Common Problems With Breastfeeding

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    So often in nursing school we have to write these papers that often come out sounding like an astute textbook. Confusing facts to the lay person, big words, medical terminology, etc. I wrote this directed to the patient because I think it is good practice to help remember how to talk in layman's terms.

    Many people have a misunderstanding that breastfeeding comes natural; the misconceptions that all a mother has to do is put her baby at her breast and call it good. In the past, little girls grew up watching women in the family breastfeed. However, like homebirth, this is not as common today. Another misconception is that breastfeeding is painful. If done properly, breastfeeding is anything but painful; it should be euphoric. A proper position and latch is key for happy breastfeeding. Most of the common problems associated with breastfeeding can be prevented by a proper latch. Ina May Gaskin says that once a baby “successfully latches on, the knowledge of how to do it is engraved in his memory, and he will usually go for the nipple quickly each time the breast if offered” (Gaskins, 1987, 50). Below is an illustration of a proper latch:



    (Note how the baby's lips are correctly everted, and the mouth is open wide. Also notice how much breast tissue has been taken in, almost the entire areola is in the baby's mouth)

    (Breastfeeding.com, 1998-2007)

    The following are a few tips on a proper latch that can prevent some of the common problems with breastfeeding:
    • Your nipple and the areola need to be in your baby’s mouth, about halfway back onto his or her hard palate.
    • Find a position that works for you to avoid having your infant pull on your nipple; positions range from belly-to-belly hold, side hold, and football hold.
    • Try to stay relaxed, a tense mother calls for a tense baby and tension can negatively affect the milk-letdown- reflex.
    • Wait for your baby to open his or her mouth all the way, like a little bird, and then place your nipple and areola in his or her mouth; never force the nipple in either.
    • Use the rooting reflex to your advantage, stroke your baby’s lips with your nipple; even squeeze a few drops of milk onto his or her lips. Babies often imitate what they see; making puckering faces could encourage a baby to open his or her mouth.
    • Do not use a bottle until your baby is six months old—if at all.
    You will know if you have established a good latch if enough of your nipple and areola are in your baby’s mouth, which should be accompanied by audible swallowing (Gaskins, 1987, 50) (Pillitteri, 2007, chap. 25). It is never shameful to seek advice from a lactation consultant or experienced mother. The following are some of the common problems with breastfeeding, especially for first time mothers.

    Engorgement

    Engorgement is a common occurrence when breast milk first comes in after 3-4 days postpartum. It usually goes away within 24 hours for most moms, but I have heard of some moms that continue have engorgement problems throughout breastfeeding. Women may notice that their breast become distended, which is accompanied by hardness, tenderness, and perhaps heat in the breast. The skin appears red, shinny, and tense. This is referred to as “primary engorgement, and it is caused by vascular and lymphatic congestion arising from an increase in the blood and lymph supply to the breast” (Pillitteri, 2007, 737).

    When dealing with engorgement, prevention is always best. This can be done through your baby by emptying the breast or having your infant at your breast more often. The best way to treat engorgement is also by way of your baby by putting him or her on your breast. Sometimes engorgement can be so much that it is hard for your baby to get a proper latch. Your breast may also be very sensitive at this time. Manual expression to get things going at this time may be necessary. Another trick aside from manual expression is warm packs combined with massage to promote drainage and breast softness (Pillitteri, 2007, 738). In between nursing, you can place cold cabbage leaves from the fridge inside your bra (Levine, 2007).

    Sore and Cracked Nipples

    Sore nipples are a common occurrence, especially with new moms, and can almost entirely be avoided thought a proper latch. Most important of a proper latch is that your infant opens his or her mouth wide enough to get the entire nipple and areola in his or her mouth; which is done for two reasons. One is so that the sinuses empty completely since milk forms in response to being used. This also helps with milk production. In relationship to sore nipples however, the position of your nipple to the anatomical structure of your baby’s mouth comes more into play. Take your finger and place it just inside your mouth and feel the roof of your mouth; that is the hard palate, now imagine having your nipple being smashed against this surface. Now stick your finger in your mouth just a little bit further until it becomes slightly softer; that is the soft palate and a more favorable place for your nipple to rest. Feed your baby often and wear a good supportive bra.

