Nursing When Well-Endowed FAQ

by KMom

Copyright 1996-2000 Kmom@Vireday.Com. All rights reserved.


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

Rest assured that women with all extremes of breast size (whether large or small) can breastfeed successfully. However, very well-endowed women (size DD cup or more, pre-nursing) may need to experiment with different positions and technique modifications to see what works best with their body. While breastfeeding experts do not all agree on what works best for large-breasted women, here are some hints that have helped others who are well-endowed.....YMMV (Your Mileage May Vary)!

1. Use The Football Hold.

It is beyond the scope of this FAQ to adequately describe and demonstrate all three of the traditional nursing holds, so it is vital for you to get a good basic breastfeeding book that discusses all the holds and gives illustrations to demonstrate them (not all manuals cover all the holds, especially the Football Hold, the one that works best for larger women). Don't depend on this FAQ alone---educate yourself! Just remember that many traditional breastfeeding advisors don't always understand the special needs of the very well-endowed woman, and it is up to you to experiment and find what works best with your body type. Two resources, The Nursing Mother's Companion by K. Huggins or the video on breastfeeding positions from Medela (see below) are especially good in describing and showing the football hold.

In this hold, the baby is held to one side, under your arm, like a football when running (!); this is also sometimes called the "clutch" hold or simply "tucking the baby under the arm." It allows greater freedom of arm movement for mom, and a better view/control of baby's head as he latches on. It is especially good for very well-endowed women, for women who have had C-sections, for preemies or multiples, or for women who are experiencing soreness in traditional cradle positions. The key to success is to use lots of pillows to bring baby to your level instead of leaning your breast into your baby. Be sure your back is well-supported with pillows as well, and raise your knees with a small footstool. A luxurious recliner like a LazyBoy is better for positioning than a traditional rocker with high arms; a sofa with lots of extra pillows works well too. Tuck the baby under your arm so that his head is on your lap pillow, cradled in one hand, and his bottom is against the back of the chair (his legs may need to be bent upward at the hip so that he is not arching his back by pushing against the back of the chair while trying to latch on). Support your breast gently with your other hand, keeping your fingers away from the areola. Pre-express a small amount of milk to be sure your nipples are erect and to entice baby's sense of smell, then tickle your baby's lips with your nipple. When he opens VERY wide, pull him in quickly for a latch, being sure his lips cover most of the areola (the dark area around the nipple) and not just the nipple itself. Both his upper and lower lips should be flanged outward and you should soon hear the sound of swallowing. If there is a problem, reposition as often as necessary, and expect to have to retry fairly frequently since both you and the baby are learning new skills. This is completely normal. Over time you will find how to latch on quickly and efficiently.

2. Be Sure Baby Latches on to the Areola, Not Just the Nipple.

Your areola is the dark area surrounding your nipple. It probably got much darker during your pregnancy in order to help your baby find and focus on it, since babies see strong contrasts of color much better. Milk is stored behind the areola in milk 'sinuses.' These need to be squeezed/massaged in order to activate them into ejecting the foremilk, and to signal the body to make more milk (the hindmilk). It is very important to be sure that the baby latches on to most/all of the areola, not just the nipple. If the baby gets only the nipple or not enough areola, the baby will not get enough milk and will miss the all-important rich hindmilk. Often, the nipple itself is damaged with this kind of inadequate coverage, and is a common source of soreness in breastfeeding. Be sure, too, that the fingers supporting your breast are well-back from the areola during the process of latch-on. Fingers that are too close to or touching the areola interfere with baby getting enough areola in its mouth. This is especially a problem for women with very large areolas, so these women must take special care to keep their fingers back from the areola when supporting the breast.

Women with small areolas will have complete coverage from baby's mouth in a proper latch-on, while moms with larger areolas will have coverage of most of it. It's hard to know in the latter situation whether enough areola is in baby's mouth, but the results will tell you. If baby is swallowing and seems to be getting enough milk, and if mom is not experiencing soreness and most of the areola seems to be covered, then all is probably well. If in doubt, ask a lactation specialist. If coverage seems inadequate, the problem is probably that baby is not opening wide enough and mom is settling for an inadequate opening. Baby must open WIDE in order to get enough coverage, so wait till his mouth is nearly the size of yawning before pulling him in for latching. This is not easy to wait for at first, but will become so with practice---tickling his lips or cheek repeatedly with your nipple may help encourage him to open up. When you see him opening the appropriate amount, be ready to attach very quickly as things can change fast! Be patient if it takes many tries to get the baby on well at first--this is a new skill for him! And if you do have to re-attach repeatedly in order to get the latch right (this is very common), be sure to detach by breaking his suction first with your little finger so you do not damage any vital breast tissue. Just slide your pinkie into the corner of his mouth between his gums until you feel and hear the suction release.

3. Get Professional Help Quickly When Needed!

There are many delicate subtleties to positioning that are too difficult to cover here, so if you have any trouble or soreness at all, be sure to get immediate assistance from a PROFESSIONAL lactation consultant. This is very important. Nurses and doctors are generally not well-trained in breastfeeding assistance and may even steer you wrong; a private lactation consultant is often better than one from a hospital. Find a professional specializing in lactation--an International Board-Certified Lactation Specialist (IBCLC) is your best bet, as they are well-trained in all aspects of lactation. Be sure they have experience and knowledge about helping well-endowed women, then ask for help mastering the football hold before trying the traditional cradle holds.

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' (it is unusual for this to be true), 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 (see section below on Supply Problems). Don't supplement unless the IBCLC tells you to or unless baby is showing signs of dehydration (not enough wet diapers, sunken fontanel, etc.---see a nursing book for more details). Mature milk can sometimes take extra time to 'come in', especially after a difficult, highly-medicated birth (and especially after a C-section), but the pre-milk (colostrum) is usually enough to sustain a baby during that extra time and is the ideal first food for baby (it 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). Colostrum is usually yellowish or clear and does not resemble milk, so don't panic if your first 'milk' doesn't look like you thought it would. It is so highly concentrated that not much is needed, so don't worry if not enough seems to be there at first---this does not indicate what your production will be once your mature milk comes in. Many women assume that if a baby cries even after nursing, he is still hungry and needs supplementation, but babies cry for many reasons and sometimes for no reason at all except to be comforted. Check thoroughly for other reasons and resist the temptation to supplement unless the baby is showing signs of needing it. If you are in doubt, contact a professional lactation consultant BEFORE supplementing; they will know the danger signs to look for and can tell you if baby does indeed need it. They also can help with ways to boost your production (including herbs) while supplementing so that you do not have to give up on breastfeeding; a doctor will usually just prescribe supplemental bottles without considering whether they are truly necessary and whether further methods could be used to boost mom's production. Your best bet for solving supply problems is an IBCLC! They will work hand-in-hand with your doctor to ensure your baby's health.

Using unnecessary supplementary bottles early on is a common source of breastfeeding 'failure' but it is very tempting in the vulnerable post-partum state, so it happens a lot. In addition, many doctors and hospitals routinely order extra bottles and give pacifiers, setting up such 'failure', and often send free formula samples home with mom, which can be a difficult temptation to resist. 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. Formula companies even send unsolicited *cases* of free formula in the mail, 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 your child). They know that a breastfeeding child who gets bottles is likely to wean to formula quickly, thus making the company more money. New mothers who intend to breastfeed have to be very careful to avoid falling into this seductive marketing trap. Take the formula to your local battered-woman's shelter or donate it to a friend who is already bottle-feeding. Studies clearly show that giving free samples to mothers who intend to breastfeed shortens the breastfeeding period markedly.

