Breastfeeding: management of common difficulties

There are many reasons why mothers stop breastfeeding or start with formula feed, even though they decide to breast exclusively. The reason can be maternal, i.e. related to the mother of the baby or can be related to the baby itself. Hence nurses need to use all the learnt skills to support mothers through these difficulties.

Common breast-feeding difficulties:

• Not enough milk.
• Crying baby.
• Refusal to breast feed.
• Physical conditions.
• Inverted/flat nipples.
• Sore nipples.
• Breast engorgement.
• Plugged ducts.
• Mastitis.
• Fungal infection.

A. Not enough milk

The most common reason women stop breastfeeding is that they believe they do not have enough milk.

Causes

• Mother: Lack of confidence/lack of information regarding breastfeeding management.
• Mother worried that the baby did not seem satisfied as he takes frequent feeds and he was fussy after feeds.
• Young mothers lack a strong support system.
• Sociocultural influence: Bottle feeding practice in the family or influence from the social media.
• Misconceptions of normal baby behavior can create anxieties in inexperienced parents.
• Poor milk extraction, if baby
• Does not get fed frequently enough.
• Cannot latch on properly.
• Is separated from the mother.
• Is fed with formula feed.
• Is sleepy and difficult to keep awake during the first several days after birth.
• Preterm babies have feeding difficulty due to poor sucking reflex.
• Baby’s take breastfeed longer and more often during growth spurts period (2/3/6 weeks and 3 months of age).

Possible signs that a baby is not getting enough breast milk

• Baby cries often, very frequent/long breastfeeds.
• Baby refuses to breastfeed.
• Baby has hard, dry, or infrequent small stools.
• No milk comes out when mother expresses.

Reliable signs

• Poor weight gain: Less than 500 g per month (for the first six months of life, a baby should gain at least 500 g in weight each month).
• Small amount of concentrated urine: Less than 6 times per day.
  (an exclusively breastfed baby who is getting enough milk usually passes dilute urine at least 6-8 times in 24 hours).

How to help mothers with not enough milk

• Many mothers worry about the size of their breasts. Women with small breasts often worry that they cannot produce enough milk. Assure mother that differences in the sizes of breasts are mostly due to the amount of fat, and not the amount of tissue that produces milk. Hence mother with any size and shape of breast can produce enough milk.
• Find out whether the baby is really getting enough breast milk or not (using the reliable signs).
• If the baby is not getting enough breast milk, find out the reason and help the mother.
• If the baby is getting enough breast milk, but the mother thinks that he is not, then build mother confidence.
• Position baby so that the baby can latch on properly.
• Advice mother to breastfeed often and let baby decide when to end the feeding.
• Offer both breasts at each feeding. Have baby stay at the first breast as long as he/she is sucking and swallowing. Offer the second breast when the baby slows down or stops.
• Avoid giving baby formula feed in addition to breast milk, especially in the first 6 months of life.
• Try to feed more often or try to stimulate more milk production by expressing by hand or using a breast pump.

Healthy eating for women who are breastfeeding

• A lactating mother requires nutritious food to secrete adequate quantity/quality of milk and to safeguard her own health.
• The daily diet of the lactating woman should contain an additional 500 calories.
• Mother should take three meals plus two extra snacks in each day.
• The foods included in diet should provide adequate contents of iron, calcium, vitamins and minerals required by lactating mother.
• Nurse should advice the lactating mother on including following variety of foods,

Advice for breastfeeding mother

• Limit tea/coffee as it hampers iron absorption.
• Take iron, folate and calcium supplements regularly, at least for 3 months as prescribed by physician.
• Drink at least 6-8 glasses of water in a day.
• Avoid alcohol and tobacco

B. crying baby

Introduction

Many mothers start unnecessary foods or fluids because they think that their baby ‘cries too much. They think that their babies are hungry and they do not have enough milk. An important way to help a breastfeeding mother is to counsel her about her baby’s crying.

