Breastfeeding Problems

---

Introduction — Breastfeeding a healthy infant is often accompanied by challenges. These challenges can be difficult to deal with, especially when combined with the normal anxieties of parenting a newborn infant.

Problems associated with breastfeeding can include engorgement, sore or painful nipples, plugged ducts, and infection of the breast (mastitis). Because these problems can cause distress, mild discomfort, or significant pain, many women stop breastfeeding after a few weeks. However, these problems can be treated effectively, allowing the woman to continue breastfeeding, which benefits her and her infant's health.

Engorgement — Engorgement refers to swelling within the breast tissue, which can be painful. In some women with engorgement, the breasts become firm, flushed, warm to the touch, and feel as if they are throbbing. Some women develop a slightly elevated temperature (eg, less than 101º F or 38.3º C). Engorgement during the first few weeks after delivery may be caused by swelling of the breast tissue and accumulated milk; engorgement at later times is usually due solely to accumulated milk. Frequent episodes of engorgement may increase the risk of developing plugged ducts or mastitis.

The best treatment for engorgement is to empty the breasts frequently and completely by breastfeeding. It may be more difficult for an infant to latch-on (form a tight seal around the nipple and most of the areola) when the breasts are engorged because the nipples become flattened. A correct latch-on allows the infant to obtain an adequate amount of milk and helps to prevent nipple soreness and injury.

If the breasts are engorged, expression of milk by hand or breast pump can help to soften the areola and allow the baby to latch on more easily. However, it is important to avoid overstimulating the breasts with hand and/or pump expression because this could worsen engorgement.

While some women believe that cabbage leaves help to relieve engorgement pain, there is no clear evidence that they are any more effective than cold compresses or breast massage.

Hand expression — Hand expression of milk between feedings may be necessary to avoid engorgement. There are a number of techniques to express milk by hand. Milk ducts open in several areas on the nipple; after let-down, milk should squirt easily from multiple openings when the area behind the nipple is gently compressed.

One suggestion is as follows:

• Hold the hand in a c-shape, with the thumb on top. The fingers should be 1 to 1.5 inches behind the nipple. Keep the fingers together to avoid cupping the breast and apply gentle pressure with the thumb on top of the breast, pressing straight back against the chest.
• While pushing against the chest, roll the thumb and fingers towards the nipple. Work around the entire breast. It may help to use both hands.                                                                                             
  
• Continue pressing inward and rolling the fingers over the breast tissue. It may be necessary to apply pressure closer to or further away from the nipple to find the right area.

Breast pump — It is also possible to use a breast pump to relieve engorgement, although a pump should not be used for more than about two to five minutes, as this could stimulate even more milk production. Pumps are often inefficient at removing milk during early engorgement.

It is important to use the correct size flange if a breast pump is used. The flange is the piece that is held against the breast and draws the nipple in to pump milk. Using a flange that is too small can injure the nipple and cause pain. In addition, using a flange that is too small may decrease milk supply because it does not allow for adequate milk to be removed.

Cold pack or showers — Use of a cold compress or ice pack can be helpful in relieving the discomfort of engorgement. The use of heat for a longer period (eg, a hot pack) is not recommended to treat engorgement because this can increase tissue swelling. However, using heat and massage just before a nursing session may improve milk flow. Standing in a warm shower, allowing the spray to fall on the breasts, can promote milk release.

Massage — Massaging the breast gently prior to a feeding may promote milk flow and help to soften the breast. Using the fingertips, gently knead the breast in a circular motion, working from the chest wall and moving towards the nipple.

Reverse pressure softening — Reverse pressure softening can help to move some of the swelling away from the nipple so that the infant is able to latch on the breast more easily. Lying down while performing reverse pressure softening can enhance the technique's effectiveness.

• Place the middle three fingers of each hand on the left and right side of the nipple. The fingertips should be touching the edges of the nipple.

                                                                                                                                                                                                 This figure depicts the position of the hands for reverse pressure softening, which can help to reduce swelling near the nipple that is caused by engorgement. Lying down while performing this technique may be helpful. The fingernails should be short, the fingertips curved, and the hands should be positioned on opposite sides of the nipple.                                                                                                                                       

• Push the fingers back firmly but gently against the base of the nipple, towards the chest wall, and count to 50. This may need to be repeated.
• Once the nipple/areola is softened, try to latch the baby to the breast.

Pain medications — Acetaminophen (Tylenol®) or ibuprofen (Advil®, Motrin®) are safe to take while breastfeeding and may be effective in treating the discomfort related to engorgement.

