Not enough milk… and then far too much

angry person

In addition to my nipple trauma, I had been swinging wildly between having a screaming infant and nothing to offer but (seemingly) empty breasts, and ending up with a couple of beach balls whenever C went more than three hours between feeds. I heard this was quite normal, and that my supply would ‘settle down’ soon, but it ended up adding yet another major stress to my day.

For at least a couple of weeks, the problem was particularly horrendous. C was wanting to feed almost every hour (including all through the night), making me feel as if she wasn’t getting anything out of me at all. I put this prolonged period of frenzied feeding down to a growth spurt, despite the fact that the books claim these only last 24 hours (not my experience at all – C’s last at least a week, it seems!) Eventually her ravenous hunger ceased, and she managed a four hour sleep overnight. At the moment, four hours to me is virtually sleeping through, so in theory I should have had a reasonable night. Unfortunately, I awoke two hours after her last feed with my breasts buzzing, and proceeded to lie awake watching her and almost willing her to wake up, while I swelled to watermelon proportions…

In theory I could express a bit in these situations to relieve the pressure, but I’m terrified to do this in case C then wakes up and I don’t have anything left (which is silly, because I know it doesn’t work like that, but I’m awash with paranoia). Of course, when C does then want feeding, the milk shoots out of me like an industrial water gun, leaving her gagging and gulping down significant amounts of air. Arrgh! I was almost reduced to rocking in the foetal position, repeating, ‘my supply will settle down soon, my supply will settle down soon…’

Nipple solutions 3: pumping

bottleIn addition to using a nipple shield, both the health visitor and the NCT helpline lady suggested I try expressing milk and feeding it from a bottle, to give my nipples a bit of a rest. C’s response to the shield was not encouraging, so using a breast pump was really the only option I had left if I wanted to carry on. So far I’d just about been able to put up with the pain: if I gritted my teeth through the initial agony, the remainder of the feed was just about bearable. The sight of my nipples, however, was really quite perturbing. The open wound on the outside edge of one was so deep it looked as if the nipple were in danger of detaching. The psychological effects of seeing this type of damage were considerably worse than the pain. I could only assume it was getting worse with each feed, and therefore that I was mutilating myself further.

Despite the obvious arguments for using a pump, and possessing one that was bought before C even arrived, it took me another couple of days to get around to using it. I don’t know quite why I was so reticent, but I think it had something to do with feeling guilty and inadequate not being able to get it right on my own. The turning point was speaking to my friend Zara. It turned out that she’d had exactly the same problem – right down to the fissures in the same place – and had pumped to help with the healing. She’d also had the same feelings of guilt and inadequacy, but had come through the other side and said that it made a massive difference. I wasn’t going to get any extra points for prolonging the pain, so I should just get on with it.

Some women find expressing milk easier than others. The key is prompting the letdown reflex – after that getting milk out is reasonably straight forward. Without your baby actually suckling, however, letdown isn’t always that easy to initiate. Looking at a picture of your baby (or indeed your baby herself) is one way of getting the vital oxytocin flowing. The solution for me was pumping from the really mangled left hand side, while C fed from the slightly less injured right hand side. For about four days, I expressed on the left and fed on the right, feeding C the expressed milk in a bottle if she was still hungry.

Using the pump and feeding simultaneously gave me an interesting way to monitor the extent to which the expressing helped. I had the same injury on both sides (albeit not as badly on the right), but only used the pump on one. It definitely provided me with some relief – expressing was much less painful than feeding – and the nipple did heal eventually, but the right side also healed completely, without any intervention. The healing actually occurred slightly faster on the right hand side, although this might be expected, as the injury wasn’t quite so serious. It seemed that the midwife who told me that things would eventually improve of their own accord was right after all. I think the problem for me was caused by the fact that my nipples weren’t quite the right shape initially (for C’s mouth at any rate – I don’t know if it would be different with another baby) and the skin broke so they could be stretched into a better one. Certainly, they now look quite different to how they did originally – pointy where they were once quite flat. When they healed, extra skin grew over the fissures where they’d stretched, rather than the skin knitting together at the point where it was originally joined, providing further evidence that my nipples were simply going through a (very painful!) transitional process.

