In medicine, mommy blogs, and most pregnancy books, including this one, much time and energy is spent on improving the labor and delivery process and outcomes. For the most part, the postpartum period is an afterthought and there is little planning for this time or support for the mothers navigating an entirely new set of challenges, while still physically recuperating from pregnancy and delivery. Most parents spend more time on their baby registry than on preparing for the actual realities of new parenthood. While some would argue that no book or class can adequately prepare expectant mothers and fathers for what is to come, most new parents express the desire for more than just on-the-job training and feel they would benefit from more parenting information prior to delivery and increased help after the baby arrives.¹

With increasing awareness about the importance of breastfeeding and the resultant public health campaign to expand breastfeeding in the United States and throughout the world, some positive developments have occurred in postpartum care, but most of those improvements have been limited to the hospital, with little to no continuity with care providers following discharge. In the traditional postpartum care model, mothers who have an in-hospital vaginal delivery spend 1 to 2 days in the hospital after the birth of their child and do not see their obstetrician or midwife until well after delivery. If they are struggling with laceration healing, sleep deprivation, breastfeeding, infant care, or postpartum depression and anxiety, they are frequently isolated and left floundering at home, trying to solve the problem themselves or searching independently for resources in the community. While pediatricians see new infants frequently during this time period, these visits do not necessarily address the needs of new mothers. All too often, it is only discovered at a woman’s routine postpartum visit, a full 6 to 8 weeks after delivery, that she is experiencing significant depression or anxiety, she abandoned breastfeeding due to considerable challenges, or her perineal laceration is not healing in the way it should be. Her relationship may also be strained to the breaking point as she and her partner struggle to parent together.

It is important for both women and their care providers to be better informed about the common challenges women face in the postpartum period, as well as the commonly suggested remedies to these problems. In the absence of proper or timely medical feedback, women receive a plethora of advice of varied quality from a multitude of sources. Women are often desperate to try anything that may improve their situation, but much of what is recommended to new mothers in regards to breastfeeding or infant care struggles has not necessarily been shown to be effective and women can expend a great deal of energy and money trying treatments that are not likely to solve their problem. Providers need to be familiar with these difficulties and the advice women are likely to receive so they can have an intelligent dialogue and direct their patients to those remedies that are most likely to be helpful.

The World Health Organization recommends all infants be exclusively breastfed for at least 6 months after birth and partial breastfeeding continue until 2 years of age.² This recommendation is supported by multiple studies demonstrating decreased infant morbidity with this duration of exclusive breastfeeding.³ However, most countries observe low rates of exclusive breastfeeding and shorter than recommended breastfeeding durations. This is observed even in countries where the rate of breastfeeding initiation is high, suggesting this problem is not a result of mothers being unwilling or unmotivated to breastfeed. Rather, it is a result of mothers being unable to achieve successful breastfeeding and overcome breastfeeding challenges. Most of the available research regarding breastfeeding focuses on modifications in antepartum care and in-hospital intrapartum and postpartum care. While antepartum education regarding breastfeeding has been shown to improve the rates of women initiating breastfeeding, as well as reduce the number of women not breastfeeding at all, education alone has not been shown to significantly impact exclusive breastfeeding rates later in the postpartum period.^4–6 Antenatal breastfeeding education is better thought of as an initiating step in a process of breastfeeding support. The most effective intervention demonstrated by the literature, shown to improve all parameters including breastfeeding initiation, duration of any breastfeeding, and exclusive breastfeeding rates, is the combination of practices included within the 10 steps of the Baby-Friendly Initiative.

