Breastfeeding problems

Overview

Please note: This page refers to 'woman', 'mother' and ‘breastfeeding’ throughout. We recognise that not all people who are pregnant or who have given birth identify as women or mothers, and that other terms such as breast-milk feeding may be preferred. Similarly, where the term 'parents' is used, this includes anyone who has main responsibility for caring for a baby.

Breastfeeding has significant, far-reaching benefits for mothers, infants and society. Breastfed infants have a lower risk of infections, Sudden Infant Death Syndrome, asthma, type 2 diabetes, and probably obesity. For mothers, breastfeeding reduces the risk of breast cancer and possibly ovarian cancer, improves mental health and reduces the risk of post-natal depression. Despite this, the UK has the lowest breastfeeding rates in the world. Bristol has higher than national average rates but there is huge variation across the city, reflecting health and social inequalities. Therefore, providing women with accurate, consistent advice at all opportunities is important, especially in the first 6-8 weeks while they learn this skill, and will help to ensure they are supported to continue feeding for as long as they want to.

Good positioning and attachment of the baby at the breast is crucial to effective breastfeeding. If breast problems, feeding difficulties or growth faltering occur, ensure a full feed has been observed by a trained supporter to check positioning and attachment. See the Infant Feeding Support page for more details of support in BNSSG. 

The GP Infant Feeding Network is a national network of primary care professionals and supportive colleagues advocating for improvements in infant feeding practice. Their website provides a wealth of written information for primary care professionals, including a list of consultation resources and resources for parents, and is well worth looking at. 

The NICE CKS - Breastfeeding problems also covers the management of common problems.

Pain on breastfeeding

There are many causes of pain in breastfeeding and a good history and assessment of feeding is essential to identifying the problem and treating it effectively. 

The GP Infant Feeding Network page on Positioning and Attachment demonstrates the role of good positioning and attachment of the infant at the breast in enabling comfortable feeding. 

The Breastfeeding Network: If Breastfeeding Hurts is a helpful patient-facing guide to determine the likely cause of breastfeeding related pain.

Cracked nipples – Common in early days when learning the skill. Proper attachment should mean the nipple rests against the soft palate of baby’s mouth. Otherwise the nipple may rub on the hard palate and become pinched and damaged. Ensure a full feed has been observed by a trained breastfeeding supporter. Bear in mind the possibility of a tongue tie. Expressing breast milk and applying to the nipples can help to manage the cracks. 

Milk bleb/blister – A blocked nipple pore caused by a thin layer of skin growing over a milk duct which presents as a painful white-ish dot on the nipple caused by inflammation. Gentle moist heat can help. De-roofing may cause further trauma and inflammation. Can consider trying topical steroid cream to reduce.

Blocked duct – a colloquial term for ductal narrowing caused by inflammation and oedema, which causes focal pain and swelling in an area of the breast. No systemic symptoms. Continue responsive feeding/expressing, with trained support as needed. Massage may cause further trauma and inflammation so gentle light touch only; similarly high heat may also contribute to further inflammation. Cold compress may help soothe. A galactocele may result causing a smooth round painless swelling with possible milky nipple discharge when pressed. If any doubt about the diagnosis manage as a breast lump.

Nipple vasospasm – Leads to blanching and severe throbbing pain during and after feeding. Under recognised and may be misdiagnosed e.g. as thrush. Causes include suboptimal positioning and attachment, mechanical trauma, and Raynaud’s of the nipple. 

Raynaud’s causes blanching followed by cyanosis or erythema with resolution of pain when normal colour returns and is unrelated to feeding. Advise to avoid cold exposure, stop smoking, limit caffeine, warm compress after feeding. If needed, Nifedipine can be trialled at 10mg TDS or 30mg MR once daily for 2 weeks.

Patient information leaflet: The Breastfeeding Network: Raynaud’s Phenomenon in Breastfeeding Mothers

Nipple skin changes – Eczema triggers include lanolin, beeswax, chamomile in nipple creams, soap, shampoo, fragrances. Manage as for eczema at other sites with emollients and topical steroids applied after feeds if needed. Manage suspected psoriasis similarly. NB Paget’s if unilateral and not responding to treatment. 

