breastpumps and proactive encouragement and assistance) has made bfing rates lower. Actually brags about its 37% rate of exclusively or partially breastfed infants as a satisfactory measure of its 'success'! [Seems like if its lactation program and proactive encouragement were really satisfactory, it ought to have a much higher rate than 37%. Demonstrates that if this is considered high, bfing rates among diabetics must have been particularly pitiful in the past and attests to the many obstacles some diabetic mothers can face.]

Marasco, L et al. Polycystic Ovary Syndrome: A Connection to Insufficient Milk Supply? Journal of Human Lactation.  May 2000.  16(2):143-8.

One of the first *official* reports to document that women with PCOS may have trouble with milk supply and thus with breastfeeding.  Reports a case series of 3 women with an independent diagnosis of PCOS who had major supply problems despite pumping and taking herbs and doing everything 'right.'  Highly interesting because it discusses possible causes for insufficient milk syndrome in PCOS.  No real conclusions, but finally, some official attention to the bfing problems that some PCOS moms experience!  It's a beginning.

Prematurity and Breastfeeding

* more extensive references can be found at www.lalecheleague.org/cbi/biospec.htm 

Gotsch, Gwen.  Breastfeeding Your Premature Baby.  Available from La Leche League International, www.lalecheleague.org

Hylander, MA et al.  Human Milk Feedings and Infection Among Very Low Birth Weight Infants.  Pediatrics.  September 1998.  102(3):E38.  

212 Very Low Birth Weight (VBLW) infants admitted to the NICU were studied.  The incidence of infection was significantly lower in human milk-fed babies (29% vs. 47%), and the incidence of sepsis/meningitis was also lower (19.5% vs. 32.6%).  After controlling for confounding variables, human milk feeding cut the risk of infection by more than half (odds ratio, 0.43), and also cut the risk for sepsis/meningitis by half as well (odds ratio, 0.47).  "The incidence of any infection and sepsis/meningitis are significantly reduced in human milk-fed VLBW infants compared with exclusively formula-fed VLBW infants." 

Hylander, MA et al.  Association of Human Milk Feedings with a Reduction in Retinopathy of Prematurity Among Very Low Birthweight Infants.  J Perinatol.  Sept. 2001.  21(6):356-62.  [from abstract]

The incidence of Retinopathy of Prematurity (ROP) differed significantly by type of feeding:  41% in human milk feedings vs. 63.5% in formula-feedings.  After controlling for confounding factors, human milk feeding cut the risk for ROP by more than half.  The authors suggest that this may be because "Human milk has many antioxidant constituents including inositol, vitamin E, and beta-carotene that may protect against the development of ROP."

Blaymore-Bier, JA et al.  Breastfeeding Infants Who Were Extremely Low Birth Weight.  Pediatrics.  December 1997.  100(6):E3.  [from abstract and from discussion in The Breastfeeding Answer Book.]

Compared the clinical effect of breastfeeding and bottle feeding on 12 Extremely Low Birth Weight (ELBW) infants.  Infants were breastfed and bottlefed for 10 days, and their weight gains, oxygen saturation, respiratory rate, heart rate, and axillary temperature were measured every minute during each type of feeding.  During bfing, the infants had a higher oxygen saturation rate and a higher temperature, and were less likely to desaturate to <90% oxygen.  However, they gained more weight during bottle feeding.  Authors emphasize the need for breastfeeding support to help mother's milk supply, and that some supplementation may be needed to optimize weight gain.  [This assumes that greater weight gain is automatically more advantageous, which it may not be.] This study, among others, disproves that the prior belief among NICU staff that breastfeeding was more work, more stressful, more likely to cause oxygen desaturation, etc.  Breastfeeding is actually easier on preemies than bottlefeeding.

Meier, P and Anderson, GC.  Responses of Small Preterm Infants to Bottle and Breastfeeding. MCN. 1987. 12:97-105.  [from abstract and from discussion in The Breastfeeding Answer Book.]

This study also compared bfing to bottlefeeding and their effects on preemies' transcutaneous oxygen pressure, skin temperature, and feeding ability. 5 infants weighing less than 1500 grams (ages 32-39 weeks) were followed through breastfeedings and bottlefeedings.  Babies tolerated breastfeeding better.  The authors conclude that infant weight as a way to determine readiness to breastfeed should be re-examined, and that putting time limits on breastfeeding sessions is of no benefit.

