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 solutions 1: doing nothing

creamMy nipple fissures weren’t showing any signs of improving, so after a day of deliberation, I phoned the National Childbirth Trust. I was starting to realise that the fact that there were helplines (and whole charities, in the case of La Leche League) dedicated to solving breastfeeding problems should probably have served as a warning that it might not be that easy. The counsellor who answered the phone was helpful, if a little abrupt. She asked me which direction my nipples pointed (!) and when I said it was slightly outwards, rather than directly forwards, she said that they were probably getting bent backwards in C’s mouth when I was holding her in the cradle feeding position. She suggested using a different position to feed her (such as the rugby/football hold, where C’s mouth would approach the nipple from the opposite direction) while I waited for them to heal. This seemed sensible advice, and after a few goes, C and I managed to perfect some new feeding positions. Although I can’t say it was definitely less painful, the knowledge that C’s mouth probably wasn’t putting pressure on my nipples in the same way seemed to help at least psychologically.

The NCT counsellor, like every midwife I spoke to, also recommended I use Lansinoh cream – ‘absolutely loads of it, as a barrier’ – to protect my nipples. I had been religiously applying it since the bleeding had started, and following advice, continued to do so as the state of my nipples got worse. After a few more days, I stopped to think about this: the state of my nipples was getting worse…

Up to now, still in a post-birth haze, I’d been relying on the NHS resources, reading the leaflets and speaking to midwives and health visitors. They’d been very understanding and sympathetic, but things weren’t really improving, and I was getting desperate. I decided to start Googling in earnest, searching for things like ‘nipple fissures’, and going beyond the first page – sometimes even as far as the fifth! What I ended up with was quite a lot of hits for ‘anal fissures’ (not terribly useful), but in amongst these and the general parenting advice sites, was a scientific paper looking at treatments for cracked nipples1.

The study compared using lanolin cream (like Lansinoh) with using breast milk, and leaving nipples untreated. A short summary of the results goes as follows: the women who used breast milk on their nipples, or who did nothing at all, recovered significantly faster than the ones using lanolin (for a longer discussion see the is lanolin cream a waste of money? post).

Armed with this knowledge, I dumped the Lansinoh, and within only a few hours, things seemed to improve. I can’t be sure whether this was as a direct consequence of not applying the cream, but it seemed to be working, and I decided to stick with it.

  1. Saudi Med J. 2005 Aug; 26(8):1231-4

Nipple nightmares 2: fissures

mother holding babyHaving been told that my initial breastfeeding difficulties – cracked, bleeding, excruciatingly painful nipples – were quite normal (despite what the official literature said), I was looking forward to the three week deadline after which everything would be functioning as it should. I was, however, slightly perturbed by the fact that as he deadline approached, no improvement was evident. In fact, my nipples were getting much, much worse. My husband expressed genuine concern that C was going to chew one of them off! By this stage, the bleeding had stopped, but it had been replaced by deep, ulcerated gashes on the outside edge of each nipple. I dreaded feeding, and as C wanted to do so 10-12 times a day, I spent all 24 hours either in pain, or anticipating its imminent start.

‘A mother’s guide to breastfeeding’, provided by my health visitor, wasn’t particularly reassuring. The only place it mentioned what I had finally come to recognize as fissures was in the ‘problem solving chart’ on the back cover. Apparently, this meant that C had tongue tie! I thought this was unlikely, as we’d seen her sticking her tongue right out of her mouth. Nevertheless, the information sent me into another panicked state, and I was on the phone yet again to the maternity unit.

On the next visit, the midwife assured me that C didn’t have tongue-tie. In fact, she seemed remarkably unperturbed by what I felt was the pretty horrifying sight of my nipples. Although she didn’t know quite what the problem was, she acknowledged that some mothers have these difficulties, and that many of them give up as a result. She was confident that things would improve, and said that I should consider getting a nipple shield to make things more bearable in the short term. She also suggested I call a breastfeeding helpline. I was sceptical they would be able to tell me anything I didn’t already know, but by this point anything was worth a try.

Nipple nightmares 1: bleeding

mother breastfeedingThe first couple of days at home were pretty breezy. Before I left hospital I was assured by two midwives that C was latching on properly – cheeks puffed out, chin pumping, ears wiggling – so I was confident we had the technique sorted. Family visited and I assured them everything was going well, demonstrating our successful feeding on several occasions. By the time I got to day four, however, things weren’t quite so easy. Accompanying the hormone-induced plunge into despair inadequately named ‘the baby blues’ (that coincides with the start of proper milk production) was a serious deterioration of my nipples.