In-Hospital Support: The Baby-Friendly Initiative

The Baby-Friendly Initiative was launched in 1991 as a joint effort by the World Health Organization and the United Nations Children’s Fund (UNICEF) to promote global breastfeeding through broad implementation of the Ten Steps to Successful Breastfeeding and the International Code of Marketing of Breast-milk Substitutes.⁷ The goal of the Ten Steps is to help hospitals adopt evidence-based practices which promote breastfeeding, while the International Code aims to reduce the negative influence of formula marketing on breastfeeding within the hospital.⁸

There are multiple studies supporting each of the steps promoted by the Baby-Friendly Initiative. Since the broader adoption of the Baby-Friendly Initiative and subsequent certification of Baby-Friendly hospitals, there have also been a number of studies evaluating the implementation of these steps collectively. The first of these was a large randomized control study of over 17,000 mother–infant pairs in Belarus, which demonstrated significant improvement in duration of breastfeeding with adherence to the Baby-Friendly Initiative, as well as a significant increases in the rates of predominant and exclusive breastfeeding.⁹ Follow-up studies in Brazil, Switzerland, Taiwan, the United States, as well as other countries have supported these findings; however, the majority of the evidence in support of the Baby-Friendly Initiative is based on research performed outside the United States.^11–15 Research has also shown, perhaps unsurprisingly, that the greater the number of steps which are actually implemented, the more positive the effect on breastfeeding outcomes, again demonstrating the importance of a comprehensive approach to breastfeeding support and promotion.¹⁶

Outpatient Support

However, even with full implementation of the Baby-Friendly Initiative, the rates of exclusive breastfeeding and breastfeeding duration still fall short of the goals of World Health Organization, American Academy of Pediatrics, and other health organizations. Continuation of breastfeeding support in the outpatient setting and appropriate management of breastfeeding complications is equally important as the establishment of a strong breastfeeding foundation during the antepartum and immediate postpartum periods.

There are many approaches to outpatient breastfeeding support. Mothers may receive individual breastfeeding counseling sessions with a certified lactation consultant (IBCLC) or lactation counselor (CLC). Lactation consultants and counselors offer similar services, though lactation consultants have significantly more training than lactation counselors and are generally considered preferable when a significant breastfeeding challenge arises. Individual sessions with a certified lactation provider have been shown to improve rates of breastfeeding initiation, any breastfeeding, and exclusive breastfeeding.^17,18 Research has also demonstrated an association between access to breastfeeding specialists and overall breastfeeding prevalence.¹⁹ Breastfeeding support and counseling may also be provided in group setting, either through professionally led breastfeeding support groups, or peer-led groups. These groups may be affiliated with the hospital, birthing center, or medical office that provided care during pregnancy and delivery or exist privately within a woman’s local community. La Leche League is the most well-known peer-led breastfeeding support group and offers online resources as well. Both professional and peer-led group support has been shown to be helpful.²⁰ Mothers may also receive professional telephone or online support; however, face-to-face counseling and evaluation of the mother–infant dyad is the most beneficial.

Family support, particularly partner support, is also incredibly important for breastfeeding mothers. Lack of partner support is associated with early cessation of exclusive breastfeeding and less maternal confidence, while mothers who describe better partner support are more likely to report higher confidence with breastfeeding in general.^21,22 Research is ongoing to examine whether breastfeeding promotional interventions specifically geared toward fathers may aid in increasing breastfeeding rates.²³ However, from questionnaires of mothers and their partners about their experiences with breastfeeding, it appears partners play an integral role in helping women breastfeed and that breastfeeding should be something parents approach as a team.²⁴ Professionals should also be mindful of involving both parents when breastfeeding challenges arise. Sharing in the burden of breastfeeding with their partner may also help prevent the negative emotional effects that often accompany breastfeeding struggles.

