Patient education: Common breastfeeding problems (Beyond the Basics)

BREASTFEEDING PROBLEMS OVERVIEW — Breast milk is the optimal source of nutrition for virtually all babies. It meets almost all of the nutritional needs of a full-term baby until approximately six months of age, when some pureed foods are usually added to the diet. Breastfeeding has many health benefits. (See "Patient education: Deciding to breastfeed (Beyond the Basics)", section on 'Why is breastfeeding important?'.)

Although experts recommend that babies be exclusively breastfed for at least six months, many people who start out breastfeeding stop before this time. Often, people stop because common problems interfere with their ability to breastfeed. Luckily, with guidance and support as well as appropriate medical treatment when needed, it is usually possible overcome these obstacles and continue breastfeeding for a longer time.

This topic discusses common problems associated with breastfeeding and how to handle them. Other aspects of breastfeeding are discussed elsewhere. (See "Patient education: Deciding to breastfeed (Beyond the Basics)" and "Patient education: Breastfeeding guide (Beyond the Basics)" and "Patient education: Health and nutrition during breastfeeding (Beyond the Basics)" and "Patient education: Pumping breast milk (Beyond the Basics)".)

INADEQUATE MILK INTAKE — If your baby is not gaining weight well or has signs of dehydration, they may not be getting enough milk. This is not a reason to give up on breastfeeding, because, in most cases, this can be solved by figuring out the cause and some breastfeeding problem-solving.

Signs of inadequate intake — Ways of determining whether a baby is getting enough milk include:

●Baby's behaviors – You can get an idea of whether your baby is getting enough milk from how well they feed. During the first week of life, full-term babies (meaning that they were born within three weeks of their due date) generally breastfeed 8 to 12 times in 24 hours. During this first week, try to be sure that your baby feeds at least every four hours. After the first week, most babies will still wake frequently, but it's okay to let them sleep longer than four hours (unless they were born prematurely, in which case, they might need to feed more often). By four weeks after delivery, babies generally feed seven to nine times in 24 hours.

By the fifth day of life, most babies who are getting enough milk urinate six to eight times a day and have three or more bowel movements a day. Once your milk comes in, your baby's bowel movements should look pale yellow and seedy.

●Baby's weight – The most important sign of milk intake is the baby's weight. Full-term babies lose an average of 7 percent of their birth weight in the first three to five days of life. They typically get back to their birth weight within one to two weeks. Once your milk has come in (by day 3 to 5), your baby should not keep losing weight. If a baby has lost 10 percent of their weight or fails to return to their birth weight when expected, health care providers start to explore potential causes and solutions. If you weigh your baby at home, you need a digital infant scale to accurately weigh them. Remember to change the diaper first.

In some cases, the health care provider might ask you to weigh the baby before and after a feeding to see how much milk they drank. If you do this, leave the baby in the same diaper and clothes for the "before" and "after" weights (even if they wet the diaper or had a bowel movement during the feeding).

Your baby might go through periods when they seem hungrier than usual. As long as your baby is feeding well, having plenty of wet and dirty diapers and is gaining weight, they are most likely just having a growth spurt. If you keep breastfeeding frequently, your breasts will start making more milk to keep up with your baby's needs.

Causes of inadequate intake — Inadequate milk intake may be related to inadequate milk production, poor milk extraction by the baby, or a combination of these factors.

●Inadequate milk production – A common reason for inadequate milk production is not breastfeeding (or pumping) frequently enough. Frequent breastfeeding (or pumping) stimulates the breasts to make more milk. The baby might not breastfeed frequently enough because they are sleepy, separated from their mother too much, or being fed some formula (which makes them less hungry).

Less common reasons for inadequate milk production include insufficient development of the milk-producing tissue (called glandular tissue (figure 1)) during pregnancy, previous breast reduction surgery or radiation, hormonal imbalance, or certain medications that interfere with milk production. Breast augmentation surgery (breast implants) usually does not interfere with milk production.

●Poor milk extraction – Sometimes, a baby has difficulty getting the milk out of the breast even if the milk supply is adequate. This might be because they are not latching on to the breast effectively or not sucking well. This type of problem is more common in premature or slightly premature (also called "late preterm") babies. Occasionally, the baby does not feed well because of a medical problem, such as Down syndrome or tongue-tie (ankyloglossia). Many babies with ankyloglossia can breastfeed, particularly with guidance from a lactation specialist.