Reasons why babies cry

• Discomfort: Dirty/wet nappy, feeling too hot/cold.
• Tiredness: Too many visitors.
• Illness or pain.
• Hunger: Not getting enough milk, growth spurt.
• Mother’s food: Mother should avoid eating gas producing foods as this can causes colic for baby.
  Foods listed below are gas producing and should be avoided by lactating mothers.
• Vegetables: Onions, celery, carrots, brussels, sprouts, cucumber, cabbage, cauliflower, radishes, beans, peas, potatoes.
• Fruit: Bananas, apple, apricots, prunes, dried fruit (grape).
• Fatty foods especially fried foods.
• Caffeine and cigarettes may pass through breast milk and hence should be avoided.
• Colic: Refers to a baby crying continuously at certain times of day, often in the evening.
• Baby pulls up his legs, when he has abdominal pain. He may appear to want to suckle, but it is very difficult to comfort him.
• Crying usually becomes less after the baby is three months old.

How to help mothers whose babies cry a lot

• Find the cause of the crying so that you can help the mother.
• Help the mother to talk about how she feels and empathize with her. She may be tired, frustrated and angry.
• Assess a breastfeed to check baby’s suckling position and the length of a feed.
• Nurse may suggest and demonstrated various positions to comfort a crying baby to mothers.

C. Refusal to breastfeed

Meaning

Refusal by the baby is a common reason for stopping breastfeeding. It causes great distress/frustration to the mother.

Causes of breast refusal

• Pain from bruise (vacuum, forceps).
• Blocked nose, sore mouth (thrush, teething).
• Any illness.
• Difficulty with breastfeeding technique: Poor attachment, pressure on back of head when positioning, mother shaking breast and restricting length of feeds.

Change which upsets baby (3-12 months)

• Separation from mother (e.g. if mother returns to work).
• New care giver or too many care givers.
• Change in the family routine.
• Mother is ill.
• Mother has breast problem, e.g. mastitis.
• Mother has menstruation cycle.
• Change in smell of mother.

How to Help Mothers whose Babies Refuse the Breast?

• Keep baby close to mother (skin-to-skin contact).
• Offer breast whenever baby is willing to suckle.
• Help mother to position baby so that he can attach easily to the breast.
• Express breast milk into baby’s mouth or feed baby by cup/spoon/Palada.
• Advice mother to breast feed in different positions.
• Avoid pressing the back of baby’s head or shaking her breast.
• Avoid using bottles, pacifiers.
• Consult doctor, if same problem persists.

D. Physical conditions

1) inverted/flat nipples

Meaning

Refers to nipples that turn inward instead of pointing outward/flat/do not protrudes. Inverted or flat nipples make breastfeeding harder. Mother can easily test whether her nipples are flat or inverted by gently compressing areola about an inch behind nipple. If the nipple does not become erect, then it is considered to be flat. If the nipple retracts, it is considered to be inverted.

Management

Build the mother’s confidence: Explain to mother that;

• It may be difficult at the beginning, but with patience and persistence she can succeed.
• Baby suckles from the breast-not from the nipple.
• As baby breastfeeds, he/she will stretch mother’s nipple out.
• Skin-to-skin contact helps baby to explore her breasts.
• Mother should hold her baby in a proper position so that he/she can attach better to the breast.
• If a baby is not able to attach/suck breast, mother can express milk and feed the baby by Palada/cup/spoon.
• Stimulate nipple: Nipple may be stimulated/pulled by using manual or syringe method.
• In manual method, mother is taught to use her fingers and try to pull nipples out.
• In syringe method the mother is taught to use syringe as demonstrated to gently suck and pull out the inverted nipples.

2) Large nipples

• The latch for babies of mothers with very large nipples will improve with time as the baby latch and sucks well.
• If mother has a good milk supply, baby will get enough milk even with a latch that is not perfect.
• If a baby cannot suckle effectively (first/second week), express breast milk and feed the baby with a Palada/cup/spoon.
• Expressing milk helps to keep breasts soft, so that it is easier for the baby to attach to the breast and it also helps to keep up the supply of breast milk.

3) Sore nipples

Introduction
Nipples may become sore and tender with the initial latch and first few sucks. It usually occurs in the first week (3-6th days) after delivery. Untreated sore nipple can progress the development of a crack, which offers a portal of entry for bacteria and yeast that are present on the skin surface and lead to development of infection. Pain from sore nipples may decrease the women’s desire to put her baby to breast, this in turn leads to engorgement and reduced milk production.