Low Milk Supply

Low milk supply is a common concern in the first few weeks of breastfeeding and one of the most commonly cited reasons for early weaning. For approximately 35% of all mothers who wean prior to 6 months of age, inadequacy of milk production is their primary reason for doing so.²⁵ In those mothers who wean the earliest, in the first week of breastfeeding, the rate of concern regarding milk supply appears even higher, with up to 65% of mothers in one study listing poor supply as their reason for breastfeeding discontinuation.²⁶ However, in studies that examined actual milk production via 24-hour testing and weighing, an imperfect but generally accepted method of estimating breast-milk production, mothers’ perception of insufficient milk supply was not found to be associated with true insufficient supply.^27,28 Mothers most frequently rely upon their perception of their infant’s satiety when making the determination regarding the sufficiency of their supply, though most mothers receive little instruction in interpreting infant satiety cues.^29–31 Mothers who feel their babies are fussy or unsettled or feed too frequently are more likely to feel their milk supply is low and begin supplementing or stop breastfeeding altogether. Alternatively, more confident mothers are less likely to perceive a low supply and are less likely to wean early. Helping mothers understand true indicators of poor milk supply and gain breastfeeding confidence is one simple way to help more mothers reach their breastfeeding goals.

Lactogenesis II is the process whereby breast milk begins to be produced in copious amounts, sufficient to supply the long-term nutritional needs of the baby. The timing of lactogenesis varies, occurring anywhere from 32 to 96 hours after birth, though it is considered delayed when it is more than 72 hours after birth. Lactogenesis begins when the placenta delivers and there is an immediate and rapid decrease in maternal progesterone levels and an increase in circulating levels of prolactin. Milk production is inhibited by peptides within breast milk so frequent emptying of the breast is an important part of ensuring an adequate supply.

Delayed lactogenesis is a common problem and has a significant impact on overall breastfeeding rates. As many as one in four women experience delayed onset of lactogenesis and delayed lactogenesis is a risk factor for formula supplementation, low supply long term, lack of breastfeeding exclusivity, and early discontinuation of breastfeeding.³² Mothers who are more likely to experience delayed lactogenesis include those with diabetes, obesity, premature delivery, polycystic ovarian syndrome, and depression or anxiety treated with SSRIs.³³ Events during labor and delivery also increase the risk, including long and stressful labors, cesarean section, postpartum hemorrhage, and retained placenta. First-time mothers are also more likely to have delayed lactogenesis, with lactation occurring 10 to 35 hours later in primiparous patients when compared to multiparous patients.³⁴

Fortunately, while delayed lactogenesis is common, failed lactogenesis is not. Failed lactogenesis is defined as a condition in which a mother is never able to achieve full lactation with a sufficient milk supply. There is insufficient data to precisely quantify the prevalence of failed lactogenesis, but is estimated to affect around 5% of women, though some report that the number may be as high as 15%.³⁵ It may be a result of either a primary inability of the mother to generate a sufficient milk supply or secondary factors, such as improper breastfeeding management or infant conditions, such as tongue tie, prematurity, or congenital heart disease. Many of the risk factors for delayed lactogenesis are also risk factors for failed lactogenesis, both due to the conditions themselves and mismanagement of delayed lactogenesis.

While many risk factors associated with failed lactation cannot be changed, it is important for mothers and their care providers to be aware of the risk factors for both delayed and failed lactation. Mothers who wish to breastfeed and are at risk of lactation failure should receive early and increased breastfeeding support from qualified lactation consultants and their obstetrics providers. Early recognition of those mothers with an inability to achieve sufficient lactation is essential, as negative early breastfeeding experiences, often centered around a prolonged process in vain to achieve lactation, are associated with depressive symptoms at 2 months postpartum.³⁷ In fact, in a survey of over 10,000 women in the United Kingdom, among those mothers who wanted to breastfeed and were unable, a twofold increase in the risk of postpartum depression was observed.³⁸ In other words, helping mothers breastfeed is not just good for babies, it is important for mothers too. However, equally essential is adequately supporting mothers when it is not going well and providing reassurance that an inability to breastfeed does not make someone less of a mother or negatively impact their baby. There is a delicate balance between breastfeeding promotion and promotion of maternal well-being. A formula-fed baby with a happy mother is always better than a breastfed baby with a guilt-ridden and depressed mother.

