Breastfeeding difficulties

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Breastfeeding difficulties
Nipple shield3.jpg
Infant nurses through nipple shield, a device which can assist with certain breastfeeding difficulties.
Specialty Obstetrics, pediatrics, midwifery   OOjs UI icon edit-ltr-progressive.svg

Breastfeeding difficulties refers to problems that arise from breastfeeding, the feeding of an infant or young child with milk from a woman's breasts. Although babies have a sucking reflex that enables them to suck and swallow milk, and human breast milk is usually the best source of nourishment for human infants, [1] there are circumstances under which breastfeeding can be problematic, or even in rare instances, contraindicated.

Contents

Difficulties can arise both in connection with the act of breastfeeding and with the health of the nursing infant.

Breastfeeding problems

While breastfeeding difficulties are not uncommon, putting the baby to the breast as soon as possible after birth helps to avoid many problems. The policy of the American Academy of Pediatrics on breastfeeding instructs to, "delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed." [2] Many breastfeeding difficulties can be resolved with research based hospital procedures, properly trained nurses and hospital staff, speech pathologists and lactation consultants. [3] Another source of information is the volunteer-based breastfeeding promotion organization, La Leche League.

A variety of factors and conditions can interfere with successful breastfeeding:

Low milk supply

Breast pain

Pain often interferes with successful breastfeeding. It is cited as the second most common cause for the abandonment of exclusive breastfeeding after perceived low milk supply. [19]

Inverted nipples

Inverted or retracted nipples sometimes make attachment to the breast difficult. [20] These mothers need additional support to feed their babies. Treatment is started after the birth of the baby. The nipple is manually stretched out several times a day. A pump or a plastic syringe is used to draw out the nipple and the baby is then put to the breast.

Engorgement

Breast engorgement is the sense of breast fullness experienced by most women within 36 hours of delivery. Normally, this is a painless sensation of "heaviness". Breastfeeding on demand is the primary way of preventing painful engorgement.

When the breast overfills with milk it becomes painful. Engorgement comes from not getting enough milk from the breast. It happens about 3 to 7 days after delivery and occurs more often in first time mothers. The increased blood supply, the accumulated milk and the swelling all contribute to the painful engorgement. [21] Engorgement may affect the areola, the periphery of the breast or the entire breast, and may interfere with breastfeeding both from the pain and also from the distortion of the normal shape of the areola/nipple. This makes it harder for the baby to latch on properly for feeding. Latching may occur over only part of the areola. This can irritate the nipple more, and may lead to ineffective drainage of breast milk and more pain. Reverse pressure softening (RPS) is a technique that can soften the areola enabling deeper latching and more milk transfer; RPS involves gentle positive pressure in the direction of the chest wall from the fingertips around the areola. [22] Engorgement may begin as a result of several factors such as nipple pain, improper feeding technique, infrequent feeding or infant-mother separation.

To prevent or treat engorgement, remove the milk from the breast, by breastfeeding, expressing or pumping. Gentle massage can help start the milk flow and so reduce the pressure. The reduced pressure softens the areola, perhaps even allowing the infant to feed. Warm water or warm compresses and expressing some milk before feeding can also help make breastfeeding more effective. Some researchers have suggested that after breastfeeding, mothers should pump and/or apply cold compresses to reduce swelling pain and vascularity even more. [23] One published study suggested the use of "chilled cabbage leaves" applied to the breasts. Attempts to reproduce this technique met with mixed results. [24] Nonsteroidal anti-inflammatory drugs or paracetamol (acetaminophen) may relieve the pain. A warm shower and using cold compresses to help ease the discomfort. [23]

Nipple pain

Sore nipples (nipple pain, or thelalgia) are probably the most common complaint after the birth. They are generally reported by the second day after delivery but improve within 5 days. [25] Pain beyond the first week, severe pain, cracking, fissures or localized swelling is not normal. The mother should see a doctor for further evaluation. [23] Sore nipples, a common cause of pain, often come from the baby not latching on properly. Factors include too much pressure on the nipple when not enough of the areola is latched onto and an improper release of suction at the end of the feeding. Improper use of breast pumps or topical remedies can also contribute. [26] Nipple pain can also be a sign of infection. [27]

Candidiasis

Symptoms of candidiasis of the breast include pain, itching, burning and redness, or a shiny or white patchy appearance. [28] The baby could have a white tongue that does not wipe clean. Candidiasis is common and may be associated with infant thrush.

