Correcting a Weak Suck
From: NEW BEGINNINGS, Vol. 21 No. 5, September-October 2004, p. 169
Before Grace was born, I meant to go to a La Leche League meeting, but never got around to it. I was thinking about attending one in my ninth month, but since Grace came nine days early, I missed my chance. However, I had read the Sears' Breastfeeding Book and felt confident I would have no problems getting started breastfeeding, especially since Grace's birth was uncomplicated and completely drug- and intervention-free.
I was under the impression that babies cried when they were hungry, and that they should be fed on demand. However, the pediatrician at the hospital told me to breastfeed every two hours. A nurse told me to breastfeed every four hours. I didn't know who to believe, and Grace wasn't giving me any clear signals that she was hungry. Mostly, she just slept. I compromised and tried to feed her about every three hours during the day, with a slightly longer interval at night.
When Grace latched on, it hurt. I grimaced and gritted my teeth. I figured my nipples had to "toughen up" and that it would hurt until I got used to breastfeeding. Grace would breastfeed for a few minutes and then fall asleep, so at least the pain didn't last very long.
About three days after Grace was born, my milk came in. I woke up with firm, full breasts and I decided I should breastfeed Grace every two hours to avoid painful engorgement. We continued this way for a day or two. My breasts never seemed to empty after a feeding, but they never got painfully engorged, so I figured everything was okay. I knew that Grace should have five or six wet diapers per day, but I couldn't tell whether the diapers were wet or not.
Soon, however, an obvious problem developed. Grace began to cry whenever I tried to put her to my breast. The more I tried, the more upset she became. After several unsuccessful attempts to latch her on, I was in tears. My nipples were very sore.
My husband, Steve, called the pediatrician's office and asked if we could come in for some help. They told us to come in right away. A weight check revealed that Grace had lost seven ounces since we left the hospital five days before. One of the nurses spent over an hour with us, helping me soothe Grace and get her latched on properly. Not only did she stop crying, but it only hurt a little bit. She stayed latched on and peacefully breastfed for at least 20 or 30 minutes—much longer than she had ever nursed before. Ecstatic, I went home confident that all was well.
Three days later, back at the doctor's office, I was shocked to discover that Grace had lost more weight (about three ounces). I was very upset, but determined to continue my efforts to breastfeed. I asked for a referral to a lactation consultant. The nurse referred me to a board certified lactation consultant named Jeanine, and even called her for me. Jeanine arranged to visit us in our home a few hours later.
When Jeanine arrived, she helped me improve Grace's latch-on and positioning. She showed me how to clutch Grace along my side in the football hold. In that hold, it was quite easy to control the position of Grace's head, which helped me to get her latched on properly. Jeanine told me to breastfeed at least eight to 12 times per day, for at least 10 minutes of good sucking per breast.
I followed Jeanine's instructions to the letter and was hopeful Grace would gain weight. Unfortunately, when we went to the doctor's office for a weight check a few days later, Grace weighed in at five pounds, 11 ounces. She had lost another 4 ounces! I felt total despair. The doctor suggested gently that it was time I supplement with formula. I cried. Here was this tiny baby and I couldn't even nourish her! It was time, once again, for a home visit from Jeanine.
When Jeanine arrived, she explained to me that Grace probably had a weak suck, meaning that she wasn't getting enough milk, even with proper latch-on and frequent long feedings. To find out exactly how much milk Grace was getting, Jeanine weighed her on an electronic scale before and after a complete 40-minute nursing. During that feeding, Grace barely consumed 30 ml, according to the scale. I was pleased that she got any milk at all, but Jeanine said it wasn't nearly enough. She told me that I would need to supplement, at least for a while, so we discussed the options.
First, we needed to find out whether I was producing enough milk to meet Grace's needs. It was possible I had plenty of milk, but that Grace simply couldn't remove it effectively from my breasts. It was also possible that my milk supply was dwindling and was no longer sufficient to sustain Grace. Jeanine had me pump my breasts with an electric hospital grade pump. I was only able to express one to two ml of milk, which suggested that my supply had indeed dwindled.
We had three goals. The first, and most urgent, goal was to get some calories into Grace. Since I was only able to express a few drops of milk, it seemed most expedient to supplement Grace with formula in addition to whatever milk I could express. Although I was resistant to the idea of giving my baby formula, it seemed like the smart choice in this special circumstance. Perhaps if I got some quick calories into Grace while I waited for my milk supply to increase, she would become less lethargic and sleepy and have more energy for eating.
The second goal was to rebuild my milk supply. The third goal was to have Grace learn to breastfeed effectively. It seemed clear that the best way to achieve these goals was to supplement Grace at the breast, either with a syringe in the corner of her mouth, or with a nursing supplementer. After trying both, I settled on the nursing supplementer. I liked it because it was hands-free and provided a steady drip of milk in Grace's mouth. I placed about an ounce of formula (plus those precious few milliliters of expressed milk) in the supplementer and taped the spaghetti-like tube to my breast so that the end of the tube would be deep in Grace's mouth. When Grace latched on, even if she sucked weakly or not at all, the supplementer dripped slowly into her mouth. If she actually sucked properly, she would get a faster flow of supplement. That way, Grace could get the nourishment she needed while being rewarded for good sucking technique. Since she would be fed only at my breast, she would learn that the breast is her source (and only source) of food.