That said, there are many possible solutions to poor supply that may help mothers achieve their breastfeeding goals; however, the first step is to determine if there is a modifiable health condition which is impairing production. Initially, a complete examination of the mother should be performed, ruling out an anatomic or surgical breast abnormality, mastitis, retained placenta, or hormonal abnormality. Blood work should be obtained, examining thyroid and testosterone levels, as well as a blood count to look for anemia. The infant should also be examined for signs of malnutrition, dehydration, or structural abnormalities of the mouth, including tongue tie, which is the most common. The infant’s latch should be observed for adequacy. If the mother has a history of any condition with impaired glucose control, such as diabetes, obesity, or PCOS, metformin may also be considered. It has been suggested through improving insulin sensitivity, metformin may improve lactogenesis, as modulation of insulin receptors is observed in the transition of colostrum to breast milk and aids in the increase in fat and protein synthesis observed in the later stages of lactogenesis.³⁹ The safety of metformin in lactation has been well established, with no increases in the risk of neonatal hypoglycemia having been observed.⁴⁰ Studies are ongoing examining the efficacy of metformin in treating impaired lactation.

If examination fails to demonstrate an underlying medical or latch-related cause for impaired milk supply, the first treatment usually recommended is increased stimulation of the breast and expression of breast milk. This can be done by shortening the interval between feedings, offering both breasts at each feeding, and pumping in between or immediately after feeds. Interestingly, there is limited data demonstrating the efficacy of this practice in improving milk supply, though there is some evidence that complete emptying of the breast increases the rate of lactogenesis, providing support for the advice to pump following feeds to ensure the breast is empty.⁴¹ Yet, many mothers drive themselves to exhaustion, in an endless cycles of nursing and pumping, often advised to pump up to 15 or 20 minutes following each feeding, even when no milk is being expressed. This schedule is difficult if not impossible to maintain. A more reasonable approach would be a trial of a short duration of pumping following daytime feedings, with the priority given to achieving effective and frequent nursing sessions and adequate maternal rest. Breast massage during nursing and pumping may help increase the amount of milk expressed.⁴² Newborns, especially in the setting of low milk supply, should be nursing at least every 2 to 3 hours. If the baby is going longer stretches without nursing, an additional pumping session could be considered to encourage supply. This is particularly important if the baby is receiving formula supplementation and, when supplementing, formula should always be offered after the infant has nursed from both breasts, not as a replacement for a nursing session.

Another proposed solution to low supply is increased maternal hydration and caloric intake, but there have only been a few studies examining these recommendations. The few studies on increased hydration failed to show that hydration had an impact on breast-milk production, though proper hydration is generally regarded as important for nursing mothers.⁴³ One older, small study examining the caloric intake of mothers with and without insufficient milk supply demonstrated that mothers with sufficient supply were eating 50% more than their counterparts with insufficient supply and that increasing calories did improve milk supply.⁴⁴ While small in scope, it does support the current recommendations that nursing mothers maintain a caloric intake of at least 500 kcal above non-lactating women. Other studies have examined whether specific nutrient supplementation may increase milk supply; however, this practice has not been shown to be beneficial.⁴⁵

Galactogogues are also commonly recommended to lactating mothers who are struggling with supply. Galactogogues are substances believed to augment maternal milk synthesis.

Most of the studies on both pharmacologic and botanical galactogogues are limited by size, inconsistency in alternative breastfeeding support provided, and lack of randomization, controls, or blinding and, consequently, most experts are reluctant to recommend the routine use of galactogogues for low milk supply.⁴⁷ However, some agents may be beneficial and providers should consider them if alternative methods of improving milk supply have been ineffective. The most promising pharmacologic agent appears to be domperidone, which was associated with increased milk production in two well-conducted randomized trials and is the only galactogogue supported by this level of evidence. It is usually administered in doses of 10 to 20 mg, three to four times per day, for up to 8 weeks. This medication is not FDA approved for this purpose and is, in fact, strongly discouraged by the FDA due to concerns about cardiac arrhythmias associated with its use, though these cases were rare and in a different patient population.⁴⁸ The existing evidence does not seem to support the FDA’s level of concern and domperidone is widely available for the purpose of increasing milk supply outside of the United States. Metoclopramide, brand name Reglan, has also been well studied as a galactogogue and demonstrated some efficacy in observational studies; however, the one randomized trial performed failed to show a benefit. It is usually administered at a dose of 30 to 45 mg per day, divided into three or four separate administrations, for 1 to 2 weeks, followed by a weeklong taper. Metoclopramide is associated with more maternal side effects than domperidone, including restlessness, drowsiness, fatigue, diarrhea, depression, and even acute dystonic reactions in a very small number of women (<0.05%). However, metoclopramide is the most easily accessible pharmacologic galactogogue in the United States and may be the only option some women and their providers have. Sulpiride, an antipsychotic medication that has been observed to cause galactorrhea in both men and women, is another suggested pharmacologic galactogogue; however, it is also associated with neurological side effects, in addition to weight gain, so it is less commonly used.⁴⁷