Management of inadequate intake

●Evaluation – If your baby has signs of inadequate milk intake, your health care provider will start with an evaluation which may include:

•Ask you about the changes in your breasts during pregnancy and after the birth and, specifically, whether you have engorgement

•Review any health problems that you or your baby have, as well as any medications you take and your relevant medical history (eg, whether you have had breast surgery or radiation in the past)

•Examine of your breasts (fullness, shape, and condition of the nipples)

•Examine the baby's mouth for signs of dehydration, any abnormalities, and/or an underlying medical problem

•Observe a breastfeeding session

●Management – In many cases, milk intake can be improved by using optimized breastfeeding techniques, including using comfortable positions (figure 2) and helping the baby latch on properly (figure 3). If you are having trouble with this, a health care provider can direct you to community resources (often a lactation consultant) for assistance. If you have a digital baby scale, your health care provider may have you check your baby's weight more frequently until you can be sure that they are feeding and growing well.

Stressful situations can interfere with milk let-down (when milk is released from the milk glands into the milk ducts (figure 1)); this makes it more difficult for the baby to extract milk. Staying calm and relaxed will help your milk flow.

Occasionally, a baby may need supplements of formula or expressed (pumped) breast milk to make sure that they are getting enough nutrition. However, in most cases, the supplements should be small and temporary while you work to increase your milk production and help the baby feed effectively. When possible, the supplemental formula should be given with a syringe, cup, spoon, or supplemental nursing system at the breast, rather than using a bottle and artificial nipple. This way, your baby won't be confused by the artificial nipple. Before starting a supplement, talk to your health care provider about whether it is necessary and how to give it to your baby safely.

Certain medications called galactagogues (or lactagogues) claim to increase milk production, but it's unclear whether these medications actually work and whether they are safe for a nursing baby, so most experts do not recommend using them. Herbal supplements to improve milk supply have also not been well studied for safety or efficacy.

NIPPLE AND BREAST PAIN — Several things can cause pain during breastfeeding. Most of these problems can be fixed, and you can continue breastfeeding.

To determine the cause of your pain, your health care provider will:

●Ask you about the pain (when it started, what makes it better or worse) and other aspects of your health including any skin conditions you have.

●Examine your nipples and breasts for signs of injury, infection, skin problems, or engorgement (which means that the breasts get overly full).

●Examine the baby for reasons that they might have difficulty breastfeeding, which include ankyloglossia (also called tongue-tie) and other mouth abnormalities.

●Observe you breastfeeding to see if the baby is latching on effectively. If the baby is not latching on properly, this can injure the nipple and also prevent the breast from emptying. This, in turn, can lead to engorgement, plugged ducts, and breast infections.

The main causes of nipple or breast pain are described below.

Nipple pain — Sore nipples are one of the most common complaints by people who are newly breastfeeding. Pain due to nipple injury needs to be distinguished from nipple sensitivity, which normally increases during pregnancy and peaks approximately four days after giving birth.

You can usually tell the difference between normal nipple sensitivity and pain caused by nipple injury based on when it happens and how it changes over time. Normal sensitivity typically subsides 30 seconds after the baby begins suckling. It also diminishes on the fourth day after giving birth and completely resolves when the baby is approximately one week old. Nipple pain caused by trauma, on the other hand, is more severe and persists or gets worse after suckling begins. Severe pain or pain that continues after the first week after birth is more likely to be due to nipple injury.

Normal nipple sensitivity — If you have some discomfort related to normal nipple sensitivity, keep in mind that this sensitivity usually goes away after the first few suckles of a feeding and stops happening after the first week or two of nursing. If you find the "pins and needles" sensation of milk let-down to be uncomfortable, rest assured that this discomfort also resolves in the first weeks of breastfeeding. If needed, you can take acetaminophen (sample brand name: Tylenol) or ibuprofen (sample brand names: Advil, Motrin) to ease your discomfort.

Nipple injury — Nipple injury usually is due to incorrect breastfeeding technique, particularly poor latch-on. Other factors that can make pain caused by injury worse include overuse of breast pads (pads inserted into the bra to absorb any leaking milk, which can keep the skin damp), use of potentially irritating products, and biting by an older baby.

Here are some things that you can do to prevent nipple injury:

●Learn how to position your baby so that the baby can latch on properly (figure 2). If you feel pain while breastfeeding, try releasing the baby's mouth from the nipple, then helping them latch on properly (figure 3). Videos that show how to latch a baby correctly are available here. If you are having trouble with this, get help from a health care provider or a lactation consultant.