If supplementation does become medically necessary, however, 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, though not always of course. If this is your desire, be sure to always NURSE FIRST and then use one of the alternatives to bottles (such as syringes, cups, spoons, or eyedroppers) that can help preserve the breastfeeding relationship (see section on "Never restrict nursing time"). Don't use bottles (or pacifiers), as many babies easily become nipple-confused and are not able to switch sucking techniques between breast and artificial nipple. In difficult cases, a supplementary nursing device such as a "Lact-Aid" can provide baby with the nourishment he needs while still preserving breastfeeding and stimulating supply (see a nursing manual for further information). Lact-Aids are reportedly MUCH better than any other supplemental nursing systems; contact Lact-Aid International, (423)744-9090, for more information. Babies who have problems with weak sucks (such as preemies or cleft-affected babies) can often be helped by a special device such as a Haberman Feeder (available from "Mommy's Little Helpers"; see below for reference information). It is especially important to have such babies evaluated by a professional IBCLC. Babies who are ill or who have special needs benefit particularly from the protective properties of breastmilk, so keeping up as much breastfeeding as possible can often make a difference to these children, though it is not easy.

In short, do not rely on your doctor to help diagnose or rectify supply or suck problems; they are often too unaggressive in their approach and they usually have little training in lactation. You need a lactation specialist, and you need it as EARLY as possible. The same is true if you are experiencing soreness. Nursing manuals can only go so far in helping you with positioning; it often takes the eye of an experienced professional to detect subtle problems that need correcting, or to identify other potential problems such as thrush or plugged ducts. Don't let the problem escalate by delaying treatment. Furthermore, a lactation specialist can help you clearly determine whether supplementation is medically necessary and help you preserve breastfeeding, if desired, even when supplementation is necessary.

4. Support The Breast When Nursing.

Be sure to support the breast with your hand in the "C" hold or with a rolled-up washcloth, especially in a cradle position. Some women find that they only need the "C" hold for latching on in the football hold, while others find they need to use it to support the breast constantly throughout the whole feed, no matter what hold they use. Experiment to find what works for you.

The "C" hold is where you use one hand (preferably your outside hand--the hand on the same side you are nursing from) to support the breast. Place your palm under your breast gently, keeping the fingers well-away from the areola (if you can place the edge of your hand against your chest wall and still be able to support the whole breast, this is desirable, but some women need to 'cheat' away from the wall a bit in order to support the breast adequately). Lightly curve your thumb around the side and top of the breast, forming the letter 'C' with your hand. Again, keep the fingers and thumb well-back from the areola, since fingers that are too close can interfere with baby's latch-on and cause him to not get enough areola in his mouth. This causes soreness in the mother, and baby is unable to access the milk sinuses behind the areola (dark area around nipple), thus not getting enough food.

Using the outside hand (i.e., the left hand if you are nursing on the left side) allows greater control over the breast than the inside (opposite) hand since the tendency in larger breasts is to fall to the outside, but use whichever hand works best for you. While the advantage of the outside hand is that it offers greater control, it does make a traditional cradle hold impossible, since this is the hand and arm usually used to hold the baby. An alternative may be to use the "cross-cuddle" hold, where the baby is supported by the opposite hand while you use the outside hand to guide the breast. Women who are moderately well-endowed may be more successful with this than those who are exceptionally endowed, but it's worth a try! Some people find a 'sling' under the breast helpful, while others find this idea distasteful. Usually, a hand or washcloth is enough, but it's vital that the hold be very gentle, as pressure from the hand may cause problems with clogging of the milk ducts or even mastitis in susceptible women. Keep it light!

5. Always Bring the Baby to the Level of Your Nipple.

Always bring the baby to your breast, never your breast to the baby. Never lean into the baby. Don't be afraid to use lots of pillows by your side or on your lap in the football hold, and don't forget a few pillows behind your back to support it too. A reading pillow or lumbar support pillow behind your back is especially helpful. When using the cradle position, try letting the older baby rest between your legs instead of on top of them in order to bring him to the right level, or order a special nursing pillow to help baby be at the correct height (these are available in larger sizes; see the Clothing FAQ on this website). If your back hurts when nursing, you are probably trying to lean into the baby too much instead of bringing the baby to your level.

6. Set Up a Nursing Station.

Wherever you will be nursing frequently, set up a nursing station, complete with pillows, footstool, recliner if desired, flat surface for glass of ice water or one-handed healthy snacks, extra burping cloths, etc. Have one station upstairs and one downstairs, or as needed. It is important not to have to constantly fetch pillows and rearrange them whenever baby needs to nurse, and it's terribly inconvenient to have to get up in the middle of a nursing session to get a glass of water (staying well-hydrated is critical to mom's supply). Consider getting a plush recliner for wherever you nurse the most; they are heaven for many well-endowed nursing moms.

7. Find a Way to Sleep and Nurse.

Sleep is a very precious commodity to a new mom, so find a nursing position you can sleep and doze in. Some well-endowed women are able to nurse when prone, but others find it too difficult. It is very difficult to describe without illustrations how to nurse when prone, but basically, mom is on her side in bed. It is important that her back not be at a 90 degree angle ( _l_ ) to the bed, but at about a 45 degree angle instead (either _\_ or _/_ depending on whether she wants to nurse from the top or bottom breast). She should use pillows behind the back to support herself in this position. Baby should be tummy-to-tummy with her. Mom then places her fingers beneath the breast and lifts upwards (if using the lower breast) or (for the top breast) leans over while supporting the breast and latches baby on when he roots with a nice wide mouth. (Remember, good areola coverage is vital!)

A few mothers find it easier to have baby 'upside down' so that baby's feet are near mom's head and his belly is opposite her face. This is more uncommon but if it works---great! Another possibility is the "Australian" hold, where mom lies flat on her back on the bed. She latches baby on to the breast while the rest of baby's body is held gently at an angle to her side, halfway on and halfway off of her body. Some feel that this position is better saved for when baby is older and has better head control, but not everyone agrees. Other women just sit up in bed, being sure they have adequate back support, and doze while nursing in a sitting position. Your partner can be your backrest!

Most women find it easiest to nurse at night if baby sleeps with them (be sure your bed is not too soft and that there are no gaps where baby could become trapped, don't use a waterbed, etc.). Other women find that having baby in a crib or bassinet beside the bed allows them to sleep better while still offering quick access in the night (this is called a 'sidecar' arrangement). Others prefer that baby sleep in its own room in a crib, but this means getting up every time baby needs to nurse in the night. In this situation, you may wish to invest in a plush recliner for your bedroom or nursery. Then use pillows to support baby and your back, lean back, and nurse in the football hold while you grab some winks. This is also very comfortable for the end of pregnancy when a good sleeping position is hard to find, or if heartburn is a problem! Recliners, whether used in the bedroom or living room, are a terrific aid for a well-endowed nursing mom, so if at all possible, you should definitely plan to get one, preferably in the latter stages of pregnancy.

It is vital to feed baby frequently at night (don't expect baby to 'sleep through the night' for quite a while yet), so experiment to find whatever arrangement best fits your situation and still allows you to grab some sleep. Try all of these suggestions and find what works best for YOU.

8. Buy a GREAT-Fitting Nursing Bra!

Consult the Plus-Size Maternity and Nursing Clothes FAQ on this website for retailers who carry nursing bras in large cups and/or large band sizes. Good ready-made nursing bras are available up to about a 48J, and there are good resources for custom-made nursing bras in any size, too. Goddess 510, Leading Lady 491, and Motherwear 'Extra Support' are all good large-cup nursing bras, and Custom Couture's makes an excellent custom bra. Bra back extenders are often a must in late pregnancy and early engorgement in order to extend the fit for a temporary increase in size at these times, and they can easily be removed after engorgement when you find your regular long-term nursing size. Oftentimes, a nursing bra may feel a bit uncomfortable at first, due to the expansion of your ribcage due to baby, but an extender can ease this transition. However, if your bra is very uncomfortable, return it immediately. Comfort and good fit is extremely important in a nursing bra.

