Wednesday, July 13, 2011

Breastfeeding Basics - Part IV: Six Weeks to Six Months

By now, you've read the Introduction and Parts I, II, and III of this series. I hope that you're finding breastfeeding and mothering in general to be getting easier.

I debated how to divide up the next few sections. I considered doing a post just on the next six weeks, up through three months, and then do a three to six month post. But, I chose to combine these because most of the issues I want to cover could come up really at any time, from birth to six months, and not that much changes from here on out until you start offering solid foods (to be covered in the next part). What I'll do, then, is divide Part IV into two subsections, up through three months and then up through six months, and then cover the more universal issues that may arise.

Six Weeks to Three Months

By now, you've weathered at least two growth spurts. When you come out of the six-week growth spurt and into "after the first six weeks" territory, you'll realize how much your baby has grown. You'll notice that he nurses more effectively, probably for a shorter amount of time, and, if you're lucky, maybe less often as well. In the next six to eight weeks, your baby will start smiling (if he hasn't already), laughing, showing better and better head control, showing interest in grabbing items, and recognizing and showing delight in human faces, especially those of his close family. His hunger signals should become more obvious and readable to you, and you're probably starting to see some real personality emerge. Your baby isn't just a needy lump anymore (no offense, but, really, in those first few weeks, they don't do much but eat, sleep, cry, and poop, right?). He's an enjoyable human being in his own right, and you can actually start to play with him and interact with him.

In addition, you are starting to feel more like yourself again. Sure, you're probably feeling sleep-deprived, but the major aches and pains and soreness and general not-yourself-ness you felt after the birth should be greatly improved. Your postpartum bleeding should be done with or mostly done, you've been back for your postpartum visit with your OB or midwife, and you're much more up-and-at-'em than you have been since the baby was born.

This is a good time to point out the symptoms of postpartum depression. This is only tangentially relevant to this blog post, so I'm pointing you elsewhere for detail. Basically, if you're feeling melancholy, depressed, overly anxious, having disturbing thoughts or desires about harming yourself or your baby, strong feelings of guilt or failure, etc., please seek help. These feelings are not normal and you don't have to live with them or expect to "snap out of it" on your own. There are plenty of resources out there to help identify, diagnose, and treat postpartum depression (PPD), and many of the medications used for the treatment of PPD, if needed, are safe for breastfeeding.

By the time you reach about three to four months postpartum, your milk production should have largely adjusted to the needs of your baby. You'll find you're feeling engorged less often, if at all, and hopefully leaking less (if this was a problem for you to begin with). You may also find, if you're pumping, that it's harder to produce as much for the pump. This is all due to the switch-over from hormonally driven production to demand-based production. In the first phase of breastfeeding, milk production is stimulated and controlled by hormones. As time goes on, the automatically-produced hormones cease, and your baby's demand - the amount of milk she takes in and the frequency of her feedings - instead stimulates the breasts and brain to produce milk in line with what your baby needs.

Be forewarned that there is another growth spurt around three to four months of age.

Three to Six Months

Now is the time to sit back and enjoy the progress you've made. Making it to six months exclusively breastfeeding is a great accomplishment! In these three months, just keep nursing on demand. Don't worry about giving water or other foods. Just nurse your baby when he's hungry!

During this time, you may find your baby is developing some annoying habits. Some babies will suddenly decide they only like to nurse in certain positions or places. Many babies become very distractible around four months of age because they've suddenly become aware of the world around them and want to participate. It can definitely be frustrating to have the baby pop on and off the breast constantly while nursing. Whenever practical, you can nurse in a darkened, quiet room to minimize distractions. At least this way, he'll get a good meal in a few times a day, even if the rest of the day is more erratic. As he gets more used to the world "happening" around him, and he starts to make the connection between popping off the breast and being hungry, he should become more reliable again.

Also during this time, your baby will probably start teething. Symptoms of teething may include excessive drooling, difficulty finding a comfortable position lying down, suddenly refusing to nurse, wanting to nurse more, chewing on hands (or your nipples), chin or cheek rash (due to the drool), diaper rash and mucousy poop (due to swallowing excess saliva), stuffy nose, mild fever (not higher than about 99 degrees Fahrenheit), red, inflamed gums, ear infection or ear ache, difficulty sleeping, and general fussiness. Some babies show almost none of these symptoms, while others may have all of them. Teething can make nursing difficult for both of you, as it may hurt him to suck, and his latch may suffer as he tries to adjust his latch to the changes in his mouth. Also, these symptoms may go on for weeks before a tooth actually comes through. It's usually not quite as hellish as I'm making it sound here, and you'll find effective ways to help soothe and calm your baby. It may be as simple as allowing him to chew on a cool washcloth, or you may want to give him Infant Tylenol (as directed!!) to help dull some of the pain of teething. Once the tooth comes through, you may have to help him readjust his latch once more so that it's comfortable for you.

Bottom teeth should never come in direct contact with your breast, as a baby with a proper latch should put his tongue over his bottom teeth. The top teeth should rest only lightly on the breast and not dig in. If you have tooth marks on your breast, you may need to help him readjust his latch. Often, he will adjust it on his own in a day or so as he figures out what to do with this new thing in his mouth.

