Breastfeeding - Potential Problems

Some women breastfeed without problems. But for many women, it is natural for minor problems to arise at first, especially if it is their first time breastfeeding. The good news is that most problems can be overcome with a little help and support. Some more serious problems may require you to see your doctor, and it is important to know the warning signs for these situations.

Here are some of the most common problems that you might face, and some solutions to overcome them.

1. Sore Nipples
2. Engorgement
3. Plugged Ducts and Breast Infection
4. Thrush
5. Nursing Strike
6. Inverted, Flat, or Very Large Nipples

Sore Nipples

Breastfeeding should not hurt. There may be some tenderness at first, but it should gradually go away as the days go by. Poor latch-on and positioning are the major causes of sore nipples because the baby is probably not getting enough of the areola into his or her mouth, and is sucking mostly on the nipple. If you have sore nipples you are more likely to postpone feedings because of the pain, but this can lead to your breasts becoming overly full or engorged, which can then lead to plugged milk ducts in the breast. If your baby is latched on correctly and sucking effectively, he/she should be able to nurse as long as he/she likes without causing any pain. Remember: if it hurts, take the baby off of your breast and try again. Ask for help if it is still painful for you.

Solution:

• Check the positioning of your baby's body and the way she latches on and sucks. To minimize soreness, your baby's mouth should be open wide with as much of the areola in his or her mouth as possible. You should find that it feels better right away once the baby is positioned correctly.
• Don't delay feedings, and try to relax so your let-down reflex comes easily. You also can hand-express a little milk before beginning the feeding so your baby doesn't clamp down harder, waiting for the milk to come.
• If your nipples are very sore, it can help to change positions each time you nurse. This puts the pressure on a different part of the nipple.
• After nursing, you can also express a few drops of milk and gently rub it on your nipples. Human milk has natural healing properties and emollients to soothe them. Also try letting your nipples air-dry after feeding, or wear a soft-cotton shirt.
• Wearing a nipple shield during nursing will not relieve sore nipples. They actually can prolong soreness by making it hard for the baby to learn to nurse without the shield.
• Avoid wearing bras or clothes that are too tight and put pressure on your nipples.
• Change nursing pads often to avoid trapping in moisture.
• Avoid using soap or ointments that contain astringents or other chemicals on your nipples. Make sure to avoid products that must be removed before nursing. Washing with clean water is all that is necessary to keep your nipples and breasts clean.
• Try rubbing pure lanolin on your nipples after breastfeeding to soothe the pain.
• Making sure you get enough rest, eating healthy foods, and getting enough fluids also can help the healing process. If you have very sore nipples, you can ask your doctor about using non-aspirin pain relievers.
• If your sore nipples last or you suddenly get sore nipples after several weeks of unpainful nursing, you could have a condition called thrush, a fungal infection that can form on your nipples from the milk. Other signs of thrush include itching, flaking and drying skin, tender or pink skin. The infection also can form in the baby's mouth from having contact with your nipples, and it appears as little white spots on the inside of the cheeks, gums, or tongue. It also can appear as a diaper rash on your baby that won't go away by using regular diaper rash ointments. If you have any of these symptoms or think you have thrush, contact your doctor and your baby's doctor, or a lactation consultant. You can get medication for your nipples and for your baby.

IMPORTANT: If you still have sore nipples after following the above tips, you may need to see someone who is trained in breastfeeding.

Engorgement

It is normal for your breasts to become larger, heavier, and a little tender when they begin making greater quantities of milk on the 2^nd to 6^th day after birth. Sometimes this fullness may turn into engorgement, when your breasts feel very hard and painful. You also may have breast swelling, tenderness, warmth, redness, throbbing and flattening of the nipple. Engorgement sometimes also causes a low-grade fever and can be confused with a breast infection. Engorgement is the result of the milk building up, and usually happens during the third to fifth day after birth. This slows circulation, and when blood and lymph move through the breasts, fluid from the blood vessels can seep into the breast tissues. All of the following can cause engorgement:

• poor latch-on or positioning
• trying to limit feeding times or infrequent feedings
• giving supplementary bottles of water, juice, formula, or breast milk
• overusing a pacifier
• changing the breastfeeding schedule to return to work or school
• the baby changes the nursing pattern by beginning to sleep through the night or breastfeed more often during one part of the day and less often at other times
• having a baby that has a weak suck who is not able to nurse effectively
• fatigue, stress, or anemia in the mother
• an overabundant milk supply
• nipple damage
• breast abnormalities

Engorgement can lead to plugged ducts or a breast infection, so it is important to try to prevent it before this happens. If treated properly, engorgement should only usually last for one to two days.