SORE OR PAINFUL NIPPLES — The nipples normally become more sensitive during pregnancy, with the greatest sensitivity occurring around the fourth day after delivery. Normal sensitivity can be distinguished from pain caused by nipple injury based upon how long discomfort continues after nursing begins.

• Normal soreness is bothersome for the first 30 to 60 seconds of breastfeeding, but then improves.
• Tissue injury (such as a bruise, crack, or blister on the nipple) usually causes pain that continues or worsens throughout the nursing episode. Nipple bruising, cracking, and/or blistering may develop if the infant fails to latch on correctly or does not take a large portion of the area behind the nipple into his/her mouth.

In general, normal nipple sensitivity completely resolves within about seven days after delivery. Pain that continues beyond the first postpartum week is more likely to be due to tissue damage. If tissue damage is suspected, care should be taken to clean the affected area after nursing to reduce the risk of developing an infection.

If pain continues throughout a nursing session, does not improve over the first week, or if there is any concern about an infection, a lactation consultant or healthcare provider who is knowledgeable about breastfeeding should be consulted. To locate a lactation consultant in your area.

Potential causes of nipple soreness In most cases, sore nipples are caused by problems with latching or positioning the infant correctly.

In other cases, sore nipples are caused by a problem such as tongue tie or a yeast infection of the skin.

Tongue tie Infants who have anklyoglossia, also known as "tongue tie," are often not able to latch-on correctly, which can cause nipple injury to the mother and limit the amount of milk the baby consumes. Normally, the infant's tongue extends outward to draw the nipple and a portion of the areola into the mouth. The infant's tongue then compresses the milk ducts against the roof of the mouth.

Normally, the infant's tongue compresses the sinuses, located in the areola, against the roof of the mouth, which stimulates the flow of milk. Infants who are tongue-tied have a short frenulum (the tissue connecting the infant's tongue to the floor of the mouth). This limits the infant's ability to extend the tongue and compress the sinuses in the mother's breast, potentially causing nipple soreness.

Infants who are tongue-tied have a short frenulum (the tissue connecting the tongue to the floor of the mouth). This limits the infant's ability to extend the tongue and compress the milk ducts in the mother's breast, potentially causing nipple soreness.

Tongue-tie is a relatively common finding in newborns. In one study, tongue-tie was present in 3 percent of infants with breastfeeding problems in the hospital and 13 percent of infants with breastfeeding problems after discharge. About half of these infants had difficulty with latch-on and half of the mothers had nipple pain.

A procedure to release the short frenulum (called frenuloplasty) improved latch-on in all cases and significantly decreased maternal pain. In most cases, frenuloplasty is done in a physician's office. The baby is able to breastfeed immediately after the procedure. Nipple pain may be somewhat improved after the procedure; however, it may take several weeks before the damaged breast tissue is fully healed.

Yeast infections Some mothers experience burning nipple pain, red or itchy nipples, or shooting pains deep in the breast. These are common signs of a yeast infection. Nipple injury increases the risk of developing a yeast infection, as does an infant with oral thrush (yeast) or recent antibiotic use (sometimes given during labor or for some other condition).

Because the yeast infection can be passed between a mother and her infant, both the infant and the mother should be treated simultaneously. Infants can be treated with a prescription solution (nystatin) that is applied to the cheeks and tongue with a cotton swab or small syringe. Mothers may be treated with an antifungal cream (eg, miconazole) or an oral medication such as fluconazole (Diflucan®).

Yeast can be difficult to eliminate and reinfection is common. It is especially important to remove potential sources of reinfection. Anything that comes in contact with the infant's mouth (eg, pacifiers, bottle nipples, toys) should be boiled in hot water daily and replaced at the end of each week. Items that cannot be boiled (eg, breast pump parts) should be washed in hot soapy water. The mother's bras and any other clothing that comes in contact with the breasts should be washed in hot water and dried in a hot dryer or allowed to dry in the sun.

Sore nipple treatment Women with injured nipples are at risk of developing a skin or breast infection.