Bra-size increase is extremely difficult to predict, but you might try ordering a size or two larger in band size, plus a cup or two larger in cup size (caution: many women differ from this formula!). Order in your 8th-9th month or so, and try only 2-3 bras at first. Ask for advice from the supplier since cups and sizing varies greatly between manufacturers. Once engorgement is over and you are down to your long-term nursing size, THEN you can invest in further bras. By then you will know what size, type, and brand of nursing bra you prefer.

NEVER use an underwire nursing bra as the wires can press up against sensitive breast tissue and cause plugged ducts and mastitis problems. This is especially important for large-breasted women. Cut-out nursing bras (where a flap remains at the bottom of the bra to 'support' the breast even when nursing) are also not recommended by many experts. Athletic/tight bras can reduce milk supply greatly, and loose, unsupportive bras that simply pull up or down can cause uneven drainage problems, soreness, and plugged ducts as well. (This is a particular problem for large-breasted women, so avoid these looser bras like the plague!) If you are having trouble with your bra irritating your pregnancy belly in late pregnancy, try tucking a cloth diaper underneath your breasts, or order a Pambras Bra liner from Amplestuff (see Clothing FAQ for ordering information). Be very strict about hygiene as well (see hygiene section below), since yeast infections can add to the irritation.

A good nursing bra unfastens easily, supports the breast well without pressing against sensitive duct tissue, is made of comfortable material that wears well against the skin, comes in adequate sizes for you, and washes well. They are worth their weight in gold, so don't be hesitant to invest in a good one.

9. Practice Good Breast Hygiene.

Women with large breasts sometimes develop skin infections and irritations underneath the breasts. In pregnancy, when yeast infections are more common, this can result in having a topical yeast infection (a yeast infection in the folds of the skin). In addition, large women are somewhat more prone to gestational diabetes in pregnancy, and these higher blood sugar levels can also promote yeast infections of different kinds. Reducing your sugar intake may help, even if you don't have GD, and this includes cutting out things like fruit juices as well (sweetened or unsweetened), since fruit juice raises blood sugar at rates nearly equivalent to sugared sodas. Frequent usage of antibiotics can also be a cause. If you have an ongoing or recurring yeast infection problem, consult your health provider about it and ask about the possibility of gestational diabetes testing. It's probably just pregnancy hormones, but if you have GD, you need to know about it as soon as possible--don't bury your head in the sand!

Normal breast care in pregnancy is to wash them every day with water. Don't use soap, body gel, or shampoo on them because these are often too drying and irritating. Your breasts also have their own system for self-cleansing; if you wash too often or with soap, you can sabotage this process. Dry thoroughly with a towel, especially under the breasts. Then turn your portable hair blow-dryer (on cool) onto the areas underneath to be SURE all excess moisture is gone. (Excess moisture can cause or exacerbate topical yeast infections greatly.) Wash your bra frequently as well, using hot water and bleach. If you have a chronic, very stubborn yeast infection, you may need to get a whole new set of bras in order to eradicate the problem entirely. Finally, NEVER use cornstarch or talcum powder under the breast, as this can add to irritations and feed the yeast infection.

If you DO develop a yeast infection under the breasts, be especially vigilant in your hygiene. Drying with a blow-dryer and changing your bra often is critical. Another treatment is to apply plain yogurt (the kind with live bacterial cultures) on the affected skin areas---only a small amount is needed! A less messy alternative that some have found useful is to sprinkle acidopholus powder on the area (these capsules can be bought at health food stores--get the refrigerated kind). With particularly stubborn cases, some women find it necessary to treat their bra as well or buy new ones. YMMV. Be sure to check other prime areas for topical yeast infections, including groin creases, fat creases in the skin, and belly buttons.

Sometimes people recommend that you buff your nipples with a washcloth to 'toughen' them up for nursing; this advice is thought to be outdated. In fact, some experts worry that this can cause greater problems, so it's best to avoid it. Neither are special creams necessary before delivery. After delivery, if you have nipple soreness or cracking (which is most likely due to positioning problems, so don't forget to get help!), the only cream that is recommended by most experts is "Lansinoh" which is so pure, hypoallergenic and non-toxic that it does not even need to be wiped off before nursing. Another possible cause of soreness and cracking is thrush, a yeast infection that affects both mother and baby. Both people must be treated carefully in order to cure thrush (for more information, see section on Investigating Soreness Problems below).

10. Experiment with Nursing in Public.

This is more challenging for larger women, but it can be done. If you can manage the cradle hold well, then just cover up with a blanket or lift your shirt discreetly. Two-piece outfits (a top and a bottom) make nursing easier. Shirts or dresses that button down from the top can be used for nursing but are not very discreet, so if you are easily flustered or embarrassed, avoid these. Special nursing wear with various types of hidden nursing openings is available in the clothing FAQ on this website, but only to a 3x or so. This special nursing wear is usually not necessary except for very special occasions, when you may wish to find an extremely nice dress that would still allow you to nurse (most dresses are NOT breastfeeding-friendly). Nursing wear tends to be very pricey, so you may want to just use two-piece outfits that lend themselves easily to nursing. However, some women swear by nursing tops, so you could try purchasing one or two and see if you find them more convenient or not.

For those whose best position is the football hold, get a large diaper bag (well-filled) and use it to help support the baby while nursing. Sit down cross-legged on the floor or normal-style on a couch, then place the diaper bag just behind one leg. Lay baby down with his head in your lap and his body across your leg and the diaper bag, then lift your shirt slightly and proceed as normal. A small blanket can assist here as well if needed for modesty. Practice this first at home to get used to it, but with a bit of practice, this is really quite handy and quite discreet. You may get funny looks from women who are able to use the across-the-lap cradle position, but don't pay any attention--do whatever it takes to make it work! What matters is the nutrition and antibodies you are giving your baby. If you treat nursing in public nonchalantly, most onlookers don't even notice that you are doing it. If you are really bothered by it, seek out a quiet corner, private office, or a dressing room, but never use a bathroom, as it is as unpleasant and unsanitary a place to eat for any baby as it is for any adult.

To most people's surprise, nursing in public is actually easier than trying to use a bottle of either formula or pre-expressed milk in most cases. Once you get used to it, it is far more convenient, so pursue getting comfortable nursing in public. Surprisingly, it's also easier when traveling, so it's well worth the hassle of learning! Don't risk your hard-won breastfeeding relationship by bringing along a bottle because you are too embarrassed to learn how to breastfeed in public.

Nursing in public can be particularly challenging emotionally to women with large breasts. Used to years of harassment and shame from rude comments and stares, it can be difficult to overcome the long-term programming we have bought into. Even when we have broken free of many of the other hassles and stereotypes, breastfeeding publicly can remain an intimidating obstacle. However, make it a goal not to be a prisoner of your past and other people's ignorance. Don't let them win!

Declare your independence and take steps to conquer this goal. You may need to do it in small increments, which is fine. Start by rehearsing at home and finding out which clothes and positions are most discreet so you won't feel too exposed at first. Practice with a blanket if that makes you feel better. Then practice in front of your husband or partner, and ask his support in giving you advice. Some women say that trying in front of a mirror was helpful; others did not feel it was helpful. Do what works for you. Progress to nursing in front a trusted friend or relative or at a La Leche meeting (it may bother you less to nurse where others are also nursing). Again, it may be strange to them if you don't use the cradle position they are all probably using, but don't worry about it---do what works for you. Next, progress to nursing in a quiet, nearly private corner at a busy place like a mall or the airport, then slowly move closer to the busier parts each time you are out and need to breastfeed. Keep challenging your limits, but do it in small increments that you are ready to handle. Don't put yourself in a position that you know will be awkward or humiliating, and do surround yourself with supportive people. Finally, work up to breastfeeding wherever you need to, whenever you need to.

