LATCHING ON.

Before you begin, get comfortable. Make sure your back is supported, you might need a cushion or pillow. If you are using pillows to lift the baby to the level of your breast, get these organised too. Something to mop up the milk if baby is a little sick ought to be close and a drink for you (when the milk starts to flow, you may find that an enormous thirst comes over you). It will feel like a bit of a performance at first, but once you become more confident you may find that the mountain of pillows disappears to one!

You need to be sitting slightly forward (back supported) with relaxed shoulders and hopefully every other part of you relaxed as well. If you are feeling tense then baby will sense it and may not settle to feed properly.

It may seem extremely basic but it is important to hold the breast properly. When a breast is full it is easily damaged. Cup the breast underneath with all your fingers with the thumb gently on top, taking care not to squeeze or to pull the skin. Alternatively, you could put your fingers on your rib cage so that your breast is resting on your forefinger with your thumb as before. In both cases the breast will be lifted slightly. You have to find the method that suits you best. If you are particularly big in the breast department, cupping might be better.

When the baby is latched on correctly she will have the nipple and most of the areola (the pinkish, brown skin around the nipple) in her mouth. Bear in mind that no one areola is exactly the same, so if you are in any doubt as to the position of the baby, get someone who is trained to have a look. 

To get the baby on the breast, the baby’s mouth must be wide open. Using the rooting reflex (which is a natural reflex the baby has to help it feed) to your advantage, tickle the baby’s mouth corner or nose with the nipple. The mouth will open (but it needs to be wide) then move the baby quickly but smoothly to the breast. It takes practice and you may need a hand initially but practice makes perfect. Baby should be held comfortably, facing the breast ("tummy to mummy") so that her nose is level with the nipple (you may need pillows or cushions to lift the baby to the correct height initially). That way all you have to worry about is getting baby on.

Next, when baby is on the breast have a look at her mouth position; it should be wide open with both lips curling outwards.

When baby starts to feed, the movement in her jaw should be seen almost to the temple. If the baby is on properly there should be no need to pull the skin away from her nose; just try not to mash the baby into your breast so much. Relax your hold and check once again. You’ll do a lot of checking at first but as you get used to the "feel" of the correct position, you won’t need to.

Removing baby from the breast has to be done carefully as pulling her off will hurt and damage the nipple. Put a clean, little finger gently into baby’s mouth, between the gums, and release the "grip".

Change breast pads frequently as moist ones may harbour bacteria and could possibly cause an infection in you or the baby.

Nipple shields look like Mexican hats and (you’ll be surprised to hear) fit over your nipple. They are used to protect the nipple and reduce nipple pain. Their use is controversial: some midwives are for them and others against. If they are used, it should only be for a day or two and only when the milk is in, as baby will find it difficult to get enough colostrum through the shield. (Inch and Fisher, 2000). The problem for baby is that it interferes with the amount of milk she is able to get from the breast. This results in a longer feed &/or a shorter interval between feeds. So, in actual fact, the wear and tear on the nipple is probably not improved. It could also reduce your milk supply or maybe cause engorgement (sore, tender and over full breasts) and, again, if the root of your problem is a poorly positioned baby you need a midwife or a trained supporter to watch you feed otherwise the problem won’t go away.

Some women find creams soothing for sore and cracked nipples. Find an oily one. Look closely at the ingredients to check that the oil used is not nut based (in case of allergy). Avoid using anything on the nipple that might dry it out i.e. Soap, nipple sprays with alcohol in them. The nipple is a naturally oily area and doesn’t appreciate being dried out. (Inch and Fisher. 2000. Huml.1999.)

If the nipple isn’t too badly affected, leaving them clean and dry will suffice. You could even rub some breast milk into them as breast milk in itself is healing. (WHO / UNICEF, 1993).

If your nipples are very sore and cracked, and you can’t bear to have baby feeding from you, a breast pump either electric or hand held could be a good idea. Again, a temporary measure just to allow your nipples to heal and your toes to uncurl! Whatever is expressed could then be bottle, cup or spoon fed to baby-you’ll then need to work on your feeding technique (sorry to repeat it again!). It cannot be assumed either that using the breast pump prevents damage to the nipple, you may be adding to your problems. (Nicholson, 1985).

Hand expression is a gentle alternative to a pump. Start off by gently massaging the breast from the top towards the nipple moving over the whole of the breast (not forgetting the area underneath). Use small circular movements.

Apply hot flannels or have a warm bath before you start to help the milk to flow. Then gently place the fingers of one hand below the nipple on the margin where the areola meets the skin of the breast. Your thumb is placed above the nipple in the same way. You should be able to feel the lactiferous sinuses (temporary storage spaces for the milk; it’s these baby squeezes when feeding) like soft beads.

With your fingers in the correct position push backwards into your ribs. The action then is a rolling and squeezing of your fingers and thumb together. You have to be gentle so as not to bruise the delicate breast tissue inside, and to avoid rubbing the skin, as the friction will make the area sore. It may take a little while to get the milk to flow but keep squeezing as described and eventually the milk will appear. Work one breast then the other and keep working each breast until the milk stops flowing. The milk needs to be caught in a sterile bowl and then transferred to either a container or bottle (sterile) to store in the fridge for later. As previously mentioned the milk may be given to baby either by bottle, cup or spoon. Just a quick word – there is a knack to this. Be patient and relaxed and work methodically. Rotate the finger position around the nipple (to get all the stores of milk from the ducts), push into the ribs and roll the fingers. You may also have to repeat the massage to encourage the milk to flow again.

You can still feed from sore and cracked nipples in the usual way. The nipple will heal itself (so long as the baby is latched on properly!) The pain should subside over the next few days. If the baby is on OK the initial pain should ease. Give it a few seconds - which might feel like a lifetime! If the baby is not on properly, remove safely and try again. This method of treating sore nipples is more likely to lead to successful breast feeding than expression and resting as the milk production and breast-emptying cycle is more efficient when baby is doing it!

It is fine to make a few mistakes. Be kind to yourself. Breastfeeding is all about a little know-how and confidence. Once you and your baby have learnt how to do it, things will get easier. Also, don’t be backwards in coming forwards. Get some help if you need it. Cultivate some breastfeeding friends, ring the organisations listed and ask your midwife. Use these people if you have a problem - that's what they are there for.

References:

Kearney MH, Cronenwett LR, Barret JA. Breastfeeding problems in the first week postpartum. Nursing Research 1990. 39(2): 90-94.

Ziemer M, Joseph G. Skin changes and pain in the nipples during the first week of lactation. Journal of Obstetric, Gynaecologic and Neonatal Nursing 1997. 22(3): 46-51.

Inch S. Fisher C. Breast feeding-Early problems.

The Practising Midwife. . 2000. 3(1): 12-15.

Huml S. Sore nipples. Anew look at an old problem through the eyes of a dermatologist.

The Practising Midwife.1999 2(2): 28-31.

Breastfeeding Counselling: A Training Course Participant’s Manual.

WHO/ UNICEF.1993.

Nicholson.W. 1985. Cracked nipples in beast feeding mothers – a randomised trial of three methods of management. Newsletter of nursing mothers of Australia. 21(4): 7-10.