Inadequate glandular tissue.
Peripartum support
Pain management decisions should balance the possible adverse effects on the infant. Meperidine should be avoided, since it has a long neonatal half-life and may accumulate with breastfeeding. Codeine should be avoided because of the rare but serious consequences in the case of an ultra-rapid metabolizer. Morphine, Nalbuphine, and butorphanol have lower transfer into human milk.[45] Effects of epidural anesthesia on breastfeeding are still being studied.
Postpartum support
Providers should continue to encourage successful breastfeeding by identifying any concerns and referring for lactation consultation and or support groups when needed. The infant should be seen by its own health-care provider within 48 hours after discharge.[2]
Breastfeeding techniques
Proper positioning to keep the baby’s head, shoulders, and hips in alignment while facing the mother is important. Effective newborn positions of comfort include the so-called football (or clutch) hold, the cross-cradle hold, and the cradle hold. The side-lying and football positions are preferable after a cesarean delivery.
An important part of proper technique is learning how to achieve a proper latch. An effective latch will not cause pain to the mother, and allows freely flowing colostrum and milk to be transferred to the infant, which in turn leads to development of good milk supply. With nose pointed to nipple, and with a wide open mouth, the baby should take as much areola in the mouth as possible, chin into the breast, with the lips flanged out “like a fish” (Figure 3-2). Once the baby is latched well, suckling begins with bursts of 10–20 sucks before a pause; increased milk volumes yield audible swallows. Typically newborns feed about 15–20 minutes per breast, but watching for signs of continued suckling are more important than watching the clock. When sucks slow to 3–4 sucks before a pause, the baby is likely finishing that breast. Breast compressions to stimulate breast emptying while babies are well latched can be helpful. A mother should be taught to help the baby release the breast by inserting her finger gently into the corner of the mouth to break the seal if necessary. Newborns eat at least 8–12 times per 24 hours and will sometimes feed in “clusters” with very frequent feeds, followed by a longer break between feedings.[45] Pacifiers should generally be avoided for the first 3–4 weeks until breastfeeding is well established.[2]
Early breastfeeding challenges
If the mother has substantial pain with latching, or the infant is clicking, indenting its cheeks, or not sustaining a latch, help may be needed. Early intervention to correct latch and improve milk transfer can prevent nipple damage, poor infant weight gain, and low milk supply. Mothers with abraded or cracked and bleeding nipples should be seen urgently by a lactation professional. If direct breastfeeding is ineffective or must be interrupted, continued breast emptying is critical.
Nipple pain
Nipple pain is typically due to problems with latch. Pain that persists throughout a feeding, and between feedings should be assessed with an evaluation of mother’s breasts and nipples, an oral motor examination of the baby, and observation of a feeding with pre- and post-weight check by a lactation professional. Help with repositioning and latch can prevent further problems, and moisture-retaining occlusive dressings can improve wound healing. A thorough protocol for sore nipples outlining a decision diagnosis tree and treatments is available.[46] If direct breastfeeding is impossible due to severe pain, continued breast emptying is critical to preserve the milk supply until the situation is resolved.[45]
Engorgement
The spectrum of engorgement ranges from physiologic fullness of the breasts, particularly around days 3–5, to severe symptomatic engorgement with firm and painful overfilling and edema. Moderate symptoms of engorgement are experienced by most lactating women.[47] Engorgement must be differentiated from a plugged milk duct and mastitis. Engorgement can occur following an abrupt change in feeding frequency or missed feedings. See Table 3-3 for differential diagnosis of engorgement.
Primary prevention and treatment of engorgement are frequent breastfeeding with effective milk removal. Measures to improve milk removal every 1–3 hours include moist, warm packs or a warm shower 20 minutes before a feeding; breast massage with hand expression to help the baby latch to the full breast; and use of hand expression or electric pump if infant latch is not possible. Comfort measures include a supportive bra and analgesics.[47]
Plugged ducts
Localized areas of milk blockage that commonly present as a painful knot or cord within the breast are possibly plugged ducts; they may decrease in size with nursing or pumping. They can occur when a mother wears tight or constricting clothing, with a change in the feeding pattern, or with inadequate draining of the breast. Mothers with a plugged duct feel well and have no fever or signs of systemic illness. Treatment involves application of heat prior to nursing or pumping, and massage of the affected area before and during feeding. Pointing the infant’s nose to the area of blockage during breastfeeding may improve drainage. If a plugged duct does not resolve within 48–72 hours or systemic symptoms develop, the mother should be evaluated.[45]
Mastitis
Affecting 3%–20% of breastfeeding women, mastitis typically occurs in the first six weeks of lactation.[48] Clinical signs and symptoms of mastitis include a single localized and wedge-shaped area that is warm, tender, erythematous, and edematous. Mothers often have myalgias, fever, and flulike symptoms. Predisposing factors include damaged nipples, infrequent or missed feedings, inefficient milk removal, milk oversupply, milk bleb, or maternal stress and fatigue. Treatment involves frequent and effective milk removal from the affected breast by direct breastfeeding, hand expression, and/or pumping. There is no risk to healthy term infants who continue to breastfeed from a breast with mastitis.