As for biologic galactogogues, shatavari, torbangun, fenugreek, and milk thistle have all demonstrated some efficacy in increasing milk production in a small number of flawed studies. The extensive historical use of biologic galactogogues among many cultures also certainly suggests some benefit, as ineffective remedies tend to fall out of favor with time.⁴⁹ However, at this time and in terms of actual evidence, most of the “natural” remedies fall into the “may help, unlikely to hurt” category. Given the large percentage of women who experience low-supply concerns, there is definitely a need for more research into the potential application of galactogogues within the broader treatment of impaired lactogenesis.

Persistent Sore/Cracked Nipples

Nipple pain is another common cause of breastfeeding discontinuation. There are many possible causes for nipple pain including:

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  Suboptimal positioning and poor infant latch

  
  
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  Infant ankyloglossia (tongue tie)

  
  
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  Nipple friction and fissures

  
  
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  Infections

  
  
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  Milk blisters or blebs

  
  
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  Raynaud’s phenomenon

The first recommendation for persistent nipple pain is an evaluation of positioning and latch. The nursing mother should be encouraged to assume a comfortable seated or side-lying position. When sitting, she should be semi-reclining, with a supported back, relaxed shoulders, and feet on the ground. The baby should be lying across the mother’s body, supported by a nursing pillow if needed in order for the infant’s nose to be in line with the mother’s nipple and head slightly tilted back. The baby’s head and neck should be supported, but not gripped and the chin should be brought to the nipple, waiting for the baby to open their mouth wide and take the breast from the base of the areola, over the nipple, toward the top of the areola. A baby with a good latch should have a mouthful of breast, not just the nipple. The chin should be touching the breast and the nose should be tilted upward, allowing the baby to breathe without difficulty. Many lactation counselors and consultants encourage women to manually grasp their breast with their hand in a “C” fashion, creating a “breast sandwich” for the baby to latch onto, which can also be helpful. If the latch is uncomfortable, a finger can be inserted into the baby’s mouth to break the suction and position the baby again. Helping mothers achieve proper breastfeeding positioning and latch has been shown to promote longer breastfeeding durations and decrease the incidence of breastfeeding problems.⁵⁰ Furthermore, correction of improper positioning and latch has been shown to improve nipple pain in up to 65% of patients.⁵¹

Flat or inverted nipples can create a particular challenge in achieving a proper latch. Often, this condition will self-correct through the process of infant suckling. Alternatively, a simple device, referred to as a Latch Assist, that applies a small amount of suction to the nipple prior to nursing can help draw out the nipple prior to infant latching and decrease related nipple pain issues. Nipple shields can also assist in achieving a latch in the setting of flat or inverted nipples, as well as assisting mothers with generalized nipple pain. Nipple shields have a mixed reputation in the literature and among lactation consultants, due to concerns that they prevent complete emptying of the breast, impairing the development of proper milk supply, and prevent babies from being able to independently latch, thus interfering with long-term breastfeeding success. However, they are generally regarded positively by the mothers utilizing them for pain or latch issues and are often credited by mothers for preventing their discontinuation of breastfeeding.⁵² While some studies have shown issues with supply surrounding shield use, the majority of studies have not shown this and nipple shields may offer a short-term solution to nipple-related breastfeeding concerns. The majority of women do not utilize shields for more than 6 weeks.

