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Management of Common Lactation

and Breastfeeding Problems 5

Lisa H. Amir and Verity H. Livingstone

Lactation is a physiologic process under neuroendo- 5.1 Prenatal Period

crine control; breastfeeding is a technical process by
which milk is transferred from the maternal breast to
Prenatal breastfeeding goals are to assist families to make
the infant. Success depends on maternal health, ade-
an informed choice about infant feeding, prepare women
quate mammogenesis, unimpeded lactogenesis, suc-
cognitively and emotionally for breastfeeding, identify
cessful galactopoiesis, effective milk transfer and
and modify risk factors to lactation and breastfeeding and
appropriate quality and quantity of daily milk intake.
offer anticipatory guidance. These goals can be achieved
Each phase of lactation and breastfeeding is inuenced
by providing prenatal breastfeeding education and by
by multiple predisposing, facilitating, or impeding
performing a prenatal lactation assessment [2, 3].
biopsychosocial factors: puberty, pregnancy, child-
birth, breast stimulation and drainage, maternal milk
ejection reex, maternal and infant breastfeeding tech-
5.1.1 Informed Choice
nique, frequency and duration of suckling and the pat-
tern of breast use. All these factors are inuenced by
other factors such as maternal knowledge, attitude, Health professionals must assist families in making an
motivation, mood and health; infant health and behav- informed decision by discussing the recommended infant
ior; and support from family, friends and healthcare feeding guidelines, including benets of breastfeeding
professionals. and the risks of breast milk substitutes [46]. The World
The concept of breastfeeding kinetics as developed Health Organization recommends exclusive breastfeed-
by Livingstone conveys the idea that there is a dynamic ing for the rst 6 months, with the introduction of com-
interaction between a breastfeeding mother and her plementary foods and continued breastfeeding for up to
infant over time [1]. Most disorders of lactation are iat- 2 years or beyond [7, 8]. Dettwyler has examined the
rogenic due to impeded establishment of lactation or relationships between age at weaning and life history
inadequate ongoing stimulation and drainage of the variables, such as length of gestation, body weight and
breast. Most breastfeeding difculties are due to the eruption of molars, among nonhuman primates [9]. She
lack of knowledge, poor technical skills or lack of sup- estimates that if humans followed primate patterns rather
port. Almost all problems are reversible. Prevention, than cultural customs, children would continued to be
early detection and management should become a rou- breastfed for somewhere between 2.5 and 7 years [9].
tine part of the maternal and child health care. Benets of Breastfeeding

To the Infant

Human milk is species specic; it is the ideal nutri-

L. H. Amir ()
tion because the protein and fat content are uniquely
Mother and Child Health Research center, La Trobe University,
Victoria, Australia suited to the needs of the infant. It also provides pro-
e-mail: tection against iron and vitamin deciencies [10].

I. Jatoi, M. Kaufmann (eds.), Management of Breast Diseases, 77

DOI: 10.1007/978-3-540-69743-5_5, Springer-Verlag Berlin Heidelberg 2010
78 L. H. Amir and V. H. Livingstone

Breast milk contains more than 100 biologically essential fatty acids known to be vital for myelination
active ingredients. It offers immunologic protection and proper brain and retinal development. Some brands
to an otherwise immunodecient neonate [11]. The of formula contain excess vitamin D [31].
enteromammary immune cycle provides specic Bacterial contaminants: Powdered infant formula
maternal antibodies to infant antigens [12]. It protects is not a sterile product [32, 33]. The most serious bac-
against otitis media, gastroenteritis, respiratory tract terial contaminant, Enterobacter sakazakii, can cause
infections, urinary tract infections, other bacterial and rare, but life-threatening neonatal meningitis, bactere-
viral diseases and necrotizing enterocolitis [1320]. mia and necrotizing enterocolitis [32, 34].
Breastfeeding provides a close interaction between Contaminants: A variety of other contaminants
mother and infant and helps the two develop a including excessive aluminum, lead and iodine have
strong, positive, emotional bond, which has long- been identied, and many brands of formula have been
term psychological advantages [21]. withdrawn due to these discoveries [3537].
The action of breastfeeding facilitates correct jaw Impaired cognitive development: Several well-con-
and dental development [22]. trolled studies have reported signicantly lower intel-
Breastfeeding may prevent overweight and obesity ligence quotient scores and poorer development in
in children and adults [19, 23, 24] and is associated children who lack breast milk in their diet [3841].
with lower blood pressure [25]. Allergies: More formula-fed infants develop atopic
dermatitis [42].
Morbidity and mortality: The added risk of bottle-
To the Mother feeding can account for 7% of infants hospitalized for
respiratory infections and, in the United States, for-
Breastfeeding provides psychological satisfaction mula fed infants have a tenfold risk of being hospital-
and close maternal bonding between mother and ized for any bacterial infection. They have more than
infant [26]. It offers a regular opportunity to sit and double the risk of contracting lower respiratory tract
relax during the often exhausting early parenting infections, and otitis media is up to 34 times more
period [27]. prevalent [43, 44]. Formula-fed infants have a higher
Women who do not breastfeed are at increased risk incidence of childhood cancers and inammatory
of developing premenopausal breast cancer [28] bowel diseases in adulthood [4547]. Formula feeding
and possibly ovarian cancer [29]. accounts for 226% of insulin-dependent diabetes
Using breastfeeding as the sole nourishment activ- mellitus in children [48, 49].
ity causes lactation amenorrhea, which is an effec- Costs: It costs approximately $1,000$2,300 to for-
tive and reliable method of contraception and child mula feed an infant for 12 months (depending on the
spacing [30]. type of formula used) [50]; therefore, many infants in
It reduces postpartum anemia. low-income families are at risk for receiving low-cost
and inappropriate alternative uids and the early intro-
To Society duction of table foods. It is also time consuming to
purchase and prepare formula. Lack of breastfeeding
Breast milk is a natural resource that is replenished results in increased healthcare costs [51, 52].
and does not leave waste.
The future of a society depends on the health of its
children. 5.1.2 Prenatal Education
Breastfeeding is the most health-promoting, disease-
preventing and cost-effective activity mothers can do.
Breastfeeding is a learned skill that should be taught
prenatally; physicians can use models in their ofces The Hazards of Infant Formula to help reinforce the learning process [53]. Industry-
developed literature on infant feeding should not be
Inadequate nutrition: Infant formula may contain distributed because it gives mixed messages to breast-
inadequate or excessive micronutrients. They lack feeding families [54].
5 Management of Common Lactation and Breastfeeding Problems 79

5.1.3 Prenatal Lactation Assessment Complications of pregnancy such as gestational

diabetes, pregnancy-induced hypertension and pre-
term labor may result in early maternal infant sepa-
Lactation is essential for the survival of most mamma-
ration, which can interfere with the initiation of
lian species and can be considered the nal stage of the
lactation. Antenatal expression of colostrum may
reproductive cycle. Mammogenesis begins in the
be useful when potential neonatal hypoglycemia is
embryo and continues throughout life, with active
anticipated [62].
growth phases during puberty and pregnancy. It is con-
Maternal infections such as hepatitis B and C,
trolled by a complex hormonal milieu. Clinical signs of
human immunodeciency virus (HIV) or cytomeg-
successful mammogenesis are breast growth, increased
alovirus may be transmitted to the infant in utero,
breast sensitivity and the excretion of a colostrum-like
but the added viral load through breast milk is prob-
uid by the end of pregnancy (lactogenesis I [55]).
ably clinically insignicant [63]. In industrial coun-
Failure of mammogenesis presents clinically as a lack
tries, it would seem prudent to advise HIV-positive
of or an abnormality in breast growth and development
women not to breastfeed [64].
during puberty or pregnancy.
Women who use illicit drugs, such as amphet-
amines, cocaine or heroin should be informed about
the risks and counseled about abstinence [65]. If the Screening for Risk Factors use continues, the women should be advised not to
breastfeed. Maternal smoking is not advisable;
During the prenatal period, physicians have an oppor- however, the risks of smoking and articial feeding
tunity to screen women for certain biological, psycho- are greater than the risks of smoking and breast-
logical and social risk factors that might interfere with feeding [66, 67]. Breastfeeding should therefore be
mammogenesis, successful lactation or breastfeeding. recommended in spite of smoking. Moderate use of
A formal prenatal lactation assessment should be per- alcohol should not be a contraindication to breast-
formed in the third trimester as a routine component of feeding [65].
antenatal care for all women. A previous unsuccessful breastfeeding experience
may herald future problems.
Previous or chronic psychiatric disorders, including
Maternal Biological Risk Factors depression, may recur in the postpartum period and
for Successful Lactation interfere with maternal parenting abilities. These
mothers need extra help during the early postpartum
Anatomically abnormal breasts, including hypoplas- period.
tic or conical breasts, may never lactate adequately
because of insufcient glandular development asso-
ciated with failure of mammogenesis [56, 57]. Infant Biological Risk Factors
Breast surgery, in particular reduction mammo- for Successful Lactation
plasty, may interfere with glandular or lactiferous
duct function [58, 59]. Several infant factors interfere with the establishment
Certain endocrinopathies, including thyroid, pitu- of lactation and breastfeeding. These include neonatal
itary and ovarian dysfunction and relative infertil- illness, which necessitates early maternal/infant sepa-
ity, may interfere with lactation [60, 61]. ration, and sucking, swallowing or breathing disor-
Chronic maternal illnesses, such as diabetes melli- ders. Some factors can be identied or predicted
tus, systemic lupus erythematosus and hyperten- prenatally.
sion, may cause maternal fatigue but usually do not
affect lactation.
Women with physical disabilities usually can Psychological Risk Factors
breastfeed, but they may have to be given guidance
and assistance with regard to safe, alternative nurs- There is interplay between the many forces that inu-
ing positions. ence a womans choice of feeding methods [6870].
80 L. H. Amir and V. H. Livingstone