●Try to keep your nipples dry and allow them to air-dry after feedings.

●Do not use harsh soaps or cleansers on your breasts.

●Avoid use or overuse of breast pads that have plastic backing.

●If your baby's mouth has any abnormalities, make sure to have them addressed as soon as possible. For example, if your baby has tongue-tie, surgery to correct it may make it easier for the baby to latch on properly.

●If your baby is biting your nipple, position the baby so that their mouth is wide open during feedings. That will make it harder to bite. Also, stick your finger between your nipple and the baby's mouth any time they bite you and firmly say "no." Then put the baby down in a safe place. The baby will learn not to bite you.

Here are some things you can do to promote healing if your nipples are already injured:

●Always start nursing with the breast that does not have the injury.

●If your nipples are cracked or raw, you can put expressed breast milk or an ointment on them, such as purified lanolin (if you are not allergic), and cover them with a nonstick pad. This will keep the injured part of your nipple from sticking to your bra. If you think that your nipple might be infected or you have a rash, see your health care provider.

●Use cool or warm compresses, if they seem to help. Avoid ice.

●Take a mild pain reliever, such as acetaminophen (sample brand name: Tylenol) or ibuprofen (sample brand names: Advil, Motrin), before feeding.

●If nipple pain prevents your baby from emptying your breasts, try using a pump or hand expression to empty your breasts. This will give your nipples a chance to heal and prevent engorgement. Use the milk you remove to feed your baby.

●Do not use vitamin E oil on your nipples. At high levels, it could be toxic to your baby.

Nipple eczema — Some people can get eczema (also called atopic dermatitis) in the nipple area. This usually causes itching or burning and a red, scaly rash (picture 1). This is more common in people who have had eczema in other locations on their body. Other things that might cause nipple eczema or make it worse are use of irritating soaps or fragrances and overuse of breast pads. Occasionally, it can be caused by an allergic reaction to creams such as lanolin or foods that your baby has eaten before breastfeeding.

If you have a rash on your nipples, talk to your health care provider. They can help decide if it is caused by eczema or some other skin condition. If the problem is eczema, it might improve by avoiding hot showers and irritants (soaps or fragrances) and keeping your nipples dry, as discussed above. Or, your health care provider might recommend applying a cream that contains a steroid to your nipples. If you are using a prescription cream, you can continue breastfeeding but should gently wipe off visible cream that was not absorbed before each feeding.

Nipple vasoconstriction — Nipple vasoconstriction is when the blood vessels in the nipple tighten and do not let enough blood through. People with this problem can have pain, burning, or numbness in their nipples in response to cold, nursing, or injury. The nipples can also turn white or blue and then pink when the blood returns.

One way to tell nipple vasoconstriction apart from other causes of nipple pain is that it can be predictably triggered by cold, while other causes of pain cannot.

To manage nipple vasoconstriction, try to keep your whole body warm and dress warmly. Also, if possible, try to breastfeed in warm conditions. It might also help to avoid nicotine and caffeine since they can make the problem worse.

Engorgement — Engorgement is the medical term for when the breasts get too full of milk. It can make your breast feel full and firm and can cause pain and tenderness. Engorgement can sometimes impair the baby's ability to latch, which makes engorgement worse because the baby cannot then empty the breast.

Here are some things you can do to prevent and deal with engorgement:

●Learn how to position your baby so that the baby can latch on properly (figure 3 and figure 2). If you are having trouble with this, get help from a health care provider or a lactation consultant.

●If the engorgement makes it hard for your baby to latch on, manually express a small amount of milk before each feeding to soften your areola and make it easier for the baby to latch on (figure 4). To do this, place your thumb and forefingers well behind your areola (close to your chest) and then compress them together and toward your nipple in a rhythmic fashion. You can also use your hand to present your nipple in a way that is easier to latch on to and to help get milk out for the baby while the baby is suckling.

●You can use a breast pump to help soften your breast before a feeding, but be careful not to do it too much. Using a pump too much will stimulate your breast to make even more milk, which will make engorgement worse.

●Apply cool compresses between feedings. You can also try taking a warm shower; this can enhance let-down and may make it easier to get milk out.

●Take a mild pain reliever, such as acetaminophen (brand name: Tylenol) or ibuprofen (brand names: Advil and Motrin).