Most well-endowed women, with time and patience, are able to learn to breastfeed comfortably in public. However, if you never do get completely comfortable with breastfeeding in the open, go with the level you can live with. Push your envelope, but don't make yourself neurotic. If you need to always use a blanket---fine. If you prefer to seek out a quiet bedroom at a friend's house, do it. If you prefer to find a dressing room (no bathrooms!) in a store, or a quiet, semi-secluded area in a furniture store, go for it. The important thing is to challenge your limits at times, but still stay in a comfortable enough place that will allow you to do what's really important---nourish your baby in the best, most healthy way. Don't compromise baby's health by resorting to formula just because nursing in public is hard for you (take steps to find a middle-of-the-road way instead), but don't berate yourself if you never feel enough at ease to just attach your baby while speaking to a board meeting. Give yourself time---you'll find a compromise that works for you.

11. Educate Yourself Thoroughly Ahead of Time.

Be sure you have read up on breastfeeding before giving birth! Take along a copy of Nursing Mother's Companion in your suitcase to the hospital---you'll be surprised how much you'll consult it! Check other books on breastfeeding out from a library to compare notes, but be aware that some may be outdated or give bad advice. If in doubt, go with the advice from Nursing Mother's Companion or Womanly Art of Breastfeeding. Take a breastfeeding class at the local hospital or health education center; these can be REALLY valuable. Don't expect your obstetrician to help you much with breastfeeding; most OB's do not deal with this much, and many are poorly educated about lactation. Neither will your pediatrician be much help, in all likelihood, and may actually be a hindrance. In breastfeeding, it is up to YOU to be proactive and take charge. Read up ahead of time, and actively pursue further information from other nursing mothers. The best advice usually comes from moms who have breastfed longer than 6 months, since when learning something new, it's best to consult an experienced expert in the field. There is nothing wrong with someone with less experience, but they may not have had enough problem-solving time to be an expert yet, or they may not have experienced and conquered some of the difficulties that can arise. The experienced voice may have suggestions or advice the less-experienced voice does not know about.

A good source for experienced experts that is *free* is the La Leche League or the Nursing Mother's Council. Some people hesitate about these organizations, but they are really very helpful, so find a group that suits your attitudes and situation. Take the advice you need for yourself and leave the rest behind---don't deny yourself its benefits because you don't 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. Take full advantage of their library of books to be checked out, as many of these are invaluable.

It is especially important to seek out the company of other nursing mothers shortly after birth or in the first week or two post-partum. This is when most breastfeeding problems occur and when most new moms get poor advice from doctors or relatives that interferes with breastfeeding. It is no surprise that breastfeeding 'failure' occurs most often in this period or shortly after, and getting help during this time is absolutely critical to resolving things. If breastfeeding does 'fail', frankly, it is not usually failure on the part of the mom, but on the part of her health care team to support her adequately. But there are many precautions that the new mom can take to sidestep this possibility as much as possible.

Definitely watch the Medela video listed below (it's available for check-out from many LLL groups too, or you can purchase it) and watch it multiple times both pre- and post-partum. This is an amazing new skill that you and baby will be learning, and book learning only goes so far! Watch the video for hands-on demonstrations and try to get exposure to other nursing moms for live demos! Direct observation is extremely important in breastfeeding, just as it is in any other skill. Be patient with yourself; you are learning complex new behaviors, and so is baby. Allow yourself time to learn, just as you would if you were learning to play an instrument, and consult the experts.

Finally, it's important to re-emphasize the need to seek professional help as soon as you run into a problem. Sometimes larger women are embarrassed to get the help that they need and delay too long. Don't let embarrassment over large breasts keep you from this help. These consultants have seen ALL kinds of breasts before, and they really don't care if yours sag or have a roadmap of blue veins all over them-----really! They know that most women do not look like Cosmopolitan models, and they know that breasts come in ALL shapes and sizes. Don't let your embarrassment or the harassment of a lifetime shoot you down in this too. If you let it still affect you, the naysayers still have power over you. It's time to declare your independence from them and to empower yourself!

12. Nurse FREQUENTLY and avoid bottles and pacifiers religiously.

NEVER restrict the time or amount of nursing baby does in the early weeks, and don't use ANY supplemental bottles or pacifiers in the first 6 weeks. Insist on this at the hospital as well (you may have to be quite assertive). Try placing a sign with baby that states that NO supplemental bottles are to be given, and definitely have your baby room in with you. Sometimes hospital staff can actively sabotage breastfeeding, even with the best of intentions, so you must be vigilant that no supplemental bottles are given.

It is not uncommon for large babies (8-9 lbs. and over) to be given supplemental bottles routinely. Many health providers just assume that such a baby is in danger of hypoglycemia (low blood sugar) and will need glucose water or formula to stabilize. Tell the staff that if they are in doubt, they can test the baby's blood to be sure, but unless it is DOCUMENTED that baby has low blood sugar, your big baby is NOT to be given any supplemental bottles. For babies of diabetic mothers (of whatever type, including gestational diabetes), hypoglycemia is indeed a danger for baby. It is definitely appropriate for these babies to be tested soon after birth to determine whether their blood sugar is low. It is NOT appropriate to automatically assume that their blood sugar WILL be low and to routinely give these babies a bottle. Most health providers will agree that if the blood sugar level is marginal, nursing and then retesting blood sugar is enough, repeating the process as necessary. Colostrum is an IDEAL food for a hypoglycemic baby, and it is highly concentrated so not a lot is needed. However, if the blood sugar has dipped too low or is not rising fast enough in response to nursing, the baby WILL need supplemental formula or glucose water (opinions vary, but formula is probably better since it has protein that will even out a baby's blood sugar rise). This does NOT have to be given via bottle, however---insist that the staff use cups, spoons, eyedroppers or syringes instead. If you have any type of diabetes, it is wise to learn this technique ahead of time so you can be ready with it if needed, and it is also wise to teach it to your spouse or a doula/labor assistant so that they can use it for you if you are unavailable due to a C-section (you can find out about this technique from a LL. leader or an IBCLC). Other cases where a baby might routinely be given a supplement because of concern about hypoglycemia include very low birth-weight babies and babies whose birth involved a great deal of trauma or difficulty. Again, ask the staff to document the problem before proceeding, and to use non-bottle methods if supplementation becomes necessary.

Definitely leave behind any free samples of formula you may be given upon discharge. In the emotional and often exhausting days just after birth, these can prove to be too much of a temptation, especially to friends or relatives who just want to 'give mom a break.' Your milk supply is based on supply and demand and any interference in the first weeks can be devastating. If baby does not nurse at least every 1-3 hours, your breasts will 'think' they do not need to produce as much milk and you may have supply problems. If you don't nurse often enough in the first few days (very common with sleepy babies and moms after a medicated or difficult birth), your mature milk may take longer to come in. Nervous moms, relatives, and health providers may then use a bottle for supplemental formula, thus lengthening even more the time between nursings (AND causing possible nipple confusion in the baby), providing even less stimulation for the breasts, resulting in less milk and the need for more supplements, and thus a truly vicious cycle is born.

Adding to this confusion is the common advice (even from some health providers) telling mom to nurse the baby only 5-10 minutes per side to lessen possible soreness and get the nipples 'used' to nursing. A newborn should not be restricted like this, and correct positioning is the key to avoiding soreness in most cases. Many newborns need 20-40 minutes for a feeding, and some (especially the sleepy ones) take 45-60 minutes for a feeding. If your baby is sleepy and has trouble staying awake for a whole feeding or does not want to wake at least every 3 hours for a feeding, try undressing him to his diaper and rubbing his back or tickling his feet, talking to him all the while. If he is near your uncovered breasts and smells the milk, he will likely soon awaken for more, but he may need more active encouraging---do whatever it takes. (You can add a blanket after he starts nursing to keep him warm, if needed.)

