Diseases

Twins: Breastfeeding (Breastfeeding: Common Breastfeeding Challenges) Information

Breast infection (mastitis)

Even if you are taking medicine, continue to breastfeed during treatment. This is best for both you and your baby. Ask a lactation consultant for help if needed. Mastitis (mast-EYE-tiss) is soreness or a lump in the breast that can be accompanied by a fever and/or flu-like symptoms, such as feeling run down or very achy. Some women with a breast infection also have nausea and vomiting. You also may have yellowish discharge from the nipple that looks like colostrum. Or, the breasts may feel warm or hot to the touch and appear pink or red. A breast infection can occur when other family members have a cold or the flu. It usually only occurs in one breast. It is not always easy to tell the difference between a breast infection and a plugged duct because both have similar symptoms and can improve within 24 to 48 hours. Most breast infections that do not improve on their own within this time period need to be treated with medicine given by a doctor. What you can do

1. Breastfeed often on the affected side, as often as every two hours. This keeps the milk moving freely, and keeps the breast from becoming overly full.
2. Massage the area, starting behind the sore spot. Use your fingers in a circular motion and massage toward the nipple.
3. Apply heat to the sore area with a warm compress.
4. Get extra sleep or relax with your feet up to help speed healing. Often a breast infection is the first sign that a mother is doing too much and becoming overly tired.
5. Wear a well-fitting supportive bra that is not too tight, since this can constrict milk ducts.

• You have a breast infection in which both breasts look affected
• There is pus or blood in the milk
• You have red streaks near the area
• Your symptoms came on severely and suddenly

Breastfeeding a baby with health problems

There are some health problems in babies that can make it harder to breastfeed. Yet breast milk and early breastfeeding are still best for the health of both you and your baby - even more so if your baby is premature or sick. Even if your baby cannot breastfeed directly from you, it's best to express or pump your milk and give it to your baby with a cup or dropper. Some common health problems in babies are listed below. Jaundice Jaundice is caused by an excess of bilirubin, a substance that is in the blood usually in very small amounts. In the newborn period, bilirubin can build up faster than it can be removed from the intestinal track. Jaundice can appear as a yellowing of the skin and eyes. It affects most newborns to some degree, appearing between the second and third day of life. The jaundice usually clears up by two weeks of age and is not harmful. Two types of jaundice can affect breastfed infants - breastfeeding jaundice and breast milk jaundice.

• Breastfeeding jaundice can occur when a breastfeeding baby is not getting enough breast milk. This can happen either because of breastfeeding challenges or because the mother's milk hasn't yet come in. This is not caused by a problem with the breast milk itself.
• Breast milk jaundice may be caused by substances in the mother's milk that prevents bilirubin from being excreted from the body. Such jaundice appears in some healthy, breastfed babies after about one week of age. It may last for a month or more and it is usually not harmful.

• Severe spitting up, or spitting up after every feeding or hours after eating
• Projectile vomiting, where the milk shoots out of the mouth
• Inconsolable crying as if in discomfort
• Arching of the back as if in severe pain
• Refusal to eat or pulling away from the breast during feeding
• Waking up often at night
• Slow weight gain
• Gagging or choking, or problems swallowing

Breastfeeding and special situations

Twins or multiples Did you know? Many twin and multiple babies are smaller or born premature. Please see the Premature and/or low birth weight section for other tips for caring for these babies. Also, talk with a lactation consultant about more ways you can successfully breastfeed. The benefits of human milk to mothers of multiples and their babies are the same as for all mothers and babies - possibly greater, since many multiples are born early. But the idea may seem overwhelming! Yet many of these moms find breastfeeding easier than other feeding methods because there is nothing to prepare. Many mothers have overcome challenges to successfully breastfeed twins and more even after going back to work. Being prepared It will help to learn as much as you can about breastfeeding during your pregnancy. You can:

• Take a breastfeeding class.
• Find Internet and print resources for parents of multiples.
• Join a support group for parents of multiples through your health care provider, hospital, local breastfeeding center, or La Leche League International.
• Let your health care provider and family members know that you plan to breastfeed.
• Keep in mind that even if your babies need to spend time in the NICU (neonatal intensive care unit), breastfeeding is still possible, with some adjustments.
• Find a lactation consultant with multiples experience before the babies are born so that you know where to turn for help. Ask her where you can rent a breast pump if the babies are born early.

