June 24, 2000 -- It's 4 in the afternoon, and her baby boy wants to nurse -- again. "You find out after they're born: You can't go anywhere. When he needs to eat, he needs to eat," says Robin, a New York mom who has been at home with her newborn for two weeks now.
Like many women, Robin felt pressured to at least try breast-feeding. "My husband was very adamant," she tells WebMD. But she worries: She's had difficulty getting the baby started nursing. And she has no idea whether he is getting enough milk.
"My husband and I never realized how difficult this would be," she says. "If you want to measure how much they're eating, you can't do that with the breast. You don't have an ounce meter on your nipple."
New mothers often hear that "breast is best." In fact, the American Academy of Pediatricians (AAP) recommends that mothers breast-feed for at least 12 months. In a policy statement, the AAP says breast-feeding is "primary in achieving optimal infant and child health, growth, and development."
But ask mothers and you'll find that breast-feeding is not as easy as it looks. "For some women, it's not a nice experience at all," pediatrician James Sargant, MD, tells WebMD. "I can say from my own experience that some mothers feel relief when I talk to them ... [and] make them feel OK about quitting." Sargant is an associate professor of pediatrics at Dartmouth Medical School in Lebanon, N.H.
A recent study involving 350 mothers in New Zealand showed that most new mothers stop breast-feeding when the baby is about 7 months old. In that study, only 30% of the mothers continued to breast-feed for a year.
"The most common reason for stopping, especially in the early months, was a belief that milk production was inadequate," writes A. Vogel, the study's author. "Later, many mothers simply felt that they had breast-fed their infants long enough." Vogel is with the department of pediatrics at the University of Auckland in New Zealand.
Other factors affecting a woman's decision to quit breast-feeding, pediatricians say, are problems with nipples as well as mastitis, an inflammation of the mammary glands. Also, giving babies pacifiers and formula in the early days seems to deter long-term breast-feeding.
The pressure of returning to work also is an issue, Vogel says: In the study, "younger women [under 25] and those returning to work full time in the first year were relatively likely to stop, as were those who originally planned to stop by age 6 months."
Doctors agree that any amount of breast-feeding -- even during just the first few weeks -- offers the baby a host of health and developmental benefits. To help new mothers get past the barriers to long-term nursing, WebMD turned to a lactation consultant and a pediatrician for advice.
How can mothers know whether they are producing enough milk?
Lactation consultant Cynthia Garrison, BS, IBCLC, of Magee-Womens Hospital in Pittsburgh, tells WebMD: "We often send mothers home with a "feeding log," a real simple chart where they can keep track of the numbers of feedings, wet diapers, and dirty diapers in a 24-hour period, so they see that it's falling within the ranges of normal.
"Because what goes in must come out, we instruct mothers that if baby is having 4-6 wet diapers within the first day, increasing [along with the baby's milk intake] to six to eight, and they're having at least two dirty diapers every day, then life is going quite well. They can be a little more relaxed and understand that as the baby matures, they will start spacing feedings out; they won't need to feed as often. The babies' stomachs are getting bigger."
Babies' elimination habits can vary, adds Andrea McCoy, MD, chief of pediatric care at Temple University Children's Hospital in Philadelphia. "So even though the baby may stool with every feeding, I caution mothers not to be overly concerned if the baby doesn't stool every day."
A good medical follow-up is essential for babies, because assuring that they are gaining enough weight is the best way to be sure the mother has an adequate milk supply, McCoy tells WebMD.
How can new mothers get past nipple problems?
The baby's position while nursing is key, Garrison says. Mothers need to put them in a position in which they can reach the area an inch to an inch-and-a-half around the nipple. Otherwise, the baby is feeding on the end of the nipple, which causes the mother pain.
The ideal position, explains McCoy, "is the cradle hold, where they are on the side, level across your chest, with head slightly down ... but making sure the head is not hanging down and tugging at the nipple, and making sure that the head is adequately supported. Many moms initially feel uncomfortable, that they're suffocating the baby in the breast tissue, but the tip of the nose presses against the breast tissue and pushes the little airway open so the baby can continue to breathe."
If nursing hurts, ask a health care provider for help, Garrison says. "There are too many women told it's going to hurt in the early days. If they tough it out, and they never look for ways to correct this ... they think they have to go through this pain. Different tolerances of pain mean some women won't continue. "
"The skin of nipples is tender, and it does need to get a little bit toughened up," McCoy adds. "After mothers get past that, it usually subsides after the first few days. Persistent pain with nursing is unusual ... it could also indicate that the mom or baby has [an] ... infection that could be causing the pain. Because it normally shouldn't hurt, except for that tingly feeling that moms get when their milk lets down. That's very brief, right at the beginning of the feeding.