After the first few days, baby will most likely awaken more regularly and space his feedings more evenly, but frequent nursing in the first few days is so important to establishing supply and bringing in the mature milk quickly that it is vital NOT to "let sleeping babies lie" more than a couple of hours (this will also help prevent severe engorgement--see below). A general guide is to nurse at least 8 times in 24 hours, or at least every 2-3 hours; more often if your baby is a preemie or if you are worried about your breast being overly large for him to latch onto. And remember that colostrum (the first 'milk' after birth) does not usually come in great quantities because it is highly concentrated. It may seem like you are not making enough milk in spite of numerous feedings, but unless baby shows signs of listlessness or dehydration, all is probably well. The more you nurse, the sooner the mature milk comes in, but it can be delayed by a traumatic birth or lots of drugs, so be patient and don't panic prematurely. If in doubt, consult a lactation professional.

13. Investigate Supply Problems Promptly.

If needed, use a hospital-grade breastpump to keep up or increase your supply, but remember not to be alarmed if you don't get great results at first---many women don't in the beginning. Don't judge the adequacy of your milk supply based on how much you can pump, since nursing is FAR more efficient than pumping. In many cases, herbs such as Fennel, Fenugreek and Mother's Milk Tea can help boost supply. Be SURE to ask a lactation consultant about trying these, and don't wait too long to start if there's a problem. Doctors and nurses are notoriously reluctant about recommending these and generally are not educated about them, so you may need to consult your IBCLC instead. Fennel, Fenugreek and Mother's Milk Tea can all usually be purchased in health food stores, but consult a lactation professional for advice on dosage. In extreme cases, there may be other, stronger drugs that can be used to help build or jump-start supply problems, but quick intervention is key and a doctor may not be willing to pursue these quickly enough. Your lactation consultant can recommend a doctor who would be more willing to help in these situations.

In rare cases, supply problems can be caused by retained placental fragments, hormone imbalances, thyroid deficiencies, anemia, dehydration or poor nutrition in the mother, antihistamines or decongestants given to the mother, or by excessive amounts of vitamin B6 (which can reduce prolactin levels in mom). Prolactin levels can be tested, as can thyroid levels, though doctors are often reluctant to order these tests. Hormonal birth control methods such as the Pill, Mini-Pill and Depo-Provera can also cause supply problems in some women who are more sensitive. Though the mini-pill and Depo Provera are often recommended as not affecting a nursing mother's supply, anecdotal evidence suggests strongly that some women ARE affected, so it's best to use barrier methods instead for the first several months. After this, some of the affected women may tolerate the mini-pill or Depo, but it should be started cautiously and monitored carefully for any drop in the woman's milk supply.

An often overlooked cause of supply problems is an inadequate suck in baby. Some babies are born with weak or faulty sucks. These babies may be tongue-tied (have a short frenulum), have a protruding tongue, try to thrust the tongue too far out, or suck on their own tongue instead of on the breast. Symptoms of inadequate sucks can include things like clicking noises when nursing or dimples on the cheeks when nursing. The Nursing Mother's Companion has an excellent discussion of many of these problems, but an accurate diagnosis MUST be made by a lactation professional like an IBCLC as these are very complex issues. Treatment is possible; a baby's suck CAN be re-trained but it takes patience; diagnosis and frequent feedback from a well-trained lactation professional is critical to the process.

While most supply problems are usually caused by supply and demand inequities or by nipple confusion caused by supplemental bottles, occasionally there are medical causes that can reduce or limit supply, and sometimes emotional problems relating to a very traumatic birth can psychologically inhibit milk production. There are also legitimate cases where a woman cannot make enough milk, but these are very unusual and many times women are told this when in fact their case was mismanaged. Be sure to investigate all possibilities rigorously before accepting a diagnosis like this. If in fact you are one of these rare women who cannot produce enough milk, you have not 'failed' at breastfeeding in any way, and you should never feel guilty. Similarly, when the 'failure' is actually caused by medical mismanagement or lack of support, the 'failure' is not that of the mother, but of the health providers. It is normal to grieve for this lost opportunity, but it is not your fault. How wonderful you live in an age when a substitute is available! Grieve as you need to, and then move on when you can. Your baby needs you too.

If you must use formula or expressed milk with baby for a medical or supply reason, it can be given by syringe, spoon, cup, or eyedropper (ask for a lactation consultant IMMEDIATELY in order to be shown how, and if you think you may have a high-risk birth, learn this skill ahead of time. La Leche has special cups for sale just for this purpose). You may encounter resistance to using alternative supplementation methods from nurses and doctors. Insist anyway and get professional lactation support----the other health personnel may just be unfamiliar with the technique needed, and it's definitely time they learned! Also investigate the possibility of using a Lact-Aid Supplemental Nursing System, which would enable you to still preserve breastfeeding while providing baby with supplementation. Using bottles even occasionally truly is one of the most common causes of breastfeeding 'failure', both from nipple confusion and interference in supply and demand, so don't be hesitant to pursue these other alternatives aggressively if your baby does end up needing help.

14. Learn More About Pumping, If Needed.

If you need to use bottles eventually, wait until at least 4-6 weeks have passed to minimize nipple confusion and prevent supply problems. This is EXTREMELY important! Many working moms who are expert pumpers recommend investing in/renting an excellent pump; the cheap ones can make the situation worse and can even damage your nipples. Use a hospital-grade pump, and consider one that pumps both sides simultaneously. Though this is expensive, it will be cheaper than paying for formula. Don't be surprised if you have very little output at first from pumping; new moms often find this, and it does NOT indicate that you are not making enough milk when nursing (nursing ALWAYS produces much more). Pumping efficiency doesn't seem to occur for some women until at least 6-8 weeks post-partum--some even later--when supply becomes better-regulated, so don't panic. It may be helpful to try massaging your breasts periodically during pumping to encourage multiple let-downs. Also, women with very large breasts (and especially large areolas) may find that they need a pump with a bigger 'flange'. Medela and Ameda/Egnell both carry larger flanges just for this purpose. Other women prefer a flexible plastic flange so they can massage the areola themselves while still pumping. Reportedly, some women who are well-endowed find that some pumps work better for them than others, though of course not everyone agrees. The Medela "Pump In Style" (PIS) is a new, very popular, and affordable entry in the breastpump market, but some women contend that it is not a good choice for very large-breasted women. Again, YMMV.

Another common tip from working moms is that "AVENT" bottles and nipples are the least confusing to babies that must learn to go between breast and bottle, so you may want to invest in them vs. other types like Nuk or Playtex, though some people swear by Nuks instead. YMMV. (Avent has a web page at http://www.avent.co.uk/avent.html.) If you plan to work outside the home, be sure to consult a support group like misc.kids.breastfeeding for hints, or read _The Working Woman's Guide to Breastfeeding_, by Nancy Dana and Anne Price, available from the La Leche League catalogue. Another source of information is the Pumping FAQ available at http://www.greatstar.com/lois/pump.html. Pumping, working, and breastfeeding CAN be done successfully, but lots of guidance helps. You will definitely want to consult with the many other women who are also combining nursing, pumping, and working.

