7.1. Full breasts

Symptoms: Full breasts occur from 3–5 days after delivery when the breast milk “comes in”. The mother feels uncomfortable and her breasts feel heavy, hot and hard. Sometimes they are lumpy. The milk flows well, and sometimes drips from the breast.

Cause: This is normal fullness.

Management: The baby needs to be well attached, and to breastfeed frequently to remove the milk. The fullness decreases after a feed, and after a few days the breasts become more comfortable as milk production adjusts to the baby's needs.

7.2. Breast engorgement (1)

Symptoms: The breasts are swollen and oedematous, and the skin looks shiny and diffusely red. Usually the whole of both breasts are affected, and they are painful. The woman may have a fever that usually subsides in 24 hours. The nipples may become stretched tight and flat which makes it difficult for the baby to attach and remove the milk. The milk does not flow well.

Cause: Failure to remove breast milk, especially in the first few days after delivery when the milk comes in and fills the breast, and at the same time blood flow to the breasts increases, causing congestion. The common reasons why milk is not removed adequately are delayed initiation of breastfeeding, infrequent feeds, poor attachment and ineffective suckling.

Management:

• The mother must remove the breast milk. If the baby can attach well and suckle, then she should breastfeed as frequently as the baby is willing. If the baby is not able to attach and suckle effectively, she should express her milk by hand or with a pump a few times until the breasts are softer, so that the baby can attach better, and then get him or her to breastfeed frequently.
• She can apply warm compresses to the breast or take a warm shower before expressing, which helps the milk to flow. She can use cold compresses after feeding or expressing, which helps to reduce the oedema.
• Engorgement occurs less often in baby-friendly hospitals which practise the Ten Steps and which help mothers to start breastfeeding soon after delivery.

7.3. Blocked duct

Symptoms: A tender, localised lump in one breast, with redness in the skin over the lump.

Cause: Failure to remove milk from part of the breast, which may be due to infrequent breastfeeds, poor attachment, tight clothing or trauma to the breast. Sometimes the duct to one part of the breast is blocked by thickened milk.

Management: Improve removal of milk and correct the underlying cause.

• The mother should feed from the affected breast frequently and gently massage the breast over the lump while her baby is suckling.
• Some mothers find it helpful to apply warm compresses, and to vary the position of the baby (across her body or under her arm).
• Sometimes after gentle massage over the lump, a string of the thickened milk comes out through the nipple, followed by a stream of milk, and rapid relief of the blocked duct.

7.4. Mastitis (2)

Symptoms: There is a hard swelling in the breast, with redness of the overlying skin and severe pain. Usually only a part of one breast is affected, which is different from engorgement, when the whole of both breasts are affected. The woman has fever and feels ill. Mastitis is commonest in the first 2–3 weeks after delivery but can occur at any time.

Causes: An important cause is long gaps between feeds, for example when the mother is busy or resumes employment outside the home, or when the baby starts sleeping through the night. Other causes include poor attachment, with incomplete removal of milk; unrelieved engorgement; frequent pressure on one part of the breast from fingers or tight clothing; and trauma. Mastitis is usually caused in the first place by milk staying in the breast, or milk stasis, which results in non-infective inflammation. Infection may supervene if the stasis persists, or if the woman also has a nipple fissure that becomes infected. The condition may then become infective mastitis.

Management: Improve the removal of milk and try to correct any specific cause that is identified.

• Advise the mother to rest, to breastfeed the baby frequently and to avoid leaving long gaps between feeds. If she is employed, she should take sick leave to rest in bed and feed the baby. She should not stop breastfeeding.
• She may find it helpful to apply warm compresses, to start breastfeeding the baby with the unaffected breast, to stimulate the oxytocin reflex and milk flow, and to vary the position of the baby.
• She may take analgesics (if available, ibuprofen, which also reduces the inflammation of the breast; or paracetamol).
• If symptoms are severe, if there is an infected nipple fissure or if no improvement is seen after 24 hours of improved milk removal, the treatment should then include penicillinase-resistant antibiotics (e.g., flucloxacillin). However antibiotics will not be effective without improved removal of milk.