Meier, P.  Bottle and Breast Feeding: Effects on Transcutaneous Oxygen Pressure and Temperature in Small Preterm Infants.  Nurs Res. 1988.  37:36-41. [from abstract and from discussion in The Breastfeeding Answer Book.]

Examined small preterm infants in how they responded to breastfeeding and bottlefeeding sessions.  71 feeding sessions were examined; 32 by bottle and 39 by breastfeeding.  Transcutaneous oxygen pressure patterns "suggested less ventilatory interruption" during breastfeeding than during bottlefeeding.  Infants became warmer during breastfeeding than bottlefeeding.  Calls for replication of results, but "these results do not support the widely held assumption that breastfeeding is more stressful than bottlefeeding for small preterm infants."

Schanler, RJ et al.  Feeding Strategies for Premature Infants: Beneficial Outcomes of Feeding Fortified Human Milk Versus Preterm Formula.  Pediatrics.  June 1999.  103(6 Pt 1):1150-7.  

"The benefits of improved health (less sepsis and necrotizing enterocolitis) associated with the feeding of fortified human milk outweighed the slower rate of growth observed in this study of 108 preterm infants.  Infants fed human milk were discharged an average of 15 days earlier than infants [on] preterm formula."  [as summarized on the above LLL web page]

Valentine, CJ et al.  Hindmilk Improves Weight Gain in Low-Birth-Weight Infants Fed Human Milk.  J Pediatr Gastroenterol Nutr.  May 1994.  18(4):474-7.

Many low-birthweight babies have a hard time gaining weight initially, and this may be especially true of those fed human breastmilk.  This study hypothesized that by emphasizing the consumption of hindmilk (the richer, fattier, and more caloric milk that is produced at the end of pumping/nursing), preemies' weight gain could be improved while still receiving all the immunological benefits of human milk.  Mothers who had an abundance of milk through pumping and who were non-smokers were asked to pump two separate bottles; one of 'foremilk' from the first 3 minutes of pumping, and one of hindmilk, from the rest of pumping.  Dividing the milk like this was called 'fractionating.'  

The fractionated fat-rich hindmilk was then preferentially fed to the preemies (fortified with standard preemie fortifying formula).  Hindmilk samples were also analyzed for composition; hindmilk was found to be richer in fat and calories.  The babies gained significantly better on the hindmilk than they did when previously fed milk made up of a composite of foremilk and hindmilk.  One strategy that bfing preemie mothers can use, then, is to preferentially feed hindmilk as a way to help the baby increase its weight gain.  Babies should get foremilk sometimes too; but making sure they get plenty of hindmilk is important to weight gain.  

Hurst, NM et al.  Skin-to-Skin Holding in the Neonatal Intensive Care Unit Influences Maternal Milk Volume.  Journal of Perinatology.  May-June 1997.  17(3):213-7.  [from abstract]

This study found that mothers who held their babies skin-to-skin (kangaroo style, few or no clothes) resulted in a significant increase in milk production volume compared to those who did not hold their babies skin-to-skin.

Bier, JA et al.  Comparison of Skin-to-Skin Contact with Standard Contact in Low-Birth-Weight Infants Who Are Breastfed.  Arch Pediatr Adolesc Med.  December 1996.  150(12):1265-9.  

Evaluated the effects of skin-to-skin contact on the preemie's physiologic status, the mother's milk production, and the duration of bfing.  Compared infants held skin-to-skin (diaper only, held upright between mother's breasts, both mother and infant covered with blanket) with those held in standard contact (infant clothed, wrapped in blankets, and held cradled in mother's arms).    Babies held skin-to-skin had higher oxygen saturation and half as many desaturation episodes; no differences were noted in temperature, heart rate or respiratory rate.  Mothers who held babies skin-to-skin had a more stable milk production, and bfed for longer periods.  90% of skin-to-skin moms continued to breastfeed for the duration of hospitalization (vs. 61% of standard contact moms), and 50% of skin-to-skin moms continued to breastfeed through 1 month after discharge (vs. 11% in the standard contact group).  

Siddell, E and Froman, R.  A National Survey of Neonatal Intensive Care Units: Criteria Used to Determine Readiness for Oral Feedings.  JOGNN.  1994.  23(9):783-89.  [from abstract and from discussion in The Breastfeeding Answer Book.]