• How to know your babies are getting enough milk
• How to troubleshoot common breastfeeding challenges
• Ways to keep milk supply up

• Breastfeeding soon after birth and often is helpful for multiples the same way it is for one baby. The more milk that is effectively removed, the more milk a mother's body will make.
• If the babies are born early, double pumping often will help the mother make more milk.
• The doctor's weight checks can tell you if your babies are getting enough breast milk. For other signs that your babies are getting enough breast milk, see the How to know your baby is getting enough milk section.
• It helps to have each baby feed from both breasts. You can "assign" a breast to each baby for a feeding and switch at the next feeding. Or, you can assign a breast to each baby for a day and switch the next day. Switching breasts helps keep milk production up if one baby isn't eating as well for a bit. It also gives babies a different view to stimulate their eyes.

• Double clutch ("football") - Place both babies in the clutch hold. You will need pillows at your side (and maybe one on your lap) and you will place the babies on the pillows with their legs going toward the back of the chair or couch. If you are placing the babies in front of you, try to keep their whole bodies turned toward you, their chests against your chest. Their bodies must not be facing up. This is very important to help prevent nipple pain and to make sure that the babies are getting enough milk.
• Cradle-clutch combination - Place one baby (usually the easiest to latch or stay latched) in the cradle position and then position the second baby in the clutch position.
• Double cradle - Place the babies in front of you with their legs overlapping, making an X across your lap.

• Can't tolerate formula
• Has severe allergies
• Isn't thriving on formula

Common breastfeeding challenges facts*

*Common breastfeeding challenge facts medical author: Melissa Conrad Stoppler, MD

• Lactation consultants are trained to help women find ways to make breastfeeding work.
• Many women have no problems breastfeeding, while others will experience some challenges. These challenges can often be overcome.
• Developing a good latch is important to prevent sore nipples.
• Checking a baby's weight and growth is the best way to make sure he or she is getting enough milk.
• Engorgement refers to the feeling of pain or fullness in the lactating breasts.
• Clogged or plugged ducts are relatively common and can be relieved by massage, warm compresses, and frequent breastfeeding.
• A plugged duct feels like a tender, sore lump in the breast.
• Mastitis is an inflammation or infection of the breasts that can be accompanied by fever.
• Breast infections that do not heal within 24 to 48 hours may need treatment with antibiotics.
• Most mothers are able to make enough milk for twins, and some fully breastfeed triplets or quadruplets.
• Breastfeeding after breast surgery is usually possible; the extent depends upon the type of surgery and the reasons it was performed.
• Some health problems in babies can make breastfeeding more difficult.

Common breastfeeding challenges overview

Breastfeeding can be challenging at times, especially in the early days. But it is important to remember that you are not alone. Lactation consultants are trained to help you find ways to make breastfeeding work for you. And while many women are faced with one or more of the challenges listed here, many women do not struggle at all! Also, many women may have certain problems with one baby that they don't have with their second or third babies. Read on for ways to troubleshoot problems.

Engorgement

It is normal for your breasts to become larger, heavier, and a little tender when they begin making more milk. Sometimes this fullness may turn into engorgement, when your breasts feel very hard and painful. You also may have breast swelling, tenderness, warmth, redness, throbbing, and flattening of the nipple. Engorgement sometimes also causes a low-grade fever and can be confused with a breast infection. Engorgement is the result of the milk building up. It usually happens during the third to fifth day after birth, but it can happen at any time. Engorgement can lead to plugged ducts or a breast infection, so it is important to try to prevent it before this happens. If treated properly, engorgement should resolve. What you can do

1. Breastfeed often after birth, allowing the baby to feed as long as he or she likes, as long as he or she is latched on well and sucking effectively. In the early weeks after birth, you should wake your baby to feed if four hours have passed since the beginning of the last feeding.
2. Work with a lactation consultant to improve the baby's latch.
3. Breastfeed often on the affected side to remove the milk, keep it moving freely, and prevent the breast from becoming overly full.
4. Avoid overusing pacifiers and using bottles to supplement feedings.
5. Hand express or pump a little milk to first soften the breast, areola, and nipple before breastfeeding.
6. Massage the breast.
7. Use cold compresses in between feedings to help ease pain.
8. If you are returning to work, try to pump your milk on the same schedule that the baby breastfed at home. Or, you can pump at least every four hours.
9. Get enough rest, proper nutrition, and fluids.
10. Wear a well-fitting, supportive bra that is not too tight.