If your baby bites you during this time, it is typically not meant aggressively. He may just be seeking relief from the teething symptoms. The best way to deal with biting while nursing is to immediately put the baby down, make an exaggerated sad face, and say "No bite! That hurts Mommy!" Then allow him to nurse more. If he associates biting with not nursing, he should stop biting. If you yelp or make a funny noise but don't withdraw the breast, he may think it's funny and start biting more often just to see your reaction. It's difficult, and it hurts, but you definitely want to stop this behavior quickly if it happens.

Common Issues

Thrush is an infection caused by yeast. Thrush can be present on your nipples or in the baby's mouth or both. It is passed back and forth by nursing. Symptoms of thrush in the mother may include suddenly very sore nipples, especially at latch-on, pink or red or scaly nipples, cracking or bleeding nipples despite no change in baby's latch, a burning sensation within the breast during nursing or let-down, concurrent vaginal yeast infection. Symptoms of thrush in the baby include whitish patches in the mouth that do not wash away, pain in the mouth, excessive gassiness if the yeast invade the digestive tract, yeasty diaper rash. Mother and baby may show some or all of these symptoms, possibly not simultaneously. It can be very difficult to positively diagnose thrush.

There are many treatments for thrush. Some work better for some people. You may need to work at it for a few weeks to find the best treatment for you and your baby. Options range from prescription Nystatin (either cream for you or an oral suspension for baby's mouth and for your nipples), over-the-counter Monistat or Lotrimin (cream to apply to your nipples), gentian violet, grapefruitseed oil, or a combination of the above. A good place to get ideas for how to identify and treat thrush can be found here.

Plugged Ducts and Mastitis
A plugged duct is exactly what it sounds like - when a milk duct become clogged with solidifying milk. This usually occurs due to unresolved engorgement but can happen any time, especially if your baby has gone longer than usual without nursing. It can also occur if you are wearing restrictive clothing such as a bra with an underwire that is not properly positioned.

A plugged duct must be treated, as it can lead to mastitis, which is an infection of the milk duct. Untreated mastitis can lead to abscess or even loss of milk. It is important to identify and treat plugged ducts and mastitis promptly.

A plugged duct feels like a sore spot on the breast. I associate the feeling of a plugged duct with the way a bruise feels or a tender muscle after a cramp or strain. It will be a single spot on your breast, and you can usually feel a lump at that spot if you prod with your fingers.

To treat a plugged duct, nurse on the affected breast as often as possible (but don't let the other side become too engorged!). You can also pump or hand-express in between feedings. Keep the breast as empty as possible. Massage the affected area as you nurse and pump to encourage the plug to break free. Apply moist heat to the site of the plug to encourage milk flow. Direct the hot water from the shower to the breast as well, and massage while applying heat or in the shower. Get plenty of rest and drink lots of fluids to keep your immune system as strong as possible to fight off infection. After about 24 hours, you should find yourself feeling better. Sometimes the site of the plug may feel tender for a day or two after the plug is released.

Symptoms of mastitis include general fatigue, possible fever, increased pain in the affected breast, redness on the outside of the breast that corresponds to the site of the plugged duct, and flu-like symptoms. These symptoms usually come on quite suddenly and in conjunction with a plugged duct. Begin treating the plugged duct and rest and drink plenty of fluids. If your home treatment is effective, you should feel better within 12 to 24 hours. If your symptoms get worse, or you do not feel better within 24 hours, call your doctor, as you may need antibiotics to help clear the infection.

Pumping and Storing Milk
You may need to return to work after six weeks, or you may decide that you'd like to be able to be away from your baby during the day for other reasons. If you plan to continue exclusively breastfeeding, you'll need to pump and store breastmilk for the baby to eat while you're away. It is best to start pumping a few weeks before returning to work. I'm not going to get into a lot of detail here, as this is meant to be short. I'll just give you a few highlights.

  1. Pumping takes practice. Your body is used to responding to your baby's sucking, not to a pump. You'll need to figure out ways to stimulate let-down with the pump. Some helpful hints include keeping a picture of your baby with you when you pump, relaxing as much as possible while pumping, not looking at the pump while using it, having something nearby that you associate with nursing (even a video or audio recording of your baby on your phone can help!). 
  2. You want to pump more than you need. You may not want to have too much more than you need, but you may have "off days" where you don't produce as much, or you might spill your milk one day (boo!), or you might have a mommy-brain moment and forget to properly refrigerate your milk, or your baby may suddenly be extra-hungry one day and drink more than usual while you're gone. Having extra milk in the freezer as backup will be helpful!
  3. Pump on a schedule. If possible, pumping on a regular schedule will mimic your baby's reasonably regular feeding habits, stimulating your breasts to produce the milk you need when you need it.
  4. Storing milk: Breastmilk can be stored at room temperature for four to six hours, in a fridge for up to three days, in a standard freezer for four to six months, and in a deep freezer for six to 12 months. You can store milk in the most convenient way for you, in a bottle, milk storage bag, ice cube tray, or whatever other solution you find. Make sure the receptacle is clean and can be frozen safely (if you're putting it in the freezer).

Keep at it! You've made it through the hardest part. In the next section, we'll talk about introducing solids and what to expect as your baby approaches her first birthday!

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