Beliefs: Many women have preconceived ideas Prenatal Breast Examination
about feeding their infants. They may have anxieties
and concerns over their ability to breastfeed, they may After reviewing the womans history, a careful breast
believe their breasts are too small or their nipples too examination should be performed.
large, or they may fear the consequences of altered
breast appearance. They may have had previous unsuc-
cessful breastfeeding experiences or family members
Size and Symmetry
who offer negative advice. It is important to clarify
beliefs surrounding breastfeeding.
It is not until pregnancy that the full maturation of the
Attitudes: The physician should explore the wom-
mammary glands occurs. Lactogenic hormones, includ-
ans attitudes toward breastfeeding, returning to work
ing estrogen, progesterone, prolactin, insulin, thyroid
and breastfeeding in public. Prenatal exploration of
and growth hormones, trigger the development of the
these areas helps families start addressing their own
mammary epithelial cells, acinar glands and lactiferous
ducts. By 16 weeks of gestation, lactation can occur.
Knowledge and skills: The physician should explore
The breasts usually enlarge by at least one bra cup size
the womans knowledge by asking what she knows
or about 200 mL during pregnancy or in the rst month
about infant feeding and how she is planning to feed
postpartum [74, 75]. Variations in breast appearance or
her infant.
asymmetry may indicate lactation insufciency and
therefore should be noted; future milk synthesis should
be closely monitored. Scars give clues to potential
Social Risk Factors
glandular, ductal or nerve disruption.
Women are more likely to succeed in breastfeeding if
they have support from their family and friends. In the
prenatal phase, the goal is to help to foster a positive Nipple Graspability
emotional environment among family, friends and
community. For infants to latch and suckle effectively, they should
Family support: Throughout history, women have be able to grasp the nipple and areola tissue and form a
been supported in their decision to breastfeed by grand- teat. The areola can be gently pinched to assess its
mothers, sisters, close friends or doulas. Nowadays, elasticity and graspability. Nipples may protrude,
with the disintegration of the traditional family, lack of pseudoprotrude, remain at, pseudoinvert or truly
support often culminates in abandonment of breast- invert. They may be large or small. There is no evi-
feeding [71, 72]. dence to support nipple preparation such as nipple
Peer support: Single teenaged mothers experience stretching exercises or the use of nipple shells because
considerable peer pressure to continue the carefree life the anatomy of the nipple and areola is not altered by
of youth, and they may opt for the perceived freedom prenatal exercises [76]. The action of sucking by the
of bottle-feeding rather than the commitment to breast- infant helps to thaw out the nipple and form a teat dur-
feeding. Peer support programs have been shown to be ing the process of breastfeeding. It is only true inverted
an effective way of helping to increase the duration of nipples that may impede correct latching and suckling.
breastfeeding [73]. The Nipplette (Avent, Suffolk, England) was designed
Community support: Many women are embar- to help correct inverted nipples prenatally [77]. Cutting
rassed about breastfeeding in public. A prenatal dis- off the needle end of a 20-mL syringe and reversing
cussion around the issue of breastfeeding in public the plunger can make a simplied version [78]. The
may help. Employment outside the home need not be ange end of the syringe can be placed over the nipple
a reason for stopping breastfeeding; planning, exi- and gentle suction applied to draw out the nipple
bility and good child care can support a mother slowly. There are no data to conrm that the syringe
to maintain lactation during prolonged hours of works, but clinical experience suggests that it may
separation. be useful in helping to make the nipple area more
5 Management of Common Lactation and Breastfeeding Problems 81

graspable [78]. There is no need to apply lotions or oils with articial foods. The immature gut is not
to the breasts to soften the skin, and normal daily bath- designed to digest cow milk or soya milk [92].
ing with soap is recommended. Review the availability of community resources
postpartum; close follow-up in the postpartum
period is crucial for successful breastfeeding [4]. Anticipatory Guidance

After completing a careful history and physical exami-

nation, the following anticipatory guidance should be
offered. 5.2 Intrapartum Period
Avoid medicated or interventional labor. Soon after
natural childbirth, infants exhibit an instinctive 5.2.1 Establishing Lactation
rooting behavior to locate and latch onto the breast.
Medications and complications of childbirth may Breastfeeding should be considered the fourth stage of
interfere with this neurodevelopmental behavior labor; childbirth is not complete until the infant is
[79, 80]. latched on to the breast and suckling, thus triggering
Initiate breastfeeding or breast pumping as soon as lactogenesis. Soon after delivery, neonates exhibit a
possible following complete delivery of the pla- natural locating reex and can nd the nipple them-
centa because it is thought that early breast stimula- selves, if permitted. Once the nipple is located, they
tion initiates lactation [27, 81], although evidence is root, latch onto it, and suckle instinctively. Studies
conicting [75]. have shown that this process may take 60120 min and
Breastfeed or pump on demand, every 23 h because that the locating and suckling instinct can be impaired
regular breast drainage and stimulation facilitates if foreign objects are inserted into neonates mouths
lactogenesis [82, 83]. soon after birth or if the infant is sedated secondarily to
Practice rooming and bedding in for 24 h per day. maternal medication [93, 94].
Maternal-infant separation impedes regular breast Early suckling is crucial for four reasons. Firstly, it
drainage and stimulation [8486]. allows an imprinting to occur as the neonate learns to
Combined mother and infant nursing care facilitates grasp and shape a teat and suckle effectively while the
patient-centered teaching [87]. nipple and areola are still soft and easily grasped.
Relieve engorgement early to prevent involutional Secondly, the neonate ingests a small amount of colos-
atrophy of lactocytes [88]. trum, which has a high content of maternal secretary
Avoid routine supplementation because it causes IgA, which acts as the rst immunization to the
breast confusion by removing an infants hunger immuno-immature neonate. Thirdly, following partu-
drive, thereby decreasing breast stimulation and rition and the delivery of an intact placenta, the inhibi-
drainage [89, 90]. tory effects of the hormones of pregnancy are removed,
Avoid rubber nipples and paciers. If infants are and the prolactin receptors in the mammary gland
demonstrating hunger cues by sucking, they are become responsive. Lastly, early suckling stimulates
hungry. Offering a pacier is not an appropriate the release of lactotrophs, including prolactins, which
maternal response to these infants cues. The infant trigger the onset of milk synthesis. Frequent episodes
should suckle on the breast frequently to establish of breast stimulation cause surges of prolactin, which
successful lactation [81, 91]. maintain lactogenesis. Clinical signs of successful lac-
Exclusive breastfeeding ensures that the infant togenesis are fullness of the breasts postpartum with
receives adequate colostrum, including secretary the production of colostrum initially and then a gradual
immunoglobulin A (IgA) and other unique hormonal change to transitional milk and mature milk within
factors that contribute to the infants health, growth about 3648 h [95].
and development [12]. Galactopoiesis is the process of ongoing milk syn-
Avoid formula because it predisposes the neonate to thesis. It follows successful mammogenesis and unim-
potential allergies and other risk factors associated peded lactogenesis. The rate of milk synthesis varies
82 L. H. Amir and V. H. Livingstone

Fig. 5.1 Ten steps to Every facility providing maternity services and care for newborn infants should:
Successful Breastfeeding 1. Have a written breastfeeding policy that is routinely communicated to all health care staff
2. Train all health care staff in skills necessary to implement this policy.
3. Inform all pregnant women about the benefits and management of breastfeeding.
4. Help mothers initiate breastfeeding within a half hour of birth.
5. Show mothers how to breastfeed and how to maintain lactation even if they should be separated
from their infants.
6. Give newborn infants no food or drink other than breast milk, unless medically indicated.
7. Practice rooming in - allow mothers and infants to remain together 24 hours a day.
8. Encourage breastfeeding on demand.
9. Give no artificial teats or pacifiers (also called dummies or soothers) to breastfeeding infants.
10. Foster the establishment of breastfeeding support groups and refer mothers to them on discharge
from the hospital or clinic.