Fungal infections

A fungal infection, also called a yeast infection or thrush, can form on your nipples or in your breast because it thrives on milk. The infection forms from an overgrowth of the Candida organism. Candida exists in our bodies and is kept at healthy levels by the natural bacteria in our bodies. When the natural balance of bacteria is upset, Candida can overgrow, causing an infection. A key sign of a fungal infection is if you develop sore nipples that last more than a few days, even after you make sure your baby has a good latch. Or, you may suddenly get sore nipples after several weeks of pain-free breastfeeding. Some other signs of a fungal infection include pink, flaky, shiny, itchy or cracked nipples, or deep pink and blistered nipples. You also could have achy breasts or shooting pains deep in the breast during or after feedings. Causes of thrush include:

• Thrush in your baby's mouth, which can pass to you
• An overly moist environment on your skin or nipples that are sore or cracked
• Antibiotics or steroids A chronic illness like HIV, diabetes, or anemia

1. Change disposable nursing pads often.
2. Wash any towels or clothing that comes in contact with the yeast in very hot water (above 122°F). Wear a clean bra every day.
3. Wash your hands often, and wash your baby's hands often - especially if he or she sucks on his or her fingers.
4. Put pacifiers, bottle nipples, or toys your baby puts in his or her mouth in a pot of water and bring it to a roaring boil daily. After one week of treatment, discard pacifiers and nipples and buy new ones.
5. Boil daily all breast pump parts that touch the milk.
6. Make sure other family members are free of thrush or other fungal infections. If they have symptoms, make sure they get treated.

Inverted, flat, or very large nipples

Some women have nipples that turn inward instead of protruding, or that are flat and do not protrude. Nipples can also sometimes be flattened temporarily due to engorgement or swelling while breastfeeding. Inverted or flat nipples can sometimes make it harder to breastfeed. But remember that for breastfeeding to work, your baby has to latch on to both the nipple and the breast, so even inverted nipples can work just fine. Often, flat and inverted nipples will protrude more over time, as the baby sucks more. Very large nipples can make it hard for the baby to get enough of the areola into his or her mouth to compress the milk ducts and get enough milk. What you can do

1. Talk to your doctor or a lactation consultant if you are concerned about your nipples.
2. You can use your fingers to try and pull your nipples out. There are also special devices designed to pull out inverted or temporarily flattened nipples.
3. The latch for babies of mothers with very large nipples will improve with time as the baby grows. In some cases, it might take several weeks to get the baby to latch well. But if a mother has a good milk supply, her baby will get enough milk even with a poor latch.

Low milk supply

Most mothers can make plenty of milk for their babies. But many mothers are concerned about having enough. Checking your baby's weight and growth is the best way to make sure he or she is getting enough milk. Let the doctor know if you are concerned. For more ways to tell if your baby is getting enough milk, visit the How to know your baby is getting enough milk section. There may be times when you think your supply is low, but it is actually just fine: When your baby is around 6 weeks to 2 months old, your breasts may no longer feel full. This is normal. At the same time, your baby may nurse for only five minutes at a time. This can mean that you and baby are just adjusting to the breastfeeding process - and getting good at it! Growth spurts can cause your baby to want to nurse longer and more often. These growth spurts can happen around 2 to 3 weeks, 6 weeks, and 3 months of age. They can also happen at any time. Don't be alarmed that your supply is too low to satisfy your baby. Follow your baby's lead - nursing more and more often will help build up your milk supply. Once your supply increases, you will likely be back to your usual routine. What you can do

1. Make sure your baby is latched on and positioned well.
2. Breastfeed often and let your baby decide when to end the feeding.
3. Offer both breasts at each feeding. Have your baby stay at the first breast as long as he or she is still sucking and swallowing. Offer the second breast when the baby slows down or stops.
4. Try to avoid giving your baby formula or cereal as it may lead to less interest in breast milk. This will decrease your milk supply. Your baby doesn't need solid foods until he or she is at least 6 months old. If you need to supplement the baby's feedings, try using a spoon, cup, or a dropper.
5. Limit or stop pacifier use while trying the above tips at the same time.

Nursing strike

A nursing "strike" is when your baby has been breastfeeding well for months, and then suddenly begins to refuse the breast. A nursing strike can mean that your baby is trying to let you know that something is wrong. This does not usually mean that the baby is ready to wean. Not all babies will react the same to the different situations that can cause a nursing strike. Some babies will continue to breastfeed without a problem. Others may just become fussy at the breast, and others will refuse the breast entirely. Some of the major causes of a nursing strike include:

• Mouth pain from teething, a fungal infection like thrush, or a cold sore
• An ear infection, which causes pain while sucking
• Pain from a certain breastfeeding position, either from an injury on the baby's body or from soreness from an immunization
• Being upset about a long separation from the mother or a major change in routine
• Being distracted while breastfeeding - becoming interested in other things around him or her
• A cold or stuffy nose that makes breathing while breastfeeding difficult
• Reduced milk supply from supplementing with bottles or overuse of a pacifier
• Responding to the mother's strong reaction if the baby has bitten her
• Being upset about hearing arguing or people talking in a harsh voice while breastfeeding
• Reacting to stress, overstimulation, or having been repeatedly put off when wanting to breastfeed