15. Massage Breasts Periodically While Nursing and Investigate Soreness Problems.

Massaging the breasts gently while nursing helps to ensure that all ducts are being emptied, which is especially important if you have any lumps or sore spots. Don't forget the areas underneath your breasts and the areas up by your arms. This is especially important to do if you are well-endowed and have a tendency towards lumpy or fibrocystic breasts, but be careful to use a light touch. If you are using the "C" hold to support your breast, be sure your touch is gentle and not causing duct problems. Watch carefully for any signs of a plugged duct and be sure your bra is not the problem by being either not supportive enough, or conversely, being too tight or rubbing in certain areas. Bras are often the source of recurring duct problems, so you may want to purchase a different type if you are having ongoing problems.

Soreness is often one symptom of a plugged duct, so increase your nursing time as much as possible, use hot compresses and massage, and seek help from a good nursing manual, or, if it does not clear up quickly, a lactation consultant. Another common source of plugged ducts in larger-breasted women is sleeping on too-full breasts. Try wearing your nursing bra to bed, at least for the first few months, and see if you can find a way to sleep that does not put so much pressure on the breasts. An untreated plugged duct can turn into mastitis, which can be very serious. Watch for hardened red spots or lumps, a white 'plug' on the nipple, fever, chills, achiness or nausea. This will need treatment from a health professional, but in the meantime, increase your nursing times as much as possible and try to aim baby's chin in the direction of the problem. A full discussion of plugged ducts and mastitis is far too complex for this FAQ, so be sure to seek extra help. Finally, antibiotics are often needed to help get rid of mastitis, but be sure to watch afterwards for signs of thrush.

Thrush, a yeast infection of the nipples and/or of baby, is another common cause of soreness in many women. Some women are very prone to it, while others get it after a course of antibiotics. Thrush pain is often described as itching, burning, or shooting, and baby often concurrently has curdy white patches in its mouth or a yeasty diaper rash. If you have ongoing, unexplained soreness even after having checked your latching position and baby's suck, recurrent thrush is often the culprit and you may need to be very aggressive in its treatment. Both you and baby must be treated, and often your bras as well. Rarely, the yeast will go deeper and get into the milk ducts, causing 'ductal yeast' which is even harder to treat. However, with stronger measures and drugs, even difficult cases of thrush can be handled.

Continue nursing frequently in all of these cases (since less-frequent nursing will make things worse) and see a lactation consultant as soon as possible. The La Leche League homepage has more information on treating these common maladies as well, and puts out several informational pamphlets about them.

16. Dealing with Leakage Problems and Overactive Let-Downs.

Many people assume that large breasts will produce more milk than small ones, and that leakage will be a huge problem for well-endowed women. This is not true. Some small-breasted women leak copiously, and some very large-breasted women never leak at all. However, if you do leak, be sure to use nursing pads in your bras (ones without plastic liners) and to change and wash them frequently. You will also want to wear a bra to bed and to sleep on a towel as well. Pre- expressing milk may be especially important for you so that your baby is not overwhelmed by a gush of milk. If your baby seems to gasp and choke at first, or seems to pull off the breast quickly or frequently, this may be the problem (overactive let-down). Pumping or pre-expressing a little ahead of time may be your best bet. Another technique that can help is to nurse flat on your back in the Aussie Hold (see section on Nursing and Sleeping) so that the milk has to flow against gravity.

One possible consequence of overactive letdowns is a foremilk/hindmilk imbalance. In this, the baby receives too much of the lactose-rich foremilk, and not enough of the fat-rich hindmilk. The abundance of lactose in baby's intestines causes too much gas, and baby is often fussy or colicky for no apparent reason, even after food allergies are ruled out. Baby's stools are often green, frothy, and explosive, and baby is very gassy. Another side effect (which does not always occur) is an inadequate weight gain, since baby is not getting enough of the very important fatty hindmilk. Even women without an obvious overactive letdown can experience this imbalance, especially if baby does not nurse long enough on one side before switching to the other side. For example, the advice for sleepy babies is to stimulate them in order to nurse frequently, switching sides often. However, if baby does not nurse either side long enough to receive more of the rich hindmilk, he can get too much foremilk and present these same symptoms. The 'cure' is to be sure baby gets enough time at the breasts in one session that he will get the hindmilk, or to reattach frequently to the same breast over and over in one nursing session, then use the same technique on the other breast at the next nursing session. Either way, it is important to establish first that the problem is not an allergy to a food mom is eating, which can complicate matters still further. (See following section.)

17. Stay Well-Hydrated and Well-Nourished.

Drink lots of water to keep both you and the baby well-hydrated. Try to down at least one glass of water every nursing session---some women find ice-water especially refreshing during nursing. One hint is to keep a jug or thermos of ice-water made up ahead of time near your nursing stations, or you can assign another person in the house (like a spouse or older child) to be your water-fetcher. A lack of good hydration in the mother can cause supply problems, so drinking often is very important. If you tend to get overly warm when nursing, ice water and a small fan trained on you can help a lot.

Eating well is also vital. Nursing mothers burn 500-600 calories extra just from nursing, and many pregnancy experts recommend that a nursing mother (especially in the first few months) consume the same amount as in pregnancy; some even advocate increasing intake to about 200 calories more than in pregnancy! This DOESN'T mean that you get to go overboard, of course. Good nutrition is always vital, but especially so in pregnancy and nursing. YOU are the source of all of your baby's nutrition, so you must be absolutely sure to get a balanced diet. Some babies are more sensitive than others to items in their mother's diets, but usually nursing mothers don't have to restrict any foods, even spicy ones. However, if your baby is excessively colicky, fussy, or gassy, you may want to try eliminating certain foods from your diet in order to see if this is what is bothering the baby. The most common culprits are dairy foods (very common), citrus foods, peanuts, chocolate, caffeine drinks (including many sodas), eggs, tomatoes, corn, or wheat (gluten). Sometimes certain vegetables like cabbage, beans, and onions cause baby to be extra gassy. It is very unlikely that your baby is sensitive to all of these; it may only be dairy or peanuts, or it may be none of these (again, most nursing moms don't have to restrict their diets at all). If you suspect that there may be a problem, try an elimination diet for 2 weeks or so. Take all these foods out, then after 2 weeks start adding them back one by one. (A nursing manual can give you more details on doing this effectively.) However, be sure to read labels, as dairy (casein) and wheat (gluten) and egg products are found in MANY manufactured products. If your elimination diet is to be conclusive, you have to be sure to cut out ALL sources of the offending foods. Many breastfeeding support groups can give you further advice about this issue.

18. Avoid Dieting While Breastfeeding.

Many post-partum women are anxious to get out and start losing their pregnancy weight, but significant restriction of food when nursing can cause problems for baby and mom. It is generally recommended that a nursing mother not diet in the first several months of nursing. This is to prevent any interference with milk supply and to ensure good nutrition so mom won't become run-down, but it also stems from a concern that many environmental toxins are stored in fat layers and dieting may release these too suddenly into the breastmilk. These are all very valid concerns---take them seriously.

Women's weights respond very differently to breastfeeding, depending on the person. Most lose weight much more easily and effectively when breastfeeding, and some are able to do it effortlessly. Larger women in particular can sometimes lose weight very easily during the breastfeeding period (perhaps due to a change in metabolism?), but this is certainly not true for ALL large women. For most women, regardless of size, maintaining a healthy pregnancy-level intake while increasing exercise is enough to help them lose weight slowly enough that toxins and undernutrition are not a problem. However, for a few (especially for those on the smaller side or those who are chronic dieters), nursing may help them lose most of their pregnancy weight but not all. For these women, the body seems to want to hang on to those last few pounds in order to have some fat reserves for nursing. In this case, the body's needs should be respected. Those last pounds will come off after weaning, but don't place more importance on those 5 lbs. than on your baby's health and wean early just for this reason.