• Saline rinse — To reduce the risk of infection, sore nipples may be rinsed with warm water or a salt water solution and then gently dried. A salt water solution can be made at home by combining 1/2 teaspoon of table salt in eight ounces (one cup) of warm water. This solution should be made fresh each time to avoid bacterial growth.
• Nipple ointment — A topical ointment may be recommended for treatment of sore nipples. One combination treatment includes a mixture of an antibiotic ointment, steroid ointment, and antifungal powder, known as "All Purpose Nipple Ointment" (APNO). This combination requires a prescription and can be specially made by a pharmacy. A thin layer of the ointment is applied to the nipples after feeding. The ointment does not need to be wiped off before nursing.
• Moist healing — Moisture may help sore nipples to heal. A purified lanolin (eg, Lansinoh, Purelan) or hydrogel dressing (eg, Comfortgels®, Soothies®) may be applied after feeding; these are available without a prescription in some pharmacies. A thin layer of lanolin ointment should be applied to the nipple after feeding, and it is not necessary to wash the lanolin off before the next feeding. The hydrogel dressing should be removed before nursing and may be stored in the refrigerator between uses.

PLUGGED DUCTS — Plugged ducts are areas in the breast where the flow of milk is blocked, usually by plugs of skin cells and milk. As the milk duct fills and stretches, the surrounding breast tissue becomes tender. Signs of a plugged duct include a tender or reddened lump in the breast. This usually occurs in one breast, develops gradually, and the discomfort is mild. Fever is not a typical sign of a plugged duct. Repeated episodes of plugged ducts can lead to the development of a galactocele, an enlarged area containing a thick, creamy, cheesy, or oily material within the duct.

 Galactoceles often appear quickly and may be quite large (up to the size of an egg).

Plugged duct treatment Treatment of a plugged duct includes frequent and complete emptying of the breast. Nursing from the affected side first may help to more fully empty that breast and begin the flow of milk. Positioning the infant with the nose pointed toward the plugged area may facilitate drainage of the affected area. Massage and a warm shower often promote milk release, and rest is encouraged. Plugged ducts that do not resolve within 72 hours should be evaluated by a healthcare provider.

If plugged ducts occur repeatedly in the same area of the breast, it may be helpful to change nursing positions at each feeding or to avoid bras and other clothes that compress the breast (eg, an underwire bra). Massaging the breast while breastfeeding is also suggested. Instructions about positioning are available separately.

MASTITIS — Mastitis is an infection of the breast. It typically causes a hard, red, tender, swollen area of one breast, and fever >101º F (38.3º C). Other symptoms include muscle aches, chills, and feeling ill.

Mastitis treatment Treatment of mastitis includes continued nursing, a medication for pain control (eg, ibuprofen), and an antibiotic. Breast massage during nursing or pumping afterwards may help to reduce discomfort. The woman should rest as much as possible as she recovers. Stopping breastfeeding is not usually recommended during mastitis treatment; women should consult with a healthcare provider if there is any reason for concern. There is little to no risk of passing the infection to the infant as a result of breastfeeding during an episode of mastitis.

An oral antibiotic is usually recommended for 10 to 14 days. Mastitis should begin to improve within 24 to 48 hours of the first antibiotic dose. If improvement does not occur in this time period, further evaluation is recommended.

BLOODY NIPPLE DISCHARGE — A small percentage of women have bloody nipple discharge in the first few days after delivery, resulting in bright red or rusty colored colostrum. The condition is related to an increase in blood vessels in the breast ducts during pregnancy and typically resolves within a few days. It is not necessary to stop nursing or to substitute infant formula if blood is seen in the colostrum or breast milk, although the woman should consult with her healthcare provider.

Blood may appear in breast milk as a result of cracks in the nipple, trauma to the breast, or other conditions. Blood is often detected because the infant's stool becomes bloody. The color of the milk can range from pale pink to bright red.

If blood is seen during breast pump use, the pump settings and length of pumping should be modified. Using a high vacuum setting or pumping for long periods can cause bleeding in the breast tissue, which may cause the milk to appear bloody.

If no obvious source is identified, the woman is usually asked provide a milk specimen for microscopic examination. This is important because, in rare cases, blood in the breast milk is a sign of breast cancer. If the examination is normal, the bleeding usually resolves spontaneously and nursing can continue.

OVERACTIVE MILK EJECTION REFLEX — Milk production increases rapidly between three to four days after delivery until approximately two to four weeks postpartum. The amount of milk a woman produces depends in part upon how frequently the breasts are emptied.

As milk production increases, milk ejection may occur too rapidly for an infant to swallow. This can cause the infant to gag, cough, or push away from the breast shortly after latch-on. It may appear that the baby does not like breastfeeding or breast milk. However, it is usually the milk's flow rate, and not the taste, that is bothersome.

