Common Breastfeeding Difficulties
Objectives
After completing this session participants will be able to identify the causes of, and help mothers with, the following difficulties:
‘not enough milk’
a crying baby
breast refusal
In previous sessions we have looked at ways to find out how mothers are managing with breastfeeding.
These include:
.
good counselling skills to encourage a mother to tell you what is worrying her.
assessing a breastfeed, using your skills of observation to see if a baby is well positionedand well attached
.
taking a detailed feeding history.There are many reasons why mothers stop breastfeeding or start to mix feed, even if they decided, antenatally, to breastfeed exclusively.
When helping mothers with difficulties you will need to use all the skills you have learnt so far. Lay counsellors and community health workers have important roles to support mothers through these difficulties, as mothers may not visit a health facility to seek help.
‘N
OTE
NOUGHM
ILK’
One of the commonest reasons for a mother to stop breastfeeding is that she thinks she does not have enough milk. Almost all mothers can produce enough breast milk for one or even two babies. Usually, even when a mother thinks that she does not have enough breast milk, her baby is in fact getting all that he needs.
Sometimes a baby does not get enough breast milk. But it is usually because he is not suckling enough, or not suckling effectively (see Session 3 'How breastfeeding works'). It is rarely because his mother cannot produce enough.
So it is important to think not about how much milk a mother can produce, but about how much milk a baby is getting.
72 Session 14: Common Breastfeeding Difficulties
Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual
Reliable signs that a baby is not
getting enough milk
Poor weight gain
• less than 500 grams per month
Small amount of concentrated urine
• less than 6 times per day
For the first six months of life, a baby should gain at least 500g in weight each month. One kilogram is not necessary, and not usual. If a baby does not gain 500g in a month he is not gaining enough weight.
An exclusively breastfed baby who is getting enough milk usually passes dilute urine at least 6- 8 times in 24 hours. If a baby is having other drinks, for example water, as well as breast milk, you cannot be sure he is getting enough milk if he is passing lots of urine.
Possible signs that a baby is not
getting enough breast milk
• Baby not satisfied after breastfeeds • Baby cries often
• Very frequent breastfeeds • Very long breastfeeds • Baby refuses to breastfeed
• Baby has hard, dry, or green stools • Baby has infrequent small stools
• No milk comes out when mother expresses • Breasts did not enlarge (during pregnancy) • Milk did not ‘come in’ (after delivery)
There are several possible signs that a baby is not getting enough milk. Although these signs
may worry a mother, there may be other reasons for them, so they are not reliable. For example, a baby may cry often because he has colic, although he might be getting plenty of milk.
Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual
R
EASONS WHY AB
ABY MAY NOT GETE
NOUGHB
REASTM
ILK BREASTFEEDING FACTORS MOTHER: PSYCHOLOGICAL FACTORS MOTHER: PHYSICALCONDITION BABY'S CONDITIONDelayed start Lack of confidence Contraceptive pill, diuretics
Illness
Feeding at fixed times Worry, stress Pregnancy Abnormality
Infrequent feeds Dislike of breastfeeding Severe malnutrition
No night feeds Rejection of baby Alcohol
Short feeds Tiredness Smoking
Poor attachment Retained piece of
placenta (rare)
Bottles, pacifiers Poor breast development
(very rare) Other foods
Other fluids (water, teas)
These are C
OMMONThese are N
OTC
OMMONThe reasons in the first two columns (‘Breastfeeding factors’ and ‘Mother: psychological factors’) are common. The reasons in the second two columns (‘Mother: physical condition’ and ‘Baby's condition’) are not common. So it is not common for a mother to have a physical difficulty in producing enough breast milk.
How to help mothers with ‘not enough milk’
Firstly find out whether the baby is really getting enough breast milk or not (using the reliable signs). If the baby is not getting enough breast milk you need to find out WHY so that you can help the mother. If the baby is getting enough breast milk, but the mother thinks that he isn’t, you need to find out WHY she doubts her milk supply so that you can build her confidence.
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Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual
Babies who are not getting enough breast milk: Low milk intake
Use your counselling skills to take a good feeding history. Assess a breast feed to check positioning and attachment and to look for bonding or rejection. Use your observation skills to look for illness or physical abnormality in the mother or baby. Make suggestions depending on the cause of the insufficient milk. Always arrange to see the mother again soon. If possible see the mother and baby daily until the baby is gaining weight and the mother feels more confident. It may take 3-7 days for the baby to gain weight.