Both mother and baby must be treated to get rid of this infection. [28] First-line therapies include nystatin, ketaconazole or miconazole applied to the nipple and given by mouth to the baby. [28] Strict cleaning of clothing and breast pumps is also required to eradicate the infection. [29]

Another non-prescription treatment of candidia is gentian violet. [28] It usually works, and relief is rapid. It is messy, and will stain clothing. The baby's lips will turn purple, but the purple will disappear after a few days.

Milk stasis

Milk stasis is when the milk ducts are blocked and cannot drain properly, usually due to swelling and insufficient breast emptying during the engorgement phase. This may affect only a part of the breast and is not associated with any infection. It can be treated by varying the baby's feeding position and applying heat before feeding. If it happens more than once, further evaluation is needed. Milk stasis is an urgent matter for mothers who wish to breastfeed, as failure to remove milk from the breasts causes milk production to decrease and eventually stop.

Mastitis

Mastitis is an inflammation of the breast. It causes local pain (dolor), redness (rubor), swelling (tumor), and warmth (calor). Later stages of mastitis cause symptoms of systemic infection like fever and nausea. It mostly occurs 2–3 weeks after delivery but can happen at any time. [30] Typically results from milk stasis with primary or secondary local, later systemic infection. Infectious organisms include Staphylococcus sp., Streptococcus sp. and E. coli . Continued breastfeeding, plenty of rest and adequate fluid supply is the best treatment for light cases.

Overactive let-down

Overactive let-down (OALD) is the forceful ejection of milk from the breast during breastfeeding. The forceful spray of milk can cause the baby to consume too much milk too quickly as well as to swallow air during the period of rapid swallowing following the let-down.

Raynaud's of the nipple

Nipple blanching, or vasospasm of the nipple Nipple-blanching.jpg
Nipple blanching, or vasospasm of the nipple

Nipple pain can be caused by vasospasm of the nipple. In essence, blood does not flow properly to the nipple which causes the nipple to blanch. This can be caused by trauma to the nipple through early breastfeeding or candidal infection of the nipple. The pain is intense during the latch stage and in between breastfeeding sessions there is a throbbing pain when the nipple is blanched. The nipple can be massaged to help blood flow return to reduce pain, as well as avoiding cold. In some instances, heart medication, nifedipine, is used to help the blood flow return to the nipple. [31]

Infant health problems

Infants with classic galactosemia cannot digest lactose and therefore cannot benefit from breast milk. [32] Breastfeeding might harm the baby also if the mother has untreated pulmonary tuberculosis, is taking certain medications that suppress the immune system. [32] has HIV, [32] [33] or uses potentially harmful substances such as cocaine, heroin, and amphetamines. [2] Other than cases of acute poisoning, no environmental contaminant has been found to cause more harm to infants than lack of breastfeeding. Although heavy metals such as mercury are dispersed throughout the environment and are of concern to the nursing infant, the neurodevelopmental benefits of human milk tend to override the potential adverse effects of neurotoxicants. [34]

Weak sucking reflex

Artificial teats (nipples) or dummies (pacifiers) can suppress the sucking reflex in infants. In addition, when a baby is put to the breast for shorter periods of time, milk production decreases. The time spent sucking by the infant on the pacifier or artificial teat reduces the time on the breast. [35] [36] The CDC also currently (2022) reports that early use of pacifiers can have a negative outcome on the success of breastfeeding and they suggest that it should be delayed until breastfeeding is firmly established. [37]

Transmission of infection

Tuberculosis

It is not safe for mothers with active, untreated tuberculosis to breastfeed until they are no longer contagious. [2] According to the American Academy of Pediatrics 2006 Redbook:

Women with tuberculosis who have been treated appropriately for 2 or more weeks and who are not considered contagious may breastfeed. Women with tuberculosis disease suspected of being contagious should refrain from breastfeeding or any other close contact with the infant because of potential transmission through respiratory tract droplets (see Tuberculosis, p 678). Mycobacterium tuberculosis rarely causes mastitis or a breast abscess, but if a breast abscess caused by M. tuberculosis is present, breastfeeding should be discontinued until the mother no longer is contagious.

