My Baby’s Latch is “Perfect” so Why Does Breastfeeding Hurt?

Stating “breastfeeding shouldn’t hurt” always draws a lot of comment from mothers who unfortunately did have a lot of pain with breastfeeding. Many mothers who are having pain find that the pain suddenly disappears after a few weeks or months. Why does this happen? Is it simply a case of it being  normal for some women to have pain? As I’ve mentioned before, I don’t think it is. Pain, especially “toe-curling pain” while nursing is NOT normal, but I do know that it is sometimes hard to find an answer as to what is causing the pain.

The most common reason for pain when nursing is that your baby is not latched on properly, but what if your baby’s latch seems to be OK? I work with a lot of moms who are having pain with breastfeeding, and they often tell me that they were told by another care provider that their baby’s latch looks “perfect” so there shouldn’t be any pain. This leaves moms feeling confused, frustrated and feeling like they are doing something wrong. How a baby’s latch feels, is far more important than what it looks like from the outside. Some latches do look “perfect” from the outside and yet something is going on inside the baby’s mouth that is causing problems (and some latches look “wrong” from the outside, yet mom isn’t having any pain and baby is nursing effectively, so everything is good!).  If a baby is truly latching on well but mom is still in pain, the two main reasons for it that I see in my practice are tongue and/or lip-tie and structural restrictions caused by delivery or position in the womb.

Tongue and lip-tie: Many years ago, tongue-tie was routinely checked for, and clipped at birth. As society turned more towards bottle feeding, this practice fell out of favour because tongue-tie doesn’t usually cause any problems with bottle feeding (although it certainly can!). Because of this, the knowledge about tongue-tie has been lost and many health care providers know very little about it, or don’t see it as a problem. Today, as more and more women are breastfeeding, we are struggling to regain that knowledge because tongue and lip-tie certainly have an impact on breastfeeding.  Posterior tongue-ties in particular, (where the frenulum, or membrane under the tongue is attached towards the base of the tongue rather than the tip of the tongue) are sneaky, and easily missed by many health care providers. If you are having pain with breastfeeding and your baby’s latch looks good then it’s important to have your baby checked for tongue and lip-tie by someone knowledgeable.

Structural restrictions due to birth interventions or baby’s position in utero: This one is largely overlooked, and is probably the biggest cause of pain in those situations where everything “looks” ok, tongue and lip-tie have been ruled out,  but breastfeeding is still painful. Birth and breastfeeding are closely linked, and there are many things during labour and delivery that can have a direct impact on breastfeeding. Birth interventions such as vacuum, forceps or c-section tend to be the most common causes of structural issues, but sometimes even in an intervention free birth there can be structural issues due to the baby’s position in utero.

Forceps and vacuum extraction can cause bruising and swelling of the head and face, and due to the pressure exerted, they can cause distortion of the cranial bones. Although a baby’s cranial bones are designed to move over one another as baby descends through the birth canal, the forces exerted by vacuum or forceps can often cause shifts in the cranial bones that are not easily self-corrected by the baby after birth. All of these things can cause irritation to the baby’s cranial nerves, and it is the cranial nerves that control everything through the mouth and jaw. This irritation can lead to alterations in sucking patterns that result in pain for mom, and/or ineffective milk transfer. These babies may also be generally fussy due to discomfort. Imagine how you would feel if you were pulled or vacuumed out of a tight space by your head!

Babies are meant to pushed out by mom’s uterine contractions, so when a baby is delivered by C-section, or even when a well-meaning doctor tries to speed up a vaginal delivery by pulling on the baby, it can cause structural issues within the baby’s spinal cord that can affect sucking. It can also result in a strong preference for nursing on one side over the other, pain on one side but not the other, or even an inability to latch at all on one side. Even when there are no interventions during delivery, sometimes the position that a baby is in while in utero can have an impact on breastfeeding. If a baby is stuck in a certain position it can cause tightening of the neck muscles on one side, or even torticollis. I’ve also seen jaw distortions in babies who spent a lot of time in utero with their hand pressed against the side of their face. Again, these things can cause sucking issues or issues with baby being unable to achieve a comfortable latch/position.