Breast engorgement:

Common when milk first comes in, causing very full, painful breasts and difficulty latching. Can also occur later on due to reduction in feed frequency e.g. during weaning or illness. Allow unrestricted access to the breast, hand express a little before latching to improve attachment - see the UNICEF hand expression video. Cold compress may soothe, as can well-fitting bras and simple analgesia.

Infection:

Bacterial:

Superficial bacterial infection can result from persistent cracked/fissured nipples (see above; ensure a full feed has been observed by a trained supporter).  

Candidal:

Commonly diagnosed but differentials include poor positioning and attachment and vasospasm, as above. Pain from thrush always persists after a feed, mostly affects both breasts, and is present whether directly feeding or expressing, helping to distinguish from positioning and attachment problems. Baby can show signs of white spots in the mouth, discomfort during feeds, or persistent nappy rash. Always treat both mother and baby. See BNSSG Antimicrobial Prescribing Guidelines 

Mastitis and breast abscess

Mastitis is inflammation of the breast. It is a spectrum including focal duct narrowing, mastitis, bacterial mastitis and breast abscess. Milk stasis is thought to cause it but has not been proven. Other contributing factors include poor positioning and attachment, oversupply, disruption to the breast/milk microbiome, stress. Symptoms include pain, redness and flu-like illness. Most cases are not bacterial and can be managed conservatively.

Trained support to optimise positioning and attachment, continue responsive feeding (but not aiming to “empty the breast”, no need for added expressing - this may further worsen the situation by upregulating supply), rest, hydrate, cold compress between feeds (avoid high heat as this may cause further inflammation), gentle light massage only if needed.

If no improvement after 24 hours, worsening of symptoms, or obvious infected wound is present then treat with flucloxacillin - see BNSSG Antimicrobial Prescribing Guidelines. Arrange admission if signs of sepsis (and alert the hospital infant feeding team to keep mother & baby together), or urgent assessment by the Breast Surgeons at Southmead if a breast abscess is suspected (see below).

Breast Abscess

A well-defined, red, fluctuant, extremely tender swelling, sometimes with overlying oedema. 

If there is large area of redness on the breast or any mass felt in the breast or an abscess is suspected, refer urgently to the breast care centre office hours [ext 47000] for USS and review. If in doubt, refer to breast care centre for review. Out of hours refer to the on call surgical registrar. 

A woman with a breast abscess should be reassured that she is likely to fully recover and is able to continue breastfeeding without causing harm to the baby.   

See the Mastitis and Breast Abscess Remedy page for more info how to refer.

NBT have also produced a Mastitis Prevention and Treatment Guideline

Patient information leaflet: Mastitis and Breastfeeding (The Breastfeeding Network)

Oversupply

Common in first weeks, usually settles, but can persist causing discomfort and fullness not resolving with feeding, excessive leaking, and frequent blocked ducts/mastitis. Infants can cough/splutter with let-down, clamp down on the nipple to control the flow, fuss and pull off, have frequent green stools, and even falter in growth due to discomfort associated with feeding. Ensure access to trained breastfeeding support/infant feeding specialist to help manage.

Low milk supply

Perceived low supply is one of the most common reasons for discontinuation of breastfeeding due to erosion of confidence and on-going distress. True low supply is unusual however, and many breastfeeding journeys can be saved with appropriate assistance from trained breastfeeding supporters; see the GPIFN page on low milk supply. 

Causes of low milk supply

Maternal prolactin deficiency:

• Drugs, e.g. oestrogen, combined hormonal contraceptives, dopamine, ergotamine, pyridoxine, nicotine, and alcohol.
• Anterior pituitary dysfunction, e.g. severe post-partum haemorrhage, or post-partum pituitary necrosis (Sheehan's syndrome, rare).
• Retained placental fragments.
• Thyroid disorders, e.g. hypothyroidism or post-partum thyroiditis.
• Eating disorders, e.g. bulimia.

Maternal anatomical factors:

• Hypoplastic breasts (rare - widely spaced breasts with prominent areolas, due to insufficient glandular tissue - suspect if reduced breast development during adolescence, pregnancy and/or post-partum).
• Breast surgery (e.g. may interfere with normal nipple sensation which affects milk supply, or breast reduction surgery may remove glandular tissue).