throughout the day and between mothers. It is con- breastfeeding to begin. Neonates instinctively know
trolled by regular and complete drainage and is pri- how to locate the breast and suckle, but mothers must
marily an autocrine (i.e., local) action. Recent studies be taught.
suggest that ongoing milk synthesis is inhibited by the The World Health Organization and the United
buildup of local suppressor peptide called feedback Nations Childrens Fund recognized the importance of
inhibitor of lactation (FIL) [96]; regular suckling successful establishment of breastfeeding in the hospi-
removes this inhibition [97, 98]. Prolactin surges stim- tal, and they launched the global Baby Friendly Hospital
ulate the breast alveoli to actively secrete milk, and Initiative in 1992. This is an educational quality assur-
oxytocin causes the myoepithelial cells surrounding ance program for hospitals based on the joint statement
the glands and the ductules to contract and eject milk Protecting, Supporting and Promoting Breastfeeding
down the ducts to the nipples. These contractions The Special Role of Maternity Services, which outlines
effectively squeeze the fat globules across the cell ten simple steps designed to protect these delicate physi-
membrane into the ducts. As a feed progresses, the ologic processes [103] (Fig. 5.1).
quality and quantity of milk produced change. The
fore milk, at the beginning of the feed, is composed
mainly of milk that has collected between feeds, and it
has lower fat and higher whey content than hind milk. 5.2.3 Factors that Interfere
The fat content increases as the degree of breast full- with Lactation
ness decreases [99]. Serum prolactin levels should
increase several-fold following suckling; lack of a pro- Insufcient maternal milk is the most common reason
lactin response may be signicant. Prolactin levels fall given for stopping breastfeeding in the early weeks.
over the rst 46 weeks, and the suckling-induced pro- The cause is often iatrogenic resulting from misman-
lactin surges are markedly reduced by 3 months, virtu- agement during the critical early phase. Many mater-
ally disappearing by 6 months, and yet lactation can nal and infant factors contribute to lactation failure,
continue [100, 101]. Current understanding is that the including premammary gland, mammary gland, and
requirement of blood prolactin for lactation is permis- postmammary gland causes.
sive rather than regulatory [102]. Failure of Mammogenesis

5.2.2 Factors that Help to Establish
In the normal course of events, mammogenesis begins
Lactation in the embryo and continues throughout life with
active growth phases during puberty and pregnancy.
Following childbirth, mothers and neonates should Mammogenesis is controlled by a complex hormonal
remain together, skin to skin, to allow the process of milieu that cannot be covered in depth in this chapter.
5 Management of Common Lactation and Breastfeeding Problems 83

The hormones involved include the pituitary hormones: of the pituitary gland via prolactin and other lactogenic
prolactin, adrenocorticotropic hormone, growth hor- hormones. The decline of placental hormones, particu-
mone, thyrotropin, follicle-stimulating hormone and larly progesterone, following delivery of an intact pla-
luteinizing hormone. In addition, steroid hormones centa, associated with early and frequent suckling, are
from the ovary, adrenal glands and placenta, plus thy- the major triggers to establishing milk synthesis.
roid hormones and insulin, contribute to mammary Clinical evidence of lactogenesis II is an increase in
growth and function either directly or indirectly [75]. breast size, which occurs about 60 h postpartum, but
Failure of mammogenesis presents clinically as a can range between 24 and 102 h after birth [108].
lack of, or an abnormality in, breast growth and develop- Failure of lactogenesis presents clinically as lack of
ment during puberty, adulthood or pregnancy and may breast engorgement and lack of colostrum production.
be due to any or a combination of the following factors:

Preglandular Failure
Preglandular causes of failure of lactogenesis include
The most common cause of premammary glandular an intrinsic lack of lactogenic hormones, biologically
failure is a deciency of mammary growth stimulating inactive lactogens or lactogenic antibodies [109]. In
hormones, but other possibilities include the presence addition to the pituitary and hypothalamic pathologies,
of biologically inactive hormones or antibodies to the factors predisposing to a reduction in pituitary hor-
hormones preventing their normal action [104]. mone production in the postpartum period, in particu-
Pathological conditions associated with disrupted pro- lar prolactin, include drugs such as bromocriptine and
duction can be hypothalamic or pituitary in origin. retained placental fragments [110]. The latter demon-
Destruction of the hypothalamus can occur as a result strates the inhibitory effect of estrogen and progester-
of encephalitis, inltration of tumor following lym- one on the initiation of lactogenesis.
phocytic hypophysitis, or idiopathic causes [105].
Pituitary causes include space-occupying lesions,
hyperplasia, empty sella syndrome, acromegaly, pitu- Glandular
itary stalk section, and Sheehan syndrome [106]. A
pregnancy-specic mammary nuclear factor (PMF) Glandular causes include a lack of mammary gland
has been identied, which is stimulated by progester- responsiveness to lactogenic hormones, including
one. PMF may suppress genes involved in mammary plasma membrane receptor decits or faulty gene tran-
gland development [107]. scription [111].

Glandular Failure Postglandular

Glandular failure is dened as lack of mammary gland Postglandular causes relate to a delay in the initiation
response to normal lactogens during pregnancy. A of breastfeeding. The length of delay that becomes sig-
PMF imbalance or end-organ receptor failure, such as nicant has not been claried, but it undoubtedly plays
estrogen or prolactin mammary gland receptor decits, a role. Unlimited access to the breast increases milk
may occur. The regulatory factors involved in the intake and infant growth in the rst 2 weeks [112]. The
development of the myoepithelial cells prior to lacta- use of supplementary feeding with formula, which is
tion are not well understood. routine in some hospitals, may have a detrimental effect
on milk synthesis in a mother who planned exclusively
to breastfeed after hospital discharge [113]. Unrelieved Failure of Lactogenesis engorgement is also recognized as having a negative
feedback effect on milk synthesis. This condition may
Lactogenesis II, or the onset of copious milk secretion, be due to the buildup of inhibitor factors in the milk or
occurs close to parturition. It is under endocrine control to pressure effects by the milk volume.
84 L. H. Amir and V. H. Livingstone Failure of Galactopoiesis intraductal ow of milk and reduces circulation, rap-

idly causing pressure atrophy at the alveoli and inhibit-
The action of many hormones is involved in the main- ing the establishment of a good milk supply. Impairment
tenance of lactation. Failure of galactopoiesis presents to milk drainage as a result of lactiferous duct outlet
clinically as lack of copious milk production. Causes obstruction also may occur following mammoplasty or
of failure of galactopoiesis include the following: surgical reconstruction of the breast, although newer
surgical techniques attempt to maintain the integrity of
the lactiferous ducts [59, 116, 117]. Neifert et al. found
Preglandular a threefold increase in the risk of lactation insuf-
ciency in women who had undergone breast surgery
An intrinsic lack of lactogenic hormones is one cause. compared to women without surgery [58]. Where there
Contributing factors to reduced milk synthesis include was a periareolar incision, the risk was 5 times greater
certain drugs (e.g., estrogen-containing contraceptives, than when there was no history of breast surgery [58].
pseudoephedrine [114]), heavy smoking or superim- Breast fullness or engorgement may prevent infants
posed pregnancy. from latching effectively. This leads to sore nipples,
caused by tongue trauma, inadequate breast stimula-
tion, drainage and insufcient milk intake by the infant.
Glandular If the breast milk intake is low, the infant remains hun-
gry and may receive formula supplement and become
Glandular causes include unresponsiveness to lacto- satiated. The net result is milk retention, impeded lac-
genic hormones or secondary to failure of mammogen- togenesis and maternal unhappiness. Hot compresses
esis or lactogenesis. and manual expression of milk before latching helps to
improve the attachment, and cold compresses reduce
swelling after feeds [118, 119].
Postglandular The uid requirements of healthy newborn infants
are minimal for the rst few days. Neonates drink
The most common cause of lactation failure is a delay 720 mL of colostrum per feed initially, and they do
in early and frequent breast simulation and inadequate not require extra uids. Prelacteal and complementary
drainage, which commonly occurs when mothers and feeds may upset the process of lactogenesis by remov-
infants are separated because of existing or anticipated ing the neonates hunger drive and decreasing the fre-
health problems. Newborns usually suckle effectively quency of breast stimulation and drainage [90, 120].
when they are positioned appropriately at the breast; Night sedation may offer a temporary respite, but the
however, the maternal physiological ability to lactate lack of breastfeeding at night can impede lactogenesis
rapidly declines if both breasts are not stimulated because of irregular breast stimulation and drainage.
quickly following parturition and drained every 2 or If frequent efcient breastfeeding is not possible, for
3 h. There is a window for the initiation of lactation, example, if a mother is separated from her sick infant,
and studies have shown that the duration of lactation she should be shown how to express her milk regularly,
correlates inversely with the time of the rst breast either by hand or by using a breast pump, to ensure com-
stimulation. The extrinsic lack of prolactin surges fail plete breast drainage and prevent milk stasis. Contrary
to trigger and maintain lactation [115]. to popular belief, this does not lead to an excessive milk
Inadequate drainage as a result of infrequent suck- synthesis but prevents early and irreversible involution.
ling or ineffective breastfeeding techniques leads to Mothers should pump at least 6 times daily [121].
the lack of removal of the milk and a buildup of local
inhibitor factors in the retained milk, which shuts down
ongoing milk synthesis. Involution of the glands com-
mences, leading to premature weaning. After delivery, 5.2.4 Milk Transfer
there is considerable vascular and lymphatic conges-
tion in the breast tissue, leading to a rise in interductal Milk is transferred from the breast by the infant during
pressure. If unrelieved, the engorgement impedes the breastfeeding, in combination with the maternal milk
5 Management of Common Lactation and Breastfeeding Problems 85