Many of these structural issues do work themselves out eventually, or the baby learns to compensate for the restrictions and is eventually able to nurse effectively. This is why many moms find that the pain eventually goes away. In the mean time though, mothers struggle with unnecessary pain and often a very frustrating breastfeeding relationship. There are however ways to help. Many parents find that in these situations, complementary therapies such as chiropractic care and or craniosacral therapy can make a big difference for breastfeeding. There are other complementary therapies as well such as osteopathy or Bowen therapy that can also be very effective. The important thing to keep in mind that when choosing a care provider is that you want to find someone who is trained to work with babies and has experience doing so. If complementary therapies are not a possibility, or not something you are comfortable with, infant massage may also be beneficial (and is a wonderful way to connect with your baby). If you’re wondering whether your baby may have structural issues that are contributing to your struggles with breastfeeding, this article by Dee Kassing provides great information about some of the things to look for. This post from Renee Beebe is a great example of the difference that skilled bodywork can make.

10 Tips for Getting Breastfeeding off to a Good Start

1: Educate yourself and establish a network of support before your baby arrives

You’re preparing for the birth of your baby by reading and researching, and it’s important to prepare for breastfeeding the same way. Now is the time to find good sources of information, and determine where you can go for help and support after your baby is born. If you’ve had issues in the past with breastfeeding you may want to schedule a prenatal consult with an International Board Certified Lactation Consultant (IBCLC) to determine what the problems were and how to avoid or minimize them. Breastfeeding is a learned skill and we are meant to learn about it by seeing other women breastfeeding their babies.  Many of us however, grow up never having seen another woman breastfeed. Because of this, La Leche League or other peer support meetings during pregnancy are a great idea. You can see normal breastfeeding in action, gather information and add to your network of support.


2: Minimize interventions as much as possible during labour and delivery

Any kind of intervention during birth such as an epidural, induction, vacuum, forceps or C-section, can have a negative impact on breastfeeding. That’s not to say that breastfeeding is doomed if you do have interventions during birth, but it can certainly make breastfeeding more complicated, and it often leads to a cascade of interventions that can lead to premature weaning. Your birth has a direct impact on breastfeeding, so a  good prenatal class is not only helpful for learning how to cope during labour and delivery, but it is also helpful for getting breastfeeding off to a good start. Look for a class that will teach you and your partner how to actively manage your labour, not how to be a good patient! A doula is another wonderful way to ensure you have the support you need during labour and delivery and the postpartum period.


3: Keep your baby skin-to-skin after birth as much as possible

Providing there are no medical complications, your baby should be put skin-to-skin with you immediately after birth, and stay there undisturbed until after he has breastfed (or attempted to breastfeed) for the first time. Things such as weighing, vitamin K, eye ointment, etc. can all wait until after the first feed. If you’re not able to have your baby skin-to-skin immediately, and you are handed your baby all bundled up, take those blankets (and hat and mittens) off! For skin-to-skin contact your baby should be dressed in only a diaper and your chest should be bare. Among other things, skin-to-skin contact keeps your baby’s heart rate, breathing, temperature, oxygen saturation and blood sugar stable, it’s good for milk production and it also ensures that your baby is colonized with your bacteria (to which you have antibodies in your milk) rather than hospital bacteria. Keeping your baby skin-to-skin as much as possible during the early days/weeks allows you and your baby to get to know one another, helps both of you recover from birth, helps with breastfeeding and it is healing for your baby if there have been interventions during birth. Skin-to-skin contact is a great way for Dad and baby to bond too!


4: Remember your baby knows how to latch on

A good latch is important for both your comfort, and your baby’s ability to transfer milk. Thoughts on latching have changed in recent years, and the more we learn, the more we are reminded that babies know what to do as long as they have easy access to mom’s breast! Any help with latching should be mostly hands off. Forceful attempts at latching can actually cause problems such as breast aversion and make breastfeeding more difficult. The most important thing to remember about latching is that babies find your breast by feel, not sight. Their face has to be in contact with your breast so that they can figure out where they are and latch on.


5: If things are not going well, keep baby skin-to-skin, hand express and spoon feed your colostrum

If your baby is not latching or not nursing well, then keep your baby skin-to-skin and hand express and spoon feed. Hand expression works better than pumping  until your milk increases in volume around day three, because the small volumes of colostrum tend to get lost in the pump parts. The small volumes of colostrum in the early days are perfect for your baby’s small stomach. Frequent hand expression and spoon feeding ensures that your baby is getting what he needs, and stimulates your milk production at the same time. Along with skin-to-skin contact, hand expressing and spoon feeding, input from a skilled IBCLC is helpful to get breastfeeding back on track.


