Breastfeeding: What's the normal learning curve?

Here's Part 2 of Jamie's excellent series about breastfeeding for Ask Moxie. Part 1 is here.

Menita asked: 

"What is breastfeeding supposed to feel like?  Are there stages?  What's the learning curve?  What would you recommend a new mother do in the first days/weeks of her baby's life?"

In reverse order:  What would you recommend a new mother do in the first days/weeks of her baby's life?

Ideally, planning for breastfeeding starts before your baby arrives.  I'm not talking primarily about reading up on it, although that can certainly be helpful.  I'm talking about finding support, if you aren't close to anyone who has breastfed happily, and about planning for birth.

A friend of mine was dissecting her first breastfeeding experience recently and she said, "What I needed was an older sister."  While there are no older sisters at BabiesRUs (quick! alert the purchasing director!), when it comes to breastfeeding you can often find a stand-in -- someone to say, "Yes, it sucks right now; yes, you can do it; yes, it's worth it."  Even if you don't feel that you need the information available at La Leche League meetings, or those of another breastfeeding support group, the connections you can make with more experienced mothers are like money in the bank.  Or at least like money in the Bank of Breastfeeding Satisfaction and Efficient Problem-solving.  You can also find some support online.

Before you have your baby, think too about the support available closer to home.  If your baby won't latch, do you want your spouse to say, "Let me bring you the formula," or, "Let me bring you the cordless phone and let's talk to the LC together"?  If your mother or your mother-in-law will be there to help, does she know how you feel about breastfeeding? I think it's wise to have those conversations before you bring the baby home, because uneventful breastfeeding is, unfortunately, not the reality many first-time mothers face these days.

Why? Part of the answer is that uneventful birth is not the norm in the US these days.  Keep in mind that most birth interventions can affect breastfeeding.  Even IV fluids (innocuous enough, you'd think) are associated with swollen areolae in the postpartum period, which can make it tough for baby to transfer much milk.  A baby sleepy from labor drugs may not have the first idea what to do with that breast you are waving energetically in his face.  Which can lead to itchy nurses saying, "We don't want him dehydrated," which can lead to formula supplementation, which can lead to nipple preference, which can all be immensely frustrating.

Don't get me wrong:  breastfeeding is a robust process and you can go on to nurse happily after a nightmare birth and a discouraging start at the breast.  At the same time, a typical US birth experience ends in a medicated baby and a mother who's dealing with a laceration, or an incision, along with a heaping helping of doubt about her body's ability to do what it was designed to do.  A low-intervention birth lays a good foundation for low-intervention breastfeeding.

Babies are born ready to suckle -- they've been practicing sucking and swallowing for weeks in utero.  There appears to be a sensitive window in the first hour after birth, in which baby is primed to nurse well and to keep nursing.  When a baby first comes to breast, he's practicing on small amounts of colostrum, which is thicker than mature milk. This lets him get the hang of nursing before he's inundated with high-volume fast-flowing milk.

When mother and baby are both healthy, it's a terrific idea to bring baby to breast right after the birth, and keep him there as long as everybody's happy -- no baths, no eye ook, no weighing and administrative folderol.  In those first days, offer the breast whenever your baby squeaks.  Chewing his hand?  Offer the breast.  Turning toward you?  Latch him on. Gazing contemplatively into the middle distance?  You could give it a whirl anyway.

If you need help, keep asking until you get it.  (Or have someone keep asking for you while you catch up on sleep)    If nursing is painful, find out why.   Don't keep doing the same miserable thing over and over again, hoping it won't hurt so much the next time.  Look again at how to latch; consider kangaroo care if baby doesn't seem interested in nursing.  Don't think in terms of a three-hour schedule; watch for early hunger cues or early waking cues and practice connecting baby and breast at every opportunity.   You have a couple of hurdles to clear in the next few days, and the more comfortable you are with nursing, the easier it is to stride right over them.

Are there stages?

The delivery of the placenta signals the body to begin making milk in quantity.  Somewhere between day 2 and day 6, the milk comes in.  If baby is nursing often and effectively, you probably won't get engorged (engorgement = miserably rock-hard breasts, too swollen for baby to transfer milk), even though your breasts may fill up impressively.  If you begin to get uncomfortable, it's important to remove enough milk to get comfortable again, in order to ward off engorgement and mastitis. This is hurdle #1 -- the flatter nipple and firmer breast may confuse your baby briefly.  (In point of fact, they may confuse you too.  I know I was horrified when my breasts were suddenly bigger than my nine-pounder's giant head.)  With frequent milk removal, things will level out soon.

The second hurdle:  newborn jaundice.  Most newborns experience some degree of jaundice as their extra red blood cells are broken down.  Bilirubin is excreted primarily in babies' stools, and they need to keep nursing so they can keep pooping it out. But jaundice makes them sleepy and less interested in the breast.  If jaundice is evident before your milk is in, you may be advised to supplement with formula.   