ejection reex. The rate of transfer of milk from the

breast to the infant depends on various factors, includ-
ing milk synthesis and the volume of pooled milk, the
strength and frequency of the milk ejection reex, and Midline Straight from tip to toe
the technical process of breastfeeding [122]. The milk
ejection reex, or letdown, is stimulated by oxytocin Mother provides shoulder girdle stability
released from the posterior pituitary following direct
nipple stimulation and via hypothalamic triggering. It Mother positions baby snugly against her body &
causes smooth-muscle contractions and propels milk Rebecca Glover
through the ducts and out of the nipple pores. The
character of the reex varies between women and over Fig. 5.2 A positionally stable baby (from [126], used with
time; some mothers have a well-developed letdown,
whereas others have a slow, irregular reex. With con-
ditioning, oxytocin release occurs in response to infant
crying or as the mother prepares to feed [100]. and opening the mouth wide. This often requires
Condence facilitates the ejection reex and anxiety teasing the baby and encouraging the mouth to
may impede it [123, 124]. open wider than before. When the mother can see the
gaping mouth, she should quickly draw the baby for-
ward over the nipple and onto areola tissue. The Factors that Help Milk Transfer babys bottom lip, jaw and chin sink into the breast
rst, so that he takes a good mouthful of breast [126].
Basic Breastfeeding Skills The amount of areola available to the mouth depends
on the size of the areola and on the neonates gape. It
Breastfeeding is a technical process of transferring is incorrect to assume that all the areola tissue should
milk from the breast. It depends on careful positioning be covered. The lips should be everted or anged and
and attachment of the infant to the breast and on an placed well behind the nipple base. The chin is
intact suckling ability of the infant. Parenting starts at extended into the breast and the nose is adjacent to it.
birth; therefore, hospital staff should encourage moth- Young infants do not have the ability to maintain their
ers to assume this role as soon as possible. Mothers position at the breast alone, and so the mother must
should be shown how to breastfeed [87, 125]. continue to sandwich her breast and support the
Positioning. The mother should be sitting comfort- infants back and shoulders throughout the duration
ably with her arms and back supported and her feet of the feed. Older infants are able to latch and main-
raised on a small stool. The infant should be placed on tain themselves more easily and suckle comfortably
her lap, facing the uncovered breast; a pillow may help in an elbow crook.
raise up the baby. The infants body should be well Suckling. An infant who is correctly latched and has
supported and straight, with the infant snug against her a mouthful of soft breast tissue will draw the nipple
body [126] (Fig. 5.2). Breastfeeding is easier if two and the areola tissue to the junction of the hard and soft
hands are used to start with. The breast should be palate to form a teat and then will initiate suckling.
cupped with one hand underneath using the thumb and The more elastic and extensible the breast tissue, the
ngers to shape the breast to form an oval that matches easier it is for the young infant. A xed, retracted or
the shape of the mouth, lifting the breast up slightly engorged nipple and areola tissue make it harder for
while directing the nipple toward the infants mouth. this to occur. The jaw is raised and the gums compress
The other hand is used to support the infants back and the breast tissue; the tongue protrudes over the lower
shoulders. The infants arms should be free to embrace gums, grooves and undulates in a coordinated manner.
the breast and the body held very close to the mother, The cheeks and tongue help to form a bolus of milk.
stomach to stomach. The jaw lowers, and the soft palate elevates to close the
Attachment. The latching technique involves nasopharynx; a slight negative pressure is created, and
brushing the nipple against the infants upper lip and the milk is effectively transferred and swallowed in a
waiting until the infant roots, lifting his or her head coordinated manner [127, 128] (Fig. 5.3).
86 L. H. Amir and V. H. Livingstone

resulting in sore nipples and ineffective milk transfer.

Babys suction Retrognathia, cleft lip or palate, an uncoordinated,
creates a vacuum; weak, utter, or a bunched-up tongue may interfere
this latches the with effective sucking dynamics, often because the jaw
breast in babys
mouth until baby
Junction of fails to compress the breast or the tongue and cheeks
Hard & Soft Palate
releases the are unable to create the necessary negative pressure to
suction at the draw in the milk [129]. These infants may benet from
end of the feed. Soft Palate
Tongue suck training, but clinical experience suggests that as
the mandible elongates and facial muscles strengthen,
the dynamics of sucking improve naturally [130].
Esophagus Ankyloglossia (tongue-tie) is an important cause of
suckling difculties. The tethered tongue is unable to
protrude over the gum and cannot move upward; the
Fig. 5.3 The essential mouthful (from [126], used with
teat is not stripped correctly, and less milk is trans-
permission) ferred. The nipple often becomes traumatized and sore.
The infant may not thrive, and milk production
decreases because of inadequate drainage. A simple Factors Impeding Milk Transfer surgical release of the frenulum is required and should
be done as soon as possible when clinically indicated;
The milk ejection reex is a primitive one and is not after a few weeks, it is often difcult to alter the way
easily blocked. The effects of adrenaline can reduce it these infants suckle [131133]. Recently, a posterior
temporarily if the mother is subjected to sudden tongue-tie has been recognized as a cause of nipple
unpleasant or extremely painful physical or psycho- pain [134]. In addition to restricted tongue movement
logical stimuli. This could include embarrassment or and elevation, palpation of resistance at the base of the
fear, inducing a stress reaction with the release of tongue indicates a posterior tongue-tie [135].
adrenaline, which can cause vasoconstriction and
impede the action of oxytocin. Over time, however,
this inhibition seems to be overcome. The strength and
frequency of the ejection reex depend on hypophysial 5.2.5 Milk Intake
stimulation of the posterior pituitary and suckling pres-
sure on the lactiferous ducts, causing oxytocin release.
Over the rst few days, the infant drinks small vol-
The more milk that has pooled between feeds, the more
umes of colostrum of 720 mL per feed. This rapidly
is ejected with the initial let down [100, 123].
increases to approximately 760840 mL/day, with
Inefcient milk transfer may be the result of poor
approximately seven or eight feeding episodes. The
maternal breastfeeding technique in positioning the
milk intake per feed is about 80120 mL. Breasts have
infant at the breast or in facilitating his or her attach-
a great capacity to yield milk and can produce double
ment because of a lack of knowledge or maternal
this amount. If necessary, a woman can feed from one
or infant physical disabilities. In addition, improper
breast exclusively [136].
positioning and attachment lead to decreased breast
stimulation and inadequate drainage, which result in
decreased milk production and decreased milk intake.
Simple correction of the position and latch is often Frequency
the only remedy needed to improve the quality of the
feed. Infants are able to recognize hunger and should be fed
Inefcient milk transfer also may result from poor according to their cues. Most newborns breastfeed
neonate suckling technique either because of an inabil- every 23 h, causing frequent surges of prolactin,
ity to grasp the nipple correctly or because of a suck, which help to ensure full lactation. Mothers who have
swallow or breath disorder. Large, well-dened nipples a low milk supply should be encouraged to breastfeed
may entice the neonate to suckle directly on the nipple, frequently to ensure good drainage and stimulation.
5 Management of Common Lactation and Breastfeeding Problems 87 Duration Factors that Impair Milk Intake

Studies show that the duration of a breastfeed varies A happy to starve infant that sleeps for long periods
between mother-infant pairs [137]. The rate of milk may fail to thrive because of inadequate daily milk
transfer is not uniform. Some breastfeeding pairs have intake. A pause in feeding after a few minutes of sucking
a rapid milk transfer and, hence, a very short feed. This may be interpreted incorrectly as the infant having had
is because of the large amount of milk that has col- enough, leading to early termination of the feed. A cry-
lected in the breasts since the previous feed and the ing, discontented infant may be given a pacier to pro-
well-established milk ejection reex. Others have long long the time between feeds. A mother also may be under
feeds because milk ejection is poor, the breastfeeding the impression that only one breast should be used at
technique is relatively ineffective, or milk production each feed and choose not to feed off the second side even
is slow and the pooled milk volume is low, which con- though the neonate is still hungry. Newborns frequently
sequently leads to a slowed milk transfer. Previously pause while feeding, and these episodes may last several
held beliefs that most of the feed is taken in the rst minutes. Problems arise when a mother terminates a feed
few minutes or that both breasts should be used at each or switches to the other side prematurely because this
feed fail to recognize the uniqueness of each nursing alters the quality and quantity of the milk consumed.