Solution:

• Minimize engorgement by making sure the baby is latched on and positioned correctly at the breast, and nurse frequently after birth. Allow the baby to nurse as long as he/she likes, as long as he/she is latched on well and sucking effectively. In the early days when your milk is coming in, you should awaken a sleepy baby every 2 to 3 hours to breastfeed. Breastfeeding often on the affected side helps to remove the milk, keep it moving freely, and prevent the breast from becoming overly full.
• Avoid supplementary bottles and overusing pacifiers.
• Try hand expressing or pumping a little milk to first soften the breast, areola, and nipple before breastfeeding, or massage the breast and apply heat.
• Cold compresses in between feedings can help ease pain. Some women use cabbage leaves to soothe engorgement. Although their effectiveness has not been proven, many women find them soothing. You can use either refrigerated or room temperature leaves. Make sure to cut a hole for your nipple, apply the leaves directly to your breasts, and wear them inside your bra. Remove them when they wilt and replace with fresh leaves.
• If you are returning to work, try to pump your milk on the same schedule that the baby breastfed at home.
• Get enough rest and proper nutrition and fluids.
• Also try to wear a well-fitting, supportive bra that is not too tight.

IMPORTANT: If your engorgement lasts for more than two days even after treating it, contact a lactation consultant.

Plugged Ducts and Breast Infection (Mastitis)

It is common for many women to have a plugged duct in the breast at some point if she breastfeeds. A plugged milk duct feels like a tender, sore, lump in the breast. It is not accompanied by a fever or other symptoms. It happens when a milk duct does not properly drain, and becomes inflamed. Then, pressure builds up behind the plug, and surrounding tissue becomes inflamed. A plugged duct usually only occurs in one breast at a time.

A breast infection (mastitis), on the other hand, is soreness or a lump in the breast that can be accompanied by a fever and/or flu-like symptoms, such as feeling run down or very achy. Some women with a breast infection also have nausea and vomiting. You also may have yellowish discharge from the nipple that looks like colostrum, or the breasts feel warm or hot to the touch and appear pink or red. A breast infection can occur when other family members have a cold or the flu, and like a plugged duct, it usually only occurs in one breast. It is not always easy to tell the difference between a breast infection and a plugged duct because both have similar symptoms and can improve within 24 to 48 hours.

Solution:

Treatment for plugged ducts and breast infections is similar, but most breast infections need to also be treated with an antibiotic.

• Soreness can be relieved by applying heat to increase circulation to the sore area and to speed its healing. You can use a heating pad or a small hot-water bottle. Cabbage leaves should not be used for a plugged duct. It also helps to massage the area, starting behind the sore spot. Use your fingers in a circular motion and massage toward the nipple.
• Breastfeed often on the affected side. This helps loosen the plug, keeps the milk moving freely, and the breast from becoming overly full. Nursing every two hours, both day and night on the affected side first can be helpful.
• Rest. Getting extra sleep or relaxing with your feet up can help speed healing. Often a plugged duct or breast infection is the first sign that a mother is doing too much and becoming overly tired.
• Wear a well-fitting supportive bra that is not too tight, since this can constrict milk ducts.
• If you do not feel better within 24 hours of trying these steps, and you have a fever or your symptoms worsen, call your doctor. You may need an antibiotic. Also, if you have a breast infection in which both breasts look affected, or there is pus or blood in the milk, red streaks near the area, or your symptoms came on severe and suddenly, see your doctor right away.
• Even if you need an antibiotic, continuing to breastfeed during treatment is best for both you and your baby. Most antibiotics will not affect your baby through your breast milk.

Thrush

Thrush (yeast) is a fungal infection that can form on your nipples or in your breast because it thrives on milk. The infection forms from an overgrowth of the candida organism. Candida usually exists in our bodies and is kept at healthy levels by the natural bacteria in our bodies. But, when the natural balance of bacteria is upset, candida can overgrow, causing an infection. Some of the things that can cause thrush include: having an overly moist environment on your skin or nipples that are sore or cracked, taking antibiotics, birth control pills or steroids, having a diet that contains large amounts of sugar or foods with yeast, having a chronic illness like HIV infection, diabetes, or anemia.

If you have sore nipples that last more than a few days even after you make sure your baby's latch and positioning is correct, or you suddenly get sore nipples after several weeks of unpainful nursing, you could have thrush. Some other signs of thrush include pink, flaky, shiny, itchy or cracked nipples, or deep pink and blistered nipples. You also could have shooting pains deep in the breast during or after feedings, or achy breasts.

The infection also can form in your baby's mouth from having contact with your nipples, and appear as little white spots on the inside of the cheeks, gums, or tongue. It also can appear as a diaper rash (small red dots around a rash) on your baby that won't go away by using regular diaper rash ointments. Many babies with thrush refuse to nurse, or are gassy or cranky.