In areas where BCG vaccination is the standard of care, the WHO provides treatment recommendations and advises mothers to continue breastfeeding. [38] TBC may be congenital, or perinatally acquired through airborne droplet spread. [39]

HIV

Research published in the Lancet [40] [41] has highlighted a lower risk of HIV transmission with exclusive breastfeeding by HIV positive mothers (4% risk), compared to mixed feeding (10-40% risk). Research on the timing of HIV transmission in 2000 revealed that a "substantial transmission occurs early during breastfeeding," concluding that 75% of all breast milk transmission had occurred within the first 6 months during a randomized control trial in Kenya. [42] This research is of particular importance in developing countries where infant formula is not widely available or safe to prepare. In fact, the World Health Organization recommended breastfeeding in 1987 and 1992 for seropositive and seronegative women in areas where malnutrition and infectious diseases are the major cause of infant mortality. [43] [44] In 1996 UNAIDS issued a recommendation that women in developing countries consider the risks and benefits of each feeding practice on an individual level; they recommended women make an informed choice about infant feeding. [45] In the days before the AIDS epidemic was clearly understood, some researchers pointed to the need to increase breastfeeding rates and pointed to the risks of formula feeding, citing increased rates of marasmus and diarrhea. [46] D Jelliffe and E Jelliffe also criticized the marketing of infant formulas by US companies to resource-poor countries, something they termed "comerciogenic malnutrition." A more recent article from 1992 describes how the health of an infant can be compromised by water, which in many resource-poor countries holds the risk of environmental pathogens that are not present in breastmilk. [47]

Transmission of drugs and toxins

Medications

The vast majority of over the counter and prescription medicines are compatible with breastfeeding, but there are some that might be passed onto the child through the milk. [48]

Tobacco smoke

If one does continue tobacco smoking after giving birth, however, it is still more beneficial to breastfeed than to completely avoid this practice altogether. There is evidence that breastfeeding offers protection against many infectious diseases, especially diarrhea. Even in babies exposed to the harmful effects of nicotine through breast milk, the likelihood of acute respiratory illness is significantly diminished when compared to infants whose mothers smoked but were formula fed. [49] Regardless, the benefits of breastfeeding outweigh the risks of nicotine exposure.

The main concern about smoking and breastfeeding is that infants may have smoking-induced reductions to the milk iodine content. [49] Smoking can adversely affect the lactation process by decreasing milk production and altering the milk composition. Smoking reduces daily milk output by roughly 250–300 mL. Not only will this be problematic on a daily basis for not producing enough milk, it will also cause the mother to wean her baby early. [50] The altered milk composition also caused infants to exhibit daily behaviors such as colic and crying which can promote early weaning, again something that is not beneficial to the infant. [49]

Also, the nicotine obtained from smoking travels through a woman into her breast milk, thus giving nicotine to her child. [51]

Heavy use of cigarettes by the mother (more than 20 per day) has been shown to reduce the mother's milk supply and cause vomiting, diarrhoea, rapid heart rate, and restlessness in breastfed infants. Sudden Infant Death Syndrome (SIDS) is more common in babies exposed to a smoky environment. [52] Breastfeeding mothers who smoke are counseled not to do so during or immediately before feeding their child, and are encouraged to seek advice to help them reduce their nicotine intake or quit. [53]

Other substance abuse

With respect to alcohol, the American Academy of Pediatrics states that when breastfeeding, "moderation is definitely advised" and recommends waiting for 2 hours after drinking before nursing or pumping. [54] A 2014 review found that "even in a theoretical case of binge drinking, the children would not be subjected to clinically relevant amounts of alcohol [through breastmilk]", and would have no adverse effects on children as long as drinking is "occasional". [55]

If the mother consumes too much caffeine, it can cause irritability, sleeplessness, nervousness and increased feeding in the breastfed infant. Moderate use (one to two cups per day of coffee, tea, or cola) usually produces no effect. [56] Breastfeeding mothers are advised to restrict or avoid caffeine if her baby reacts negatively to it. [57] Cigarette smoking is thought to increase the effects of caffeine in the baby. [58]

Cannabis

Cannabis is listed by the American Association of Pediatrics as a compound that transfers into human breast milk. Research demonstrated that certain compounds in marijuana have a very long half-life. [59]

Diet

An exclusively breastfed baby depends on breast milk completely so it is important for the mother to maintain a healthy lifestyle, and especially a good diet. [60] Consumption of 1500–1800 calories per day could coincide with a weight loss of 450 grams (one pound) per week. [61] While mothers in famine conditions can produce milk with highly nutritional content, a malnourished mother may produce milk with decreased levels of several micronutrients such as iron, zinc, and vitamin B12. [34] She may also have a lower supply than well-fed mothers.