7.5. Breast abscess (2)

Symptoms: A painful swelling in the breast, which feels full of fluid. There may be discoloration of the skin at the point of the swelling.

Cause: Usually secondary to mastitis that has not been effectively managed.

Management: An abscess needs to be drained and treated with penicillinase-resistant antibiotics. When possible drainage should be either by catheter through a small incision, or by needle aspiration (which may need to be repeated). Placement of a catheter or needle should be guided by ultrasound. A large surgical incision may damage the areola and milk ducts and interfere with subsequent breastfeeding, and should be avoided. The mother may continue to feed from the affected breast. However, if suckling is too painful or if the mother is unwilling, she can be shown how to express her milk, and advised to let her baby start to feed from the breast again as soon as the pain is less, usually in 2–3 days. She can continue to feed from the other breast. Feeding from an infected breast does not affect the infant (unless the mother is HIV-positive, see Session 7.7).

Sometimes milk drains from the incision if lactation continues. This dries up after a time and is not a reason to stop breastfeeding.

7.6. Sore or fissured nipple

Symptoms: The mother has severe nipple pain when the baby is suckling. There may be a visible fissure across the tip of the nipple or around the base. The nipple may look squashed from side-to-side at the end of a feed, with a white pressure line across the tip.

Cause: The main cause of sore and fissured nipples is poor attachment. This may be due to the baby pulling the nipple in and out as he or she suckles, and rubbing the skin against his or her mouth; or it may be due to the strong pressure on the nipple resulting from incorrect suckling.

Management: The mother should be helped to improve her baby's position and attachment. Often, as soon as the baby is well attached, the pain is less. The baby can continue breastfeeding normally. There is no need to rest the breast – the nipple will heal quickly when it is no longer being damaged.

7.7. Mastitis, abscess and nipple fissure in an HIV-infected woman (2)

If a woman is HIV-infected, mastitis, breast abscess and nipple fissure (especially if the nipple is bleeding or oozing pus) may increase the risk of HIV transmission to the infant. The recommendation to increase the frequency and duration of feeds is not appropriate for a mother who is HIV-positive.

Management for a woman who is HIV-positive:

• She should avoid breastfeeding on the affected side while the condition persists.
• She should remove the milk from the affected breast by expression, to help the breast to recover and to maintain the flow of milk. She should be helped to make sure that she can express her milk effectively.
• If only one breast is affected, the baby can continue to feed on the unaffected breast, and can feed more often from that side to increase production and ensure an adequate intake.
• Give antibiotics for 10–14 days, rest and analgesics as required, and incision if there is an abscess, as for an HIV-negative woman.
• She can resume breastfeeding from the affected breast when the condition subsides.
• Some mothers decide to stop breastfeeding at this time if they are able to give replacement feeds safely. They should continue to express enough milk to allow the breasts to recover, until milk production ceases.
• If both breasts are affected, she will not be able to feed the baby from either side, and will need to consider other feeding options as a permanent solution. She may decide to heat-treat her own milk and give that, or to give formula. She should feed the baby by cup.

7.8. Candida infection (thrush) in mother and baby (3)

Symptoms:

In the mother:

• Sore nipples with pain continuing between feeds, pain like sharp needles going deep into the breast, which is not relieved by improved attachment.
• There may be a red or flaky rash on the areola, with itching and depigmentation.

In the baby:

• White spots inside the cheeks or over the tongue, which look like milk curds, but they cannot be removed easily.
• Some babies feed normally, some feed for a short time and then pull away, some refuse to feed altogether, and some are distressed when they try to attach and feed, suggesting that their mouth is sore.
• There may be a red rash over the nappy area (“diaper dermatitis”).

Cause: This is an infection with the fungus Candida albicans, which often follows the use of antibiotics in the baby or in the mother to treat mastitis or other infections.

Management: Treatment is with gentian violet or nystatin. If the mother has symptoms, both mother and baby should be treated. If only the baby has symptoms, it is not necessary to treat the mother.

Gentian Violet paint:

Apply 0.25% solution to baby's mouth daily for 5 days, or until 3 days after lesions heal.

Apply 0.5% solution to mother's nipples daily for 5 days.