At the same time, since all of her sucking would be done at the breast, my breasts would receive lots of stimulation to help increase milk production.
After each feeding, I pumped my breasts for 10 to 15 minutes. My goal was to "empty" my breasts completely with the pump, and then continue to pump for an additional five minutes after the breasts were no longer ejecting milk. That would send a strong signal to my body to increase my milk supply. Of course, all of the expressed milk would go in the supplementer at the next feeding. Once Jeanine was confident I knew how to work the supplementer and the pump, she left me to settle into my new routine.
And so began the most stressful period of my entire life. During the day, I fed Grace every two hours. By the time one feeding ended it was time to get ready for the next one. I had maybe 15 to 30 minutes between feedings during the day. At night, I increased the feeding interval to four hours, which allowed me to get some sleep. I used my daytime breaks to quickly shower, brush my teeth, eat a meal (prepared by Steve), or nap.
Grace showed improvement in tiny increments from day to day; just enough to keep my hopes up. And her weight gain was excellent—about one ounce per day.
At about that time, we hit an important milestone. Ten days into the supplementing routine, I was expressing enough milk so that it was no longer necessary to add formula to the supplementer. Although this did not make my routine any easier, I was thrilled that I had built my milk supply back up from almost nothing, and that I was now able to nourish my baby 100 percent with my own milk. It was an amazing feeling of accomplishment, and I felt like a major hurdle had been overcome. Grace started gaining weight more quickly (as much as two ounces per day), which also buoyed my spirits.
After two weeks, Steve returned to work, so I had to manage everything on my own. It was tough, but I had gotten pretty efficient with the routine by then. Grace was getting somewhat easier to rouse, and stayed awake more at the breast, but I still only had about 30 minutes between feedings during the day and two hours between feedings at night. It seemed like there was no end in sight, but Grace's almost imperceptible improvements (and her steady weight gain) kept me going.
Occasionally, while nursing Grace, I would hear a suck-swallow, suck-swallow rhythm that signified that she was nursing effectively. I had been listening for that sound for weeks. When I heard it for the first time, it was music to my ears.
Through all of this, I realized that Grace had grown accustomed to my "enhanced" breasts. She would latch on, but didn't start to suck until I turned on the flow from the supplementer. As soon as she felt the milk on her tongue, she would start to suck. If I turned off the flow, she would stop. Grace needed to learn how to breastfeed on an unsupplemented breast.
I started a training program that lasted for about two weeks. I put Grace on the breast, but delayed turning on the flow from the supplementer for a few moments (not so long that she would lose interest and pull away). I would also occasionally turn off the flow while she was nursing, and if she stopped sucking, I would pause for a few moments before turning it back on again. Sometimes she would suck for a moment when the supplementer was turned off, and I would quickly reward her by turning it on. As she seemed to learn the association between sucking and getting more milk, I turned the flow on and off many times during a feeding, and kept Grace on each breast for several minutes after she had emptied the supplementer.
Finally, Grace seemed to be nursing well and consistently, even when the supplementer was turned off. By then I was able to pump more than Grace needed and was starting to build up a supply in the freezer. After consulting with Jeanine, I decided to go "cold turkey" and stop using the supplementer altogether. I didn't want to confuse Grace by giving her some "easy" meals and some not so easy meals, so it made sense for us to stop using the supplementer all at once.
During the first week of unsupplemented feedings, Grace gained two ounces. I was a little disappointed that it wasn't more, but at least she gained! I continued to pump after every feeding to maintain my milk supply, just in case Grace wasn't nursing effectively enough. The following week, Grace gained five ounces. The week after that, Grace gained 10 ounces.
Ecstatic, I started to ease off on the pumping. I pumped every other feeding and not at all after the night feedings. The following week, Grace gained a whole pound! The week after that, she gained another pound! Finally, we had arrived.
I tapered off pumping gradually (to avoid engorgement) and then eliminated it altogether. I also stopped setting my alarm to wake Grace for nighttime feedings, and stopped watching the clock during the day to make sure she wasn't going too long between feedings. Grace had not only learned to suck effectively, she had developed a healthy appetite and was finally able to tell me herself when she wanted to eat. I could trust her to wake me during the night when she was hungry, and to let me know during the day when she wanted to breastfeed. I stopped counting feeding frequency and duration and gave in to the natural on-cue breastfeeding relationship that so many women are lucky enough to experience from the beginning.
By this time, Grace was two months old. She was beautiful, healthy, chubby, and alert. When people asked me how often I fed her, I blissfully replied, "I have no idea. I just feed her when she's hungry." No more counting! When people asked me whether she was sleeping through the night, I proudly answered, "No, she wakes me up several times to be nursed."
Finally, when Grace was four months old, I attended my first La Leche League meeting because I wanted to meet other breastfeeding women, share my story, and hear other mothers' stories. I found the experience so rewarding that I have continued to attend meetings regularly ever since, and became a Leader before Grace's second birthday.
Grace and I have reaped the rewards a thousand fold for the work we put in during those difficult two months. She is now three years old and still nursing. She is a very high-need child, and I don't know how I would mother her if I didn't have the ability to soothe her at my breast, providing comfort, love, sleep, and food all from one source. And knowing that she is still getting all of the health benefits of breastfeeding is hugely important to me. I feel such an amazing sense of accomplishment at what we achieved together, and I continue to treasure our breastfeeding relationship intensely as it grows and changes to meet Grace's needs.