5.2.6 Maternal Psychosocial Health Pattern of Breast Use
The psychological and social health of the mother is
The quality and quantity of milk intake depend on the
crucial throughout all stages of breastfeeding. A
pattern of breast use. Between feeds, milk is synthe-
mother who is ambivalent about breastfeeding and
sized and collects in the lactiferous ducts. This low-fat
who lacks support may allow her infant fewer chances
milk is readily available at the start of each feed. As the
to suckle, thereby inhibiting lactogenesis and galac-
feed progresses, the volume of milk the infant drinks
topoiesis. A mother who lacks condence or knowl-
will decrease, but the quality increases as more fat is
edge may interpret any breastfeeding infant problem
passed into the milk. The infant should remain at the
as being due to insufcient milk; a consequent move to
rst breast until the rate of ow of milk is no longer
bottle-feeding compounds the problem. Lack of sup-
sufcient to satisfy the infant. The second breast should
port from family and friends can negatively inuence
then be offered.
her endeavors [72, 138]. Factors that Help Milk Intake

5.2.7 In-hospital Risk Assessment
To establish lactation, both breasts should be offered
at each feed. The removal of colostrum facilitates Some mothers and infants are at high risk for lactation
ongoing lactogenesis. When lactation is well estab- and breastfeeding difculties. As discussed previously,
lished, the rst breast should be comfortably drained several biopsychosocial risk factors can be identied
before switching to the second. This will prevent milk prenatally, and this information should be readily avail-
stasis and results in a balanced milk production and able in hospitals. A routine in-hospital breastfeeding
optimum infant growth. Mothers with a high milk risk assessment should be performed [139] (Fig. 5.4).
yield may feed unilaterally, whereas mothers with a Newborns often lose weight within the rst few
slow rate of milk synthesis should feed bilaterally. days as the result of normal physiologic uid losses
When the rate of milk transfer is rapid, the infant may [140]. If breastfeeding is successfully established, this
gag, choke and pull away from the breast; frequent weight loss should be no greater than about 7%.
burping is recommended in this situation, as is man- Excessive weight loss may imply inadequate food
ual expression of some milk before attaching the intake and deserves a detailed clinical breastfeeding
infant. assessment. The underlying cause is usually easy to
88 L. H. Amir and V. H. Livingstone

Fig. 5.4 In-hospital SCREEN FOR KNOWN

breastfeeding assessment LACTATION AND
(Attending physician and/or RN)


1. How to establish breastfeeding
2. Teach basic breastfeeding skills
3. Monitor infant weight gain carefully


Infant weight loss less Infant weight loss less

Infant weight loss
than 7% and good than 7% but poor
more than 7%
breastfeeding skills breastfeeding skills

1. Alert attending 1. Consider

physician extended hospital
2. Consider extended stay
hospital stay Success: 2. Consider referral
3. Consider referral to 1. Routine ward care to lactation
lactation consultant 2. Follow Ten Steps consultant

Perform Clinical
Breastfeeding Assessment
Rule out:
1. insufficient milk synthesis
2. inefficient milk removal
3. inadequate milk intake
1. increase milk synthesis HOSPITAL DISCHARGE
2. improve milk removal PLANNING
3. increase milk intake

elucidate and management can be directed toward actual problems. All mothers should be taught the
either increasing the rate of maternal milk synthesis, signs that their baby is breastfeeding well and instructed
improving milk transfer or increasing the daily quan- to call for advice if they have concerns (Fig. 5.5). If an
tity or quality of milk intake [1, 141]. infant has lost more than 7% of his or her birth weight
If the neonates weight continues to fall, additional at the scheduled hospital discharge, or if the mother-
calories must be provided either as the mothers own infant pair has known risk factors for breastfeeding
breast milk, pasteurized donor breast milk or formula. difculties, a delayed discharge or early community
Some neonates have preexisting difculties grasping follow-up for breastfeeding assistance would be appro-
and suckling at the breast. In these situations, wide- priate. All other mothers and infants should be reas-
based rubber nipples and thin silicone nipple shields sessed within 1 week of birth [142].
are useful suck training devices that encourage normal
biomechanical jaw excursions.
5.3 Postpartum Period

5.2.8 Hospital Discharge Planning 5.3.1 Clinical Breastfeeding Assessment

Hospital stays are short. Discharge planning enables a Lactation and breastfeeding difculties manifest in many
physician to review the stages of lactation and breast- ways, including infant problems such as failure to thrive,
feeding and allows early identication of potential or colic, fussiness, early introduction of supplements or
5 Management of Common Lactation and Breastfeeding Problems 89

Fig. 5.5 Signs your baby is By three or four days of age, your baby:
breastfeeding well has wet diapers: at least 4-5 noticeable times (looks or feels wet) in twenty-four hours (pale and
odorless urine)

has at least 2-3 bowel movements in twenty-four hours (color progressing from brownish to seedy
mustard yellow).

breastfeeds at least 8 times in twenty-four hours.

is content after most feedings.

Other signs that suggest your baby is breastfeeding well are:

You can hear your baby swallowing during feeding.

Your breasts are full before feedings and soft after feedings.
Your baby is only drinking breast milk.

If any one of these signs is not present after your baby is 3 or 4 days old or if you are having problems,
please call for help.

Physician/Midwife:______________________ Community Health Nurse:

If your baby is breastfeeding well, make an appointment within the first week for you and your baby to see
either your Family Physician, Midwife, or Community Health Nurse.

Birth Weight:_____________________Discharge Weight:_________________

Weight at One Week:___________________________________________

maternal concerns such as breast discomfort, sore Factors that impede Factors that Facilitate

cracked nipples, engorgement mastitis or postpartum

depression. Different clinical complexes of symptoms unsuccessful Mammogenesis successful
and signs or syndromes reect the normal variations in
maternal lactation ability and infant breastfeeding abil- unsuccessful Lactogenesis successful
ity. These symptoms and signs are not diagnostic.
Diagnosis and problem solving starts with a detailed lactogenic hormones Breast stimulation lactogenic hormones
history and physical examination of both mother and
infant, including breastfeeding history and observa- inhibitor factors Breast drainage inhibitor factors
tion. Once the etiology and pathophysiology have been
elucidated, successful management depends on sound Milk synthesis
knowledge of the anatomy of the breast, the physiol-
Fig. 5.6 Maternal milk synthesis
ogy of lactation and the mechanics of infant suckle
combined with a clear understanding of breastfeeding
kinetics [126, 143].
The rate of breast milk synthesis varies throughout 5.3.2 Insufcient Milk Syndrome
the day and between mothers. It depends on a variety
of central and local factors, including direct breast The most common reason given for abandoning
stimulation and breast drainage [95, 144]. In clinical breastfeeding in the early postpartum period is insuf-
practice, approximately 15% of mothers have a high cient milk. The etiology is multifactorial, but most
rate of milk synthesis of 60 mL/h or more (hyperlacta- causes are reversible if the mother receives accurate
tion), and about 15% of mothers have a low rate breastfeeding management advice early in the post-
of synthesis of 10 mL/h or less (hypolactation) partum period. A small percentage is irreversible
(Fig. 5.6). (Fig. 5.7).
90 L. H. Amir and V. H. Livingstone

Fig. 5.7 Neonatal insuf- Maternal

cient milk syndrome Psychological Risk Factors

Maternal Maternal/
Biological Risk Social Risk Factors
Factors Breastfeeding Preparation

Early Breast
Parturition Lactation Initiation Stimulation
Complicated Impeded Delayed

Breast Breast
Drainage Ongoing Milk Production Stimulation
Incomplete Inadequate Inadequate

Breastfeeding Milk Ejection
Incorrect Milk Transfer Reflex
Technique Inefficient Impaired
Milk Intake
Frequency Pattern of Breast
Infrequent Use
Duration Infant Growth
Inadequate Impaired

If the mother is having difculties breastfeeding or are effective galactogogues when increased prolactin
if the infants weight is continuing to fall or is more stimulation is required [146, 147]. Mothers may need
than 7% below birth weight, a careful evaluation is support and reassurance that partial breastfeeding or
required. This involves a detailed clinical breastfeeding mixed feeding is still benecial.
assessment incorporating maternal and infant history
and breastfeeding history, and includes a careful mater-
nal and infant examination. Observation of breastfeed-
ing is required to assess positioning, latching, suckling 5.3.3 Maternal Hyperlactation Syndrome
and swallowing. An accurate test feed followed by esti-
mating residual milk in the breasts by pumping are Hyperlactation may result in a characteristic clustering
helpful measurements when assessing maternal milk of maternal and infant symptoms and signs. Milk sta-
yield and infant milk intake. Caution must be taken sis, blocked ducts, deep radiating breast pain, lactifer-
when using standard ofce scales due to their unreli- ous ductal colic, inammatory mastitis, infectious
ability in measuring small volume changes [145]. Other mastitis and breast abscess are common problems.
causes of infant failure to thrive, such as cardiac or Clinical experience has shown that most mothers expe-
respiratory problems, should always be considered. riencing any or all these symptoms have a high rate of
In broad terms, management includes avoiding the milk synthesis and have large, thriving infants, or else
precipitating factors, improving maternal milk synthe- they have started to wean and are not draining their
sis by increasing breast stimulation and drainage, breasts regularly. These symptoms and signs are all
improving milk removal by correcting the breastfeed- consequences of a rapid rate of milk synthesis com-
ing technique and increasing the infants daily milk bined with milk retention resulting from incomplete
intake by increasing the frequency and duration of breast drainage. They represent the clinical spectrum of
breastfeeding. A small percentage of neonates will the maternal hyperlactation syndrome [148, 149]
require complementary feeds. Metoclopramide (10 mg (Fig. 5.8). The pathophysiology is analogous to the
3 times a day) and domperidone (20 mg 3 times a day) renal system; retention of urine, due to incomplete
5 Management of Common Lactation and Breastfeeding Problems 91