In my experience, hospital staff can be a bit jumpy about jaundice.  Yes, it can be serious.  Serious complications are unusual, though, and usually there's no need to interrupt breastfeeding.  Here's a table from an AAP publication that may be helpful if an earnest peds resident cautions you that your 41-weeker is endangered by a bili level of 11 on day 3.  (Standard disclaimer:  I'm not a doctor and there are multiple types of jaundice.)

During the early weeks of breastfeeding, you're calibrating your future milk production.  That's why frequent early milk removal is so valuable -- the amount of milk your baby removes from the breast in the first month of nursing helps to determine the amount of milk available to him in his sixth month of nursing.

After the milk comes in, which is a clear physiological change, nursing is marked by gradual changes more than by discrete stages.   Gradually, you and your baby get more adept at nursing.  Gradually, your baby gets interested in solids; gradually, solids become a larger part of his diet.  Gradually, he nurses less, until one day he's weaned. 

Some changes are hidden.  You can't see the protein ratio of your milk, the way it changes from an ultra-digestible 90-10 whey-casein ratio when baby is tiny to a 50-50 whey-casein ratio by six months, when you're less enthusiastic about cluster feedings and baby's digestion is better able to tackle the tougher casein curds.  You can't see the zinc level dropping as baby's need for zinc diminishes.  You can't see the lysozyme level rising (lysozyme is an enzyme that takes out bacteria by dissolving their cell walls) as he gets mobile and begins the quest to fish fun things out of the toilet.  (Or the litterbox -- right, Moxie? [No comment. -- Ed.])

But the changes you can't see unfold together with the ones you can. Often, the development of the breastfeeding relationship mirrors the development of the mother.  "I'm this baby's MOTHER?" you may think in the beginning, with just a hint of panic.  "I'm this baby's mother!" you know six months later.  You're the one he loves like nobody else: your arms, your voice, your touch, your milk.

What's the learning curve? 

The learning curve varies from mother to mother.  "Give it 30 days," said the nurse who found me crying after my firstborn wouldn't nurse. I've heard mothers at support group meetings say that things clicked for them with breastfeeding at about 6 weeks.   Sometimes it takes longer to feel comfortable.  But you can know that your baby is learning, too:  developing head and trunk control, so he's not so floppy; growing bigger at an amazing rate so that his mouth isn't so small in relation to your breast; figuring out that the breast is a good place to be, and that you can help him when he gets hungry.  As much as you may feel, in the early days, that you need to sprout a third arm to discharge your mom duties effectively, it becomes second nature over time.

What is breastfeeding supposed to feel like?

Rachel Myr, a midwife and IBCLC in Kristiansand, Norway, says that nursing should feel more like making a baby than like having a baby.

If you think back to your first sexual experience, pieces of it were probably awkward and uncomfortable.  Perhaps your first dozen encounters left you wondering what all the fuss was about.  Hardly anyone, though, says, "Forget it.  Enough of that nonsense.  That's what turkey basters are for."

I hesitate to compare breastfeeding and sex because the sexualization of breastfeeding causes all kinds of problems.  But they do share some important similarities:  they make an intimate physical connection between two bodies; for most of human history they were crucial to the survival of the species; the pituitary secretes oxytocin during both acts.  They are both designed to be pleasurable (in differing degrees!), but getting to pleasurable may take some time.

There is a range of normal responses to breastfeeding.  A few women think it feels fabulous; a few women always dislike the sensation.  Most of us fall somewhere in between.  It isn't supposed to hurt.  Beyond that, feel free to define your own "supposed to."

***

In the US right now, many, many women face pain and frustrations during the early weeks of nursing, especially with a first baby. Breastfeeding advocates say breastmilk is a baby's birthright.  The flip side of that is acknowledging that mothers have a right to skilled breastfeeding assistance.  If it's not working for you, there's probably someone who can help you:  a lactation consultant if latch-on is going badly, an OT or speech therapist if your baby isn't sucking effectively, a chiropractor trained in CST if a traumatic birth is affecting your nursing relationship.  Even if there's an intransigent physical barrier to exclusive breastfeeding, partial breastfeeding may be a satisfying option for you.

Like anything else you learn to do with your body, breastfeeding comfortably takes practice and sometimes help.  Just as one woman may learn to knit in an hour while another despairs of getting it after five, breastfeeding comes more easily for some women than for others.  It does come, though, bringing with it enjoyment, and convenience, and the satisfaction of knowing that you can nourish and soothe your child like nobody else.  You can protect him from disease and promote optimal development of his brain.  You can dose him with the sleep-promoting hormone CCK; you can reduce his risk of obesity.  Once the two of you get comfortable, you can even do all that in your sleep.  That's my kind of mothering.