Nystatin:

Nystatin suspension 100,000 IU/ml; apply 1 ml by dropper to child's mouth 4 times daily after breastfeeds for 7 days, or as long as the mother is being treated.

Nystatin cream 100,000 IU/ml; apply to nipples 4 times daily after breastfeeds. Continue to apply for 7 days after lesions have healed.

7.9. Inverted, flat, large and long nipples (3)

Signs to look for: Nipples naturally occur in a wide variety of shapes that usually do not affect a mother's ability to breastfeed successfully. However, some nipples look flat, large or long, and the baby has difficulty attaching to them. Most flat nipples are protractile –if the mother pulls them out with her fingers, they stretch, in the same way that they have to stretch in the baby's mouth. A baby should have no difficulty suckling from a protractile nipple. Sometimes an inverted nipple is non-protractile and does not stretch out when pulled; instead, the tip goes in. This makes it more difficult for the baby to attach. Protractility often improves during pregnancy and in the first week or so after a baby is born. A large or long nipple may make it difficult for a baby to take enough breast tissue into his or her mouth. Sometimes the base of the nipple is visible even though the baby has a widely-open mouth.

Cause: Different nipple shapes are a natural physical feature of the breast. An inverted nipple is held by tight connective tissue that may slacken after a baby suckles from it for a time.

Management: The same principles apply for the management of flat, inverted, large or long nipples.

• Antenatal treatment is not helpful. If a pregnant woman is worried about the shape of her nipples, explain that babies can often suckle without difficulty from nipples of unusual shapes, and that skilled help after delivery is the most important thing.
• As soon as possible after delivery, the mother should be helped to position and try to attach her baby. Sometimes it helps if the mother takes a different position, such as leaning over the baby, so that the breast and nipple drop towards the baby's mouth.
• The mother should give the baby plenty of skin-to-skin contact near the breast, and let the baby try to find his or her own way of taking the breast, which many do.
• If a baby cannot attach in the first week or two, the mother can express her breast milk and feed it by cup.
• The mother should keep putting the baby to the breast in different positions, and allowing him or her to try. She can express milk into the baby's mouth, and touch the lips to stimulate the rooting reflex and encourage the baby to open his or her mouth wider.
• As a baby grows, the mouth soon becomes larger, and he or she can attach more easily.
• Feeding bottles or dummies, which do not encourage a baby to open the mouth wide, should be avoided.
• For flat or inverted nipples, a mother can use a 20 ml syringe, with the adaptor end cut off and the plunger put in backwards to stretch out the nipple just before a feed (see Figure 20).

FIGURE 20

Preparing and using a syringe for treatment of inverted nipples.

7.10. Perceived insufficiency and low breast-milk production

Symptoms: The commonest difficulty that mothers describe is a feeling that they do not have enough milk. In many cases, the baby is in fact getting all the milk that he or she needs, and the problem is the mother's perception that the milk supply is insufficient.

In some cases, a baby does have a low intake of breast milk, insufficient for his or her needs. Occasionally, this is because the mother has a physiological or pathological low breast-milk production (4). Usually, however, the reason for a low intake is a faulty technique or pattern of feeding. If the breastfeeding technique or pattern improves, the baby's intake increases. When a baby takes only part of the milk from the breast, production decreases, but it increases again when the baby takes more.

Symptoms which make a mother think that her breast milk is insufficient include:

• the baby crying a lot, and seeming not to be satisfied with feeds;
• the baby wanting to feed very often or for a long time at each feed;
• the breasts feeling soft;
• not being able to express her milk.

These symptoms can occur for other reasons, and they do not necessarily show that a baby's intake is low.

If a mother is worried about her milk supply, it is necessary to decide if the baby is taking enough milk or not.

If the baby has a low milk intake, then it is necessary to find out if it is due to breastfeeding technique, or low breast-milk production.

If the baby's intake is adequate, then it is necessary to decide the reasons for the signs that are worrying the mother.

LOW BREAST-MILK INTAKE

Signs: There are two reliable signs that a baby is not getting enough milk:

• poor weight gain.
• low urine output.

Passing meconium (sticky black stools) 4 days after delivery is also a sign of the baby not getting enough milk.