Causes

• Imprpoer positioning/latching: poor latch is evident after introduction of an artificial nipple from a bottle/pacifier.
• Inadequate milk supply; baby sucking on empty breast.
• Baby falls asleep at breast and clamps down on breast.
• Improper breaking of suction when taking the baby off the breast.
• Prolonged exposure of the nipple to moisture.
• Improper use of breast pumps.
• Oral thrush for baby.
• Sensitivity to the topical ointments applied to the breast.
• Nipple soreness may develop when the baby begins teething.

Signs and Symptoms

• Mother feel mild pain or discomfort while feeding.
• Nipple trauma: Erythema, edema, fissures, blisters, yellow/dark spots and ecchymosis.

Management

• Ensure that baby is put on (position/latching) and comes off breast properly.
• Check to ensure that nipple is back far enough in baby’s mouth.
• Hold baby closely during feeding so nipple is not constantly being pulled.
• Assess the baby’s oral cavity (tongue and frenulum) for oral thrush.
• Breast feed baby in different positions to provide relief to the sore area.
• Teach mother break suction with her finger between the baby’s gums before removing him off the nipples.
• Mother can place ice in a wet cloth and apply the cloth to her nipples prior to a feed.
• Start feed with least sore breast.
• Eliminate prolonged non-nutritive (comfort) sucking at the breast.
• Massage and compress the breast each time the baby pauses during a feed.
• After feeds, mother may apply her own little expressed milk to the sore area and allow for air drying of the areola. This helps to heal a sore nipple.
• If the mother is unable to tolerate any suckling, she may choose to pump her milk with a breast pump.
• Advice mother to wash breasts in water only (avoid soap/detergent, as it removes natural oils from the skin and makes soreness more likely).

4) Breast engorgement

Meaning
After delivery, breasts become fuller/heavier/slightly tender, when they start producing milk. As regular frequent feeds progress, this normal fullness diminishes. Breast engorgement refers to over fullness of a breast, which occurs when milk is inadequately/infrequently removed from the breast.

Causes

• It develops during 3rd-5th day after giving birth.
• It can happen at any time if there is:
• Oversupply of milk.
•  Delay in starting breastfeeding after birth.
• Poor attachment to the breast.
• Infrequent removal of milk.
• Restriction of duration (length) of breastfeeding.

Signs and Symptoms

• The skin looks shiny and transparent.
• Nipples may become flattened/inverted.
• Engorgement adversely affects the let-down mechanism, which decreases the production of breast milk.
• If milk is not removed, it can lead to plugged ducts or a breast infection (mastitis).

Management

The nurse should advice the mother on following:

• Do not ‘rest’ the breast: Start breastfeeding immediately after birth.
• Breast feed every 2-3 hourly, including night feeds (at least 8 times per 24 hours).
• Breast feed in response to baby’s cue and for as long as the baby needs.
• Breast feed with correct latch and position.
• Discourage use of artificial nipples as they do not promote efficient suckling and may confuse the baby when he goes back to the breast.
• Breastfeed often on the engorged side to remove the milk, keep the milk moving freely, and prevent breast from becoming too full.
• When engorgement has progressed to such a degree that the baby is unable to latch onto the breast, mother can be encouraged to express milk before feed to soften the areola.
• Massage the breast and apply cold compresses between feeds. This helps to decrease the mother’s discomfort.
• Take enough rest, proper nutrition, and fluids.
• Wear a well-fitting, supportive bra that is not too tight.
• Apply cabbage leaves on engorged breasts and hold them in place with a well fitted bra. When mother feels softening of breast tissue/leaking of milk, the cabbage leaves can be removed and put her baby to breast.

5) Plugged ducts

Introduction

Plugged ducts are common in breastfeeding mothers. Blocked duct occurs when the milk is not removed from part of a breast. Pressure then builds up behind the plug, and surrounding tissue gets inflamed. A plugged duct usually happens in only one breast at a time.

Causes

•  Incomplete milk removal (poor feeding technique).
• Outside pressure on specific areas of breast (tight bra, baby carrier).
• Consistently holding/carrying/rocking the baby in the same position.
• Sleeping in a position that puts pressure on the breast.
• Pressure from breast pump flange.

Signs and Symptoms

• Localized soreness.
• Swelling, lumpiness.
• Slight pain.