●Wear a bra that is supportive but not too tight.

Blocked ducts — A blocked or narrowed milk duct can cause a tender or painful lump to form on the breast. If the ducts near the surface of the nipple itself are blocked, a white dot or "bleb" can form at the end of the nipple (picture 2).

Blocked ducts are caused by swelling or pressure in the affected area, which narrows the ducts so that the milk doesn't pass through easily. Things that can lead to a plugged milk duct include poor feeding technique (in particular, not varying your breastfeeding position), wearing tight clothing or an ill-fitting bra, abrupt decrease in feeding, engorgement, and infections.

Here are some things you can do to prevent and deal with a plugged duct:

●Learn how to position your baby so that the baby can latch on properly (figure 3 and figure 2). If you are having trouble with this, get help from a health care provider or a lactation consultant. Make sure to vary your position during feedings so that every part of the breast can drain. You might even try to position the baby so that their chin is near the plugged area because this positioning can help drain that area best. Do not quit breastfeeding, as this could lead to engorgement and worsen the problem. Similarly, do not try to empty the breast with frequent or prolonged pumping, because this increases milk production and can lead to engorgement. However, you can try brief gentle pumping or manually expressing some milk after feedings to improve drainage.

●Try using cold or warm compresses or taking a warm shower and then very gently massaging your breast.

●Take a mild pain reliever, such as acetaminophen (sample brand name: Tylenol) or ibuprofen (sample brand names: Advil, Motrin).

●If your blockage does not get better within two days, see your health care provider since what appears to be a blocked duct may be something more concerning.

Galactoceles — Sometimes a blocked milk duct can cause a milk-filled cyst called a galactocele to form (picture 3). Unless they are infected, galactoceles are usually painless, but they can get quite large. If necessary, a health care provider can drain a galactocele using a needle or suggest surgery if the problem is severe. If you have a persistent breast lump, be sure to see your health care provider because breast cancer can occur during lactation.

Mastitis — Mastitis is when part of the breast becomes inflamed and swollen. When this happens as a result of breastfeeding, it is called "lactational mastitis." It is most common during the first few months of breastfeeding. But it can happen at any time.

Mastitis starts out similar to engorgement, but usually affects one breast. The swelling in the breast puts pressure on the milk ducts. This causes the ducts to narrow, so milk cannot flow to the nipple as easily and the area becomes painful.

The goal of treatment is to ease discomfort and get the milk flowing again. To do this, you can try the steps listed above for relieving symptoms of engorgement (see 'Engorgement' above). In addition:

●Feed your baby when they show signs of being hungry ("feeding cues"). If milk is flowing from the breast with mastitis, you can feed your baby on that side. The milk is safe for the baby to drink.

●Hand expression is a gentle way to remove excess milk and help decrease inflammation (figure 4).

Only use a breast pump if you need to. Do not try to empty your breast completely, as this can cause your body to produce more milk and make mastitis worse.

●Avoid using nipple shields.

●Drink plenty of fluids and rest when possible.

You do not need to stop breastfeeding if you have mastitis. Regular breastfeeding is actually the best way to help with swelling and keep milk from getting blocked again.

If milk flow is blocked for more than a day or two, this can lead to bacterial infection in the breast ("bacterial mastitis"). This can cause additional symptoms like fever, aches, or fatigue. Bacterial mastitis needs treatment with antibiotics. If you have an infection, continue to breastfeed. You will not pass the infection on to your baby.

MILK OVERSUPPLY — Some people make too much milk, which paradoxically can make breastfeeding difficult. Generally, the production of milk is determined by the baby's demand, but, in this case, the supply exceeds demand. The problem begins early in lactation and is most common for people breastfeeding their first child.

For people with an oversupply of milk, the rush of the milk can be so strong that it causes the baby to choke and cough and have trouble feeding or even to bite down to clamp the nipple. Babies whose mothers make too much milk can either gain weight quickly or gain too little weight because they cannot handle the flow of milk or because they do not get the hindmilk (last part of the milk) in the breast, which has the most calories.

If you have a problem with milk oversupply, don't worry. The problem usually goes away on its own. However, tell your health care provider about it so they can check whether you have any hormonal imbalances or take any medications that could make the problems worse.

Here are some things that you can do to deal with milk oversupply:

●Nurse in an upright position – Hold your baby upright to nurse and lean back or lie on your side (figure 5 and figure 2). This will give the baby better control of the flow of milk.