6: Be familiar with normal weight loss and gain

It is normal for babies to lose some weight in the first few days after delivery. Peak weight loss tends to be on day 3, around the same time that mom’s milk is just starting to increase in volume. From then on, we expect to see an average weight gain of about 1 oz (30g) per day in a baby who is nursing well, and we expect that baby will be back to birth weight by about 7-10 days. One thing to keep in mind in hospital is that new research tells us that if a mother has had IV fluids during labour and delivery, her baby’s weight loss tends to be greater. If weight loss is a concern and you are getting pressured to supplement with formula, ask for more time and get help from an IBCLC to assess breastfeeding. While you are waiting to see an IBCLC, keep your baby skin-to-skin and you can start hand expressing and spoon feeding if your baby doesn’t seem to be feeding well.


7: Be familiar with normal newborn behaviour

While in utero, your baby has been fed 24 hrs a day through the umbilical cord. Once your baby is born, he has to make the adjustment to intermittent feedings. He also has a tiny tummy and breastmilk is digested quickly, so frequent feedings (every 1.5-2 hrs) are perfectly normal. It is also perfectly normal for your baby to want to be held all the time and to cry when you put him down. Your baby is familiar with your scent, the sound of your voice and heartbeat and he feels safest in your arms. Many moms worry about having enough milk for their baby, but the vast majority of moms are capable of producing more than enough milk. The frequent feedings in the early weeks can be intense but they help to establish good milk production. Signs that feeding is going well include visible/audible swallowing during nursing, baby waking to feed and is feeding 8-12 times in 24hrs, baby is having 3-4 dirty diapers a day by day 4, baby is content after feeding and is gaining weight appropriately.


8: Get help sooner rather than later, and keep your supply up!

If things are not going well – you’re having pain, your baby isn’t gaining weight or is gaining slowly etc, then get help from an IBCLC as soon as possible. The sooner problems are identified, the easier they are to fix. If your baby is not nursing or not nursing well, then while you are waiting to be seen by an IBCLC, hand express or (once your milk “comes in”) pump every 2-3 hours to protect your supply. Breastfeeding problems are much more difficult to correct if milk production is also an issue. Red flags that indicate a need for help with breastfeeding include: pain during nursing, cracked/bleeding nipples, no visible/audible swallowing during nursing, a baby who quickly falls asleep at breast and isn’t waking to feed every 2-3 hours by day 2, a baby who isn’t having 3-4 dirty diapers/24hrs by day 4, or a baby who is still passing meconium on day 4.


9: Ignore the housework and accept all offers of help

Once you’re home, it’s important to remember that you are recovering from the birthing process and you and your baby need time to get to know one another and establish your milk production. Now is the time to accept any and all offers of help so that you can focus on your baby. Make a list of all the things that need to be done, and put it on your fridge. When visitors ask how they can help, you can refer them to the list and let them choose what they would like to do.


10: Keep in mind that breastfeeding is not just about food!

Babies nurse for all kinds of reasons and hunger is only one of them. They nurse because they’re hungry, thirsty, tired, over stimulated, too hot or cold, in pain or not feeling well, or just because they need some cuddles with mom. All are equally valid reasons to nurse and one of the wonderful things about breastfeeding is that it solves just about everything.  You can never go wrong with putting your baby to breast, even if they just ate. It’s not possible to spoil a baby with too much love, holding or breastfeeding, and the early years go by fast so enjoy those cuddles!

The Best and Worst Places in the Industrialized World for Breastfeeding Support

Every year, the non-profit organization and registered charity Save the Children looks at the health status, nutrition, education, economic well-being and political participation of women around the world to come up with their annual  State of the World’s Mothers report. Along with providing rankings for 165 countries around the world, each report has a different theme. This year, the report focuses on the critical impact of nutrition in the first 1000 days of life, starting with pregnancy. The report also contains an Infant and Toddler Early Feeding Score for 73 developing countries and a Breastfeeding Policy Scorecard which looks at breastfeeding practices, support and policies for 36 industrialized countries. You can read more about the best and worst places in the world to be a mother and the Infant and Toddler Early Feeding Score in this companion blog post.

