Feeding Problems in Neonates

1. Introduction

Breastfeeding is the gold standard for infant nutrition. However, technical and medical challenges often lead to early cessation. Problems are broadly classified into Maternal and Neonatal issues.

2. Maternal Problems and Management

A. Sore and Cracked Nipples

Causes: Poor attachment (most common).

• Tongue-tie in infant.
• Fungal infection (Candida).
• Improper use of breast pump.

Management:

1. Correct Positioning: Ensure the baby's mouth is wide open and the lower lip is everted (asymmetrical latch).
2. Hindmilk Application: Apply a few drops of hindmilk to the nipple after feeding and allow it to air dry (healing properties).
3. Avoid Irritants: Do not use soap, alcohol, or frequent washing of nipples.
4. Breaks: If pain is severe, a short rest (12–24 hours) with manual expression may be needed.
5. Candida Treatment: If nipples are itchy/pink/shiny, treat mother and baby with topical Nystatin or Clotrimazole.

B. Breast Engorgement

Definition: Painful overfilling of breasts causing lymphatic and venous obstruction, usually on Day 3–5.

Management:

1. Frequent Feeding: Nurse frequently to empty breasts.
2. Warm Compresses: Apply before feeding to stimulate oxytocin and let-down.
3. Cold Compresses: Apply after feeding to reduce edema and pain.
4. Cabbage Leaves: Clean, chilled cabbage leaves applied to the breast can reduce edema (mechanism unclear but widely accepted).
5. Reverse Pressure Softening: Gentle pressure around the areola to push fluid back and allow the baby to latch.

C. Mastitis

Definition: Inflammation of breast tissue (infective or non-infective), often presenting with a wedge-shaped red, tender area and systemic fever/flu-like symptoms.

Management:

1. Continue Breastfeeding: Essential to drain the breast; stopping worsens the condition. Start feeding from the unaffected side to stimulate let-down, then switch.
2. Analgesics: Ibuprofen or Paracetamol for pain and fever.
3. Antibiotics: Indicated if symptoms persist >24 hours, fissure is present, or systemic sepsis signs appear.
   • Drug of choice: Anti-staphylococcal penicillin (e.g., Cloxacillin, Cephalexin).
   • Duration: 10–14 days.

D. Breast Abscess

Definition: Localized collection of pus, usually a complication of untreated mastitis.

Management:

1. Drainage:
   • Aspiration: Ultrasound-guided needle aspiration (preferred for smaller abscesses).
   • Incision & Drainage (I&D): For large or recurrent abscesses.
2. Feeding:
   • Continue breastfeeding from the affected breast if the incision is far from the nipple and mouth does not cover the wound.
   • If incision is close to the nipple, express and discard milk until drainage stops; feed from the healthy breast.

E. Flat or Inverted Nipples

Management:

1. Antenatal: Hoffman’s exercises (rolling nipple) are no longer routinely recommended (risk of preterm labor).
2. Postnatal:
   • Syringe Suction: Use a cut 10cc/20cc syringe to pull the nipple out before feeding.
   • Nipple Shields: Thin silicone shields can help the baby latch (temporary measure).
   • Manual Stimulation: Roll nipple before feed to promote erection.

F. Insufficient Milk (Perceived vs. Real)

Diagnosis: Confirmed only if infant weight gain is poor (<15–30g/day) or urine output is low (<6 wet diapers/day).

Management:

1. Counseling: Reassure mother (growth spurts often mimic low supply).
2. Frequent Nursing: Supply equals demand; nurse more often.
3. Galactogogues: Metoclopramide or Domperidone (dopamine antagonists) stimulate prolactin. Use only after non-drug methods fail.

3. Neonatal Problems and Management

A. Nipple Confusion

Cause: Exposure to artificial teats/bottles which require different sucking mechanics than the breast.
Management:

• Avoid bottles and pacifiers.
• Feed expressed milk via paladai (katori-spoon) or cup.

B. Ankyloglossia (Tongue-tie)

Feature: Short lingual frenulum restricting tongue movement, causing sore nipples and poor transfer.
Management:

• Frenotomy: Simple surgical release if it interferes with feeding.

C. Breast Refusal

Causes: Pain (birth trauma), illness (blocked nose, sepsis), or fast let-down (choking).
Management:

• Treat underlying cause (saline drops for nose).
• Skin-to-skin contact (Kangaroo Mother Care) to promote instinctual feeding.
• Feed in a semi-reclined position if let-down is strong.

D. Cleft Lip and Palate

• Cleft Lip: Usually can breastfeed (breast tissue fills the gap).
• Cleft Palate: unable to generate negative pressure.
  • Use Special Needs Feeder (Haberman), spoon feeding, or obturators.
  • Feed in upright position (prevent otitis media/choking).

E. Preterm / Weak Suck

• Management:
  • Kangaroo Mother Care (KMC) to promote reflexes.
  • Express breast milk (EBM) via tube/spoon until suck-swallow-breathe coordination matures (~34 weeks).

4. Key Principles

• Prevention is better than cure: Early initiation (first hour) and correct attachment prevent most problems.
• Do not stop feeding: In almost all benign breast conditions (including mastitis), breastfeeding should continue.
• Avoid artificial nipples: Strictly no bottles in the first 4–6 weeks.