Poor weight gain

Babies' weight gain is variable, and each child follows his or her own pattern. You cannot tell from a single weighing if a baby is growing satisfactorily – it is necessary to weigh several times over a few days at least (see Annex 3 for tables showing the range of weights for babies of different birth weights).

Soon after birth a baby may lose weight for a few days. Most recover their birth weight by the end of the first week, if they are healthy and feeding well. All babies should recover their birth weight by 2 weeks of age. A baby who is below his or her birth weight at the end of the second week needs to be assessed.

From 2 weeks, babies who are breastfed may gain from about 500 g to 1 kg or more each month. All these weight gains are normal. The baby should be checked for illness or congenital abnormality and urine output. The technique and pattern of breastfeeding, and the mother-baby interaction should also be assessed, to decide the cause of poor weight gain, as explained below.

Low Urine Output

An exclusively breastfed baby who is taking enough milk usually passes dilute urine 6-8 times or more in 24 hours. If a baby is passing urine less than 6 times a day, especially if the urine is dark yellow and strong smelling, then he or she is not getting enough fluid. This is a useful way to find out quickly if a baby is probably taking enough milk or not. However, it is not useful if the baby is having other drinks in addition to breast milk.

Causes: The reasons for a low breast-milk intake are summarised in Table 9, and classified as breastfeeding factors; psychological factors with mother; mother's physical condition; and baby's condition (illness or abnormality).

TABLE 9

Reasons why a baby may not get enough breast milk.

Breastfeeding factors

A low breast-milk intake may be due to:

• delayed initiation of breastfeeding, so that milk production does not adjust in the early days to match the infant's needs;
• poor attachment, so that the baby does not take the milk from the breast efficiently;
• infrequent feeds, feeds at fixed times or no night feeds, so that the baby simply does not suckle enough; breastfeeding less than 8 times in 24 hours in the first 8 weeks, or less than 5–6 times in 24 hours after 8 weeks;
• short feeds, if a mother is very hurried, or if she takes the baby off the breast during a pause before he or she has finished, or if the baby stops quickly because he is wrapped up and too hot, then he or she may not take as much milk as needed, especially the fat-rich hind milk;
• using bottles or pacifiers which replace suckling at the breast, so the baby suckles less. Babies who use pacifiers tend to breastfeed for a shorter period. Pacifiers may be a marker or a cause of breastfeeding failure (5). They may interfere with attachment, so the baby suckles less effectively;
• giving other foods or drinks causes the baby to suckle less at the breast and take less milk, and also stimulates the breast less, so less milk is produced.

Psychological factors of the mother

A mother may be depressed, lacking in confidence, worried, or stressed; or she may reject the baby or dislike the idea of breastfeeding. These factors do not directly affect her milk production, but can interfere with the way in which she responds to her baby, so that she breastfeeds less. This can result in the baby taking less milk, and failing to stimulate milk production.

Mother's physical condition

A few mothers have low milk production for a pathological reason including endocrine problems (pituitary failure after severe haemorrhage, retained piece of placenta) or poor breast development. A few mothers have a physiological low breast-milk production, for no apparent reason, and production does not increase when the breastfeeding technique and pattern improve.

Other factors that can reduce milk production temporarily include hormone-containing contraceptive pills, pregnancy, severe malnutrition, smoking and alcohol consumption.

Baby's condition

A baby may fail to gain weight, or may fail to breastfeed well and stimulate milk production because of illness, prematurity or congenital abnormality, such as a palate defect, heart condition or kidney abnormality. It is always important to consider these factors and to examine a baby carefully before concluding that a mother has low breast-milk production.

Conclusion

The common reasons for a baby not getting enough breast milk are due to poor technique or mismanagement of breastfeeding, which can be overcome. Only a few mothers have long-term difficulty with milk production.

7.11. Crying baby

Signs or symptoms: The baby cries excessively, and is difficult to comfort. The pattern of crying may suggest the cause.