"Cracked nipples are usually a sign the baby is not latched on properly, or the mother has not been instructed how to care for her nipples -- making sure she cleans them, air-dries her nipples, before she covers back up," McCoy advises. "Using a lanolin cream is also very helpful in healing nipples."
What is mastitis?
Mastitis is a painful inflammation of the milk glands caused by a blockage. "It can happen even in a mom who is nursing well, just because some milk ducts get plugged and bacterial growth occurs," McCoy says.
"The most difficult thing we have to say to moms is that they should continue to nurse the baby," she tells WebMD. "That will help draw the milk out, which will help pull the infection out. If she quits nursing, her breasts will become more engorged, which increases the pain and makes the infection worse."
Symptoms of mastitis, she says, are redness, warmness, and tenderness of a portion of the breast, along with fever. See your doctor if this occurs, she says.
What about formulas?
Supplements of any type -- whether water, glucose water, or formula -- should not be given to newborns unless there is a medical reason, says the AAP statement. "Supplements and pacifiers should be avoided whenever possible and, if used at all, only after breast-feeding is well-established," it says.
Garrison adds, "Literature that comes with formulas implies that there may be times when you and your baby must be apart. You can arrange times away around the feedings. Nurse before you leave for a movie, nurse again afterward, then go to dinner with your husband. You can be creative. You don't have to leave a bottle."
How can women more easily continue breast-feeding after they go back to work?
Get yourself a good electric pump -- preferably one not made by any formula company, which is likely to be poorly made, Garrison says. "A good electric pump allows you to pump both breasts at one time; you can be done in 10-15 minutes," she tells WebMD.
Work with your employer to negotiate a schedule and set up a private area to pump, if one does not exist. Volunteer to take shorter lunch breaks in exchange for two extra 15-minute breaks during the day. Or stay half an hour later.
Women, she says, have shown great creativity in finding quiet spaces: a copy room, an infrequently used conference area, the school nurse or guidance counselor's office.
It takes practice to become comfortable breast-feeding in public, Garrison says. "It definitely takes practice to learn which of your clothing is the most discreet. I took a light crocheted blanket so there were a lot more openings for air. And I could flip that over my shoulder so nobody really knew what was going on.
If there's no solution with your employer, eliminate the feedings for the hours you will not be available to nurse the baby, McCoy advises. "It's amazing how resilient the mom's body is in adjusting to that. If it needs milk at 6 p.m., it will make milk at 6 p.m. It takes just a few weeks for the mom's body to adjust. But if they start that process a few weeks before they go back to work, their bodies will adapt, and so will their babies, in most cases."
So babies don't mind getting a bottle one time, a breast the next?
"Many babies will adjust easily to going back and forth from breast to bottle," McCoy tells WebMD. "Many lactation consultants believe that there's an issue of nipple confusion, but I think many babies will adapt very easily as long as it's more often breast rather than bottle. The other thing I find helpful is for someone other than mom to give the bottle. ... There are many babies who won't take a bottle from mom at all, if they're breast-fed, but they will take it just fine from dad or grandmother."
Also, some bottles are designed to be more similar to a natural nipple, McCoy tells WebMD. "They've been very helpful with babies who are lazy in sucking at the breast. ... It actually helps to train them with those because they have to do that deeper draw rather than a chewing motion." Ask your doctor or lactation consultant which brands of bottles are best.
What about pacifiers?
They're not a good idea, at least not at first, the experts say. In the early days, the baby needs to suck. Also, the baby needs to nurse to stimulate milk flow, Garrison says. "Once the milk is in a nice volume, because nursing takes longer than bottle feeding, babies don't need pacifiers because sucking will take care of that need. Pacifiers were created for babies who were fed by bottles, because they were full before they knew it and yet their sucking need wasn't taken care of." If mothers want to use pacifiers, they should wait until the baby is gaining weight and has plenty of wet diapers, so it's evident that feeding is going well, she says.
Generally, McCoy encourages new mothers "to try not to let the baby have a pacifier, because they will develop that shallow suck, which will not work when they get back on Mom." But, she adds, "for babies who have an additional need to suck and for moms who don't like to be the pacifier, I do encourage moms to use a pacifier to give them little bit of a break.
"I support a mom in whatever she decides," McCoy says. "In the end, she has to feel comfortable with it and enjoy being a mom. Sometimes you have to know when to say when. But it's important that they know there are people they can talk to -- the lactation consultant, the pediatrician -- when they have problems."