Infant tongue tie is another possible cause of persistent nipple pain. There is much controversy in the literature regarding the definition of infant ankyloglossia, characteristics of the varying classes of the condition, its clinical significance, and appropriateness of surgical intervention. The incidence ranges from 0.02% to 5%, depending on the definition applied, though in babies with breastfeeding challenges the incidence may be as high as 13%.⁵³ Frenotomy, a simple “snipping” of the tongue tie is frequently proposed for infants with tongue tie who have latch-related issues or mothers reporting significant nipple pain with breastfeeding. It has been shown in some studies, including randomized controlled trials, to reduce nipple pain and improve breastfeeding efficacy by maternal self-report; however, the total body of evidence in support of the procedure is generally regarded as low or insufficient.^54–57

Milk blebs or blisters are small, raised white bumps that appear on the surface of the nipple and are usually associated with pain. This may or may not be associated with a blocked duct higher up in the breast and is thought to be a result of epithelial overgrowth of the distal portion of the duct or an accumulation of particulate or fatty material in the area. Sometimes they develop early in breastfeeding due to a poor latch, but they can also develop in isolation later in breastfeeding when no latch issue or other breastfeeding complaint is present. There is little research in regards to effective treatments of milk blebs; however, it is generally recommended that an attempt be made to open the bleb by warm compresses to the nipple, rubbing the area with a towel, or piercing the bleb with a sterile needle if needed and manually draining it. Epson salt soaks may also help soothe blebs or other cracks or fissures of the nipple, as well as promote healing and prevent further infection of the nipple. Topical antibiotics, such as mupirocin ointment, can also be considered in the setting of blebs and nipple fissures, as an underlying infectious etiology is possible and the opening in the nipple may serve as an entry point for bacteria and increase the risk of mastitis. Research has shown that mothers who applied mupirocin to nipple cracks and openings reported significantly improved resolution of these complaints.⁵⁸

Raynaud’s phenomenon is a less common, but commonly misdiagnosed cause of a nipple pain. It is caused by vasoconstriction of the arterioles supplying the nipple and can result in severe pain. It is most commonly mistaken for candidiasis or thrush and many mothers and their babies are inappropriately treated with multiple rounds of antifungal medication prior to Raynaud’s being properly identified. Hallmarks of the condition are significant nipple pain, blanching of the nipple, followed by blue or red discoloration, and symptoms occurring outside of feeding episodes as well, particularly with cold exposure. The bulk of the literature concerning the phenomenon consists of case reports and series. What evidence does exist suggests autoimmune disease and a history of breast surgery may be predisposing factors. Conservative treatment includes avoiding cold exposure, breastfeeding in warm environments or under a blanket, applying warm compresses to the breast, avoiding caffeine and nicotine, and the addition of oral supplements including calcium, magnesium, fish oil, and evening primrose. However, medical management is commonly needed to improve symptoms and consists of oral nifedipine, a calcium channel blocker, which is typically given for a 2-week course at a dose of 5 mg, three times daily, or one 30 mg delayed-release tablet daily. Treatment beyond 2 weeks is usually unnecessary. Nifedipine is safe in both pregnancy and breastfeeding and has demonstrated efficacy in treating Raynaud’s symptoms.⁵⁹

Other nonspecific treatments for breastfeeding-associated nipple pain include glycerin gel dressings, lanolin cream, and all-purpose nipple ointment (APNO). As with other breastfeeding remedies, there is limited research into these specific treatments and the research that does exist does not conclusively recommend their use. However, interestingly, the research does show that most women report significant improvement in their nipple pain symptoms after approximately 10 days, regardless of the remedy they utilize. The reassurance of the apparently self-limited nature of nipple pain may be enough to help women continue breastfeeding during the critical first weeks during which most women discontinue breastfeeding.⁶⁰