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.