Fig. 5.8 Maternal Breastfeeding Technique Milk Production Pattern of Breast Use
hyperlactation Poor Excessive Both

Breast Drainage

Milk Stasis


Blocked Ducts

White Spots

Inflammatory Mastitis

Infectious Adenitis

Breast Abscess

bladder emptying, may result in lower and upper uri- of ductal cramping or colic because of myoepithelial
nary tract disease, including bladder distension, spasms, smooth-muscle contractions.
ureteric colic and hydronephrosis. This problem may
become complicated with ascending urinary tract infec-
tions, including trigonitis, urethritis, cystitis, pyelone- Milk Stasis
phritis and renal abscess.
Lactation problems occur when a mother with a A rm, lumpy, slightly tender quadrant in the breast
high milk output switches her infant from one breast to may be felt because of milk stasis. Over time, if this
the other before the rst side has been adequately area is not drained, cytokines from the milk may seep
drained. A strong milk-ejection reex causes a rapid into the interstitial tissue, causing it to become inamed
letdown of a large volume of pooled milk, and the and erythematous, signifying an inammatory mastitis
infant quickly becomes satiated before all the lactifer- [152, 153].
ous ducts are drained. Incomplete drainage may be
aggravated by poor position and latch or by impaired
infant suckling [150]. When this occurs repeatedly, Acute Mastitis
some of the ducts and lobules constantly remain full.
It was recognized in 1940 that when a breach occurs in
the mucous membrane, such as a cracked nipple, White Spot supercial skin infections could lead to a deeper cel-
lulitis, adenitis and mastitis [154]. Livingstone et al.
A small white spot may be visible on the nipple; such found that 5060% of sore, cracked nipples were con-
a spot represents edematous epithelium blocking the taminated with Staphylococcus aureus or other micro-
nipple pore and milk ow. In some situations, duct organisms [155]. Subsequent study showed that 25%
obstruction is due to a small granule of casein milk of mothers with infected, sore nipples developed mas-
precipitate [151]. Lactiferous duct outlet obstruction titis if they were not treated aggressively with systemic
can cause increased retrograde pressure. Mothers may antibiotic [156]. A high rate of milk synthesis com-
complain of sharp, knife-like cramps or shooting bined with continuous poor drainage of a segment of
pains deep in the breast, often between feeds, because the breast may result in the stagnant milk becoming
92 L. H. Amir and V. H. Livingstone

secondarily infected with common skin pathogens via Decreased Rate of Milk Synthesis
an ascending lactiferous duct infection and leads to
acute mastitis. Infectious mastitis also may be caused Reducing breast stimulation and drainage can decrease
by a blood-borne infection; however, that is uncom- the rate of milk synthesis. Decreasing the frequency and
mon and more likely in non-puerperal mastitis [157]. duration of breastfeeding reduces prolactin surges, and
Puerperal mastitis has been found to affect 17% of milk synthesis remains blocked via central inhibitory
breastfeeding women who present with breast pain, factors. Decreasing the frequency of breast drainage
redness, lumps, general malaise, chills or sweats and results in milk retention in the lactiferous ducts, and
fever [158]. inhibitor peptides collect and block ongoing milk pro-
duction via a local negative feedback mechanism. In
practical terms, the infant should remain at one breast per Chronic Mastitis feed until he or she is full and spontaneously releases the
breast. In this way, the volume of milk ingested is less,
Chronic mastitis, as in chronic urinary tract infections, but the fat content and caloric value increases as the
may be due to reinfection or a relapsed infection. feed progresses [162]. A higher fat intake often satiates
Reinfection occurs sporadically because of exposure the infant for a longer period and decreases the hunger
to a new pathogen, commonly transmitted from the drive. The interval between feeds is lengthened and milk
infant. A relapsed infection occurs shortly after com- synthesis declines, whereas the second breast remains
pletion of therapy; it signies inadequate primary full longer, and local inhibitor further reduces milk syn-
treatment and failed eradication of the pathogen. An thesis in that breast. In a small number of mothers, uni-
underlying cause, such as a nidus of infection deep in lateral breastfeeding may result in over-drainage and can
the breast tissue, should be considered. It is hypothe- contribute to the ongoing high rate of milk synthesis. In
sized that lactiferous duct infections may lead to stric- these cases, bilateral breastfeeding and incomplete drain-
ture formation, duct dilation and impaired drainage. age may result in a decline in overall milk synthesis (e.g.,
The residual milk remains infected. 23 min on the rst side followed by a good burp, and
then 35 min on the second side). If milk supply does not
become manageable with one-sided feeding, the mother
can completely express both breasts on one occasion and Breast Abscess then feed from one breast for a block of time (e.g., 46 h)
before switching breasts [163].
Inadequately treated mastitis and ongoing milk reten-
tion can develop into a breast abscess. A high fever
with chills and general malaise, associated with a rm, Decreased Milk Retention
well-demarcated, tender, uctuating mass, usually
with erythema of the skin, indicates abscess formation, Regular breastfeeding facilitates milk removal and
although, in some instances, systemic symptoms may breast drainage. When positioned and latched cor-
be absent. Ultrasonography of the breast and needle rectly, the infant is usually effective at removing milk
aspiration under local anesthesia are useful diagnostic and draining each segment. The modied cradle posi-
techniques for identifying collections of uid or pus tion allows the mother to cup the breast with her hand
and distinguishing mastitis from a galactocele or and apply rm pressure over the outer quadrant and
inammatory breast cancer [159161]. compress retained milk toward the nipple while the
infant suckles. If the milk is owing rapidly, the mother
should stop compressing the breast. Switching breast- Management Goals feeding positions and using the under-the-arm hold
allows thorough drainage of all segments and prevents
Maternal hyperlactation syndrome can be prevented milk stasis. Breastfeeding should start on the fullest
by decreasing the rate of milk synthesis and preventing breast and the infant should remain on this breast until
milk retention by improving milk removal and breast all areas feel soft. As the pressure in the duct is relieved,
drainage. breast pain and discomfort lessen.
5 Management of Common Lactation and Breastfeeding Problems 93

Removal of Obstruction Treating Infection

If a small white dot on the nipple becomes visible, Correct breastfeeding techniques and improved drain-
indicating a blocked nipple pore and outlet obstruc- age of milk are the sine qua non of treatment, but anti-
tion, gentle abrasion or a sterile needle can be used to biotic therapy may be necessary. Inammatory mastitis
remove the epithelial skin and relieve the obstruc- occurs within 1224 h of milk blockage, leading to an
tion. Occasionally, a small calculus or granule will infectious mastitis within 2448 h. Under normal con-
pop out suddenly, relieving the obstruction. On rm ditions, the milk leukocyte count is less than 106 mL of
compression, a thick stream of milk will often gush milk, and the bacterial count is less than 103 bacteria
out, indicating patency. Occasionally, breastfeeding per milliliter. Within 48 h of breast symptoms, the leu-
is ineffective at removing the thickened inspissated kocyte count increases to more than 106 mL of milk,
milk, and manual or mechanical expression may but the bacterial count remains low. This is considered
therefore be necessary. The mother should be shown noninfectious inammation of the breast, and improved
how to compress her breast rmly using a cupped milk drainage will resolve the situation quickly [152].
hand, squeezing gently toward the nipple while Infectious mastitis is dened as having a bacterial
pumping to dislodge the milk or calculus. It may be count of more than 106 mL of milk. In clinical practice,
helpful to try massaging in front of the lump toward treatment is empirical. Breast pain and erythema asso-
the nipple, as if trying to clear a pathway (Smillie ciated with u-like systemic symptoms and a fever are
CM cited by [164]). If the breast expression fails to highly suggestive of infectious mastitis and require
relieve the obstructed segment, a technique known as antibiotic therapy if not resolving within 24 h [167].
manual stripping can be used [165]. This involves Common bacterial pathogens include Staphylococcus
cupping the breast between the nger and thumb and aureus, Escherichia coli, group A b-haemolytic
applying rm, steady pressure over the tender sec- Streptococcus with occasional Streptococcus faecalis
tion, starting from the periphery over the rib cage and and Klebsiella pneumonia. In contrast, nonpuerperal
drawing the ngers and thumb slowly together toward breast infections are mixed infections with a major
the nipple, stripping out thickened milk or pus. This anaerobic component. Antibiotics of choice include
procedure should be repeated several times. The skin penicillinase-resistant penicillins such as dicloxacillin
must be well lubricated before attempting to do this. or ucloxacillin, cephalosporins, sulfonamides and
Analgesia may be necessary, but even with mastitis, clindamycin. A 1014 day course may be required.
the discomfort lessens as the procedure continues. The breast milk excretion of these antibiotics is mini-
The intraductal pressure is relieved as milk or pus is mal, and continuation of breastfeeding is considered
slowly extruded. Mothers must be taught this tech- safe. Clinical improvement is usually seen within
nique and instructed to repeat the procedure every 2448 h, the erythema subsides, the fever decreases
few hours, standing in the shower, using soapy n- and breast pain improves [167]. A persistent uctuant
gers, until the breast feels softer and milk is owing mass may indicate abscess formation.
If a breast abscess has formed, needle aspiration is
preferred to incision and drainage under local or gen- Prevention of Recurrence
eral anesthesia [160, 161]. Repeat needle aspiration
may be required [166]. In very large or loculated Excessive milk retention can be prevented by correct
abscesses, incision may be necessary. The incision breastfeeding techniques, ensuring a proper latch, reg-
should be radial, not circumferential, to minimize duct ular drainage and not skipping feeds. Mothers should
severance. A large drain should be inserted and daily avoid pressure on the breast (e.g., from their nger on
irrigations continued until the cavity closes. It is the breast, or a seat belt, or tight clothing) as the milk
important that the dressings be applied in a manner ducts are easily compressed [168]. Sleeping through
such that the infant can continue to breastfeed or the the night, returning to work, the introduction of breast
mother should use an efcient breast pump. Regular milk substitutes such as bottles of formula, the intro-
drainage prevents further milk stasis and maintains duction of table foods and weaning are all typical peri-
lactation. ods when breastfeeds may be missed. The resultant
94 L. H. Amir and V. H. Livingstone

