Table 3.
Prevention and management of breast feeding problems
| Problem and evidence | Characteristics | Management |
|---|---|---|
| Breast discomfort or pain; Cochrane systematic review (8 trials, 424 women),20 and NICE guidelines10 | A normal full breast is tender; breast engorgement can occur on days 2-7 when milk “comes in;” breasts can become shiny, oedematous, and painful; if milk is not removed, milk production will diminish | Assessment of effective breast feeding;* frequent unrestricted breast feeding; analgesia compatible with breast feeding; breast massage; hand expression if necessary; cabbage leaves or cold compresses may help, but observed effects could be a placebo effect |
| Sore nipples; formal consensus or expert opinion10; a Cochrane review is in progress | Often caused by suction trauma secondary to incorrect positioning; nipples may range in appearance from mildly red to cracked and scabbed; mothers or babies (or both) may have evidence of Candida albicans infection (thrush), particularly if receiving perinatal antibiotics | Correct positioning and attachment may prevent pain; if nipple pain persists after repositioning and reattachment, thrush infection should be considered; prescribing for thrush is contentious; topical antifungal agents should be prescribed as first line; fluconazole is not licensed for use in breastfeeding mothers, but it is licensed for use in neonates at higher doses than are likely to be transferred in breast milk; topical nipple treatments, nipple shells, or nipple shields have not been shown to be effective; evidence for the safety of nipple cream is weak; principles of moist wound healing apply21 |
| Mastitis; mainly observational studies and small poor quality trials10 | Cellulitis of connective tissue caused by a blocked milk duct and poor milk drainage; with time, bacteria (usually Staphylococcus aureus, occasionally β haemolyicstreptococci) grow; signs and symptoms range from local inflammation with minimal systemic symptoms to abscess formation and rarely septicaemia | Continue breast feeding or expressing milk to maximise effective drainage; assessment of effective breast feeding;* analgesia compatible with breast feeding; increase fluid intake; gently massage to help remove any duct blockage; if symptoms continue for more than a few hours of self management, seek professional advice to decide whether a β lactamase resistant antibiotic is indicated |
| Inverted nipples; formal consensus and expert opinion10 | Flat or inverted nipples may require skilled help with positioning and attachment | No contraindications to breast feeding; good practice is to offer women additional care and support |
| Breast implants; a case series of adverse event reports22 | Concern that exposure to biomaterials in breast implants may leach into breast milk | Safety largely unknown |
| Breast reduction surgery; small retrospective observational studies23 | Partial breast feeding is usually possible, but milk supply may be reduced because of interruption of nerves or blood vessels | Assessment of effective breast feeding* |
| Difficulty getting the baby to suck; observational studies10 | Often cited by women as a problem9; narcotic analgesia may adversely affect early sucking behaviour after birth | Assessment of effective breast feeding;* good practice is to encourage extended skin to skin contact16 and offer help to express milk |
| Early weight loss >10% of baby’s weight; expert opinion and case studies10 | Transient early weight loss is normal in healthy babies; however, hypernatraemic dehydration can occur in an otherwise healthy full term, breastfed baby because of poor milk intake, and in extreme cases can lead to brain injury and death | A traditional consensus rule is that babies who lose >10% of their weight should be assessed in a hospital where biochemical tests are available, although this rule has recently been questioned24; assessment should include urine output, stool frequency and character, observation for lethargy or fractious behaviour, and assessment of effective breast feeding* |
| Poor weight gain; observational studies and expert opinion10 (see separate discussion on growth charts) | Almost all mothers can produce enough milk; perceived “insufficient milk” is a complex phenomenon and is a common reason for giving up breast feeding8 | Assessment of effective breast feeding;* reassure and help mothers to gain confidence in their ability to produce enough milk; insufficient evidence is available to determine the optimal frequency of weighing babies; frequent weighing may be undesirable, as short term fluctuations may increase anxiety |
| Neonatal jaundice10; consensus or expert opinion | About 50% of term and 80% of preterm babies develop physiological jaundice within the first week; it is more common in breastfed babies; “breast milk jaundice” is a prolonged unconjugated jaundice, which lasts beyond 14 days, and the mechanism is unknown | Breast feed frequently and wake the baby to feed if necessary; do not routinely supplement with formula, water, or other fluids; investigate jaundice persisting beyond 14 days, even in well babies, to exclude other causes like biliary atresia |
| Ankyloglossia (tongue tie); systematic review based on 1 trial and observational studies25 | A congenital short frenulum, which is often asymptomatic, can resolve spontaneously, and may interfere with feeding; expert opinions differ about definition and diagnosis | Assessment of effective breast feeding;* early division is safe and effective when tongue tie is causing breastfeeding problems |
*Assessment of effective breast feeding should be carried out by a skilled person who has received training. It involves observing and assessing feeding pattern, positioning and attachment, sucking behaviour, and breast fullness.