Problems of Breastfeeding and Management

Problems of Breastfeeding

Breastfeeding problems can be broadly categorized into maternal factors (anatomical, physiological, and psychological) and infant factors. These issues often lead to the early cessation of breastfeeding if not managed correctly.

Maternal Problems

• Flat or Inverted Nipples:
  • Flat nipples: The nipple does not protrude enough for the baby to latch easily.
  • Inverted nipples: True inverted nipples retract deeper into the breast when the areola is compressed.
  • While the size of the resting nipple is less important than its protractility, severe inversion can make attachment difficult.
• Sore and Cracked Nipples:
  • This is frequently caused by poor attachment, where the baby sucks only on the nipple rather than the areola.
  • Fungal infection (Candida/Thrush) is another cause, often presenting with shooting pain or itching.
  • Tongue-tie (ankyloglossia) in the infant can also cause nipple pain and poor latching.
• Breast Engorgement:
  • Characterized by breasts becoming full, hard, tender, tight, and shiny.
  • Caused by accumulation of milk, blood, and edema fluid due to delayed initiation, infrequent feeding, or poor attachment.
  • Severe engorgement can flatten the nipple, making attachment difficult.
• Blocked Duct:
  • Manifests as a painful, hard swelling (lump) in the breast without fever.
  • Caused by thick milk blocking a lactiferous duct, often due to tight clothes or the baby not draining a segment of the breast properly.
• Mastitis and Breast Abscess:
  • Mastitis: Infection of the breast tissue presenting with fever, redness, heat, and tenderness. Common organisms include Staphylococcus aureus.
  • Abscess: A localized collection of pus resulting from untreated mastitis or engorgement.
• Perceived Insufficiency ("Not Enough Milk"):
  • The most common reason mothers stop breastfeeding.
  • Often a misperception caused by the baby crying, frequent feeding demands, or lack of maternal confidence ("let-down" failure due to anxiety).
• Maternal Illness:
  • Severe illness, HIV (in certain contexts), or use of cytotoxic drugs/radioactive isotopes may be contraindications.

Infant Problems

• Poor Attachment:
  • The chin does not touch the breast, mouth is not wide open, lower lip is turned in, and more areola is visible below the mouth.
  • Leads to ineffective milk transfer and maternal nipple trauma.
• Prematurity and Low Birth Weight (LBW):
  • Infants <34 weeks may have poor coordination of sucking, swallowing, and breathing.
  • They tire easily and may not empty the breast effectively.
• Nipple Confusion:
  • Caused by the introduction of feeding bottles or pacifiers. The technique for sucking on a bottle differs from the breast, leading the baby to refuse the breast.
• Ankyloglossia (Tongue-tie):
  • A short lingual frenulum restricts tongue movement, causing nipple pain for the mother and poor weight gain for the infant.
• Illness and Anatomical Defects:
  • Cleft Lip/Palate: Makes creating a seal and suction difficult.
  • Nasal Obstruction: Makes feeding difficult as the baby cannot breathe while sucking.
  • Oral Thrush: Painful white patches in the mouth interfere with sucking.
• Breastfeeding Jaundice:
  • Related to insufficient intake/dehydration in the first week (suboptimal intake jaundice).
  • distinct from "Breast Milk Jaundice," which is prolonged jaundice in a thriving infant.

Management of Breastfeeding Problems

Management focuses on supporting the mother, correcting technique, and maintaining milk flow to prevent suppression of lactation.

Management of Maternal Problems

• Flat/Inverted Nipples:
  • Antenatal: Diagnosis during pregnancy; reassurance that the baby feeds on the breast, not just the nipple.
  • Syringe Suction Technique: A disposable syringe (nozzle end cut) is used to draw the nipple out before feeding.
  • Manual Manipulation: Rolling the nipple or manually stretching the areola before feeds.
• Sore/Cracked Nipples:
  • Correct Attachment: This is the most critical intervention. Ensure the baby takes a large mouthful of breast tissue (areola).
  • Hindmilk Application: Apply a drop of hindmilk to the nipple after feeds and allow it to air dry.
  • Avoid Irritants: Do not use soap or medicated creams on nipples. Wash only with water.
  • Treat Thrush: If fungal infection is suspected, treat both mother (nipples) and baby (mouth) with Gentian Violet or antifungal medication.
• Breast Engorgement:
  • Frequent Feeding: Feed every 2–2.5 hours or on demand.
  • Expression: Express some milk manually to soften the areola before latching.
  • Warm Compresses: Apply moist heat before feeds to aid let-down.
  • Cold Compresses: Apply after feeds to reduce edema and pain.
• Mastitis and Abscess:
  • Continued Drainage: Do not stop breastfeeding. Feed from the affected side frequently to drain the breast. If too painful, express milk by hand or pump.
  • Antibiotics: Treat with antistaphylococcal antibiotics (e.g., Cloxacillin, Cephalexin) for 10–14 days.
  • Analgesics: Paracetamol or Ibuprofen for pain and fever.
  • Abscess: Requires incision and drainage; breastfeeding can continue on the healthy side, and often on the affected side (away from the incision) or EBM can be given.
• Perceived Insufficiency ("Not Enough Milk"):
  • Assessment: Check objective signs of sufficiency: weight gain, 6+ wet nappies/day, sleep after feeds.
  • Counseling: Build maternal confidence; explain growth spurts.
  • Galactogogues: Metoclopramide or herbal supplements may be considered if support fails (though not primary management).
  • Avoid Supplements: Discourage top feeds or water which reduce suckling stimulus.

Management of Infant Problems

• Correction of Attachment (The 4 Signs):
  • Ensure: 1) Mouth wide open, 2) Lower lip turned outward, 3) Chin touching the breast, 4) More areola visible above the mouth than below.
• Prematurity/LBW:
  • Kangaroo Mother Care (KMC): Provides warmth and promotes frequent breastfeeding.
  • Expressed Breast Milk (EBM): If the baby cannot suck, feed EBM using a paladai (cup/spoon) or gavage tube.
  • Non-nutritive Sucking: Allow nuzzling at the breast to mature the sucking reflex.
• Nipple Confusion:
  • Stop Bottle Feeding: Immediately switch to cup/spoon feeding if supplementation is necessary.
  • Re-lactation: Encourage skin-to-skin contact and frequent offering of the breast.
• Cleft Lip/Palate:
  • Feed in an upright position.
  • Use specific obturators or feeding plates.
  • Feed EBM with a spoon/paladai if direct latch is impossible.
• Jaundice:
  • Breastfeeding Jaundice: Increase frequency of feeds (8–12 times/day) to improve hydration and bilirubin clearance.
  • Breast Milk Jaundice: Usually benign; continue breastfeeding. In severe cases, brief interruption (24-48 hours) may be considered but is rarely necessary; phototherapy is the primary treatment.
• Working Mothers:
  • Teach expression and storage of breast milk.
  • EBM can be stored at room temperature for 8 hours or in a refrigerator for 24 hours.
  • Caregivers should feed EBM using a cup/spoon, not a bottle.