Cause:

• Pain or illness. This may be the case when a baby suddenly cries more than before.
• Hunger due to sudden faster growth, common at ages 2 weeks, 6 weeks and 3 months (sometimes called a “growth spurt”). If the baby feeds more often for a few days, the breast milk supply increases and the problem resolves.
• Sensitivity to substances from the mother's food. This may be any food, but is commonly milk, soy, egg or peanuts. Caffeine in coffee, tea and colas, and substances from cigarette smoke can also upset a baby. If the mother avoids the food or drink that may be causing the problem, the baby cries less.
• Gastro-oesophageal reflux. The baby cries after feeds, often on lying down, and may vomit a large amount of the feed, more than the slight regurgitation that is very common. The opening between the oesophagus and the stomach (cardiac orifice) is weak, allowing milk to flow back into the oesophagus, which can cause pain.
• Colic. Often crying occurs at certain times of day, typically the evening. The baby may pull up his legs as if in pain. He or she wants to feed but is difficult to comfort. The cause is not clear. Babies with colic usually grow well, and the crying decreases after 3–4 months. Carrying the baby more, using a gentle rocking movement, and pressure on the abdomen with the hands, or against the shoulder, may help.
• High-needs babies. Some babies cry more than others, and they need to be carried and held more. This problem is less common in communities where mothers carry their babies with them, and keep them in the same bed.

Management:

• If a specific cause, such as pain or illness, can be identified, it should be treated.
• The mother can try a change in her diet, such as stopping drinking milk or coffee for a week, to see if there is an improvement.
• Holding the baby upright may help reflux, or medication may be suggested.
• For colic or a high-needs baby, the mother can carry and rock the baby with gentle pressure on the abdomen. She may need reassurance that the crying will lessen as the baby grows.

7.12. Oversupply of breast milk

Symptoms:

• The baby cries as if he or she has colic and wants to feed often.
• The baby may have frequent loose stools, which may be green.
• He or she may grow well, or may have poor weight gain, suggesting low milk production.
• The mother may have a forceful oxytocin reflex, so that her milk flows fast. This can make the baby choke and pull away from the breast during feeds.

Cause:

• The baby may be poorly attached, and suckling a lot but not removing the milk efficiently. Constant suckling may stimulate the breast to produce a lot of milk.
• The mother may take her baby off the first breast before he or she has finished to put him on the second breast. The baby may get mostly low-fat fore milk, and suckle more to get more energy, and so stimulate the breasts to make more milk.
• Large amounts of foremilk overload the baby with lactose, causing loose stools and colicky behaviour.

Management:

• The mother should be helped to improve her baby's attachment.
• The mother should offer only one breast at each feed, until the baby finishes by him- or herself. The baby will get more fat-rich hindmilk. She should offer the other breast at the next feed.
• If a forceful oxytocin reflex continues, she can lie on her back to breastfeed, or hold the breast with her fingers closer to the areola during feeds.

7.13. Refusal to breastfeed

Symptoms: The baby refuses to breastfeed, and may cry, arch his or her back, and turn away when put to the breast. The mother may feel rejected and frustrated, and be in great distress.

Causes: There may be a physical problem such as:

• illness, an infection, or a sore mouth, for example thrush (see Session 7.8);
• pain, for example bruising after a traumatic delivery or gastro-oesophageal reflux;
• sedation, if the mother received analgesics during labour.

The baby may have difficulty or frustration with breastfeeding because of:

• sucking on a bottle or pacifier;
• difficulty attaching to the breast;
• pressure applied to his or her head by someone helping with positioning;
• the mother shaking her breast when trying to attach him or her.

The baby may be upset by a change in the environment including:

• a changed routine, the mother resuming employment or moving house;
• a different carer, or too many carers;
• a change in the mother's smell – for example, if she uses a different soap or perfume.

Management: If a cause is identified, it should be treated or removed, if possible.

The mother could consider how she can reduce the time she spends away from the baby, or avoid other changes that may be upsetting. She can be helped to improve her breastfeeding technique, and how to avoid the use of bottles and pacifiers. She can also be helped to:

• keep her baby close, with plenty of skin-to-skin contact, and no other carers for a time;
• offer her breast whenever the baby shows signs of interest in suckling;
• express milk into the baby's mouth;
• avoid shaking her breast or pressing the baby's head to force him or her to the breast;
• feed the baby by cup, if possible with her own breast milk, until he or she is willing to take the breast again.