The Breastfeeding Policy Scorecard for Developed Countries is new this year, and it provides an interesting look at support for breastfeeding in the industrialized world. Rankings are based on maternity leave laws, right to daily nursing breaks, percentage of hospitals that are baby friendly, state of policy support for the International Code of Marketing of Breastmilk Substitutes and breastfeeding practices. Of the 36 countries listed, Norway ranks first with a score of 9.2 and the USA ranks last with a score of 4.2. Canada ranks 31st with a score of 5.4.

From the report, we see that Norway is doing a wonderful job of supporting breastfeeding mothers:

“Norway tops the Breastfeeding Policy Scorecard ranking. Norwegian mothers enjoy one of the most generous parental leave policies in the developed world. After giving birth, mothers can take up to 36 weeks off work with 100 percent of their pay, or they may opt for 46 weeks with 80 percent pay (or less if the leave period is shared with the father). In addition, Norwegian law provides for up to 12 months of additional child care leave, which can be taken by both fathers and mothers. When they return to work, mothers have the right to nursing breaks as they need them. Nearly 80 percent of hospitals have been certified as baby-friendly and many provisions of the International Code of Marketing of Breast-milk Substitutes have been enacted into law. Breastfeeding practices in Norway reflect this supportive environment: 99 percent of babies there are breastfed initially and 70 percent are breastfed exclusively at 3 months.”

Compare this to the USA:

“The United States ranks last on the Breastfeeding Policy Scorecard. It is the only economically advanced country and one of just a handful of countries worldwide where employers are not required to provide any paid maternity leave after a woman gives birth. There is also no paid parental leave required by U.S. law. Mothers may take breaks from work to nurse, but employers are not required to pay them for this time. Only 2 percent of hospitals in the United States have been certified as baby-friendly and none of the provisions of the International Code of Marketing of Breast-milk Substitutes has been enacted into law. While 75 percent of American babies are initially breastfed, only 35 percent are being breastfed exclusively at 3 months.”

The differences between Norway and the United States is staggering (and Canada isn’t doing much better than the United States). For all the talk about “Breast is best” North America is doing a very poor job of providing parents with the support they need to actually give their babies the “best”. Most mothers want to breastfeed. Breastfeeding initiation rates are high, but breastfeeding drops off rapidly in the early weeks after birth. This happens not because mothers don’t want to breastfeed anymore, but because they haven’t received the support they need to continue. Breastfeeding is natural, but it is also something that requires community support. Conditions during birth and the first 72hrs after birth are critical for establishing breastfeeding (hence the importance of hospitals being Baby Friendly) and it is important that mothers have sufficient time off of work to establish their breastfeeding relationship which encourages a longer duration of breastfeeding.

Although not specifically about breastfeeding, below are some other key points about the United States from the report that should really be cause for alarm:

In the United States, mothers face a 1 in 2,100 risk of maternal death the highest of any industrialized nation. In fact, only three developed countries Albania, Moldova and the Russian Federation perform worse than the United States on this indicator. A woman in the U.S. is more than 7 times as likely as a woman in Ireland or Italy to die from a pregnancy-related cause and her risk of maternal death is 15 times that of a woman in Greece

The U.S. under-5 mortality rate is 8 per 1,000 births. This is on par with rates in Bosnia and Herzegovina, Montenegro, Slovakia and Qatar. Forty countries performed better than the U.S. on this indicator. This means that a child in the U.S. is four times as likely as a child in Iceland to die before his or her 5th birthday.

The United States has the least generous maternity leave policy of any wealthy nation. It is the only developed country and one of only a handful of countries in the world that does not guarantee working mothers paid leave.

The United States is also lagging behind with regard to preschool enrollment and the political status of women. Performance in both areas places it among the bottom 10 in the developed world.

An interesting (and again alarming!) point about Canada from the Save the Children Canada website:

“Norway’s under 5 mortality rate is half that of Canada (3 deaths per 1000 live births vs 6 deaths per 1000 live births)

The risks of not breastfeeding are well documented, and there is plenty of research on the best ways to encourage breastfeeding duration and exclusivity. The statistics from this report for the countries at the top of the Breastfeeding Policy Scorecard show that interventions such as requiring hospitals to be Baby Friendly, providing adequate paid maternity leave and supporting the International Code of Marketing of Breastmilk Substitutes DO work.  This report should be a wake-up call for the countries at the bottom of the scorecard!