Although it seems that both nipples would probably have recovered of their own accord if I’d continued feeding C as normal, I would strongly recommend using a pump if your nipples are suffering. It really helps to relieve the pain, and if you plan to bottle feed later on (whether with expressed milk or formula), introducing it early (and continuing regularly) means you should meet less resistance later on. Even if you take into account the constant pump dismantling, sterilizing and constructing, it’s a win-win situation!

Nipple solutions 2: shells and shields

shell

Although I’ve criticized the health service for their, ‘breastfeeding is easy as long as you do it right’ line (a criticism that I stand by), the health visitors and midwives I have spoken to have generally been sympathetic. They have also been willing to deviate from the official advice when it’s obvious that it isn’t working.

Faced with my mutilated nipples, two midwives suggested nipple shields.  A shield is a silicon or rubber teat that you hold over the nipple to protect it during a feed. It is shaped like a large nipple, with holes in the end for the milk to come through. Apparently, they can affect milk supply, so do not have NHS approval, although I have since discovered that this recommendation may be rather out of date (see the nipple shields research post). I didn’t have any luck with shields (C looked at me as if I were mad – she was going to put one of those in her mouth?!) but I have spoken to many women who found them useful.

Breast shells, on the other hand, did prove to be a hit. In contrast to shields, you use shells in between feeds, to protect sore nipples or draw flat ones out (they apply a small amount of suction). They consist of a silicon disk with a hole in the middle for your nipple, topped off with a half a clear plastic tennis ball that acts as a protective bubble around your nipple and stops the fabric of your clothes coming into contact with it. The plastic bit also has holes in, to allow air to circulate. The instructions said to always make sure these were facing upwards, an instruction that I initially failed to heed. What difference would the direction of the holes make? I discovered the answer to this when I noticed a substantial wet patch on my t-shirt. A significant amount of milk can collect in them if you have them on for any period of time, and this milk will naturally leak out of any holes it finds. If you can motivate yourself to sterilize the shells regularly, you can store this milk for later use, but it wasn’t really a priority for me at that point. In the end, I put a breast pad in each shell to soak up any rogue milk (making sure the holes pointed upwards, of course.) Although this will have hindered the air flow a little, the shells still proved very effective in preventing discomfort, and seemed to allow my nipples to heal more easily. I say ‘seemed’ because the effect may have been psychological – when using the shell, my nipple looked less mangled, and I thus assumed it was improving.

I should probably mention, however, that I didn’t exactly use the shells as specified on the box. The instructions state that you shouldn’t use them for more than a couple of hours at a time, as they can cause blocked ducts. I weighed up the potential for blocked ducts against the possibility of my nipples healing a bit faster, and decided the chance of the latter made it reasonable to risk the former. This meant, in practice, that I ended up using them all the time, including at night. Fortunately I didn’t suffer any blocked ducts, although I did end up stretching a rather expensive Elle McPherson nursing bra (and looking like Madonna during her pointy cone bra period unless I dressed very carefully).  To date, there has been very little clinical research investigating the effectiveness (or not) of breast shells (see breast shells: preserving your modesty), but they seemed to help me get through a difficult time. If you want to take the pressure off your nipples – and are willing to risk increasing it on your milk ducts – they may be worth a try.

Nipple shields: always a bad thing?

drawing of baby on scalesI have spoken to many mothers, including two midwives, who have used shields to ease nipple pain while they are breastfeeding without any apparent problems for their babies. Although they have been described (in the words of one mother) as ‘a godsend – the thing that made breastfeeding bearable for me,’ they are not recommended by the National Health Service.

What’s the problem with using nipple shields? Well, an NHS Primary Care Trust Breastfeeding Policy document cites two studies demonstrating slower milk transfer when using a shield1,2.