●Use your fingers to reduce the flow of milk – Try putting a scissors-hold on your areola or pressing on your breast with the heel of your hand to restrict flow.

●Give the baby control – Let your baby interrupt feedings, and burp them often.

●Pump very little or not at all – Avoid pumping because it can stimulate even more milk production, but you can hand pump a little at the beginning of a feeding to relieve some of the pressure.

●Apply cold water or ice to your nipples to decrease leaking.

YEAST INFECTION — Yeast infections of the nipple or breast are poorly understood and researchers aren't sure what role they play in nipple pain.

Some health care providers diagnose yeast infections based on symptoms alone, especially:

●Breast pain out of proportion to any apparent cause

●History of vaginal yeast infections or a baby with a history of yeast infections such as thrush or diaper rash

●Shiny or flaky skin on the affected nipple

Other health care providers believe that the diagnosis should only be made if the yeast infection is proven. This can be done by seeing yeast under a microscope (looking at a skin scraping) or in a culture of breast milk.

Treatments include:

●Topical antifungals – Topical antifungals are creams or gels that contain medications called antifungal medicine, which kill yeast. If you are using any of these treatments, it's important to wipe any remaining medication that you can see off of your nipples before each feeding and reapply the medication after the feed. The antifungal medicine should be a cream or gel (the ointment form should not be used, because they contain paraffins that could be harmful to the baby).

Gentian violet was sometimes used as an antifungal, but there are some concerns about its safety and it has been removed from the market in some countries.

●Antifungal pills – If you do not get better with the options described above, your health care provider might prescribe antifungal pills for two weeks. You can continue to breastfeed while taking these pills since the typical amount of drug that makes it into breast milk is safe for breastfeeding babies. Prolonged treatment with antifungal pills is almost never necessary.

BLOODY NIPPLE DISCHARGE — Some people have bloody nipple discharge during the first days to weeks of lactation. This is more common with the first pregnancy and has been called "rusty pipe syndrome." It is thought to be caused by the increased blood flow to the breasts and ducts that happens when the body starts making milk. The color of the milk varies from pink to red or brown and generally goes away within a few days. This will not harm your baby, and you should continue breastfeeding. If you have bloody discharge for more than a week, you should see your health care provider.

WHEN TO SEEK HELP — If you are unable to breastfeed due to engorgement, pain, or difficulty latching your baby, help is available. Talk to your obstetrical or pediatric health care provider, nurse, lactation consultant, or a breastfeeding counselor.

FINDING A LACTATION CONSULTANT OR OTHER SUPPORT — Resources for finding a lactation consultant, peer support (online or in-person), and other types of support are listed in the table (table 1).

WHERE TO GET MORE INFORMATION — Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Common breastfeeding problems (The Basics)
Patient education: Mastitis (The Basics)
Patient education: Breastfeeding (The Basics)
Patient education: Weaning from breastfeeding (The Basics)
Patient education: Jaundice in babies (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Deciding to breastfeed (Beyond the Basics)
Patient education: Breastfeeding guide (Beyond the Basics)
Patient education: Health and nutrition during breastfeeding (Beyond the Basics)
Patient education: Pumping breast milk (Beyond the Basics)
Patient education: Raynaud phenomenon (Beyond the Basics)
Patient education: Constipation in infants and children (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Ankyloglossia (tongue-tie) in infants and children
Breastfeeding: Parental education and support
Common problems of breastfeeding and weaning
Lactational mastitis
Maternal nutrition during lactation
Nutrition in pregnancy: Dietary requirements and supplements
Prevention of HIV transmission during breastfeeding in resource-limited settings
The impact of breastfeeding on the development of allergic disease
Safety of infant exposure to antidepressants and benzodiazepines through breastfeeding

Websites — The following organizations also provide reliable health information:

●United States National Library of Medicine

(www.medlineplus.gov/healthtopics.html)

●Centers for Disease Control and Prevention

(www.cdc.gov/breastfeeding)

●American Academy of Pediatrics

(www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/default.aspx)

●Academy of Breastfeeding Medicine

(www.bfmed.org/protocols)

●La Leche League International

(www.llli.org/resources)

●Office on Women's Health

(www.womenshealth.gov/patient-materials/health-topic/breastfeeding)

●LactMed database – For information about which medications are compatible with breastfeeding

(www.ncbi.nlm.nih.gov/books/NBK501922)