Figure 1-3: Variations in nipple shape can add to the challenge of latching for a newborn and may facilitate the need for a nipple shield to be utilized. From left to right: Rounded, flat and inverted nipples.
Figure 9: Ideally elongated nipple after nursing.
Nursing a newborn, especially for a first time mother, is an extremely challenging responsibility that requires patience, a great support network and understanding of how to read your own body as well as the newborns cues. As previously outlined, many obstacles may have already presented themselves for the mother and infant before the birth of the child.
The first days of nursing may be a seamless transition for the mother and newborn and at other times it may be a struggle and very uncomfortable. With the assistance of the lactation consultants at the hospital or birthing center, the goal is to help establish a good initial nursing relationship, milk supply and work on finding the proper latch position and learning cues from the newborn. Quiet often your stay in the maternity ward may be short and depending on the birthing history you may be headed home with your newborn in a few days.
The breastfeeding relationship is a very dynamic process that can be a pain-free, enjoyable experience that can last well past the first year of life. The infant should be able to latch and maintain the correct depth of latch with minimal assistance from the mother. The infant should effectively and efficiently be able to nurse and actively transfer milk from the breast without the need for constant manual compressions of the breast and extra work from the mother. A pull, tug, draw or vacuum should be felt from the infant as they nurse and the same feeling sustained throughout the nursing session. Some babies will only be able to actively nurse while the mother either has a letdown of milk or manually compresses milk from the breast into the babies mouth. Once the baby has nursed for a period of time, the breast should feel softer and virtually empty, signifying proper drainage from the breast. If the child still displays hunger cues, the second breast may be offered and nursing continue. Once the infant has been satisfied they will typically pull themselves off the breast so they can be burped. Depending on the age and caloric needs, the child may not need to nurse again for another 2 or 3 hours, or even longer.
This is a fairly ideal situation that has been outlined above, but not always reality. The first days postpartum consist of little sleep, recovery from birthing and many interrupted days and nights from the hospital nurses and doctors. Once you have returned home and settled down into life with the new addition, nursing behaviors may change or not improve over the course of a week. Follow-up with your pediatrician or lactation consultant can help better understand if the current issues you are experiencing are normal or abnormal. The next section will help to outline and possibly explain why certain issues you as the mother are experiencing while nursing.
This phenomenon could be occurring for a few reasons, but the best place to start is your lactation consultant to make sure your technique is correct. A well trained lactation consultant should be able to help assess both you (the mother) and the infant to optimize technique and management of milk supply. When the tongue is unable to properly extend, cup and groove around the nipple and draw it into the mouth, the infant will struggle to latch. If the infant can draw the nipple into the mouth, the next step is to have the tongue fully elevate and lift the nipple up to the roof of the mouth and allow the tongue to make a wave motion to help extract milk from the nipple. The nipple should be drawn to the back of the mouth close to the junction of the hard and soft palate and will rarely transmit into pain.
If the infant is unable to properly latch to the breast, a compensatory mechanism will occur and can result in excessive jaw movements and atypical tongue movement. This chomping or biting motion of the jaw may occur as the infants tries to nurse in this inefficient manner. In other infants the tongue can move in a forward to backward motion, almost like a piston of an engine, and rub the nipple. Some tongues will only have mobility in the front portion of the tongue and feel like a flicking or tapping on the nipple. These abnormal tongue movements can be extremely painful because the end of the nipple is highly sensitive and being traumatized.
Nipple shape and size can impact the ability for an infant to effectively latch and attempt to transfer milk. Flatter or inverted nipples can create a challenge for the infant and may require a nipple shield to help in assisting to elongate the nipple and allow for latching. The ability for an infant to latch does not necessarily mean they are able to transfer milk though. A nipple shield is also at times given the nursing mother to act as a buffer and lessen the discomfort during the nursing session and helping the child to latch.
Figure 4-8: These depict mishappened nipples after nursing. From left to right: Creased, Lipstick, Flattened, Rounded (Non-elongated)
After revisions of the tongue, the nipple shape may improve to a more ideal form, or still have some distortion. Fixing the tongue to allow for improved range of motion can improve nipple shape, but the high palate may be causing some of the distortion. The palate will start to level with time and become more flat, but this can take months to occur, just as it took months to develop in utero. The revision will allow for an improvement in the range of tongue mobility, but the infant may have to increase the mass of the tongue muscle and relearn how to coordinate and use the tongue which will take time.
Clogged ducts occur when milk is not drained from the breast ducts and cause swelling or hardening of localized areas of the breast. These can occur due to excessive supply, improper milk supply management or ineffective drainage of the breast by the infant. Foremilk has a more fluid consistency and can flow through ducts easier as compared to the hindmilk. The hindmilk has a higher fat content and caloric value, but is thicker and more difficult to extract with a poor vacuum.
When a duct is unable to be cleared, more milk is produced and continues to backup within the duct. This cycle continues and can lead to a painful infection within the breast or mastitis. Mastitis can be a serious medical complication and needs to be properly managed by a physician.