7.14. Twins

Management

Twins who are low birth weight need to be managed accordingly (see Session 6.1).

For larger twins, management should be as for singletons, with early contact, help to achieve good attachment at the breast, and exclusive on-demand feeding from birth, or from as soon as the mother is able to respond. Early effective suckling can ensure an adequate milk supply for both infants.

Mothers may need help to find the best way to hold two babies to suckle, either at the same time, or one at a time. They may like to give each baby its own breast, or to vary the side. Holding one or both babies in the underarm position for feeding, and support for the babies with pillows or folded clothes is often helpful. Building the mother's confidence that she can make enough milk for two, and encouraging relatives to help with other household duties, may help her to avoid trying to feed the babies artificially.

7.15. Caesarean section

Management

7.16. Mother separated from her baby

7.17. Illness, jaundice and abnormality of the child

ABNORMALITIES

Symptoms

Cleft lip and/or palate: attachment and suckling may be difficult because of the anatomical gap. If only the lip is affected, the breast covers the cleft, and the baby may be able to suckle effectively. Sometimes a baby with a cleft palate can suckle quite well, if there is enough palate for the tongue to press the nipple against.

Tongue-tie: the strip of tissue underneath the tongue, called the frenulum, is too short and holds the tongue down. This can make attachment difficult, which may cause sore nipples. The baby may not suckle effectively and may have a low intake of breast milk.

Muscular weakness: babies with Down syndrome or cerebral palsy have difficulty attaching to the breast and suckling because of the weakness.

Congenital heart or kidney problems: a baby fails to grow, but there is no apparent difficulty with breastfeeding or breast-milk supply. These abnormalities are not obvious, and require careful examination of the baby.

Management

Cleft lip and/or palate

The baby should be referred for surgery, which usually takes place in one or more stages after some months. It is important for the baby to grow and to be well nourished before undergoing surgery.

The mother can be helped to hold the baby in an upright sitting position at the breast with the baby's legs on either side of the mother's thigh. This makes swallowing easier and may help the baby to breastfeed, fully or partially. She can express her milk and feed it to the baby by cup or spoon until surgical help is available, or an orthopaedic device is provided to facilitate breastfeeding.

The family may need a great deal of support and help to accept the baby, to persist with feeding, and to believe that the baby will look almost normal and will be able to lead a normal life if he or she has surgery.

Tongue-tie

If tongue-tie is causing problems with feeding, the baby will need referring for cutting of the frenulum.

This is effective and can now be done simply and safely (6).

Muscular weakness

The mother should be shown how to help the baby to attach to the breast by using the dancer hand position (Figure 21). She supports the baby's chin and head to keep the mouth close on to the breast. These babies may feed slowly, and it may be necessary for the mother to express her milk and give some feeds by cup or tube. The mother will need extra support and counselling to bond with her baby, to feel that she is doing the best for him or her, and to persist.

FIGURE 21

Dancer hand position.

Heart, kidney or other abnormalities

Consider these possibilities in a baby who fails to grow despite good breastfeeding practices. Examine the baby carefully, and refer for further assessment.

References

1.

WHO. Evidence for the Ten Steps to successful breastfeeding. Geneva: World Health Organization; 1998.

2.

WHO. Mastitis: causes and management. Geneva: World Health Organization; 2000. (WHO/FCH/CAH/00.13)

3.

Mohrbacher N, Stock J. The breastfeeding answer book. 3rd revised ed. Schaumburg, Illinois, USA: La Leche League International; 2003. [4 November 2008]. http://www​.lalecheleague.org.

4.

Woolridge MW. Breastfeeding: physiology into practice. In: Davies DP, editor. Nutrition in child health. London: Royal College of Physicians of London; 2003.

5.

Kramer MS, et al. Pacifier use, early weaning, and cry/fuss behavior: a randomized controlled trial. Journal of the American Medical Association. 2001;286:322–326. [PubMed: 11466098]

6.

Hogan M, Westcott C, Griffiths M. Randomized control trial of division of tongue-tie in infants with feeding problems. Journal of Paediatrics and Child Health. 2005;41:246–250. [PubMed: 15953322]