One of the biggest determinants for a woman's meeting her breastfeeding goals is the support she receives, particularly when encountering problems. Healthcare professionals play an important role in providing that support and helping women navigate common issues that may arise during a breastfeeding journey. Some of the most common problems and their solutions are listed below.
Painful or cracked nipples: Some soreness in the early days is normal, but persistent pain or cracked and bleeding nipples are typically due to improper or shallow latch and will continue to worsen if the latch is not corrected. Observe a feeding and identify the latch aspects that need adjustment and coach the mother through how to do this. Encourage her to check the latch every feeding until good habits are established.
Nipple creams, frequently changing breast pads, and breast shells (not the same as nipple shields) may be helpful with healing. Encourage trying different feeding positions throughout the day so that the infant's gums rotate where they are coming in contact with the nipple and not irritating the same spot every feeding (Wagner, 2021).
Flat or inverted nipples: First, remind mothers that the size and shape of the nipple are mostly irrelevant once the baby takes breast tissue into his mouth. With a proper latch, the baby should pull the skin of the nipple and breast into the back of the mouth, forming a teat and sucking milk out that way, regardless of nipple shape. However, learning how to draw the nipple out and properly latch can still be a learning curve for newborns. Some methods to help mothers elongate their nipples before feeding include wearing breast shells inside the bra, pumping before feeding, and nipple stimulation. Breast shields are a potential temporary solution but are difficult to break and should not be the first solution offered (La Leche League, n.d.a).
Plugged Ducts/Mastitis/Breast Infection: Sometimes, the milk flow becomes blocked within the duct, and the breast may become red, tender, or have a hardened area; this is referred to as a plugged duct. Usually, gentle massage, warm compress, drinking water, and frequent feedings (and trying different positions) will clear a plugged duct up quickly.
Sometimes, the blockage persists, and an entire section of the breast becomes affected, resulting in increased tenderness, redness, and more systemic flu-like symptoms in the mother. This is known as mastitis. Bacteria may even begin to grow in the area of reduced milk flow, and mothers may notice purulent drainage or blood in their milk. Other interventions for plugged ducts may be useful, such as ibuprofen and antibiotics as prescribed by a healthcare provider. Even if there is drainage or blood in the milk, it is safe for the infant to continue feeding, and avoiding feeding on that side may worsen the engorgement and infection or even lead to an abscess. While plugged ducts can be managed easily at home, women with suspected mastitis should be immediately encouraged to contact their healthcare provider (Wagner, 2021).
Poor weight gain or hyperbilirubinemia in the infant: When a breastfed infant does not gain well or becomes extremely jaundice, healthcare providers must strike a balance between giving the baby adequate nourishment and working to increase the mother's supply. Supplemental feeds may be necessary and help the mother commence pumping to support her supply to work toward providing all the breast milk her infant requires for good growth. Failure to thrive and insufficient milk are complex problems that typically require collaboration between primary care providers and certified lactation consultants (IBCLCs).
When healthcare providers suggest supplemental feedings for infants, it is important to advise the mother to continue to put the infant to the breast at each feeding before providing the supplement. Pumping is especially important if the infant does not drain the breasts well. The mother must try to simulate the work of the baby with pumping.
Advising a "triple feeding" plan-feeding the baby at the breast, offering supplement, and pumping the breasts will help support breastfeeding until the family can get in to see an IBCLC and the problems can be sorted out. Also, advise that the supplement offered may be expressed breastmilk in most cases and does not necessarily need to be formula (Wagner, 2021).
Return to work: Keeping the mother and infant together is the best way to support regular breastfeeding. However, this is not always possible, especially if the mother works outside the home. Breastmilk should be expressed when a mother is separated from the infant for an extended time. Expressing milk while separated helps to prevent engorgement and decreased milk supply. Expressed milk should be stored in a clean glass or polypropylene container, labeled with the date, cooled and refrigerated, or frozen (DeMaggio, 2016).
Milk at room temperature can be kept for 4 hours optimally and 6-8 hours under very clean conditions. Fresh milk can be stored in the refrigerator for 5-8 days, thawed/fortified milk for 24 hours, and frozen milk for 6-9 months (DeMaggio, 2016).
Milk can be expressed by hand or by using a breast pump. Good handwashing is important anytime milk is expressed. Special attention should be paid to the flange's size; correct sizing of the breast flange will help the mother pump comfortably and express the most milk.
Some mothers may find that hand expression is easy and sufficient for their requirements. To express milk, manually put a container under the breast and massage the breast gently toward the nipple. Place a thumb about 1 inch back from the tip of the nipple, and the first finger is placed opposite. Press back toward the chest; gently press the areola between the thumb and finger, then release. Do this in a rhythmic motion until the milk flows or squirts out (La Leche League GB, 2016).
Teething/Nursing strikes
Many nursing mothers dread the appearance of teeth because they assume that the child will soon begin biting and end the nursing relationship. When a child bites at the breast, he is not breastfeeding, likely forgetting where he is and perhaps trying to soothe sore gums. Most children can be taught that biting is not acceptable. If the baby bites, the mother should respond quickly and firmly. A firm "NO!" and stern face, removal of the child from the lap, and the mother walking away for a period of even less than a minute will communicate that biting ends a feeding session (Wagner, 2021).
An infant who is truly ready to wean will usually do so gradually over weeks or months. If an infant has been breastfeeding well and suddenly refuses to nurse, it is probably a nursing strike. Advise the mother that most nursing strikes are over within two to four days. They happen for many reasons, and the best plan is to work through the strike with persistence and patience while trying not to take it personally. Seeking out a quiet, dim room and avoiding unnecessary stimulation may also be helpful (Wagner, 2021).
Birth control
Breastfeeding mothers with their infants full-time and nursing on demand typically do not have menses for several months. Nursing tends to postpone fertility, though breastfeeding women are not recommended to assume that they cannot get pregnant while nursing (La Leche League, 2018a).
Caution should be exercised when taking hormonal contraceptives. Some, but not all, women find that using a birth control pill, shot, or IUD can reduce their milk supply. Women should talk with their healthcare providers about choosing the best option for their needs (La Leche League, 2018a).
Maternal illness/medications
Most, but not all, therapeutic drugs are compatible with breastfeeding. Generally, the decision to use medications while breastfeeding should reflect the relative risks and benefits to both mother and child. For example, most antidepressants are only present in small amounts in breast milk, and very little is detectable in infant serum. The mother who needs the antidepressant can benefit greatly from it and be reassured that her infant is at very low risk. The nurse should check the available references and provide the family with the most current recommendations and the studies, if any, to support them (Mayo Clinic, 2020).
Typically, there is no need to "pump and dump" after most procedures, even if general anesthesia is required. The same applies to dental procedures and most radiological exams, including those with contrast. The breastfeeding mother can request a list of the drugs that will be used in procedures in advance and ask clinic staff to check the available sources so that she knows how to proceed. The Hale guide, Medications and Mother's Milk, and LactMed website or app are highly accurate and trusted resources for checking medication compatibility with breastfeeding (Mayo Clinic, 2020).