Below is the full list of where the 36 countries placed on the Breastfeeding Policy Scorecard. For the full details, and to see the score for each country, please refer to section 1:43 of the full report:

1. Norway
2. Slovenia
3. Sweden
4. Luxembourg
5. Austria
6. Lithuania
7. Latvia
8. Czech Republic
9. Netherlands
10. Germany
11. Estonia
12. Poland
13. Portugal
14. France
15. Belgium
16. Ireland
17. Italy
18. Switzerland
19. New Zealand
20. Cyprus
21. Denmark
22. Greece
23. Slovak Republic
24. Spain
25. United Kingdom
26. Finland
27. Israel
28. Japan
29. Hungary
30. Liechtenstein
31. Canada
32. Iceland
33. Monaco
34. Australia
35. Malta
36. United States



Breastfeeding is not supposed to hurt

In my post about The Truth Behind Common Breastfeeding Myths, the following myth received a lot of comments on both my blog and on my Facebook page:

Myth: It’s normal for breastfeeding to hurt. Truth: If breastfeeding  hurts something is wrong. Nursing may be a little uncomfortable during the early days as your body adjusts to a new sensation, but it should never be painful. Poor latch is the most common cause of pain in the early weeks, but there are other possibilities including sucking issues with baby from birth interventions or physical characteristics such as tongue-tie. If nursing hurts, get help as soon as possible. The earlier breastfeeding problems are addressed, the easier they are to fix. If you go to someone for help and the problem isn’t solved, keep trying until you find someone with the knowledge and experience to help.

A number of people have responded to say that they disagree with this, and that breastfeeding for them hurt for the first few weeks even though they had been told that nothing was wrong. A couple of comments on my blog pointed out that pain with breastfeeding is common with hormonal changes during pregnancy and ovulation, and asked why would this be different in the postpartum period? It’s an interesting question, and I don’t have a good answer. It’s certainly a possibility, and obviously everyone has a different pain threshold. The hormonal makeup of a mother after birth is different however than that of a mother who is pregnant or ovulating. It doesn’t make sense biologically for breastfeeding to be painful. Breastfeeding is supposed to be a pleasurable experience so that we’ll keep doing it to ensure that our species survives.

From my perspective as an RN and IBCLC, pain when breastfeeding indicates a problem. Breastfeeding can certainly be uncomfortable in the early days, but I strongly feel that it shouldn’t hurt. When assessing latch, it is really important to remember that a good latch is defined by how it feels, not by how it looks. Sometimes a baby’s latch can look perfect from the outside, but something is going on inside the baby’s mouth that is causing the pain.

Latch is very important, but so is a baby’s ability to suck effectively. I frequently see moms and babies where mom is experiencing pain and yet she has been told by someone else that her latch “looks perfect” and “nothing is wrong, your nipples just need to toughen up”. Usually in these cases something is going on in baby’s mouth that is causing the pain for mom. Tongue and/or lip-tie are a common cause, but another cause that is far less obvious is a sucking issue related to the birth process and/or baby’s position in utero. Birth interventions can have a huge impact on a baby’s ability to suck effectively. Vacuum and forceps in particular almost always result in sucking issues. Think about how you would feel if you were stuck in a small space and someone stuck a vacuum on your head, or grabbed your head in a pair of vice grips and pulled! Your head would hurt! Vacuum and forceps can cause irritation to a baby’s cranial nerves, and those nerves control the jaw and tongue, so it’s not surprising that those interventions tend to cause some issues with sucking. I also see sucking issues with C-sections, very quick deliveries, deliveries where there has been a very long pushing phase and sometimes the issues seem to be related to muscle tension in the baby that has likely been caused by their position in utero.

Sucking issues are not always obvious, and they usually require someone knowledgeable to identify them. Even issues such as tongue-tie are often missed by health care providers. Thankfully, sucking issues caused by birth interventions can usually be resolved with time spent breastfeeding and/or body work such as craniosacral therapy. They can however, cause a lot of pain for mom in the mean time even though everything looks “right” from the outside. So what do we do? Some people feel that telling women that breastfeeding shouldn’t hurt is doing them a disservice because it causes them to think that they’re doing something wrong if it does hurt. For most women however, pain indicates that something is wrong, although it may be something that baby is doing rather than anything the mom is or isn’t doing. It’s hard to know what is the best approach – do we tell moms that breastfeeding might hurt and encourage them to persevere through it, despite the fact that we then run the risk of moms not seeking help soon enough when there really is a problem, or do we say that it shouldn’t hurt so women know to seek help?

What do you think?