If you must diet, one book that many women recommend is Eat Well, Lose Weight While Breastfeeding (available from La Leche League), which seems to take a sensible, moderate approach. Probably the best approach, however, is to work hard on improving nutrition and dietary habits (without caloric restriction) while increasing exercise. If it took 9 months for your body to gain your pregnancy size, you should give it at least the same amount of time to regain its former size without traumatizing it through strict dieting (pregnancy and childbirth and all the attendant hormones are hard enough!). It's hard to endorse dieting in view of its spectacular failure rate (see FAQ section on Dieting and Pregnancy on this website), but if a woman is determined to diet, it's important to wait a while before starting and then proceed very slowly. Your baby's health is the most important issue. He loves you just the way you are--don't make him a sacrifice on the altar of our society's unhealthy fixation on thinness. Put your baby first--don't compromise his health.

19. Always Pre-Express a Few Drops of Milk.

Pre-expressing a few drops of milk before starting a nursing session if you have flat or inverted nipples can be very helpful (see nursing manuals for explanations and illustrations of this) . If your nipples are very sensitive or if you are sore, this is a good preventative strategy as well. A good nursing manual will demonstrate how to do this, as does the Medela video. Another strategy is to rub an ice-cube over your nipples before nursing. The cold may help numb them if they are sore, and the cold will also help many flat nipples become more erect. However, ice is not always convenient, so it's a good idea to learn to hand-express some milk anyway. Good technique is crucial. By the way, Lansinoh cream (available from large drugstore chains and La Leche) is often recommended for sore or cracked nipples, and it does not need to be wiped off before nursing, unlike most other creams and remedies. Leaving a few drops of breastmilk on the nipple after nursing is another good strategy, as the breastmilk has some healing properties. Leave the flaps of your bra down and let the nipples and areola air-dry after doing this. DON'T use soaps or other creams on the breast.

20. Nursing a Small or Premature Baby When You Have Large Breasts.

Another concern for large-breasted women is when you have a tiny baby (such as a preemie) and a large breast for that small little mouth to latch on to. The football hold is the best hold for small or premature babies, since it allows the most control over baby's head. For an extremely small baby or preemie, you may have to pump for a while before baby is mature enough to get a good latch-on; in the meantime you can feed the baby through alternative means like a cup, spoon, syringe, or eyedropper (do NOT use a bottle if possible----see section on Supply Problems above), or your breastmilk may be able to be fed to your baby through a tube. In some cases, a special bottle such as a Haberman Feeder may be an appropriate compromise (these are available from places like Mommy's Little Helpers, see reference information in resource section at bottom).

Your breasts automatically produce colostrum and milk that has already adapted for a preemie's special needs, so it is vital that you pump and feed him as much of it as possible. Use a hospital-grade electric double pump, which many hospital Neonatal Intensive Care Units may already have. If not, it is well-worth the rental price to get one (formula is more expensive in the long run). Your mission while you wait for your baby to mature enough to nurse is to do as much hands-on care of your baby as possible (stroking, rocking, kangaroo care, etc.), to see that baby receives your milk as much as possible through whatever method is most appropriate, to keep up your supply by pumping very frequently (you may need to investigate herbs or drugs that can help stimulate your supply), and to keep trying to encourage baby to develop a wider mouth position when rooting (an IBCLC can help you with techniques for this). Once baby is ready to try nursing, pre-express some milk so that your nipple and areola are less overwhelming in size for a tiny mouth, and then try using the nipple to stimulate a wide-open rooting response. At first baby may not be able to get adequate coverage, but keep trying. Your only measure of success is that you are learning to position the baby well for nursing and that you are encouraging him to open his mouth wider. It doesn't matter at first whether he actually latches on successfully or not; in fact, most preemies probably won't at first. Keep your expectations realistic--- this process will take quite some time. In the meantime, be sure to keep pumping AFTER each latching/nursing session, so that your supply stays up. Be patient; it is likely that you will need to pump quite a while, but it can make such a difference in a preemie's health that it is well worth the effort. Even when baby begins to get some milk, you will need to continue pumping until the baby is actively nursing and swallowing for at least 15 minute sessions at a time. The NICU nurses or an IBCLC familiar with preemies can help you decide when you no longer have to keep pumping.

Even if your baby is only small and not a preemie, nursing with large breasts may be a challenge, especially around engorgement time. Nurse as frequently as possible in the first few days in order to minimize the degree of engorgement and then be sure to use a pump or hand-express a fair amount of milk before beginning a feed during engorgement. This should reduce the overwhelming size differential. Wearing your baby in a sling or close to your skin as much as possible in the first days tends to minimize engorgement, and using warm washcloths or taking a warm shower before pre-expressing can help as well. Keep encouraging a very wide mouth by re-trying latching often, using the nipple to stimulate the baby's rooting response. Another trick is to have baby suckle on your (clean) upside-down pinkie beforehand, then substitute larger fingers until baby is better at opening its mouth wider, then quickly substitute the breast. Again, patience in trying and re-trying the latch multiple times until baby learns to open wide enough is very important. If you are having consistent difficulties getting baby to open up, this is another situation where the specialized techniques of a lactation consultant can help.

21. Breastfeeding Successfully After a C-Section.

Breastfeeding after a C-section can be more challenging, but it certainly can be done. If you know you are going to have a C-section, write it into your birth plan that baby not be given any supplements during your surgery unless it is documented that his blood sugar levels are low. Oftentimes, a supplement will be given automatically to keep the baby happy and quiet while your surgery is being finished (the part involving the baby is very brief), or it will be assumed that baby must be hypoglycemic from a difficult birth and needs help. Also include a stipulation that if a supplement IS needed, it be given by syringe, eyedropper, spoon, or cup instead of a bottle, and be sure that your spouse or your doula/labor assistant knows how to do this ahead of time. If your C-section is a surprise, you can also request this, but there may not be any personnel present who know how to do it and so it may not be honored (but you can ask!). If the baby is not hypoglycemic, request that baby not be given ANY supplements until you are awake and ready to try nursing. (See further stipulations about big babies, babies of diabetics, and babies from traumatic births in section about Avoiding Bottles above.)

Once surgery is over and you are ready to nurse, be sure to try the football hold first. Have your hospital bed 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. Also cover your incision with a pillow for good measure. The advantage of the football hold is that it keeps baby off of this incision and allows you greater positioning control. Since the cradle hold is difficult under the best of circumstances for well-endowed women, the football hold is even more important after a C-section.

If you must remain prone due to discomfort or spinal anesthesia, try nursing in a side-lying position, though this is often quite difficult for well-endowed women. If you find this positioning impossible, many women have luck with the Aussie hold described above under the Nursing and Sleep section, but 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. Be sure you use a very gentle touch since too much pressure on delicate milk ducts can cause problems with plugged ducts and mastitis. Request an IBCLC as soon as possible. Although hospital lactation consultants and nurses may be able to help, they often give poor advice or are not prepared for the situation of a very well-endowed woman. Even some IBCLCs are not well-versed in techniques for very well-endowed women, so be sure you have your copy of The Nursing Mother's Companion with you for back-up.

Another problem encountered by many C-section moms is a sleepy baby (and a sleepy mommy) from medications given during labor and surgery. This may slow down baby's nursing time, giving mom less stimulation and baby less effective sucking, and 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. Again, a baby is usually fine on just colostrum during this time, but if the time begins to stretch out too much or baby shows signs of dehydration or other problems (see an IBCLC to be sure), then some supplementation may be necessary. ALWAYS NURSE BEFORE ANY SUPPLEMENTATION, and try to be sure all supplements are given by alternative methods instead of bottles. Use a hospital-grade pump to help stimulate milk production, and promptly investigate using herbs to increase your supply if things are not progressing. 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. Don't limit baby's time at the breast, and be patient if he tends to fall asleep during nursing sessions. Just keep waking him up and giving him lots of time on each side to complete the feeding (you want to be sure he is getting lots of rich hindmilk as well as the initial foremilk). Rooming in will help this process, though you may want to have your spouse there to help you in the first day or two. Don't worry about your pain medication being unsafe for baby; you will only be given kinds that are safe. You will probably be given antibiotics, so you may need to watch for signs of thrush afterwards (see section on Soreness). You will also want to get up and walk as soon as you can after the anesthesia wears off, since this speeds healing and will eventually make breastfeeding easier. If you have a lot of edema (fluid) after the surgery, the walking also helps it go away faster, though it will still take some time. Your doctor should be aware that you are breastfeeding so he will NOT prescribe diuretics for the edema. Walking and time are the best cures for this side-effect (though ice-packs for the feet and ankles are mighty soothing!).