There are no foods that are absolutely contraindicated during breastfeeding, but a baby may show sensitivity to particular foods that the mother eats.

Workplaces

Many mothers have to return to work soon after their babies have been born. If their employers and fellow employees do not support mothers in breastfeeding (for example, providing a private breastfeeding room containing a fridge where mothers can express and safely store breast milk), mothers might stop breastfeeding. This is not ideal for their infants. A Cochrane review assessed the effects of workplace interventions to support and promote breastfeeding among mothers returning to work after the birth of their babies. [62] The review authors comprehensively searched in 2012 for studies addressing this question but found no eligible studies. "The return to work can impact the amount of breastmilk that your body produces due to the stress and changes of leaving your baby."

Related Research Articles

<span class="mw-page-title-main">Nipple</span> Part of the breast

The nipple is a raised region of tissue on the surface of the breast from which, in females, milk leaves the breast through the lactiferous ducts to feed an infant. The milk can flow through the nipple passively or it can be ejected by smooth muscle contractions that occur along with the ductal system. Male mammals also have nipples but without the same level of function, and often surrounded by body hair.

<span class="mw-page-title-main">Breast pump</span> Mechanical device used to extract milk from human breasts

A breast pump is a mechanical device that lactating women use to extract milk from their breasts. They may be manual devices powered by hand or foot movements or automatic devices powered by electricity.

<span class="mw-page-title-main">Mastitis</span> Medical condition

Mastitis is inflammation of the breast or udder, usually associated with breastfeeding. Symptoms typically include local pain and redness. There is often an associated fever and general soreness. Onset is typically fairly rapid and usually occurs within the first few months of delivery. Complications can include abscess formation.

<span class="mw-page-title-main">Areolar gland</span> Oil glands around the nipple that promote breastfeeding

Areolar glands, also known as glandulae areolares, Montgomery glands, and tubercula areolae, are 10-15 elevations found on the areola. They are usually arranged in a circle around the nipple, and can be particularly visible when the nipple is erect. Their role is to promote adequate breastfeeding of the infant.

<span class="mw-page-title-main">Breast milk</span> Milk produced by the mammary glands in the breast of a human female

Breast milk or mother's milk is milk produced by mammary glands located in the breast of a human female. Breast milk is the primary source of nutrition for newborns, containing fat, protein, carbohydrates and variable minerals and vitamins. Breast milk also contains substances that help protect an infant against infection and inflammation, whilst also contributing to healthy development of the immune system and gut microbiome.

<span class="mw-page-title-main">Breast engorgement</span> Medical condition

Breast engorgement occurs in the mammary glands due to expansion and pressure exerted by the synthesis and storage of breast milk. It is also a main factor in altering the ability of the infant to latch-on. Engorgement changes the shape and curvature of the nipple region by making the breast inflexible, flat, hard, and swollen. The nipples on an engorged breast are flat or inverted. Sometimes it may lead to striae on nipples, mainly a preceding symptom of septation mastitis.

<span class="mw-page-title-main">Inverted nipple</span> Medical condition

An inverted nipple is a condition where the nipple, instead of pointing outward, is retracted into the breast. In some cases, the nipple will be temporarily protruded if stimulated. Both women and men can have inverted nipples.

<span class="mw-page-title-main">Nipple shield (breastfeeding)</span>

A nipple shield is a nipple-shaped sheath worn over the areola and nipple during breastfeeding. Modern nipple shields are made of soft, thin, flexible silicone and have holes at the end of the nipple section to allow the breast milk to pass through.

<span class="mw-page-title-main">Breastfeeding</span> Feeding of babies or young children with milk from a womans breast

Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be pumped and fed to the infant. The World Health Organization (WHO) recommends that breastfeeding begin within the first hour of a baby's life and continue as often and as much as the baby wants. Health organizations, including the WHO, recommend breastfeeding exclusively for six months. This means that no other foods or drinks, other than vitamin D, are typically given. WHO recommends exclusive breastfeeding for the first 6 months of life, followed by continued breastfeeding with appropriate complementary foods for up to 2 years and beyond. Of the 135 million babies born every year, only 42% are breastfed within the first hour of life, only 38% of mothers practice exclusive breastfeeding during the first six months, and 58% of mothers continue breastfeeding up to the age of two years and beyond.