Comments

[Anita]

I am currently in my 11th month of breastfeeding my first child. It is pleasurable and so easy now but it took a fair bit of time and practice to get to this stage. I BF exclusively for 6 months and it took about 2 to 3 months to get it right.

There were many tears, much frustration and one trip to the lactation concultant but I can look back now and feel immensely proud and satisfied. I can remember watching my baby grow and thinking "that is all me!" and "I'm doing that!" It has been the best experience of my life.

I don't mean to gush but it really is wonderful and is worth any bad moments at the beginning. As I said it took me about 2 to 3 months before I really relaxed and started enjoying BF.

At first I felt like I couldn't do anything right. (I would cry because I couldn't get my nursing pillow in a comfy way and I would blame the pillow for all my problems and I bought three different types of pillow in an attempt to fix the problem).

Also, I can remember waiting for the 6 week mark (I was counting down the days) somehow convincing myself that I would wake up at 6 weeks and everything would change for the better (even though it had been lousy at the 5 weeks and 6 day mark!).

Everyone is different and there is no magic number and Moxie you are so right - encouragement and support is so important. (As is the right nursing pillow - haha!) So good luck to all you future and current nursing mothers..don't give up, just ask for help and you will be so glad you did!

[Claire Gee]

One of the most important ingredients of successful breastfeeding is support. I could not have breastfed my three children without the wholehearted support of my husband. He was encouraging even when I was at my lowest, in the early days of feeding my first baby. In was also lucky that my Mother, and Grandmother were pro breastfeeding, every positive voice helps. For what it's worth, I advise all my friends who are expecting their first child to pick a really comfy chair in which they can sit fairly upright. Good posture is a big part of getting it right.
Thanks for a great post Jamie.

[Melanie]

I had nursed my first for 14 mos, but 7 years later I was pregnant with twins and the idea of putting my breast in a baby's mouth seemed REALLY foreign and strange. And then there was my mother, telling me every five minutes about how my SIL's milk never came in with her twins, and this person's milk never came in, and that person . . . and then she came to the hospital and STAYED ALL DAY, telling me "They can't be hungry! They just ate!" And the docs tried to freak out about Hayden's jaundice, and Zoey wasn't gaining fast enough (on day 2!!!!!). Finally I went home, talked to my ped (who I knew was very dedicated to nursing) and read all of kellymom.com and just kept putting them to the breast. And it worked out, and it's still working out at 10 mos, and I feel very lucky.

[Lisa]

I had a friend who was determined to breast feed, and had read all the books and all the literature and was sittin' on Go when her baby came.

But no one told her about the hard part: that sometimes he would eat every 15 minutes, sometimes every hour; that sometimes he would reject the breast; that sometimes he would eat for five minutes, sometime for half an hour.

All she heard was, "It's easy!" so she was ashamed, and scared to call anyone for support and be thought of as stupid or lazy. She started supplementing by syringe (to make sure he "got enough"), then by bottle, then formula exclusively, hating it all the while. And mourning the fact that what was supposed to be so easy was, in fact, hard as hell for some people.

She still mourns it today, eight years later.

[Menita]

Thank you for this. We had a bunch of things against us in the beginning: Polly's bili spiked to very dangerous levels on day 2 because whe had ALL of the issues that make for high bili happen to her: she and I had different blood types, she was a big baby, and she had a rare after-effect of birth (happens in about 5% of births) where a very large amount of blood pooled uner her scalp - made her head look deformed, but that also raises the bili levels. SHe was in NICU and it was scary shit, so from the beginning the challenge was to keep her as hydrated as possible (read: formula and bottles from the get go). Add to that that I have inverted nipples, my milk took forever to come in, and the lactation consultant I was assigned was a sargeant major...we were doomed. Now I want to make an honest effort with #2. Thanks for this.

[Midwestern Deadbeat]

Excellent, excellent information. Thank you so much.

[Monica]

Thanks so much for this! We do supplement with formula, alas (Madam was in the NICU for 11 days after her birth, and I was not allowed to put her to the breast until day 7 or so of her life, so my supply has never been great, not even with tons of oatmeal and fenugreek), but we also breastfeed a LOT and I feel good about that. Not to get all maudlin on everyone, but when she's at the breast, head happily bobbing, I actually feel that much-vaunted incredible rush of love everyone talks about. It certainly makes Sleep Wars 2006 a lot more bearable.

[Shandra]

Yay breastfeeding! I'll just chime in: I had two advantages starting out breastfeeding: one was that I pumped with my daughter (who never made it out of hospital) and could see the way the milk was super fat rich and then increased in ounces a bit and then came in in crazy amounts, so I knew my body could do it. I clung to that image the second time around. And second we had a very easy vaginal delivery with my son and he was on the breast right away.