Another common side-effect of C-sections and other traumatic births is jaundice. This is also more common after diabetic pregnancies, when labor has been induced by pitocin, when certain drugs are used, and with epidurals. There are many types of jaundice and it is too complicated an issue to discuss in detail here, but in the most common kind (physiological jaundice--which appears a few days after birth), it is NOT necessary to stop breastfeeding, and it is usually NOT necessary to offer supplementary formula or water. Many pediatricians still believe that the old practice of "washing away" the jaundice with glucose water or formula is effective, but it is now believed that this may actually slow down the process of getting rid of the excess bilirubin causing the jaundice. In most cases, nursing a nearly naked baby VERY frequently (especially by a sunny window) is enough to get him over the jaundice, since colostrum speeds the passage of meconium (baby's first stool). Delayed passage of meconium has been observed to be associated with higher levels of bilirubin, so the best therapy is to nurse the baby frequently and *without* supplementation from birth. Your doctor will probably ask for heel sticks to test that baby's bilirubin levels do not rise too high, and if they do, special phototherapy may be needed. See a nursing manual for advice in these situations, but temporary weaning is not usually necessary. In fact, extremely frequent nursing will probably aid the process.

When you get home, take it very easy. Arrange for lots of help around the house. Your ONLY job should be to rest and to nurse baby. Take baby to bed WITH you, or use a plush recliner to relax in if that is more comfortable for you. Nurse the baby as OFTEN as possible and be sure to stay well-nourished and well-hydrated. (Reading the section on Supply Issues may also be helpful.) Other than that, your only job is to recover. This is major abdominal surgery and it is often traumatic to the emotions as well as to the body. Writing down as much as you can remember can help relive and heal the experience, and when you are ready physically, seek out more information about C-sections and recovering emotionally from them. For some women they are no big deal, but for others they are very traumatic indeed. A good resource is ICAN network, which has chapters all over the United States as well as a mailing list on the Internet. However you recover, keeping breastfeeding going through C-section difficulties can be emotionally healing in a way that nothing else can. If breastfeeding is unable to withstand the MANY pressures on it after a C-section, healing can be doubly traumatic, so be sure to seek out help if you need it, but don't feel bad if the deck was just too stacked. This is not an easy situation to handle.

22. Experiment Ahead of Time with Positioning.

Before your baby is born, use a doll or stuffed animal of an approximate size to help you practice the different positions, get more comfortable with the idea of nursing (especially the idea of nursing in front of others), and know how many pillows you may need to help support the baby. Although nursing a live baby is definitely harder, this can give you a bit of a head start. Find some private time and space and give it a try a few times, and use the time to practice deep breathing and visualizing a successful breastfeeding relationship, whether public or strictly private. Determination to succeed is a large part of success, as is adequate information and timely, expert help. You can do it! See yourself doing it internally, and then follow through!


Helpful General Breastfeeding Resources

Here are some further resources for Breastfeeding Help. Good luck in your breastfeeding relationship! It is one of the most healing and self-affirming things in this world. Many women who are ambivalent about being extremely well-endowed find the experience of breastfeeding tremendously healing. It certainly is a beautiful gift to both you and your baby!

Breastfeeding Your Baby-A Mother's Guide: Positioning #610V010 (English); Video from Medela, (800)435-8316. Further contact information below. Includes section on the football hold--one of the few videos to adequately cover this. Excellent hands-on demonstration of all 3 classic breastfeeding positions; good commentary and advice. May also be available for check-out from La Leche groups.

The Nursing Mother's Companion by Kathleen Huggins. Boston: Harvard Common Press, 1990. THE BEST AND MOST PRACTICAL NURSING GUIDE AROUND! Especially good for quick trouble-shooting when problems occur. Rated as a "best possible choice" among breastfeeding guides in the Journal of Human Lactation. *Take this book to the hospital with you--really!*

Breastfeeding Your Baby by Sheila Kitzinger. New York: Alfred A. Knopf, 1995. Excellent photos of traditional cradle holds. Good discussion of that position. Beautiful nursing photos and general advice.

CARE NW (Care and Advice on Reproductive Exposures) 1-900-225-CARE ($3 for first minute, $2 for each additional) carenw@u.washington.edu 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, call and they will research it for you. They often have more accurate and up-to-date research than many doctors, so use this service when in doubt.

The Breastfeeding Advocacy Web Page http://www.clark.net/pub/activist/bfpage/bfpage.html or http://www.clark.net/pub/activist/bfpage/medref.html General information about breastfeeding and its medical benefits-many links to other sites. Excellent resource.

La Leche League International 1-800-LA-LECHE; (847) 519-7730 P.O. Box 1209 9616 Minneapolis Avenue Franklin Park, Illinois 60131-8209 http://www.prairienet.org/llli/homepage/html Information and community support for breastfeeding mothers; great source for medical research on lactation. Its catalogue contains many breastfeeding-friendly parenting and birthing books and many of these are available for check-out from local LL chapters. A great way to save money and still research parenting!

International Lactation Consultants Association P.O. Box 4031 University of Virginia Station Charlottesville, Virginia 22903 (312) 541-1710 Professional Breastfeeding Help. Call to find a local professional breastfeeding consultants.

Extra Emphasis P.O. Box 1725 Tahoe City, CA 96145 (916) 581-0848 (info) (800) 539-0030 (orders only) (916) 581-5719 (fax) Mail-order catalogue of hard-to-find bra sizes, both in large bands/ large cups AND small bands/large cups. Also carries many non-nursing bras. Brands include Goddess, Leading Lady, TrSportT, Fancee Free, and Olga. A truly outstanding resource!

Cameo Coutures, Inc. Dallas, TX 75247 (214) 631 - 4860 Where to get custom-made nursing bras. Expensive but worth it!

Motherwear P.O. Box 114 Northhampton, Massachusetts 01061-0114 (413) 586-7532 (800) 950-2500 Comfy nursing bras to 48H; nursing wear up to 3X. Many other baby/nursing products as well; high-quality products. Great resource.

Mommy's Little Helpers 9250 Watson Rd. St. Louis, MO 63126 (800) 859-3559 (314) 849-2128 Anything you could need to help support breastfeeding, including special equipment such as the Haberman Feeder for babies having breastfeeding troubles. Also has Avent bottles and nipples and many other nursing aids. However, their nursing bras are generally not well-reviewed by larger women, though they do carry nursing bras up to 50LL.

Medela, Inc. P.O. Box 386 6711 Sands Rd. Crystal Lake, Illinois 60014 (800) 435-8316 A great deal of pumping information and resources, including an extra-large pump flange for large breasts. Also has the terrific video on positioning listed above, as well as a longer version of the video, aimed at more general breastfeeding information.

Ameda/Egnell,Inc. 765 Industrial Drive Cary, Illinois 60013 (800) 323-8750 A great deal of pumping information and resources, including an extra-large pump flange for large breasts.

Avent Bottles http://www.avent.co.uk/avent.html. The bottles and nipples often recommended as being best at minimizing nipple confusion for babies who must switch between breast and bottle. Expensive, but apparently worth it.


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