1. Try to express your milk on the same schedule as the baby used to breastfeed to avoid engorgement and plugged ducts.
2. Try another feeding method temporarily to give your baby your milk, such as a cup, dropper, or spoon.
3. Keep track of your baby's wet diapers and dirty diapers to make sure he or she is getting enough milk.
4. Keep offering your breast to the baby. If the baby is frustrated, stop and try again later. You can also try when the baby is sleeping or very sleepy.
5. Try various breastfeeding positions, with your bare skin next to your baby's bare skin.
6. Focus on the baby with all of your attention and comfort him or her with extra touching and cuddling.
7. Try breastfeeding while rocking and in a quiet room free of distractions.

Oversupply of milk

Some mothers are concerned about having an oversupply of milk. Having an overfull breast can make feedings stressful and uncomfortable for both mother and baby. What you can do

1. Breastfeed on one side for each feeding. Continue to offer that same side for at least two hours until the next full feeding, gradually increasing the length of time per feeding.
2. If the other breast feels unbearably full before you are ready to breastfeed on it, hand express for a few moments to relieve some of the pressure. You can also use a cold compress or washcloth to reduce discomfort and swelling.
3. Feed your baby before he or she becomes overly hungry to prevent aggressive sucking. (Learn about hunger signs in the Tips for making it work section.)
4. Try positions that don't allow the force of gravity to help as much with milk ejection, such as the side-lying position or the football hold.
5. Burp your baby frequently if he or she is gassy.

1. Hold your nipple between your forefinger and middle finger or with the side of your hand to lightly compress milk ducts to reduce the force of the milk ejection.
2. If baby chokes or sputters, unlatch him or her and let the excess milk spray into a towel or cloth.
3. Allow your baby to come on and off the breast at will.

Plugged ducts

It is common for many women to have a plugged duct at some point breastfeeding. A plugged milk duct feels like a tender and sore lump in the breast. It is not accompanied by a fever or other symptoms. It happens when a milk duct does not properly drain and becomes inflamed. Then, pressure builds up behind the plug, and surrounding tissue becomes inflamed. A plugged duct usually only occurs in one breast at a time. What you can do

• Breastfeed often on the affected side, as often as every two hours. This helps loosen the plug, and keeps the milk moving freely.
• Massage the area, starting behind the sore spot.
• Use your fingers in a circular motion and massage toward the nipple. Use a warm compress on the sore area.
• Get extra sleep or relax with your feet up to help speed healing. Often a plugged duct is the first sign that a mother is doing too much.
• Wear a well-fitting supportive bra that is not too tight, since this can constrict milk ducts. Consider trying a bra without underwire.

Sore nipples

Many moms report that nipples can be tender at first. Breastfeeding should be comfortable once you have found some positions that work and a good latch is established. Yet it is possible to still have pain from an abrasion you already have. You may also have pain if your baby is sucking on only the nipple. Ask a lactation consultant for help to improve your baby's latch. Talk to your doctor if your pain does not go away or if you suddenly get sore nipples after several weeks of pain-free breastfeeding. Sore nipples may lead to a breast infection, which needs to be treated by a doctor. What you can do

• A good latch is key, so visit the Bringing your baby to the breast to latch section for detailed instructions. If your baby is sucking only on the nipple, gently break your baby's suction to your breast by placing a clean finger in the corner of your baby's mouth and try again. (Your nipple should not look flat or compressed when it comes out of your baby's mouth. It should look round and long, or the same shape as it was before the feeding.)
• If you find yourself wanting to delay feedings because of pain, get help from a lactation consultant. Delaying feedings can cause more pain and harm your supply.
• Try changing positions each time you breastfeed. This puts the pressure on a different part of the breast.
• After breastfeeding, express a few drops of milk and gently rub it on your nipples with clean hands. Human milk has natural healing properties and emollients that soothe. Also try letting your nipples air-dry after feeding, or wear a soft cotton shirt.
• If you are thinking about using creams, hydrogel pads, or a nipple shield, get help from a health care provider first.
• Avoid wearing bras or clothes that are too tight and put pressure on your nipples.
• Change nursing pads often to avoid trapping in moisture.
• Avoid using soap or ointments that contain astringents or other chemicals on your nipples. Make sure to avoid products that must be removed before breastfeeding. Washing with clean water is all that is needed to keep your nipples and breasts clean.
• If you have very sore nipples, you can ask your doctor about using non-aspirin pain relievers.