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The anatomy and physiology of breastfeeding takes us only part of the way toward understanding the ideal progression of nursing, from the initial latch on the first day…to the first week…to the first month…through long-term maintenance. This chapter describes how the mother—infant dyad need to work in order to create a successful breastfeeding experience for both. This sets up the ideal nursing situation, and delineates issues that may be useful for the practitioner in a clinical setting.
4.1 Early Breastfeeding: The First Week and Month of Nursing
The first month of nursing is the most critical, because what happens during this time can determine the overall success or failure of nursing. Wagner et al. (2013) found that 92 % of breastfeeding mothers expressed concerns at day 1 and 3. The most common concerns were milk quantity (40 %), breastfeeding pain (44 %), and infant feeding difficulties at the breast (52 %). Mothers were at greatest risk of stopping nursing at day 7 due to infant feeding difficulty, and at day 14 due to poor milk quantity. For these reasons, Taveras et al. (2003) recommended that breastfeeding interventions should focus on counseling during mothers’ postpartum hospitalization and shortly after mother and baby are discharged. Timing is critical, but it is important that, in addition to providing education and support, that we offer sound clinical advice that will result in breastfeeding success, and not confusing recommendations.
This time can be very challenging for mothers. They may avoid asking for help in these early days because, not having any other experience, they assume that what is happening for them is “normal.” They may glean expectations from common lore, guidebooks, the internet, or friends and family. If they do seek professional help, they may be told to “wait it out” or focus only on one parameter, such as baby weight gain or wet diapers, and miss the window of opportunity for intervention. Or they may not recognize the pattern of a problem, since the first weeks are a time of transition—each day may be different from the last.
During the first week, the pace and duration of nursing is set. Infants begin to make associations between their time at the breast and satisfaction of their needs. In addition, as explained earlier, the mother’s physiology changes—she develops more prolactin receptors in her breasts in response to infant suckling.
After the first month, milk production shifts from global to local control. This does not mean that nursing will fail if things don’t go perfectly, but there is a limit to the improvement that is possible after the first several weeks. Furthermore, many of the breastfeeding problems that appear later have roots in issues that could have been corrected during the first week or month.
This chapter describes the ideal progression of nursing during the first week, month, and thereafter, as well as signs that signal a budding problem. It’s important to remember the multidimensional, highly individual nature of breastfeeding. It is possible for the same circumstances to result in different behaviors in different mothers and babies, leading to different nursing outcomes. “Normal” must be redefined for each mother—baby dyad, without subjective interpretation of the infant’s behavior or generalization from previous cases.
4.1.1 The Initial Latch
The ideal latch was described in Chap. 1. It is critical to note that if the baby is not able to latch on and nurse in the most efficient manner, then the expectations of normal nursing cannot be met. The latch must be corrected first, and at the earliest possible time, to allow breastfeeding to proceed as expected. The latch can be corrected with intervention or positioning, but it will not correct itself. The “wait and see” approach may result in successful nursing, but that is the exception, not the rule. Using the skiing analogy, if the equipment is not properly fitted, then there is a limit to ones success in going down the mountain. Ill-fitting equipment will never adapt to the skier. You may be able to make it down a few bunny hills, but you will never be able to progressively ski or make it down a black diamond.
So, how can we know whether or not the baby has a good latch? Merely observing a mother/baby dyad nursing is most commonly used, but external observations can be misleading. A study by Côté-Arsenault and McCoy (2012) showed that there is a poor association between number of swallows and infant milk intake in the first few days of life. Merely observing a baby nursing does not give an accurate assessment of intake. And since we cannot see inside a baby’s mouth we cannot tell how deep the latch is from the outside.
One of the most obvious indicators of a shallow latch can be elicited through the mother’s initial observation. Mothers notice right away if their baby cannot gape widely enough to latch. They try to follow breastfeeding books or professional nursing advice, but the baby simply does not open his mouth wide enough. This can result in the baby falling off the breast or frequent relatching. Sometimes mothers are told to hold the jaw down, or the baby may be labeled as lazy. Neither is the case. At birth, a baby will open his mouth as wide as he possibly can. If the gape is not there on day 1, it will not improve without intervention.
Perhaps the most reliable, common, and immediate indication of an incorrect latch is nipple pain. It is among the primary reasons women choose to stop nursing. Pain is the biggest deterrent to nursing, but it is also a very early indicator that something is wrong and needs fixing right away. The nipple is the most sensate part of the breast. It is supposed to fit all the way in the back of the throat, away from any moving parts or friction. It opens over the baby’s esophagus so milk can move efficiently into the stomach. If the nipple is not correctly positioned, it moves around in the baby’s mouth and that friction causes pain. In this way, the pain elicited by the nipple acts as an alarm for the mother, signaling that something is wrong.
If the mother experiences pain while nursing, indicating a shallow latch, many typical first-month baby behaviors can be misread. For example, if the baby nurses frequently but the mother experiences severe pain with each latch, then the pattern of frequent feeding on demand will actually decrease milk supply. This is because the breasts are not being emptied, so prolactin is not being released and FIL is building up. Pain can also trigger the release of cortisol, a stress hormone, which further suppresses milk production and can lead to increased stress and postpartum depression.
The main exception to the rule of pain is if a baby has a high, arched palate. In this case, the mother may feel no pain, even though the baby is not properly latched. The nipple may not reach the palate to be compressed, so the pain alarm is not triggered even though the palate and mouth are insufficiently filled with breast tissue and the baby easily falls off the breast.
With a sufficiently deep, locked-in latch with efficient milk transfer, this is how the first week and month of nursing should progress:
4.1.2 Week 1
At birth, an infant has all the reflexes necessary to begin nursing immediately. The immediate time after birth is a “sensitive period,” which can predispose mother and infant to bonding if they are in intimate, close contact. Therefore, skin-to-skin contact (SSC) with the mother is strongly recommended. It has been shown that infants who are allowed SSC and self-attach may continue nursing more effectively. Ideally, the naked baby is placed prone on the mother’s bare chest immediately after birth. In full term, healthy babies, this triggers a series of innate behaviors (Moore et al. 2012).
Widstrom et al. (2011) described nine behaviors that occur as a result of early SSC: birth cry, relaxation, awakening and opening the eyes, activity (looking at the mother and breast, rooting, hand to mouth movements, soliciting sounds), a second resting phase, crawling towards the nipple, touching and licking the nipple, suckling at the breast and finally falling asleep. Dani et al. (2015) confirmed the specific behavioral sequence and observed another, tenth behavior, of the infant massaging the mother’s breast with his hand.
Even during the first week, infants provide several hunger indicators. The earliest cues are rooting and putting the hand to the mouth (American Academy of Pediatrics Statement on Breastfeeding 2012). It is best to feed the baby when he exhibits these early cues and not wait for later cues, such as crying or becoming frantic, which can make latching on more challenging. It also makes the whole process of nursing more stressful.
Once the baby is able to latch on and does not cause pain for the mother or fall off the breast, feeding patterns can emerge over the first week based on the amount and type of milk available from the mother, and the size and age of the baby.
At birth, babies are born waterlogged from being immersed in a fluid-filled womb. It is expected that 7–10 % of the birth weight will be lost during the first 3–7 days due to release of this excess fluid (Noel-Weiss et al. 2008). The greatest amount of weight loss should be at day 4. A 1-day-old baby’s stomach is about the size of a large marble and can accommodate 5–10 ml of milk at each feeding. It begins to stretch on day 3, when it grows to the size of a ping-pong ball, allowing the baby to take in a commensurate amount of milk.
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