    Because the breast stays supple from the Montgomery’s tubercles on your nipple, a proper latch results in un-sore nipples. You should put the baby in a different position every time you breastfeed. Nipples should air dry for 10 to 15 minutes after feedings. Plastic lined nursing bras should not be used. Vitamin E oil can be used to prevent further irritation. Hand pumps should be avoided when any soreness begins and an electric pump should be used instead (Pillitteri, 2007, 738). Irritated nipples can also be treated with Hydrocortisone cream, but not for longer than 5 days. Also, when bathing, wash your breast without soap for this is over drying.

    Should sore nipples progress to cracked nipples some steps may be made. If not taken care of properly, mastitis (a breast infection) could result. Nipples need to be kept cleaned, and should be air dried even more often. If your baby has an infection such as thrush, aid of an electric breast pump until both conditions resolve should be used. If your nipple is only cracked on one side, and very tender; you may decide not to breastfeed on this side. This however does not mean emptying the breast is completely ignored. If your breast is not emptied by way of an electric breast pump (which may be gentler than the baby) your milk supply may dry up. If there is blood in your milk this is okay and can be giving to your baby. “After two days, gradually resume nursing, with five minute feedings on the sore breast, beginning with two times a day. Continue to express your milk at other feeding times until you are back up to a full nursing schedule” (Gaskins, 1987, 71)

    Mastitis

    Normal breast tissue feel soft on palpation during the first and second day after the birth. By the third day, the breast will feel firm and warm. By the fourth day, breasts have the characteristics of engorgement. They feel hard and are tense and painful—if only a portion of a breast is this way, mastitis should be suspected.

    Another side effect of cracked nipples—aside from the pain and irritation—is Mastitis, which is an infection of the breast transmitted through cracked and fissured nipples. Mastitis can occur as early as the 7th day after birth or until your baby is months old. As with engorgement and cracked nipples, mastitis can be prevented by:
    • Making certain your baby is positioned correctly and grasps you nipple properly, including both nipple and areola
    • Releasing your baby’s grasp on the nipple before removing him or her from your breast (by gently sticking a finger in your baby’s mouth to release the suction)
    • Washing hands in between handling perineal pads and touching the breast
    • Exposing nipples to air for at least part of every day
    • Using a vitamin E ointment to soften nipples daily(Pillitteri, 2007, 670)
    Aside from thrush, Staphylococcus aureus can be transmitted from baby to mother. Since this is a nasal-oral infection in the infant, it is much more commonly found in hospital birth babies. Contrary to common belief, breastfeeding should be continued, for keeping the breast empty helps prevent the growth of bacteria (Pillitteri, 2007, 670).

    One common treatment of mastitis is with a broad-spectrum antibiotic. After about three days the infection should start to clear up however, the antibiotic should be continued until the end of the treatment. The sooner treatment is started, the sooner the symptoms will begin to fade. However, antibiotic therapy is not the only treatment for mastitis:
    • Make a rosemary (Rosmarinus officinalis) infusion: to make an infusion, add 2-4 teaspoons of fresh or dried rosemary to a cup of boiling water. Infuse (steep) for 10 minutes, then strain.
    • Make a dandelion (Taraxacum officinale) compress: boil about an ounce of minced dandelion root in two to three cups of water until only half the liquid remains; use compresses of the resulting brew.
    • Raw garlic - At least 2-3 raw cloves per day, 4-5 cloves a day if possible. Chop a clove into 5 or 6 pieces and then swallow the pieces whole like pills.
    Raw garlic acts as a broad-spectrum antibiotic, without the added antibiotic side effects of the development of antibiotic-resistant strains of bacteria, or the development of yeast infections or thrush. The antimicrobial property in garlic, allicin, is very sensitive to heat and is destroyed when cooked. In order for it to work, it needs to be raw. Swallowing the cloves with orange juice helps with the taste for some (Kellymom, 2002).