<span class="mw-page-title-main">Lactation</span> Release of milk from the mammary glands

Lactation describes the secretion of milk from the mammary glands and the period of time that a mother lactates to feed her young. The process naturally occurs with all sexually mature female mammals, although it may predate mammals. The process of feeding milk in all female creatures is called nursing, and in humans it is also called breastfeeding. Newborn infants often produce some milk from their own breast tissue, known colloquially as witch's milk.

Lactation suppression refers to the act of suppressing lactation by medication or other non pharmaceutical means. The breasts may become painful when engorged with milk if breastfeeding is ceased abruptly, or if never started. This may occur if a woman never initiates breastfeeding, or if she is weaning from breastfeeding abruptly. Historically women who did not plan to breastfeed were given diethylstilbestrol and other medications after birth to suppress lactation. However, its use was discontinued, and there are no medications currently approved for lactation suppression in the US and the UK. Dopamine agonists are routinely prescribed to women following a stillbirth in the UK under the NHS.

<span class="mw-page-title-main">Breastfeeding promotion</span> Activities and policies to promote health through breastfeeding

Breastfeeding promotion refers to coordinated activities and policies to promote health among women, newborns and infants through breastfeeding.

Cracked nipple is a condition that can occur in breastfeeding women as a result of a number of possible causes. Developing a cracked nipple can result in soreness, dryness or irritation to, or bleeding of, one or both nipples during breastfeeding. The mother with a cracked nipple can have severe nipple pain when the baby is nursing. This severe pain is a disincentive for continued breastfeeding. The crack can appear as a cut across the tip of the nipple and may extend to its base. Cracked nipple can develop after the birth of the infant and is managed with pharmacological and nonpharmacological treatment.

A blocked milk duct is a blockage of one or more ducts carrying milk to the nipple for the purpose of breastfeeding an infant that can cause mastitis. The symptoms are a tender, localised lump in one breast, with redness in the skin over the lump. The cause of a blocked milk duct is the failure to remove milk from part of the breast. This may be due to infrequent breastfeeding, poor attachment, tight clothing or trauma to the breast. Sometimes the duct to one part of the breast is blocked by thickened milk. A blocked milk duct can be managed by improving the removal of milk and correcting the underlying cause.

<span class="mw-page-title-main">Latch (breastfeeding)</span> The way a baby fastens onto the breast while breastfeeding

Latch refers to how the baby fastens onto the breast while breastfeeding. A good latch promotes high milk flow and minimizes nipple discomfort for the mother, whereas poor latch results in poor milk transfer to the baby and can quickly lead to sore and cracked nipples. In a good latch, both the nipple and a large portion of the areola are in the baby's mouth.

Nipple confusion is the tendency of an infant to unsuccessfully adapt between breast-feeding and bottle-feeding. It can happen when the infant is put back onto breast-feeding. Nipple confusion can turn into nipple refusal in which the infant refuses both the bottle and breastfeeding.

In breastfeeding women, low milk supply, also known as lactation insufficiency, insufficient milk syndrome, agalactia, agalactorrhea, hypogalactia or hypogalactorrhea, is the production of breast milk in daily volumes that do not fully meet the nutritional needs of her infant.

<span class="mw-page-title-main">Delayed onset of lactation</span>

Delayed onset of lactation (DOL) describes the absence of copious milk secretion (onset of lactation) within the first 72 hours following childbirth. It affects around 20–40% of lactating women, the prevalence differs among distinct populations.

Nipple pain is a common symptom of pain at the nipple that occurs in women during breastfeeding after childbirth. The pain shows the highest intensity during the third to the seventh day postpartum and becomes most severe on the third day postpartum.

<span class="mw-page-title-main">Establishment of breastfeeding</span>

Establishment of breastfeeding refers to the initiation of providing breast milk of mother to baby. According to the World Health Organisation(WHO), breastfeeding is the best way to provide nourishment, including essential nutrients, energy and antibodies, to infants and toddlers. The start of breastfeeding is supported by the milk production which depends on the development of internal and external breast structure and hormonal control on milk secretion. Besides milk supply, adopting the correct approach of breastfeeding helps build up the maternal bond, which in turn promotes breastfeeding. Not only does nursing strengthen the mother-child relationship, but it also improves the intelligence and immunity of breastfed children and diminishes breastfeeding mothers' risks to have ovarian and breast cancer.

References

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