The mother’s supply can fluctuate with time, changing hormone levels and stimulation or lack of stimulation from the baby and can influence milk production. The mother may have an oversupply and/or stronger letdown and be compensating for the child’s inability to effectively nurse and empty the breast. This oversupply, and at times mixed with a stronger letdown, will allow the child to obtain enough calories and gain weight with very little nursing effort from the child. The poor or ineffective ability to latch and nurse can lead to frequent feeds, longer feeds, frustration at the breast when not satisfied and the baby can start to chomp or bite the mother. At some point the lack of effective stimulation to the mother can cause her milk supply to start dropping and potentially lead to a more frustrated baby, drop in the baby’s weight beyond acceptable rates and more discomfort for the mother. The mother’s hormones will drive much of the supply in the first months post-partum, but once these hormones regulate, the milk supply maintenance is primarily driven by effective and active nursing from the child.
The infant should be able to latch with some assistance and once at the breast, be able to maintain a deep latch with minimal assistance from the mother. The tongue is extremely vital in allowing for the infant to maintain a deep latch and hold the nipple in the mouth. The two tone lip appearance, or blister that goes around the entire circumference of the mouth, typically is caused by the lips pursing down on the breast to maintain a seal. The pursing down of the lips can be uncomfortable for the mother, cause the latch to become shallow and can lead a provider to believe the tongue is not fully functioning. When the tongue is unable to hold the nipple and make a vacuum, the latch will become shallow and the infant will slide off or down the areola and back to the end of the nipple. As the infant slides back the facial muscles will start to compensate and tighten to maintain a seal. Often parents will wrongfully assume the easier to visualize lip frenulum is the cause for this problem, however the tongue is likely the main reason for the inability to maintain a deep latch. When the tongue does not function properly, the facial muscles will contract in an effort to extract milk from the breast and the jaws will come closer together to allow for the tongue to contact the roof of the mouth. As the two jaws come together the latch depth will become shallower and the degree of discomfort and pain increase for the mother. These infants may also fatigue sooner at the breast and leading to longer feeds that are inefficient. With the proper diagnosis and treatment, the lingual frenulum may be the only revision needed and once the tongue establishes proper function, the facial muscles can relax and do less work while nursing. The upper lip blister, or sucking blister, can result from the inability of the upper lip to flange out while breastfeeding or from overcompensation of facial muscles to maintain a latch. This inability for the upper lip to flip or flange out and remain flanged out at the breast can lead to the upper lip blister, especially when the mother uses a shield for nursing. The blister can result from the upper labial or lip frenulum being too thick, very short, attached to the inside of the lip or a combination of factors. By releasing the upper lip frenulum in select cases, it can allow for a wider mouth opening or gape for the child, helping improve the seal at the breast, reduce air intake during nursing and help to reduce milk leakage.
The nipple should be drawn into the mouth and the tongue should be able to elevate upwards against the palate and express the milk from the mother. If the tongue cannot fully elevate and groove around the nipple, the child may resort to chomping down on the nipple to express milk, leading to the misshaped nipples and a poor overall seal and vacuum. The nipple should be somewhat elongated after a feeding and this is due to an effective vacuum being produced by the infant.
In some mother’s a burning, irritation or shooting pain will be experienced after nursing. This can be a result of thrush, a staph infection or vasospasm.
Thrush can mimic a burning sensation or the same feeling as when your hands or foots falls asleep, but if the infant has absolutely no signs of thrush, you may be experiencing vasospasms. Vasospasms can feel like a shooting, burning or uncomfortable tingling sensation that radiates up the breast, back through the chest wall and towards the back. It can occur during the feedings, or sometimes after the feeding. These vasospasms occur when the infant clamps down (compresses and flattens) or applies pressure to the nipple and causes the blood vessels to collapse and nerve supply to the extremely sensitive nipple to become traumatized. The nipple may appear blanched or white after feeding, signifying excessive pressure was placed on the nipple and compromising the blood flow. The infant with a poor or shallow latch, inability to maintain a deep latch or a constant chomping and biting motion may cause these symptoms to occur.
Some mother’s will experience Raynaud’s phenomenon, but this will typically occur in the hands, feet and on both breasts and is a result of poor circulation in these areas for other reasons. These locations may feel cool or cold and the mother has likely experienced and is aware of Raynuad’s prior to child birth.
If the nipple is flattened, creased or looks like a new tube of lipstick (pointed) after feedings the child may not be properly latching and nursing. Misshaped nipples can be caused by the child compressing on the nipples, rather than sucking and drawing the nipple into the mouth. This can be caused by a host of reasons from a high palate in the child, a poorly functioning tongue, a tongue with limited mobility or anatomical issues with the mother. A poor vacuum may lead to no distortion of the nipples and they appear rounded when done nursing, almost the same shape as when they started during the nursing session.