It was *still* confusing and hard and he lost more weight than I was comfortable with. I was surprised at how hard it was, emotionally.

And I'm still glad we hung in there. It's really pretty easy now. I think support is key, but so is realizing that it's not the idyllic simple process the mums you *see* seem to have, because those mums are out and about because they've finished their learning curve.

What I would want to know in advance that hasn't been said: have a beautiful spot for nursing (IMHO this is way more important to have ready in advance than how nice the crib looks). With nice calming CDs and a spot for your water bottle and a stool for your feet and art you *love* within view. And maybe a DVD player if you are apt to get bored *even with* the loving gaze to bestow upon your progeny. Or a speakerphone. Or both.

Then when you're on a cluster feed or struggling you can at least enjoy your beautiful space.

Also sleep (as well as water! drink water!) makes milk, so when people say don't bother with the housework or get your friends to make dinner - do it!!!

And finally I hate the breast vs. bottle wars. If you're making sure your child is well fed, hey. That's really the main thing. :)

[Carla Hinkle]

I did not have a terribly tough beginning at BF, especially in retrospect and hearing so many other stories, but one thing I will say is that a support network is CRITICAL.

Luckily a lovely LC had an office in my OB's building and I had heard wonderful things about her, so I went for a pre-birth consult and then started attending the BF moms support group meetings when my baby girl was 1 week old. They smoothed out the bumps I was experiencing and got me off on the right track of what was a wonderful, 9 month BF relationship. And I always emphasize to my new-mom friends that BF is really the lazy mom's friend -- once you get the hang of it, there is no fuss, no muss, barely even any waking up at night! Can't beat it.

I weaned b/c I wanted to try to have another and I was having no periods at all while nursing -- otherwise I would surely have kept it up until 1 year or more. (And since my cycles were still wonky for at least another 6-8 months after weaning, I think next time I wouldn't be so quick to wean for the "next" baby...)

Thank you for this informative, supportive BF post. I am always sad when I hear about moms who didn't have enough support during the first 4-8 weeks and gave up on BF because of that.

[Linda]

There's no way I could have exclusively breastfed twins without my husband, mom, and MIL's full support. They were awesome what with the bringing of food and folding of laundry and averting their eyes at my constant toplessness. Add to that a pediatrician who's wife was a LC and called me at home to answer questions and give me other people to call. Also, an awesome nurse who explained to us how they transition NICU babies from bottle to breast and gave us mucho supplies to use until my girls got the whole latch on AND suck thing down.

It was definitely hard work and while all the above was important, I think the #1 thing that helped me breastfeed was my unrelenting stubborness. If something wasn't working or someone told me something I didn't want to hear, I just kept asking other people until I got the answers I wanted. I refused to supplement, I refused to give up. Getting to the 12-week mark was a HUGE milestone, though, and being able to nurse laying down without suffocating my kids with my enormous bazoongas also helped.

[mary]

I've been lurking forever and this was such a timely post that I had to comment. I'm pregnant with my first and am sort of scared about this whole bf thing. We have no family here to do the laundry and feed us and that sort of thing; it's all on me and my husband (who is supportive). It seems to me that I need to find a good LC or LLL or something. Thanks, Moxie and Jamie, and the commenters too.

[lisa]

I want to chime in with another encouraging story. T was born at 32 weeks, and spent 13 days in the NICU. I wasn't allowed to breastfeed for 5 days (in retrospect I should have insisted on being able to sooner) and he was given a pacifier right away.

The hospital was very supportive, though, and I got a pump almost right away. I pumped for an entire month, until T was strong enough to nurse at every feeding.

We had a jaundice setback at one month, which was determined to be breastmilk jaundice (pretty rare) and I had to pump for two whole days while we gave him formula (hated it, both of us).

We've also been through thrush and blebs, and last week we celebrated one year of nursing. I give almost all the credit to my son- he knew what he was doing from the beginning.

[Lisa C.]

I will be sending Jamie's "breastfeeding series" to my pregnant friend at work, along with my cell phone number and a note to "call me anytime, even at 2 AM."

I love the way the information is presented here - it covers rough start-ups without being scary, which is paramount for new moms, who are already scared and are inundated with information (both bad and good)!

I, too, had an awesome support network, including my lactivist husband who brought home literature from his work library (at a dairy) and would read to me about the magic that is human milk, my mom, who nursed all five kids and pumped at work for four kids, and my LLL group.

[Ariana]

This was a wonderful essay! I'll be linking everyone to this!

[Amy F]

Ha--your example of a bili level of 11 on day 3 is exactly what we had! Yes, he was yellowy, but did he really need home health nurses to come out for 3 days, requiring 7 heel pricks between them, to determine that he was fine? Geesh. Thanks for finding the chart for me again!