Supportive measures for mastitis include maternal rest, appropriate fluid intake, and proper nutrition. Heat application before breastfeeding will encourage milk flow. Ibuprofen effectively reduces inflammation, improves milk flow, and provides analgesia. If symptoms do not resolve within 12–24 hours, antibiotics should be prescribed for presumed infection. The most common pathogen is penicillin-sensitive S. aureus. Other causative organisms include Streptococcus species, Escherichia coli, Haemophilus influenzae, Klebsiella pneumoniae, and Bacteroides species. Accordingly, first-line treatment is dicloxicillin, 500 mg four times per day for 10–14 days, or a first-generation cephalosporin. For penicillin-allergic mothers, cephalosporins are usually safe, but clindamycin is recommended for severe penicillin allergy. Methicillin-resistant S. aureus (MRSA) is emerging, so local resistance patterns should be determined. Most MRSA strains remain susceptible to vancomycin or trimethoprim/sulfamethoxazole,[48] which are safe with breastfeeding.[39, 40] Inadequately treated mastitis can progress to breast abscess. If mastitis is recurrent or chronic, further investigation is warranted. A midstream clean-catch of expressed milk may be helpful to identify the causative organism and select appropriate antibiotic coverage. Multiple recurrences in the same location warrant investigation to rule out an underlying mass or other abnormality.[48]
Breast abscess
A breast abscess is a walled-off area within the breast containing purulent material. It occurs in 5%–11% of women with mastitis.[45] Symptoms are similar to mastitis, with additional fluctuant mass not responsive to appropriate treatment. Standard therapy includes antibiotics and surgical drainage with culture of the abscess fluid to determine sensitivity of the organism. Breast abscesses may be drained by needle aspiration, but serial aspirations may be required.[48] Breastfeeding should continue on the unaffected breast and may continue on the affected breast providing the infant’s mouth does not come into contact with purulent drainage or infected tissue.
Milk fistula
This rare complication follows breast biopsy during pregnancy and lactation or after a nipple piercing. Mothers have continuous leakage from the affected area, and although inconvenient, fistulae usually resolve over time.[44]
Breast masses
The incidence of breast malignancy during pregnancy and lactation ranges from 1:3,000 to 1:10,000 women.[44] Among women diagnosed with breast cancer, 3% will be pregnant or lactating, so a new breast mass warrants careful evaluation. Mammography is safe during lactation, but the breasts should be emptied to allow optimal visualization. Ultrasonography is also safe during lactation to characterize the mass. Fine needle or excisional biopsy can be performed during lactation without prolonged interruption of breastfeeding. Most masses are benign, and 30% have pathology related to lactation, such as lactating adenoma, infarcted fibroadenoma, hypertrophied breast tissue, galactocele, inflammatory lesion, or papilloma.[45]
Bloody nipple discharge
During early lactation, nipple trauma may cause bloody discharge, which typically resolves when the latch is corrected. Sometimes mothers report brownish-red milk (“rusty pipe syndrome”) that occurs as milk ducts are distended and capillaries leak. Infants can continue to feed despite bloody nipple discharge if feedings are tolerated. If discharge is persistent and arises from a single duct, further evaluation is warranted, including a thorough breast exam to identify any masses. Most commonly, single duct bloody discharge arises from a benign intraductal papilloma, but intraductal carcinoma can occur.[44, 45]
Breast evaluation during lactation
Women may continue self-breast examinations during lactation, although the exam is challenging due to changes from lactation. Clinical breast exams should be performed at the onset of pregnancy, at the postpartum visit, and at each annual visit.
Maintenance of milk supply
Online instructions are available for increasing milk supply.[50] The best way to ensure a good milk supply is frequent and effective milk removal, preferably by direct breastfeeding, or by hand expression or an electric pump if needed. If the baby is not effectively removing milk, consultation with a lactation consultant can help to improve breastfeeding, and pumping after breastfeeding can ensure complete milk removal. Galactogues are substances or medications used to improve milk supply. Limited evidence for their efficacy exists.[49]
Long-term breastfeeding issues
Maternal nutrition
Women should be counseled to eat a healthy, well-balanced diet (one generally low in fat, sugar, and salt and high in fruits, vegetables, and fiber), with consideration for barriers of food insecurity, cost of healthy foods, and low nutrition literacy. Women who were not at a healthy weight before pregnancy or who experienced nonoptimal weight gain during pregnancy may benefit from dietitian consultation. For obese women, supervised weight loss achieved through healthy eating and physical activity is safe during lactation. Continued supplementation with prenatal vitamins is recommended daily.
Maternal illness
In most cases, mothers may continue to breastfeed in the face of a medical illness; in acute infections breast milk contains protective antibodies against offending organisms. Chronic illnesses offer no contraindication to breastfeeding, unless mothers are taking medications that are unsafe for breastfeeding and no alternative can be substituted. If a mother requires surgery, a suitable anesthetic agent can be used to reduce effects on nursing.
Extended and tandem breastfeeding
Breastfeeding of an older child may continue during a mother’s next pregnancy, provided there are no signs of preterm labor because nursing can produce uterine contractions. Pregnancy-associated nipple pain, fatigue, and nausea, as well as declines in milk production at the end of the second trimester may lead to mother- or baby-initiated weaning.
Breastfeeding support while mother and infant are separated
Reasons for maternal-infant separation and/or for inability to directly breastfeed include return to work or school, hospitalization of the mother and illness, prematurity, or congenital anomalies of the infant.
Preparing to return to work or school
Ideally, maternity leave should be maximized as much as is possible to allow time for establishment of breastfeeding, followed by a gradual return to work or school. Mothers may need to be provided with a letter to their employer regarding worksite lactation support laws, benefits, and need.[36, 45] Mothers should practice expressing milk and alternative (i.e., bottle, possibly from someone other than the mother) feeding methods two weeks prior to return to work or school if possible. Adding a pumping session each day allows milk to be stored for later use. When separated, mothers should express milk every three to four hours, or approximate the frequency of usual infant breastfeeding, in order to maintain milk supply.[45] A childcare provider may bring the baby to the mother’s worksite for breastfeeding during breaks as another option. Public breastfeeding laws in many communities protect women from indecency charges and help to ensure rights to breastfeed in any public or private location.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