    If mastitis does not reslove after 24-48 hours using a natural way, it is time to contact a doctor for possible antibiotic therapy. If mastitis progresses to an abscess [(a large portion of the breast will rupture thought the skin, with thick, purulent drainage{aka puss} necessitating incision and drainage of the abscess)], it is now time to sustain from breastfeeding but continue to pump to keep the milk supply up while the infection is being resolved (Pillitteri, 2007, 670).

    Thrush Nipples

    Yet another possible side effect of crack nipples, as mentioned earlier, is thrush. Thrush is a Candida (aka yeast) found in the baby’s mouth. It “usually appears on the tongue and sides of the checks as white or gray patches” (Pillitteri, 2007, 697). One common sign of thrush nipples are nipples that itch. Just as thrush can enter though cracked nipples, thrush can cause tender, red, cracked nipples. Some times the baby gets this thrush from his or her mother during birth if there is a yeast infection in the birth canal. For relief of the itch, Mix 1 tablespoon white vinegar with about a cup of water. Lean over the cup and soak nipple in it for a minute or so, then stand over the sink and pour it slowly over the nipple (Kellymom, 2002). Keep in mind however that this does not treat the thrush but merely helps relieve the discomfort of itching. Because Candida is yeast, an antibiotic would not treat thrush nipples.

    Ina May Gaskin gives several tips on how to treat thrush nipples:
    1. Use 1 0r 2 percent gentian violet solution on your nipples and inside the baby’s mouth. Use a cotton swab to apply several times a day. This can be obtained without and Rx
    2. Use 1 mL of nystatin suspension by dropper into the baby’s mouth four times a day for two weeks (Gaskins, 1987, 70).
    Treat your nipples like you would any other yeast or fungal infection—think tinea pedis (aka athletes foot): air dry them, keep them dry by changing breast pads when they get wet, expose them to the sun, and boil any nipple shields or bottles that come into contact with your baby’s mouth. Remember: yeast loves a wet and warm environment.

    Low Milk Supply

    Some women have trouble with their milk supply and some claim that their breast milk “never came in”. Breastfeeding needs to begin at birth. Although the actual breast milk does not come in for three to four days after the birth, your colostrum is produced several weeks before the birth and is very nutritious for your baby. Colostrum gives passive immunities from you to your baby. Beginning breastfeeding right at birth is not beneficial for colostrums alone. Aside from the bonding reimbursement, early and frequent breastfeeding is beneficial for developing and supporting milk supply—the more often your breasts are emptied, the more efficiently they will continue to keep a sufficient milk supply. To insure that your breast is emptied as much as possible and that your infant is getting enough nutrients, it is important to keep your baby awake. Make sure your newborn is fully awake before breastfeeding. If he or she repeatedly falls asleep during feedings, it may be necessary to undress your baby and make him or her a little uncomfortable in order to keep him or her awake. If your baby does not empty your breast, you can massage your breast empty to ensure good milk production.

    Mothers that are dehydrated make less milk. It is wise to drink an 8-oz glass of water during a breastfeeding period and to stay fully hydrated. Before you pick up your baby, pour yourself a glass of water and place in next to where you plan to breastfeed.