Milk removal factors:

• Insufficient access to the breast (short or infrequent feeds, no night feeds, use of a dummy, nipple shield, or giving supplementary feeds other than breast milk, maternal or infant illness or regular mother-child separation e.g. due to work)
• Suboptimal infant positioning and attachment.
• Maternal depression, stress, and/or anxiety - may result in reduced response to infant cues, reduced frequency of feeds and reduced stimulation of milk production.

Ensure a trained supporter has observed a full feed, consider investigating for causes of prolactin deficiency, and refer infants to secondary care if any concerns regarding growth or dehydration.

Infant Feeding Support

First line management should be to review the potential causes above and address as appropriate, and to access support from the infant feeding specialist teams. See the Infant Feeding Support page for details.

Galactagogues 

If referral to the infant feeding specialist service has failed to improve milk supply, galactagogue prescription can be considered, in addition to ongoing support for regular effective milk drainage. There are no licensed medications in the UK for this use but see the following:

• Lactation: Drug Treatment to increase milk supply in Lactating Mothers - These guidelines can be found on the Children's Hospital Clinical Guidelines page and then scroll down to the relevant link.
• The Infant Feeding Midwives are also happy to give advice to GP’s for individual prescriptions. 

Domperidone is listed on the BNSSG Formulary as a TLS Blue prescription medication (can be used if infant feeding support alone has not been effective). It is preferred over other galactagogues due to its better side-effect profile and evidence of efficacy. It increases prolactin levels and improves milk supply in some (but not all) patients. Measures to increase milk supply must have been tried first, and continue - domperidone will not work without increased stimulation. Provided there are no contraindications (see below), a trial can be considered, of maximum 10mg TDS for 7 days then review. Maximum effect is seen within 7 - 10 days, any longer prescription is not likely to confer any benefit. Gradual wean is advised e.g. to 10mg BD for 1 week then 10mg OD for 1 week then stop, to reduce the risk of withdrawal symptoms.

See also the GPIFN page on Galactagogues, and Domperidone and breastfeeding from The Breastfeeding Network.  

Donor Breast Milk

Families with low milk supply, or unable to breastfeed for medical reasons, may wish to explore the option of using donor breast milk. Currently the Southwest Neonatal Network Donor Milk Bank at Southmead is the only milk bank in the South West and supplies donor milk to ill and premature babies in neonatal units. If they have surplus, they can supply small amounts to mothers in the community if requested. Otherwise, an Exceptional Funding Request can be made for funding to purchase milk from The Hearts Milk Bank (a national charity), or Chester Milk Bank, although to date no applications have been successful.

The Hearts Milk Bank provides more information and support for accessing donor milk on their webpage: https://heartsmilkbank.org/milk/ The HMB does not request or accept payment directly from parents. If breastfeeding is impossible, for example as a result of previous mastectomies or medication use that is contraindicated in lactation, then contacting them early during pregnancy helps their planning. We encourage applications for funding for donor milk to be made to your local Integrated Care Board (ICB), and this can be done with the support of your GP. We are happy to provide information and support for this process.

If funding is not granted by the ICB, then the Human Milk Foundation may be able to provide some funding towards donor milk use.

If you are a doctor working in the community, and would like to enquire about using donor milk for either a sick baby or a mother who cannot breastfeed for medical reasons, please email: info@heartsmilkbank.org

Tongue-Tie

Please see the Tongue-Tie page of Remedy.

Infant Factors

Infant factors can also be the cause of breastfeeding difficulty, and it’s therefore important to explore baby behaviour and symptoms. The GPIFN has a page on these factors, The Infant, and there is also information on the following Remedy sections:

Gastroenterology

Development & Growth

Maternal Mental Health

The relationship between infant feeding and maternal wellbeing is very significant, and difficulties with one can directly affect the other.

Stressful/traumatic labour and delivery, and unplanned caesarean birth are risk factors for delayed lactogenesis, and so birth trauma and breastfeeding difficulties may co-exist. There is currently no birth debriefing clinic running at St Michael’s, but mothers who delivered at Southmead can be referred to their Afterthoughts clinic using this form. 

The Remedy Perinatal Mental Health page also has information including local resources and how to refer to the service. The GIPFN also has helpful information and resources on their Maternal Mental Health page.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.