The ‘initial soreness’ quietly mentioned in some of the leaflets just didn’t cover it. Not only did feeding result in agony extending minutes beyond the approved first 10-15 seconds, but I was starting to display serious war wounds. The first time that C vomited blood I was frantic with worry, and straight on the phone to the maternity unit. But, as the midwife reassured me (!), the blood was my own, swallowed by C while she fed. Bleeding!? No one had told me about this. Well, no one except for my friend Zara… Surely it couldn’t be normal? It certainly wasn’t according to the copious NHS breastfeeding resources.

And this was a major part of the problem. Everywhere I looked I was told that nipple soreness, cracks and bleeding were caused by the baby failing to latch on correctly: these problems were my own fault, caused by a poor technique. The thing is, when I talked to the health professionals, I was told I was doing it right, and fortunately, C seemed to be getting plenty of milk.

When the midwife next visited, I voiced my concerns. She checked my attachment – again, it seemed fine – and then admitted that she had had the same problem. Apparently, people with fair skin have a much harder time of it when it comes to breastfeeding. My nipples hadn’t darkened at all during pregnancy, so I could be particularly susceptible to problems. Hearing this was a massive relief. Ironically, being told that I might find it more difficult because of my inferior nipples made it easier to carry on (see the post on skin colour and nipple pain for more info on this). The midwife suggested I grit my teeth, and within two to three weeks it would be ‘a piece of cake’.

Early days

drawing of baby crying

Before giving birth, I heard somewhere that babies should start to suckle in the four hours after birth, and ideally straight away. When I was handed my tiny, startled daughter, I was pretty zonked, but I seemed to recall her little mouth seeking out my nipple. Or me putting my nipple near to her little mouth. Or something like that. Anyway, within a few minutes of ‘skin on skin’ she seemed to have something breast-like in her mouth and was happily sucking away.

The midwives were all suitably impressed. ‘Ooo, look she’s latched on already! That’s great. I’m sure you’ll be a natural.’ Well, of course – surely breastfeeding was the most natural thing in the world? If you were happy to let your intuition govern your actions, and you responded to your baby instinctively, then it seemed pretty straightforward. I should point out at this stage that I’d just had a calm water birth, without major trauma or pain relief, and was therefore feeling pretty earth mother about everything. Breastfeeding was the next obvious step, and I was going to be great at it.

Over the remaining hours spent in hospital, my daughter C and I slept, interspersed with periods of the suckling we were both so fantastic at. If I was honest, it was starting to sting a bit, but nothing I couldn’t handle. The next morning, I overheard a conversation between a midwife and the woman in the bed opposite me on the ward. ‘Are you breast or bottle feeding?’ the nurse asked. ‘Bottle’ she replied without hesitation. ‘He’s had loads – two lots of 30 mils just last night’. God, you had to make up that formula from scratch each time, I thought. What a pain! How can you have dismissed breastfeeding so quickly?

Before the birth

drawing of stork carrying baby

As a responsible mother-to-be, I went along to the last ‘parent craft’ class at my local health centre as a matter of course. The main theme of the class was feeding your baby. Or, more precisely, breastfeeding your baby.

Breastfeeding, as anyone who has recently had a baby will know, is STRONGLY ENCOURAGED by the National Health Service, World Health Organization, National Childbirth Trust, Unicef … in fact, pretty much any health/baby-related organization you can think of. As the midwife taking the class pointed out, she officially isn’t allowed to say anything that might encourage you to start on the formula instead.

I wasn’t worried. For me, there was no question about it: my mother and mother-in-law had both breastfed, and obviously, I would do the same. As the other conscientious first-time mothers and I sat in the class and discussed the copious advantages of breastfeeding, and disadvantages of formula, we all smugly agreed that it was the obvious option. So cheap and convenient, not to mention fantastically healthy for both you and your baby. This was all provided you got your baby to ‘latch on’ properly, but really, how hard could it be?

‘I did actually find breastfeeding quite difficult,’ said my mother. Well, I can understand that, I thought. In those days, women were actually discouraged from breastfeeding, and as Mum had frequently reminded me, she was the only woman on the whole ward who did it. Given this complete lack of support, it isn’t surprising she had a bit of trouble. I had NHS leaflets and helplines coming out of my ears, so I was obviously well equipped to deal with any of the minor difficulties that might arise. My friend Zara had mentioned a few problems too, with bleeding nipples etc. Well, that sounded pretty extreme – hardly likely to be an issue for many people!

And so I naïvely began my journey into the world of pain and paranoia that constitutes the early days (or should that be weeks?) of breastfeeding. Ultimately, with incessant, dedicated research into what was going wrong, and stubbornly gritted teeth, I made it through to the happy point where feeding no longer hurt, and was a genuinely convenient alternative to the bottle. What I discovered along the way however, was a society ill-equipped to support breastfeeding mothers, and a patronizing health service unwilling to be honest with them.