Babies who are getting enough milk but the mother thinks they are not: Apparent
milk insufficiency
Use your counselling skills to take a good feeding history. Try to learn what may be causing the mother to doubt her milk supply. Explore the mother’s ideas and feelings about her milk and pressures she may be experiencing from other people regarding breastfeeding. Assess a breastfeed to check positioning and attachment and to look for bonding or rejection. Praise the mother about good points about breastfeeding technique and good points about her baby’s development. Correct mistaken ideas without sounding critical. Always arrange to see the mother again soon. These mothers are at risk of introducing other foods and fluids and need a lot of support until their confidence is built up again.
Fig. 14.1 If a baby passes plenty of urine it usually means that he is getting plenty of breast milk
Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual
Mrs Singh says she does not have enough milk. Her baby is three months old and crying “all the time”. Her baby gained 200g last month. Mrs Singh manages the family farm by herself, so she is very busy. She breastfeeds her baby about 2-3 times at night, and about twice during the day when
she has the time. She does not give her baby any other food or drink.
What could you say to empathize with Mrs Singh?
Mrs Singh says she does not have enough breast milk – do you think her baby is getting enough milk?
What do you think is the cause of Mrs Singh’s baby not getting enough milk?
76 Session 14: Common Breastfeeding Difficulties
Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual
C
RYINGB
ABYWe will now look at another common reason for a mother to stop breastfeeding – the crying baby. Many mothers start unnecessary foods or fluids because they think that their baby ‘cries too much’. They think that their babies are hungry, and that they do not have enough milk. These additional foods and drinks do not make a baby cry less. Sometimes a baby cries more.
A baby who cries a lot can upset the relationship between him and his mother, and can cause tension among other members of the family. An important way to help a breastfeeding mother is to counsel her about her baby's crying.
R
EASONS WHYB
ABIES CRY
Discomfort (dirty, hot, cold)
Tiredness (too many visitors)
Illness or pain (changed pattern of crying)
Hunger (not getting enough milk, growth spurt)
Mother's food (any food, sometimes cow's milk)
Drugs mother takes (caffeine, cigarettes, other drugs
Colic
‘High needs’ babiesCauses of crying
Hunger due to growth spurt:
A baby seems very hungry for a few days, possibly because he is growing faster than before. He demands to be fed very often. This is commonest at the ages of about two weeks, six weeks and three months, but can occur at other times. If he suckles often for a few days, the breast milk supply increases, and he breastfeeds less often again.
Mother's food:
Sometimes a mother notices that her baby is upset when she eats a particular food. This is because substances from the food pass into her milk. It can happen with any food, and there are no special foods to advise mothers to avoid, unless she notices a problem.
Colic:
Some babies cry a lot without one of the above causes. Sometimes the crying has a clear pattern. The baby cries continuously at certain times of day, often in the evening. He may pull up his legs as if he has abdominal pain. He may appear to want to suckle, but it is very difficult to comfort him. Babies who cry in this way may have a very active gut, or wind, but the cause is not clear. This is called ‘colic’. Colicky babies usually grow well, and the crying usually becomes less after the baby is three months old.
Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual ‘High needs’ babies:
Some babies cry more than others, and they need to be held and carried more. In communities where mothers carry their babies with them, crying is less common than in communities where mothers like to put their babies down to leave them, or where they put them to sleep in separate cots.
How to help mothers whose babies cry a lot
As with ‘not enough’ milk, you have to try to find the cause of the crying so that you can help the mother. Use your counselling skills to take a good feeding history. Help the mother to talk about how she feels and empathize with her. She may be tired, frustrated and angry.
Accept her ideas about the cause of the problem and how she feels about the baby. Try to learn about pressures from other people and what they think the cause of the crying is.
Assess a breastfeed to check baby’s suckling position and the length of a feed. Make sure the baby is not ill or in pain. Check the growth and refer if necessary. Where relevant, praise the mother that her baby is growing well and it not ill or bad or naughty.