Describes the results of a questionnaire mailed to hospitals with level 2 or level 3 NICUs.  "Fewer than 50% of nurseries identified a specific feeding policy for the initiation of oral feedings.  Seventy-five percent used either gestational age or weight criteria in deciding when to start oral feedings.  Eighty-six percent considered infant behavior as well when determining feeding readiness."   According to the Breastfeeding Answer Book, 93% of the nurses also stated that standard protocol was to bottlefeed before breastfeeding. 

Field, T et al.  Nonnutritive Sucking During Tube Feedings: Effects on Preterm Neonates in an Intensive Care Unit.  Pediatrics.  September 1982.  70(3):381-4.  [from abstract]

Preemies were divided into two groups.  One group was given a pacifier for nonnutritive sucking during tube feedings in the ICU.  The other group was not.  The pacifier group averaged 27 fewer tube feedings, started bottlefeeding 3 days earlier (bfing was not an outcome in this study), had a greater weight gain per day, and were discharged 8 days earlier.  Although the authors noted more frequent "weak reflexes" in the pacifier group, they speculated that this may simply have been due to increased restfulness and diminished activity levels.  The authors suggest that "provision of a pacifier for nonnutritive sucking during tube feedings may be a cost-effective form of intervention."  

Alternative Supplementation Methods

Kurokawa, J.  Finger-Feeding a Preemie. Midwifery Today, Special Breastfeeding Supplement.  1994.  Article originally appeared in Issue #29.  Article can be found online in many places, including www.breastfeeding.com/all_about/faq_premature.html

Describes the author's experience finger-feeding her grandson, who was born prematurely at 30 weeks.  The NICU nurses assured the author's daughter that 'preemies don't get nipple confusion' but the author (a nurse-midwife and retired La Leche League leader) recognized typical nipple confusion behavior. They stopped bottles, and among other things, used finger feeding (syringe of pumped milk connected to a #5 French infant feeding tube taped to the side of the middle finger, then inserted into the baby's mouth, pad side up), along with breastfeeding every 2 hours.  Between the two, the baby started flourishing, and soon was breastfeeding and gaining well.

Stine, M.  Breastfeeding the Premature Newborn: A Protocol Without Bottles.  J Hum Lact.  1990.  6(4):167-70.  [from abstract and from discussion in The Breastfeeding Answer Book.]

Describes the protocols developed at the NICU in the Indianapolis Methodist Hospital for successfully breastfeeding premature infants without bottle-feeding.  "The babies are introduced to the breast as soon as possible, and supplementation is provided by gavage feeding.  The amount of supplement is adjusted based on maternal and nursing observations of the breastfeeding experience.  The hospital stays are not prolonged by this approach and most of the babies whose mothers intended to breastfeed are discharged exclusively breastfeeding."

Lang, S et al.  Cup Feeding: An Alternative Method of Infant Feeding.  Arch Dis Child.  1994.  71:365-69.  [from discussion in The Breastfeeding Answer Book.]

Discusses cup feeding as an alternative to bottlefeeding.  85 premature babies in Exeter, England were studied, and found that babies could be cup fed as early as 30 weeks gestation, earlier than even bfing or bottlefeeding.  81% of babies who had supplements by cup were fully bfing by hospital discharge, vs. 63% of those who had supplements by bottle.  Babies had satisfactory heart rates, breathing, and oxygen levels during cup feeding too.  From The Breastfeeding Answer Book, "The researchers noted that cup feeding requires little energy, gives the baby more control over milk intake than bottle-feeding, and involves tongue movements that are also important for successful breastfeeding."  

Newman, J.  Breastfeeding and Problems Associated with Early Introduction of Bottles and Pacifiers. J Hum Lact.  1990.  6(2):59-63.  

Discusses the harm that bottles and pacifiers can do, especially with regards to nipple confusion, lack of stimulation of the mother's hormones (prolactin and oxytocin) necessary for a good milk supply, etc.  Blames hospital routines for interfering with the prolactin reflex by separating mothers and infants, delaying the first nursing, limiting the frequency and duration of feedings, and making it hard for nurses to have time and expert knowledge in how to help women establish breastfeeding.  Discusses extensively how bottles and pacifiers lead to an escalating set of problems.  Of special interest is the section on alternatives to bottle supplementation.  Discusses the supplemental nursing system, cup feeding, finger feeding, and other methods, and how they have been used in Kenya and elsewhere.   