Management Several options are available to manage an overactive milk ejection reflex

• Nurse the infant in a semi-upright position and allow the infant to interrupt nursing frequently.
• Reduce the flow of milk by gently compressing the base of the nipple during the first several minutes of nursing to slow the initial milk flow.
• Hand express until the initial let-down occurs and then allow the baby to latch onto the breast.
• Nurse frequently to minimize the amount of milk that collects. Having less milk collected in the breasts will reduce the force of milk flow.
• Use a nipple shield to create a reservoir for the milk.

Pumping is not recommended because this will further stimulate milk production and potentially worsen the problem.

NIPPLE COLOR CHANGES — Women who have the Raynaud phenomenon or unusual cold sensitivity may develop a narrowing (constriction) of the blood vessels of the nipple related to breastfeeding. This can cause the nipple to become painful and whitened (blanched) during, immediately after, and between feedings. Some women have a two-part color change (white and blue) while others have a three-color change (white, blue, and red) of Raynaud phenomenon.

Blanching can also occur as a result of nipple compression due to poor positioning and latch-on. Nipple compression is a more common cause of blanching and nipple pain than Raynaud phenomenon, and can be addressed by adjusting the position of nursing and latch-on.

Management Measures to alleviate blood vessel constriction include the following:

• Increase the air temperature and wear warm clothing. Reusable wool breast pads may be helpful.
• Apply a warm compress just before and after nursing.
• Tobacco products (eg, cigarettes) should be discontinued completely.
• Medications that constrict blood vessels (eg, Sudafed® [pseudoephedrine]) should only be used if necessary.

Women with nipple pain that does not improve with these measures may benefit from a medication typically used to treat high blood pressure, called nifedipine. A two week trial of nifedipine is usually recommended, followed by a period of time without the medication. If pain returns after the drug is discontinued, the medication may be resumed for an additional two-week course. It is uncommon to need more than three two-week courses of nifedipine.

INFANT STOOLS — Meconium is the sticky dark-colored stool that infants normally produce for the first few days after birth. An infant's stool should transition from the dark sticky meconium to a greenish-brown color to a stool that is mustard yellow to light brown, often with visible milk curds, by the third to fifth day. Most infants have four or more stools per day by the fourth day, although fewer stools may be normal.

The persistence of meconium stools after day four may indicate that a woman's supply of breastmilk is low or that the infant is not taking in an adequate amount of milk (even if abundant milk is available). If an infant's stools are not pale yellow and seedy by the fifth day, even if the infant is otherwise healthy, the woman should contact her infant's healthcare provider to determine if further evaluation or treatment is needed.

Stool frequency During the first few weeks after delivery, breastfed infants generally pass gas or stool during or after each nursing session. Stool frequency usually decreases after approximately four to six weeks. The decrease in frequency may be abrupt. In some cases, a healthy breastfed infant may stool as infrequently as once every two weeks.

If a breastfeeding infant is otherwise healthy and gaining weight appropriately, changes in stool frequency are usually normal. However, a parent should contact their child's healthcare provider immediately if the child has less frequent stools as well as decreased sucking strength, decreased interest in feeding, or increased irritability.

Green frothy stools Stools that appear green and frothy sometimes develop when food passes especially rapidly through the baby's digestive tract. This is more likely to occur if the woman switches the infant from one breast to the other before the infant is finished with the first side. It may also occur in women with an overabundant milk supply because the infant is less likely to get as much of the hind milk.

Thorough emptying of one breast allows the baby to consume hind milk, which has a higher fat content than milk available at the start of a nursing session. The higher fat content of the hind milk helps to slow digestion and reduce excessive gas and frothy stools. Mothers are advised to allow the infant to finish nursing on one breast before switching to the other, even if the child does not take the second breast.

Women with an overabundant supply may need to decrease their milk supply by allowing the baby to nurse on just one breast for two or three feedings in a row. This signals the breast to slow milk production. The woman may partially empty the other breast if needed, just until the discomfort is eased.

BITING — Infants normally begin to have visible teeth at six to ten months of age. Infants who bite during breastfeeding can cause pain and injury to the nipple. However, it is not possible to bite and suckle at the same time.

A woman can usually teach her infant not to bite by immediately removing the infant from the breast as soon as a bite begins. The infant can then be immediately placed on a safe surface, such as a blanket on the floor. The parent can then offer a teething toy.

Women are encouraged to watch their infant closely if biting begins. Once the behavior is noted, the mother can bring the baby more deeply onto the breast, which may prevent the bite. Offering a cold teething ring or cloth to suck on prior to nursing may also make the infant more comfortable and less likely to bite. If this is done consistently, the baby usually learns quickly not to bite.