Demonstrate way to carry and comfort a crying baby. Give relevant information where appropriate.
Give relevant information where appropriate.
Fig. 14.2 Some different ways to hold a colicky baby
a. Holding the baby along your forearm
b. Holding the baby round his abdomen, on your lap
c. Father holding the baby against his chest
78 Session 14: Common Breastfeeding Difficulties
Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual
Mrs Biyela’s baby is three month’s old. She says that for the last few days he has suddenly started crying to be fed very often. She thinks that her milk supply has suddenly decreased. Her baby has
breastfed exclusively until now and has gained weight well.
What can you say to empathize with Mrs Biyela?
What can you praise to build Mrs Biyela’s confidence?
Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual
R
EFUSAL TOB
REASTFEEDRefusal by the baby is a common reason for stopping breastfeeding. However, it can often be overcome. Refusal can cause great distress to the baby's mother. She may feel rejected and frustrated by the experience.
There are different kinds of refusal:
.
Sometimes a baby attaches to the breast, but then does not suckle or swallow, or sucklesvery weakly.
.
Sometimes a baby cries and fights at the breast, when his mother tries to breastfeed him..
Sometimes a baby suckles for a minute and then comes off the breast choking or crying.He may do this several times during a single feed.
.
Sometimes a baby takes one breast, but refuses the other.You need to know why a baby is refusing to breastfeed, before you can help the mother and baby to enjoy breastfeeding again.
Most reasons why babies refuse to breastfeed fall into one of these categories.
.
Baby ill, in pain or sedated.
Difficulty with breastfeeding technique.
Change which upsets baby.
Apparent, not real, refusal.80 Session 14: Common Breastfeeding Difficulties
Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual
C
AUSES OFB
REASTR
EFUSALIllness, pain or sedation Infection
Brain damage
Pain from bruise (vacuum, forceps) Blocked nose
Sore mouth (thrush, teething)
Difficulty with breastfeeding technique Use of bottles and pacifiers whilst breastfeeding
Not getting much milk (e.g. poor attachment) Pressure on back of head when positioning Mother shaking breast
Restricting length of feeds Difficulty co-ordinating suckle
Change which upsets baby (especially aged 3-12 months)
Separation from mother (e.g. if mother returns to work)
New carer or too many carers Change in the family routine Mother ill
Mother has breast problem e.g. mastitis Mother menstruating
Change in smell of mother
Apparent refusal Newborn - rooting
Age 4-8 months - distraction Above one year - self-weaning
Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual Fig. 14.4 Sometimes a baby refuses because breastfeeding
has become unpleasant or frustrating
How to help mothers whose babies refuse the breast
H
ELPING AM
OTHER ANDB
ABY TOB
REASTFEEDA
GAIN Help the mother to do these things:
Keep her baby close - no other carersGive plenty of skin-to-skin contact at all times, not just at feeding times Sleep with her baby
Ask other people to help in other ways.
Offer her breast whenever her baby is willing to suckle When her baby is sleepy, or after a cup feed When she feels her ejection reflex working.
Help her baby to take the breastExpress breast milk into his mouth
Position him so that he can attach easily to the breast – try different positions Avoid pressing the back of his head or shaking her breast.
Feed her baby by cupGive her own expressed breast milk if possible; if necessary give artificial feeds Avoid using bottles, teats, pacifiers.
82 Session 14: Common Breastfeeding Difficulties
Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual
Mrs Barlow delivered a baby by vacuum extraction two days ago. He has a bruise on his head. When Mrs Barlow tries to feed him, he screams and refuses. She is very upset and feels that breastfeeding will be too difficult for her. You watch her trying to feed her baby, and you notice that
her hand is pressing on the bruise.
What could you say to empathize with Mrs Barlow?
What praise and relevant information can you give to build Mrs Barlow’s confidence?
Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual Summary
Notice how all the skills you have learnt so far can be used to help mothers in different
situations: listening and learning skills; confidence and support skills; assessing a breastfeed; helping a mother to position and attach her baby; taking a detailed feeding history.
In many situations there may be no treatment, so giving the mother relevant information and suggestions is very important.
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84 Session 14: Common Breastfeeding Difficulties
Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual
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Infant and Young Child Feeding Counselling: An Integrated Course. Participant’s Manual