Armstrong, H.  Feeding Low Birthweight Babies: Advances in Kenya.  J Hum Lact. 1987. 3(2):34-37.  [from discussion in The Breastfeeding Answer Book.]

Discusses the protocol that Kenya uses to feed preemies.  They use cup feeding instead of bottles.  

*See also Mathur 1993, above

Miscellaneous References

Patolia, DS et al. Early Feeding After Cesarean: A Randomized Trial. Obstetrics and Gynecology. July 2001.  98(1):113-16.  [from abstract]

Found that women may be able to eat sooner than expected after a cesarean (some as soon as 4-8 hours after surgery), and that this may facilitate a faster recovery.  Studied 60 women having a c/s by regional anesthesia. Those who had had general anesthesia, a bowel injury or bowel surgery, and those taking magnesium sulfate for high blood pressure were not considered good candidates for this study and so were excluded.  Half were offered solid food within 8 hours after surgery, and half ate nothing for the first 12-24 hours, clear liquids on the first postoperative day, and then solid food at nearly 2-3 days afterwards.  Both groups had about the same number of intestinal problems, suggesting that early feeding did no harm, but a sub-group of women whose cesareans lasted >40 minutes were  more likely to have symptoms of mild problems.  On the other hand, the early-eating group left the hospital sooner (2 days vs. 3 days).  Authors emphasize that the study is not large enough yet to definitively determine the safety of early feeding and that more research needs to be done, but it's a promising start to a subject c/s moms have been complaining about for years.

Ingram, J et al. Breastfeeding: It Is Worth Trying With the Second Baby. Lancet. 2001. 358:986-87.

Women who have given up breastfeeding with previous children are less likely to try to breastfeed with subsequent children, often in the belief that they cannot produce enough milk. However, this study suggests that second-time mothers produce significantly more milk than first-time moms, and as a result, spend less time trying to feed their babies.  The increased milk production seemed to be especially strong in the mothers who had low milk output the first time around.  

A previous study by these authors found that multiparous mothers (mothers of second or more children) produced significantly more milk than the first-time mothers.  In this study, they followed the first-time mothers from the previous study into their next pregnancy and birth.  They measured the mothers' milk output over a 24 hour period during the first and fourth weeks after birth.  They found that these second-time moms produced 31% more milk in the first week after their second child, and slightly more milk by the fourth week.  In addition, those with the lowest previous milk output had the greatest increases in milk production with the second baby.  The authors state, "Health professionals should encourage women to breastfeed all their children, whatever their experience with their first child."   

Chiropractic and Colic/Nursing

Nilsson, N.  Infantile Colic and Chiropractic.  Eur J Chiro.  1985.  33:264-65.  [As reported in The Breastfeeding Answer Book from www.lalecheleague.org.] 

"Research from Denmark, where chiropractic has been used since the turn of the century to treat infant colic, indicates that chiropractic adjustment may help reduce or eliminate colic in some babies."

Klougart, N et al.  Infantile Colic Treated by Chiropractors: A Prospective Study of 316 Cases.  J Manip Physiol Ther. 1989. 12(4):281-88.   [As reported in The Breastfeeding Answer Book from www.lalecheleague.org.] 

"One study of 316 babies with colic found that within 14 days and three chiropractic adjustments, 94% of mothers reported that the colic had improved or that the colic was gone...The researchers estimate that between 20-40% of all Danish infants with colic are treated by chiropractors."

Wiberg, JMM et al.  The Short-Term Effect of Spinal Manipulation in the Treatment of Infantile Colic: A Randomized Controlled Clinical Trial with a Blinded Observer.  J Manipulative Physiol Ther. 1999. 22:517-22.

From 1994-96, 50 infants with colic were seen.  They were divided into 2 groups; one group received spinal manipulation for 2 weeks, and the other received the drug dimethicone (like Mylicon, for gas) for 2 weeks.  The group that received spinal manipulation had twice the improvement in colic symptoms as the dimethicone group

Hewitt, EG.  Chiropractic Care for Infants with Dysfunctional Nursing: A Case Series.  Journal of Clinical Chiropractic Pediatrics. 1999. 4(1):241-44.

