BREASTFEEDING PROBLEMS OVERVIEW
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.
The management of common breastfeeding problems will be discussed here. Additional breastfeeding topics are available separately. (See "Patient information: Deciding to breastfeed (Beyond the Basics)" and "Patient information: Breastfeeding guide (Beyond the Basics)" and "Patient information: Maternal health and nutrition during breastfeeding (Beyond the Basics)" and "Patient information: Breast pumps (Beyond the Basics)".)
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 slight fever (eg, less than 101ºF or 38.3ºC).
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. Instructions for latching-on are described separately. (See "Patient information: Breastfeeding guide (Beyond the Basics)".)
If the breasts are engorged, expressing 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. Information about the use of a breast pump is available separately. (See "Patient information: Breast pumps (Beyond the Basics)".)
Hand expression — Hand expression of milk between feedings may be necessary to avoid engorgement. Milk ducts open in several areas on the nipple; after let-down, milk should squirt easily from multiple openings when you gently push the area behind the nipple (figure 1). There are a number of techniques to express milk by hand.
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 (figure 2).
- Continue pressing inward and rolling the fingers over the breast tissue. You may need 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 you should not pump 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. (See "Patient information: Breast pumps (Beyond the Basics)".)
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. Heat packs or hot water bottles are 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 (http://www.health-e-learning.com/resources/articles/41-reverse-pressure-softening).
- 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" nipple soreness occurs for the first 30 to 60 seconds of breastfeeding, but then improves.
- Nipple injury (such as a bruise, crack, or blister) usually causes pain 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 nipple injury. Women with injured nipples are at risk of developing a skin or breast infection.
If pain continues throughout a nursing session, does not improve over the first week, or if there is any concern about an infection, talk to a lactation consultant or healthcare provider who is knowledgeable about breastfeeding. To locate a lactation consultant in your area, (see 'Finding a lactation consultant' below).
Potential causes of nipple soreness — Nipple trauma usually is due to incorrect breastfeeding technique, particularly poor position or latch-on. Nipple abrasion, bruising, cracking, and/or blistering may result when an infant fails to achieve a proper latch-on. Infants with ankyloglossia are at increased risk for inadequate latch-on. Ankyloglossia, also known as "tongue-tie", occurs when the frenulum connecting the tongue to the floor of the mouth is tight and limits extension of the tongue. A review of correcting latching-on and positioning is discussed separately. (See "Patient information: Breastfeeding guide (Beyond the Basics)".)
Other contributing factors to sore nipples include plugged ducts, infections (eg, candidiasis), harsh breast cleansing, use of potentially irritating products, and skin disorders.
Sore nipple treatment — The management of mothers with nipple trauma includes the following:
- Identification of any underlying nipple condition and, if present, treatment for the specific problem. In particular, assessment of infant positioning and latch-on with correction of improper technique should be performed.
- 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. It is best to alternate the use of an ointment or cream with the hydrogel pads rather than using them together.
- Use of breast shells to protect the nipples from friction between feeds.
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 (picture 1). 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. 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. (See "Patient information: Breastfeeding guide (Beyond the Basics)".)
Mastitis is inflammation of the breast, and is thought to be caused by infection. It typically causes a hard, red, tender, swollen area of one breast, and fever >101ºF (38.3ºC). Other symptoms include muscle aches, chills, and feeling ill.
Mastitis treatment — Treatment of mastitis includes continued nursing and a medication for pain control (eg, ibuprofen). If symptoms do not resolve promptly, an antibiotic course is generally given for 10 to 14 days. Breast massage during nursing or pumping afterwards may help to reduce discomfort. Stopping breastfeeding is not recommended during mastitis treatment; consult with a healthcare provider if you are concerned. There is little to no risk of passing the infection to the infant as a result of breastfeeding during an episode of mastitis.
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 you should consult with your 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, you may be 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 you can continue nursing.
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 you produce depends in part upon how frequently your 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 stimulate milk production and potentially worsen the problem.
NIPPLE COLOR CHANGES
Women who have 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. (See "Patient information: Raynaud phenomenon (Beyond the Basics)".)
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.
- Stop smoking.
- Avoid medications that constrict blood vessels (eg, pseudoephedrine, a decongestant).
If your nipple pain that does not improve with these measures, you 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.
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. (See "Patient information: Constipation in infants and children (Beyond the Basics)".)
Continuing to have meconium stools after day four may indicate that your supply of breast milk 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, contact the 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. (See "Patient information: Constipation in infants and children (Beyond the Basics)".)
If a breastfeeding infant is otherwise healthy and gaining weight appropriately, changes in stool frequency are usually normal. However, contact your child's healthcare provider immediately if your child has less frequent stools as well as decreased sucking strength, decreased interest in feeding, or if the infant seems irritable.
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 you switch the infant from one breast to the other before the infant is finished with the first side. It may also occur if you have an overabundant milk supply because the infant is less likely to get as much of the hind milk.
Thoroughly emptying 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. 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. You may partially empty the other breast if needed, just until the discomfort is eased.
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 nurse at the same time.
To teach your infant not to bite, immediately remove the infant from the breast as soon as a bite begins. Place the infant on a safe surface, such as a blanket on the floor. You can then offer a teething toy.
WHEN TO SEEK HELP
If you are unable to breastfeed due to engorgement, pain, or difficulty latching your infant, help is available. Talk to your obstetrical or pediatric healthcare provider, nurse, lactation consultant, or a breastfeeding counselor (see 'Finding a lactation consultant' below).
WHERE TO GET MORE INFORMATION
Your healthcare provider is the best source of information for questions and concerns related to your medical problem.
This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient information: Deciding to breastfeed (Beyond the Basics)
Patient information: Breastfeeding guide (Beyond the Basics)
Patient information: Maternal health and nutrition during breastfeeding (Beyond the Basics)
Patient information: Breast pumps (Beyond the Basics)
Patient information: Raynaud phenomenon (Beyond the Basics)
Patient information: Constipation in infants and children (Beyond the Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient information: Common breastfeeding problems (The Basics)
Patient information: Breastfeeding (The Basics)
Patient information: Weaning from breastfeeding (The Basics)
Patient information: Jaundice in babies (The Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Ankyloglossia (tongue-tie) in infants and children
Breastfeeding: Parental education and support
Common problems of breastfeeding and weaning
Maternal nutrition during lactation
Nutrition in pregnancy
Nutritional composition of human milk for full-term infants
The impact of breastfeeding on the development of allergic disease
Use of psychotropic medications in breastfeeding women
Prevention of HIV transmission during breastfeeding in resource-limited settings
The following organizations also provide reliable health information.
- National Library of Medicine
- The Center for Disease Control and Prevention
- The United States Department of Health and Human Services
- American Academy of Pediatrics
- Bright Futures Lactation Resource Center
Finding a lactation consultant — Certified lactation consultants, or LC s, are available at most hospitals as well as privately, and can be an invaluable resource for instructions about breastfeeding, pumping, milk storage, and bottle feeding breast milk. The websites listed below have information about finding a lactation consultant or breastfeeding counselor.
- International Board of Lactation Consultant Examiners
- International Lactation Consultant Association