breast confusion can lead to inadequate drainage and painful nipples [171, 172]. In many cases, reposition-
milk retention. Mothers with a high milk output should ing can have a dramatic effect and instantaneously
become skilled at palpating their breasts for lumps, remove the pain and discomfort [173, 174]. However,
and the bra should be removed before feeding if it is recent research suggests that some infants exert higher
practical to do so. Areas of breast lumpiness or caking than normal intraoral vacuums causing pain to their
that persist after breastfeeding may indicate milk stasis mothers [175].
or a blocked duct. Thorough expression of this residual A small percentage of women have naturally sensi-
milk should relieve the situation and prevent second- tive nipples, which remain uncomfortable throughout
ary complications. the duration of breastfeeding, despite careful technique.
They experience sensitive nipples, even in their nonlac-
tating state. When nipple pain, excoriations, dermatitis
Supportive Measures or ulceration continue despite careful maternal breast-
feeding technique, a detailed history and physical
Mastitis is an inammatory process that can be compli- examination are required to elucidate secondary causes
cated by infection and produce systemic symptoms in of sore nipples.
an already exhausted mother. Home help and bed rest is
advisable, and analgesia such as ibuprofen or acet-
aminophen may be necessary. Hot compresses applied Nipple Trauma
to the breast, before breastfeeding or milk expression,
encourage blood ow and smooth muscle relaxation, To suckle correctly, an infant must grasp sufcient
which in turn helps milk transfer. Cold compresses breast tissue to form a teat, draw it to the back of the
after feeds may decrease inammation and edema. pharynx, and initiate suckling in a coordinated manner
Anecdotal cases of maternal toxic shock syndrome using rhythmic jaw compressions and a grooved, undu-
have been reported, and in rare circumstances, lating tongue. Many maternal nipple and infant oral
Staphylococcus toxins can be ingested by the infant anatomic anomalies can interfere with effective latch
[169]. Continuation of breastfeeding is always recom- and suckle, resulting in nipple trauma and pain. Clinical
mended. Weaning may lead to increased milk stasis ndings such as maternal inelastic, at, pseudoinverted
and abscess formation. If a mother chooses to wean or inverted nipples and infant cleft lip and palate are
abruptly or if clinically indicated, a lactation suppres- easily identied. More subtle ndings may include
sant such as cabergoline may be used (0.25 mg twice infant retrognathia, which refers to a small or posterior
daily for 2 days) [114, 170]. positioned mandible, or the Pierre-Robin malforma-
tion, which combines severe micrognathia, or a poste-
rior tongue with a relative ineffective activity of the
muscles that protract the tongue and ankyloglossia
5.3.4 Sore Nipples [129, 176].
Management includes using a semi-upright breast-
Sore nipples, particularly during the rst few days of feeding position, which allows gravity to aid in jaw
breastfeeding, are a common symptom experienced extension and minimizes the degree of overbite and
by an estimated 80% of breastfeeding mothers. It is friction. Continuous support and shaping of the breast
generally accepted that transient nipple soreness is throughout the feed with hand support of the infants
within normal limits. Factors such as frequency and head and shoulders stabilize the neck and jaw mus-
duration of breastfeeding, skin or hair color and nip- cles. Heat and gentle manipulation of the nipple may
ple preparation do not seem to make a difference in elongate it sufciently to enable a correct latch. If
preventing tenderness. Increasing or persistent dis- clinically indicated, frenotomy can release a tethered
comfort is pathological and requires careful evalua- tongue [177]. Over a period of a few weeks, a hyp-
tion. Detailed studies of infant suckling at the breast oplastic mandible rapidly elongates, the facial mus-
have illustrated how tongue friction or gum compres- cles strengthen, the nipple tissue becomes more
sion, resulting from inappropriate latch, can cause distensible, the latch improves, and nipple trauma and
trauma and result in supercial skin abrasions and pain resolve.
5 Management of Common Lactation and Breastfeeding Problems 95 Chapped Nipples and breast abscess involve an ascending lactiferous duct
infection with S. aureus or b-hemolytic streptococcus.
Dry, cracked nipples may be chapped due to loss of Management includes careful washing with soap and
moisture barrier in the stratum corneum because of con- water of the nipples to remove crusting and the use of
stant wet and dry exposure combined with nipple fric- appropriate antibiotics. Topical antibiotic ointments
tion. Management goals include avoiding further trauma such as fusidic acid (Fuccidin) or mupirocin (Bactroban)
by modifying breastfeeding technique, avoiding exces- may be effective in conjunction with systemic penicilli-
sive drying and restoring the moisture barrier. Moist nase-resistant antibiotics, such as dicloxacillin, cepha-
wound healing allows the epithelial cells to migrate losporin or erythromycin in penicillin-allergic patients
inward and heal the cracks and ulcers [178]. Moisturizers [156]. Treatment should continue for 710 days until
and emollients such as USP modied anhydrous lanolin the skin is fully healed. The source of the infection is
applied to the nipples and areolae after each feed are often from the infants oropharyngeal or ophthalmic
cheap and effective. In most situations, breastfeeding ora. In persistent or recurrent infections, it may be
should continue during therapy; if repositioning fails to necessary to treat the infant as well [179].
modify or relieve the pain and discomfort, it may be
advisable to stop breastfeeding for 4872 h to allow
healing to occur. The breasts should be emptied every Candidiasis
34 h, and an alternative feeding method should be
used. It is inappropriate to try to mask the pain by numb- Candidiasis is commonly caused by Candida albicans
ing with ice or using strong analgesia or nipple shields and less frequently by other Candida species. It may be
because this will fail to correct the underlying cause and a primary or secondary skin infection. C. albicans is
may lead to further nipple trauma. endogenous to the gastrointestinal tract and mucocuta-
neous areas. Normal skin does not harbor C. albicans;
however, almost any skin damage caused by trauma or Bacterial Infection of the Nipple environmental changes may lead to rapid colonization
by C. albicans. Isolation of the organism from a dis-
Staphylococcus aureus is frequently found distributed eased skin may not be the cause of the disease but may
over the skin. Natural barriers, such as the stratum cor- be coincidental. C. albicans can be a secondary invader
neum, skin dryness, rapid cell turnover and acid pH of in preexisting pathological conditions and may give
56, of the infants skin usually prevent infection. For rise to further pathology. Candidiasis should be sus-
disease to result, preexisting tissue injury or inamma- pected when persistent nipple symptoms, such as a
tion is of major importance in pathogenesis. As in other burning sensation on light touch and severe nipple pain
clinical situations, when there is a break in the integu- during feeds, are combined with minimal objective
ment of the skin surface, there is a predisposition to a ndings on the nipple [180]. Typical signs include a
secondary infection because of bacterial or fungal con- shiny or aky appearance of the nipple and areola
tamination, which may lead to a delay in wound heal- associated with nipple and breast pain [181]; the breast
ing. Sore nipples associated with skin breakage, appears normal without the inammation and fullness
including cracks, ssures and ulceration, have a high associated with mastitis. A high incidence of oral
chance of being contaminated with microorganisms. mucocutaneous candidiasis has been noted in the new-
The clinical ndings on the nipple and areola of local born following vaginal delivery in the presence of
erythema, excoriations, purulent exudates and tender- maternal candidal vulvovaginitis. Typical symptoms
ness are suggestive of colonization with coagulase-pos- of nipple/breast candidiasis often develop following
itive S. aureus. Livingstone et al. showed that mothers maternal antibiotic use [182, 183]. Clinical examina-
with young infants who complained of moderate to tion of the infant is mandatory because C. albicans is
severe nipple pain and who had cracks, ssures, ulcers passed from the infants oral pharynx to the mothers
or exudates had a 54% chance of isolation of S. aureus nipple, which, being a warm, moist, frequently macer-
[155]. In some clinical situations, a blocked nipple pore ated epidermis, is easily colonized and possibly
appears white and on culturing is found to be contami- infected when the integument is broken. Diagnosis is
nated with S. aureus. Most cases of cellulitis, mastitis based on clinical signs and symptoms [184, 185].
96 L. H. Amir and V. H. Livingstone