    Aside from frequent breastfeeding and mother’s hydration, there are herbs that are lactogenic, meaning they help a woman to lactated/ produce milk; the following are some of them:
    • Alfalfa leaf
    • Anise
    • Black Tea
    • Blessed Thistle
    • Caraway
    • Commercial Lactation Teas and Tinctures
    • Cumin
    • Dandelion
    • Fennel
    • Fernugreek
    • Goat’s Rule
    • Hops
    • Marshmallow Root and Leaf
    • Nettle
    • Red Clover
    • Red Raspberry Leaf
    • Umbel Seeds
    • Valerian
    • Verbena
    Not all herbs are prepared in the same way; some are used fresh while others are used dry; some soak longer than others; and different parts of each plant are used (MOBI Motherhood International, 1998-2007)

    Flat and Inverted Nipples

    Many women mistakenly think that because they have flat or inverted nipples that they will not be able to establish an effective latch. Although it may take a little more effort, this simply is not true. Sucking on a flat or inverted nipple will draw it out and lengthen it. Some times the help of a nipple shield can get the proper suction to draw the nipple out and can be removed entirely after a few weeks. Ina May Gaskin makes the following suggestions for flat or inverted nipples:
    • Offer the baby your breast within two hours after birth
    • Keep rubber nipples away
    • Experiment with ways to make your nipples stand out, ie. pinch them, use ice
    • Squeeze milk onto the baby’s lips
    • Wait for baby to be calm if upset
    • Wear breast shields during engorgement, this will help put pressure on the nipple and cause it to pop out
    • Get your milk flowing, express a little before you offer your baby your breast
    If all else fails, continue to give your baby your rich breast milk by pumping and using a bottle.

    It is no longer as common for women to learn breastfeeding from other women as they did in the past, which has led to the misconception that breastfeeding—comes natural. Seeing a women breastfeed in public is starting to become more common, but is still not common enough. Learning to breastfeed properly can take time; the treatments above are some of the methods for resolving common problems with beginning breastfeeding; all which can eventually be prevented with a proper latch.

    References
    Breastfeeding.com (1998-2007). Latch On. Retrieved Jan 2, 2008, from Breastfeeding.com

    Gaskins, I. (1987). Babies, breastfeeding and bonding (1st ed.). Massachusetts: Bergin and Garvey.

    Kellymom (2002, 3/17/2002). Natural treatments for nursing mom's. Retrieved 12/29/07, from www.kellymom.com

    Levine, M. (2007). . Humboldt State University: Nursing Instructor.

    MOBI Motherhood International (1998-2007). Lactogenic herbs: mother nature's milk boosters. Retrieved 12/29/07, from www.mobimotherhood.org

    Pillitteri, A. (2007). Maternal & child health nursing: care of the childbearing and childrearing family (5th ed.). Philadelphia: LWW.
    Last edit by Joe V on Jan 17, '08
    RN1982, Twinkleeyes, nursemiki1, and 8 others like this.
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    HeartsOpenWide joined Jul '05 - from 'Behind the Big Sequoia Sempervirens'. Age: 33 HeartsOpenWide has '4' year(s) of experience and specializes in 'Ante-Intra-Postpartum, Post Gyne'. Posts: 3,068 Likes: 2,001; Learn more about HeartsOpenWide by visiting their allnursesPage


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    1 Comments so far...

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    Article was mostly good info, but could use some updates. Nipple should be @ the soft palate, not half way onto hard palate (ouch!)
    Withholding a bottle for 6mon is a bad idea! Bottle should be introduced around 4 wks, waiting to long could end in bottle refusal. Most moms are returning to work/school anyway before 6months when most babies can begin to use a sippy cup! Check out information from the Texas Department of health, they have a wonderful video on the "chin lead latch" this is what most IBCLCs are teaching now. Cabbage leaf use should be limited, as they can dry breastmilk if used incorrectly. Always refer patients to IBCLC if they need this intervention-for correct teaching. For engorement, breast (SHELLS) will relieve engorgement. Breast (shields) or nipple shields are different and must ALWAYS be used under the supervision of an IBCLC-as milk supply/weight gain issues may arrise! There is alot more up to date information available! Google Dr. Jack Newman-he is awsome!!
    MelodyNelson, Twinkleeyes, and jen3168 like this.


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