Solution:

• If you or your baby have any of these symptoms, contact your doctor and your baby's doctor so you both can be correctly diagnosed.
• You can get medication for your nipples and for your baby. Medication for a mother is usually an ointment for the nipples, and your baby can be given a liquid medication for his/her mouth, and/or an ointment for any diaper rash.
• There are medications that have been used for years to treat thrush. More recently, though, Candida is becoming more resistant to these medicines. One of the oldest, but most effective treatments for thrush that does not require a prescription is the herbal gentian violet. It works quickly and is inexpensive. You can buy it over the counter and it is painted in the baby’s mouth and on the nipples with a clean ear swab. The downside is that it is messy and it can stain everything. Before applying it, you can undress the baby down to his or her diaper and you from your waist up. After the inside of the baby’s mouth are coated purple, you can put your baby to breast. This will transfer the gentian violet to your nipple and areola. If your nipples are not purple, you can add more gentian violet with the ear swab until they are covered. You can do this once each day for up to one week. Talk with your pediatrician if you have questions about using gentian violet on your baby.
• If you first try gentian violet and the thrush does not improve after seven days, you should contact your doctor and your baby’s doctor. He or she can give you a prescription medication. Fluconazole, ketoconazole, and itraconazole are anti-fungals that are safe for both you and your baby. Fluconazole is usually taken as a 400 milligram dose at first and then 100 milligrams twice daily for at least two weeks. Besides these treatments, you might also want to make some changes in your diet, such as increasing use of garlic and reducing or eliminating simple sugars and carbohydrates. You also can take supplements of lactobacillus and primadophilus bifidus. Talk with a lactation consultant and your doctor about the best way to treat your thrush.
• Thrush may take several weeks to cure, so it is important to try not to spread it. Don't freeze milk that you pump while you have thrush. Change disposable nursing pads often and wash any towels or clothing that come in contact with the yeast in very hot water (above 122° F).
• Wear a clean bra every day.
• Wash your hands often, and wash your baby's hands often, especially if he or she sucks on his/her fingers.
• Boil any pacifiers, bottle nipples, or toys your baby puts in his or her mouth once a day for 20 minutes to kill the thrush. After one week of treatment, discard pacifiers and nipples and buy new ones.
• Boil daily for 20 minutes all breast pump parts that touch the milk.
• Make sure other family members are free of thrush or other fungal infections. If they have symptoms, get them treatment.

Nursing Strike

A nursing strike is when your baby has been nursing well for months, then suddenly loses interest in breastfeeding and begins to refuse the breast. A nursing strike can mean several things are happening with your baby and that she or he is trying to communicate with you to let you know that something is wrong. Not all babies will react the same to different situations that can cause a nursing strike. Some will continue to breastfeed without a problem, others may just become fussy at the breast, and others will refuse the breast entirely. Some of the major causes of a nursing strike include:

• mouth pain from teething, or from a fungal infection like thrush, or a cold sore
• an ear infection, which causes pain while sucking
• pain from a certain nursing position, either from an injury on the baby's body or from soreness from an immunization
• being upset about a long separation from the mother or a major change in routine
• being distracted while nursing — becoming interested in other things around him or her
• a cold or stuffy nose that makes breathing while nursing difficult
• reduced milk supply from supplementing with bottles or overuse of a pacifier
• responding to the mother's strong reaction if the baby has bitten her
• being upset about hearing arguing or people talking in a harsh voice with other family members while nursing
• reacting to stress, overstimulation, or having been repeatedly put off when wanting to nurse.

If your baby is on a nursing strike, it is normal to feel frustrated and upset, especially if your baby is unhappy. It is important not to feel guilty or that you have done something wrong. Your breasts also may become uncomfortable as the milk builds up.

Solution:

• Try to express your milk on the same schedule as the baby used to breastfeed to avoid engorgement and plugged ducts.
• Try another feeding method temporarily to give your baby your milk, such as a cup, dropper, or spoon. Keep track of your baby's wet diapers to make sure he/she is getting enough milk (five to six per day).
• Keep offering your breast to the baby. If the baby is frustrated, stop and try again later. Try when the baby is sleeping or very sleepy.
• Try various breastfeeding positions.
• Focus on the baby with all of your attention and comfort him or her with extra touching and cuddling.
• Try nursing while rocking and in a quiet room free of distractions.

Inverted, Flat, or Very Large Nipples

Some women have nipples that naturally are inverted, or that turn inward instead of protruding, or that are flat and do not protrude. Inverted or flat nipples can sometimes make it harder to breastfeed because your baby can have a harder time latching on. But remember that for breastfeeding to work, your baby has to latch on to both the nipple and the breast, so even inverted nipples can work just fine. Very large nipples can make it hard for the baby to get enough of the areola into his or her mouth to compress the milk ducts and get enough milk.

Solution:

• Know what type of nipples you have before you have your baby, so you can be prepared in case you have a problem getting your baby to latch on correctly.
• Talk with a lactation consultant at the hospital or at a breastfeeding clinic for extra help if you have flat, inverted, or very large nipples.
• Sometimes a lactation consultant can help inverted nipples to be pulled out with a small device before your baby is brought to your breast.
• In many cases, inverted nipples will protrude more as the baby starts to latch on and as time passes. The baby’s sucking will help.
• Flat nipples cause fewer problems than inverted nipples. Good latch-on and positioning are usually enough to ensure that a baby latched to a flat nipple breastfeeds well.
• The latch for babies of mothers with very large nipples will improve with time as the baby grows. In some cases, it might take several weeks to get the baby to latch well, but if a mother has a good milk supply, her baby will get enough milk even with a poor latch