As is the practice with many chiropractic studies, this is a small case study of 2 infants with dysfunctional nursing who were able to breastfeed normally after chiropractic care.  The first baby, an 8 week-old girl, was able to nurse normally after 2 chiro adjustments over 14 days.  The second baby, a 4 week-old boy, suckled immediately after his first adjustment and had a total of 4 adjustments over 21 days.  Both also experienced greatly improved sleeping habits after treatment.  The paper cites 3 other articles on chiropractic care for dysfunctional nursing, mostly also small case series.  The author calls for further research into this subject and speculates on the mechanism of how chiro treatment may help some nursing problems. 

She writes, "Newborns may experience subtle birth-related trauma to the spine and/or cranium from a normal delivery.  Complicated labor and delivery may increase the chance of birth trauma, either from in-utero malposition or malpresentation, from the use of complementary procedures such as forceps and suction, or because of delivery by caesarian section.  This subtle birth trauma may manifest as mechanical lesions called spinal or cranial subluxations...When a spinal or cranial subluxation interferes with the nerve supply to the anatomical components of the suck reflex (namely the tongue, soft palate and pharynx), disorganized suckling may result...Chiropractic care, including both spinal adjusting and craniosacral therapy, may thus correct dysfunctional nursing by eliminating the subluxation thereby restoring normal neurological communication between the central nervous system and the tongue, soft palate, and pharynx.  Further research is needed to test this theory."  

General Breastfeeding and Childbirth Resources

Mohrbacher, Nancy and Julie Stock. The Breastfeeding Answer Book. La Leche League International. 1997 Revised Edition. Available from www.lalecheleague.org.

The ULTIMATE reference for information about breastfeeding and medical issues. Extensively referenced and researched. Very expensive book to purchase for yourself but many local LLL chapters will have this book available in their lending libraries, or one of the Leaders will.

Asselin, BL and RA Lawrence. Maternal Disease as a Consideration in Lactation Management. Clinics in Perinatology. 14(1):71-87. March 1987.

Treatise for OBs, perinatologists, pediatricians, and internists on how to handle lactation issues in women with chronic diseases such as diabetes (mostly type I), severe asthma, kidney disease, and chronic hypertension. Written by 2 doctors/medical school professors with great expertise in lactation issues; excellent resource for the medical professional. Most lay readers will find it a bit dense for their purposes, but a few may find it useful for ideas to share with their health provider about how to preserve breastfeeding in the face of chronic maternal disease.

Goer, Henci.  The Thinking Woman's Guide to a Better Birth. New York: Berkeley Publishing Group (A Perigee Book). 1999.

Outstanding review of many childbirth issues, especially induction of labor. First half of book is no-nonsense guide to pros and cons of various birthing issues; second half is a detailed medical reference section, discussing and analyzing studies. Couples can simply use the non-technical summaries in the first half, delve into the medical studies and analysis in the second half, or access both as needed.

Huggins, Kathleen. The Nursing Mother's Companion. 4th Revised Edition. Boston: Harvard Common Press. 1999.

By far the easiest-to-use and most practical of nursing guides. Pack this one in your hospital bag! Especially useful is the quick-reference Survival Guide for the First Weeks--much easier to use for trouble-shooting if you have any questions or problems. 

La Leche League International. The Womanly Art of Breastfeeding. 6th Revised Edition. New York: Penguin Putnam Inc. (A Plume Book). 1997.

Classic text on breastfeeding, very well-done for the most part. Barely addresses the football hold, however, and some women find it very preachy. Still worth reading, however, and the section on medical benefits of breastfeeding is superb---a must-read.

Behan, Eileen, R.D.  Eat Well, Lose Weight While Breastfeeding.  New York: Villard Books, 1992.

Generally a good book, with mostly sensible advice for women who want to lose weight post-partum but who are concerned about various issues like safety, minimum caloric levels, balancing food groups, etc.   

Tamaro, Janet. So That's What They're For! Breastfeeding Basics. Holbrook, Massachusetts: Adams Media Corporation. 1996.

A more humorous approach to breastfeeding, but still full of useful information. A great book to get if you are not sure whether you want to nurse or not, or if you think you should but are not really crazy about the idea. Good for spouses too. Good book, but don't make it your only nursing manual; use it in tandem with another nursing manual like Nursing Mother's Companion or Womanly Art of Breastfeeding. 

Midwifery Today: Special Breastfeeding Supplement.  Midwifery Today, 1994.  Available from www.midwiferytoday.com

Collection of articles on breastfeeding from various editions of Midwifery Today magazine.  Also reviews key breastfeeding research abstracts.  

 


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