The treatment of cutaneous candidiasis includes [189, 190]. Contact dermatitis in the nipple is an eczem-
careful hygiene, removal of excessive moisture and atous reaction to an external material applied, worn or
topical therapy with broad-spectrum antifungal agents inadvertently transferred to the skin. It may be an aller-
such as nystatin, clotrimazole, miconazole or 2% keto- gic or an irritant response. Patients may complain of
conazole. The creams should be applied to the nipple dry, pruritic or burning nipples with signs of inamma-
and areola after each breastfeed for 1014 days. In tion, erythema and edema or excoriations, desquama-
addition, other sites of candidiasis in both mother and tion or chronic plaque formation. The typical description
infant, including maternal vulvovaginitis, intertrigo or is of an itching, spreading rash. Management includes
infant diaper dermatitis, should be treated simultane- careful avoidance of all irritants such as creams, preser-
ously with a topical antifungal cream. Oral thrush in vatives, detergents, and fragrances. Irritation from fre-
the infant should be treated aggressively with an oral quent expressing can be reduced by using a lubricant,
antifungal solution such as nystatin suspension such as puried lanolin, on the nipples and areolae prior
100,000 U/g. After each feed, the oral cavity should be to pumping. A potent topical corticosteroid such as
carefully painted and then 0.5 mL of nystatin suspen- mometasone furoate can be applied thinly to the nipple
sion inserted into the mouth by dropper for 14 days. In and areola after a feed once a day for up to 10 days [189,
countries where oral miconazole gel is available, this is 190]. Regular use of emollients may prevent recurrence.
used in the infants mouth and on the mothers nipples Chronic dermatitis is often colonized with S. aureus,
[186]. Oral uconazole 3 mg/kg daily for 14 days or which may require topical or oral antibiotic therapy.
oral ketoconazole 5 mg/kg daily for 7 days may be used
for the treatment of oropharyngeal candidiasis in new-
borns. Gentian violet 0.51% aqueous solution is cheap Pagets Disease
and effective if used sparingly under medical supervi-
sion. Daily painting of the infants mouth and mothers Pagets disease is an intraepidermal carcinoma for
nipples for about 57 days is usually sufcient. which the most common site is the nipple and areola.
Excessive use may cause oral ulceration [187]. Failure It usually presents as unilateral erythema and scaling
to eradicate fungal infections is usually due to user, not of the nipple and areola and looks eczematous [191].
medication failure. Occasionally, more serious under- Unfortunately, the condition is usually part of an intra-
lying medical conditions such as diabetes or immuno- ductal carcinoma, and treatment necessitates cessation
deciencies may exist. Systemic antifungal agents may of breastfeeding.
be required; regimes vary from uconazole 150 mg
every second day for three dose [186] to 200 mg load-
ing dose , followed by 100 mg daily for 14 days [143] Vasospasm or Raynauds Phenomenon
(p. 282). In addition, topical corticosteroids may reduce
nipple pruritus and erythema [188]. Foreign objects Vasospasm, or Raynauds phenomenon, of the nipple
contaminated with yeast, including soothers and rubber manifests as a blanching of the nipple tip with pain and
nipples, should be avoided or sterilized, if possible, to discomfort radiating through the breast after and
prevent reinfection. Lay literature is full of nonpharma- between feeds [192]. It may be associated with excori-
cologic treatments for candidiasis with little evidence ated and infected nipples. There may be a history of
to support them. The healthcare provider is cautioned cold-induced vasospasm of the ngers (Raynauds
against recommending regimens that are complicated. phenomenon). Repetitive trauma to the nipple from
In an otherwise healthy person, the immune defense incorrect latch or retrognathia, combined with local
mechanism can control the growth of candida, assum- inammation or infection and air cooling, can trigger a
ing the skin integument is intact and remains dry. characteristic painful vasospastic response. Correcting
the latch and alternating breastfeeding positions
throughout the feed will prevent ongoing nipple Dermatitis trauma. Avoiding air exposure and applying warm dry
heat to the nipples after feeds may help. Standard phar-
Dermatitis of the nipple may be endogenous atopic macologic therapy for Raynauds phenomenon can be
eczema, irritant contact or allergic contact dermatitis effective in reducing the vasospasms; oral magnesium
5 Management of Common Lactation and Breastfeeding Problems 97

supplements and nifedipine are usually helpful [193, portable, but mechanical pumping stimulates greater
194]. Local infections should be treated aggressively milk production in lactating women [198].
and breastfeeding stopped for several days if necessary A variety of pharmacological lactotrophs and galac-
to allow healing to occur. togogues have been used to induce lactation [199,
200]. Estrogen and progesterone are used to promote
mammogenesis by stimulating alveoli and lactiferous Psoriasis duct proliferation. They inhibit milk synthesis by
blocking the action of prolactin on the mammary
Psoriasis may present as a pink, aky plaque over the glands and therefore are used in preparation for breast-
areola as a result of skin trauma. There is usually an feeding. Galactogogues such as phenothiazine, sulpir-
existing psoriatic history. Standard treatment includes ide, and domperidone also have been described [114].
uorinated steroid ointments and keratolytic agents, They are dopamine antagonists and block the inhibi-
which should be applied after feeds and then washed tion of prolactin, which is a potent lactotroph.
off carefully before feedings. Metoclopramide and chlorpromazine are commonly
For many years, the medical and nursing literature used galactogogues but have many potential side
has recommended a variety of management approaches effects, including sedation, extrapyramidal symptoms
for sore nipples, ranging from topical application of and tardive dyskinesia [201]. Domperidone has little
cold tea bags, carrots and vitamin E, to lanolin, masse effect on the central nervous system and has fewer side
cream, antiseptics, alcohol preparations and air drying effects [146]. Drug excretion in breast milk is very
[195]. The efcacy of each of these modalities has not limited and in combination with low milk production
been proven, however; in fact, the latter is now thought probably does not pose a risk to the infant. Relactation
to be detrimental by abstracting water from the skin is often more successful than induced lactation [202].
and precipitating protein, which leaves the skin less
pliable and more prone to ssuring. Healthcare profes-
sionals are cautioned against using nontraditional
5.3.6 Medicines and Breastfeeding
adjunct management modalities for sore nipples
because of the risk of iatrogenic disease.
Most drugs transfer into breast milk, but generally at
low, subclinical doses [203]. In general, if the medica-
tion is safe to use in infants, it will be safe for the
5.3.5 Induced Lactation and Relactation breastfeeding mother [204]. Only a small number of
medications are contraindicated during breastfeeding:
Given the growing understanding of the value of these include antineoplastic agents, ergotamine, meth-
breastfeeding in terms of nutrition and nurturing, otrexate, cyclosporine, radiopharmaceuticals [205].
women are seeking information about breastfeeding Physicians and mothers need to consider the risks and
and adoption [26]. Induced lactation in the non-preg- benets of any medicine. General advice is to use topi-
nant woman has been described for many years in both cal/local medicines where possible, choose drugs with
scientic and lay publications and includes the rst shorter half-lives, and use drugs where there is previ-
reports by Hippocrates [196]. Auerbach and Avery ous experience in lactating women. Information is
reported on 240 women who attempted to breastfeed available about safe use of medicines while breastfeed-
adopted children [197]. There are several anecdotally ing; see Fig. 5.9 for list of resources.
described methods of inducing lactation and preparing
for breastfeeding, some of which can be started before
the arrival of the infant. Direct nipple stimulation has
been described as the most important component of 5.4 Conclusion
inducing lactation and preparing to breastfeed [197].
Nipple stimulation can be performed by hand or by As the prevalence of breastfeeding continues to increase,
such mechanical means as an electric breast pump. health professionals will be expected to take a leader-
Hand stimulation has the advantage of being easy and ship role in the promotion, protection and support of
98 L. H. Amir and V. H. Livingstone

Fig. 5.9 Sources of Reference books

information on medicines for Briggs GG, Freeman RK, Yaffe SJ. Drugs in Pregnancy and Lactation. 7th Ed, Philadelphia:
breastfeeding women [206] Lippincott Williams & Wilkins, 2005.
Hale T. Medication and Mother's Milk. 11th ed. Texas: Pharmasoft Medical Publishing, 2004
(available from
A new searchable website (LactMed) has been set up by the US National Library of Medicine
World Health Organization. Breastfeeding and maternal medication
Telephone advice
Pharmacy departments of tertiary maternity hospitals

breastfeeding by providing appropriate guidance, diag- 14. Kramer MS, Guo T, Platt RW et al (2003) Infant growth
nosis and breastfeeding management throughout the and health outcomes associated with 3 compared with 6 mo
of exclusive breastfeeding. Am J Clin Nutr. 78:2915
full course of lactation. 15. Quigley MA, Cumberland P, Cowden JM et al (2006) How
protective is breast feeding against diarrhoeal disease in
infants in 1990s England? A case-control study. Arch Dis
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