The trouble with this research is that it was conducted over 25 years ago, and shields have moved on in that time. A more recent study (published in 2006) test-weighed babies after feeding with or without a thin silicone shield and found that there wasn’t any difference in their milk intake3. The same article reports the results of a survey of mothers’ attitudes to using nipple shields and found evidence that they actually help to prevent early breastfeeding termination, rather than cause it. Another survey of shield use found that 86% of women utilizing them felt that they allowed them to continue breastfeeding when they might otherwise have given up4.

One study investigating the impact of a number of factors on nursing duration initially appeared to link using a nipple shield in hospital with a greater risk of discontinuing breastfeeding5. When other factors known to affect breastfeeding duration (such as the type of delivery the mother had and whether she smoked) were taken into account, however, the relationship between shield use and early weaning declined to the extent it was no longer statistically significant.

It has been suggested that using a shield from very early on could cause nipple confusion, meaning your baby wouldn’t want/be able to feed directly from the breast. An instance of this was reported in a case study more than 20 ago, which described a baby who refused to latch normally onto the breast, having been taught to attach with a rubber bottle teat covering the nipple6. This case study, which doesn’t even really demonstrate the problem – a bottle teat is quite different to a modern shield – appears to be the only recorded evidence for shield related nipple confusion. According to an article recommending shields for feeding premature babies (a situation in which they have been shown to be very useful), ‘the term “nipple/teat” confusion remains a hypothesis,’ i.e. it might be a problem, but there isn’t yet any strong evidence to support it7.

Using a nipple shield won’t necessarily be trouble-free: you have the hassle of cleaning, sterilizing and applying it before each use, not to mention remembering it when you go out. Despite these drawbacks, some mothers undoubtedly find shields very helpful. Women who choose to use them are already experiencing breastfeeding difficulties, such as nipple or latch problems, and are therefore at greater risk of stopping anyway8. When the alternative to a nipple shield is a bottle, perhaps trying one isn’t such a bad idea after all.

  1. Acta Obstet Gynecol Scand. 1987;66(1):47-51.
  2. Early Hum Dev. 1980 Dec;4(4):357-64.
  3. J Obstet Gynecol Neonatal Nurs. 2006 Mar-Apr;35(2):265-72.
  4. J Hum Lact. 1996 Dec;12(4):291-7.
  5. Midwifery. 2008 Mar;24(1):55-61.
  6. J Hum Lact. 1986 ;2(1):28-30.
  7. Infant. 2005 ;1(4):111-115.
  8. J Hum Lact. 2004 Aug;20(3):327-34.

Using formula might stop you sleeping at night

bed

One of the common myths perpetuated about breastfeeding is that it causes your baby (and you) to sleep less soundly at night. Formula is said to be heavier and harder to digest, knocking your baby out for longer, whilst ‘weaker’ breast milk just isn’t as satisfying. A friend of mine was criticized for not using formula (by her mother, of all people) for this very reason. I’ve met lots of breastfeeding mothers who are doing fine sleep-wise, and bottle feeding ones who are knackered, and have always thought this was nonsense, so I was happy to hear recently about some research that confirms what I always expected1.

The study examined the sleeping patterns of 133 parents of three month old babies over a 48 hour period. The parents were asked to report how much sleep they got, while the actual amount was measured using a special device called a wrist actiograph. Mothers who breastfed exclusively reported getting a greater amount of sleep than those who supplemented with formula at night, and the actiograph confirmed that they did indeed get on average an extra 40-45 minutes. As it can take a while to prepare formula, this isn’t entirely surprising – the extra time might be due to the fact of having to make up the bottle. Here’s the really interesting thing, though: mothers whose partners shared the night feeds (in theory allowing them to sleep longer) STILL slept less than mothers exclusively breastfeeding. It seems that when the baby wakes, the mother does too (thanks, biology!) and when she doesn’t need to feed the baby, she instead lies there worrying about whether her partner is doing it properly… So, although the results confirm how hard it is for mothers to sleep easily (even if they have a partner willing to help out), they are very encouraging for breastfeeders – an extra 40 minutes can make a BIG difference!

  1. J Perinat Neonatal Nurs. 2007 Jul-Sep;21(3):200-6.
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