Management

The Nurse should advice the mother on following:

• Breast feed more frequently on affected breast.
• Beginning feed on the breast with the plug will help with removal of the plug by taking advantage of more vigorous suck early in the feed.
• Breast feed baby with his chin pointed toward the plugged duct.
• Feed baby in different positions so that every part of the breast gets emptied.
• Avoid positions that put pressure on one spot for long periods, e.g. always sleeping on one side/holding baby one way/ baby sleeping on mother’s chest.
• Use warm compresses/take a warm shower and gently massage breast in the direction from the plug towards the nipple.
• If baby does not remove milk, express milk after feeds.
• Do not stop breastfeeding, as this could lead to engorgement.
• Wear a well-fitting/supportive bra.

6) Mastitis

Meaning
Refers to breast infection, which develop from the crack in the nipple skin that provides a pathway for microorganisms (Staphylococcus aureus) into the breast.
Causes
This condition is associated with:

• Milk stasis (lack of flow).
• Breast engorgement/plugged duct and sore/cracked nipple.
• Trauma to the breast.

Signs and Symptoms
Mastitis affects part of the breast, and usually only one breast. A woman with mastitis has following signs/symptoms:

• Localized soreness.
• Inflamed area of breast becomes red, hot and tender to the touch.
• Fever, moderate to severe pain.
• Yellowish discharge from the nipple.

Management
The nurse should advice the mother with mastitis on following:

• Breast infections are located outside the duct in surrounding breast tissue and do not enter the milk. Therefore, it is reasonably safe for the baby to breastfeed.
• Breastfeed the baby in different positions with proper attachment: This helps to remove milk effectively.
• Begin feed on the affected breast first will allow the baby’s more vigorous suck to drain the milk.
• If baby does not remove milk, express milk after feeds.
• Apply warm, moist compress to the inflamed area before the feed.
• Apply cold compress after the feed to soothe the pain.
• Gently massage breast in the direction from the sore area towards the nipple.
• Wear a well-fitting, supportive bra, since a tight bra can constrict milk ducts.
• Take adequate rest for several days.
• Antibiotic therapy: If temperature is higher than 100°F and signs of breast inflammation have not resolved within 24 hours, start antibiotic therapy for a course of 10-14 days as prescribed by physician.

7) Fungal infection

Meaning
Refers to a fungal/yeast infection caused by candida albicans that is commonly found in the mouth, gastrointestinal tract and vagina of healthy persons. Under normal conditions, candida’s growth is kept in check by the body’s flora. Predisposing factors that may disturb the normal and lead to fungal infection include diabetes, pregnancy, oral contraceptive use, poor diet, antibiotic therapy, steroid therapy, immunosuppression condition, obesity and HIV. 791

How Fungal Infection Develops?

The baby contracts oral fungal infection (thrush) as he passes through the birth canal and in turn, transfers the infection back to mother’s nipple when he breast feeds.

Signs/Symptoms

• A fungal infection is associated with nipple damage early in lactation. Mother presents with severe sore nipples.
• Mother may presents with burning pain in breast and nipple during/after feeds.
• White patches or redness on the nipple.
• Baby’s mouth shows presence of oral thrush. This can be observed as white patches that look like milk curds and they cannot be wiped off.

Management

• Drugs: Treat both the mother and the baby’ infected areas such as baby’s mouth, mother’s nipple, diaper area and vagina with following antifungal drugs as prescribed by the physician after each feed;
• Nystatin/clotrimazole/miconazole/ketoconazole nitrate.
• Oral yeast infection: Rinse baby’s mouth with water after breastfeeding, shake and pour nystatin into a cup, and apply it to all surfaces of baby’s mouth. 
• Mother’s nipple: Rinse nipple with a solution of one cup of plain, tepid water followed by one tablespoon of vinegar and then air dry the nipples. An antifungal cream is then applied.
• Gentian violet (0.5%): Dip a cotton swab in the gentian violet and swab the baby’s mouth and nipple area.
• Advice the mother on following:
• Good hand washing before and after breastfeeding/diapering/using the toilet will help stop the spread of fungal infection.
• Wash all clothes in hot water and dry it properly.
• Boil all pacifiers/bottle nipples/breast pump part/baby’s toys once in a day for at least 20 minutes.
• Mother may need to decrease dairy products/sugar while increasing acidophilus, garlic, zinc, vitamin-B in her diet.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884

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