The World Health Organization recommends exclusive breastfeeding until an infant is at least six months of age to achieve optimal growth, development and health.¹ Studies have shown many benefits of breastfeeding to both mother and infant. Mothers who breastfeed have reduced rates of breast and ovarian cancer, and reduced incidence of obesity.² Infants who are breastfed show a reduction in the incidence and severity of infections including respiratory and urinary tract infections, and also reductions in the risk of developing diabetes, obesity, asthma, and eczema.² Breastfed babies are also at a decreased risk of sudden infant death and childhood cancers. 

There is some evidence to suggest that breastfeeding may also be important for child development and academic achievement.³ A 2010 report on children’s foundation years found that “no other health behaviour (than breastfeeding) has such a broad spectrum and long-lasting impact on population health, with the potential to improve life chances, as well as survival and health”.^2,4

Breastfeeding rates in Ireland are currently among the lowest in the world.⁵ Approximately 42 % of Irish mothers are breastfeeding when they leave hospital, compared with 67% in the UK and 89% in Europe as a whole.⁵

Effective and efficient breastfeeding requires optimal infant positioning and attachment to the breast, if this is not achieved problems such as reduced milk production and transfer, nipple pain and nipple damage can occur which may lead to other possible breastfeeding problems such as infection and abscess. development¹

Assessing breastfeeding women

Assessment should include history and examination of both mother and infant, including general history, pregnancy complications, medications, previous breast surgery, gestation of infant, birth weight and weight gain, behaviour at the breast (pulling, biting, coughing, breathlessness, sleepiness), cleft/lip palate, tongue-tie, and use of a pacifier.^6,7,8

The woman should be observed breastfeeding and expressing milk by a person with appropriate training and expertise. She should be asked about her breastfeeding history including previous breastfeeding experiences, problems, pain, any breast or nipple sensitivity before pregnancy, milk supply issues, pattern of breastfeeding, expressing of milk, other fluids or foods given and use of nipple shields or breast shells.^6,7,8

Discuss breast and/or nipple pain history including when the pain started, any nipple trauma, timing of the pain (during feeding, after, constant), location of the pain, and character and severity (burning, itching, sharp, dull). Ask about associated signs and symptoms (fever, breast skin changes, nipple colour changes, nipple shape or appearance after feeds) and any exacerbating or relieving factors (cold, heat, massage or touch). Determine any previous treatments such as analgesia, topical or oral drugs including antibiotics.^6,7,8

Breastfeeding problems

There are a variety of causes of breast pain in breastfeeding women and more than one cause may co-exist at one time. It is important that breastfeeding problems are recognised and managed promptly to allow the woman to continue breastfeeding without pain.  

Initially, breast pain may occur between the second and sixth day after delivery when the breast is full and the milk ‘comes in’. This is normal, and the pain usually settles within a few weeks’ post-partum. Nipple pain also often occurs for the first few minutes of breastfeeding and resolves with the continuation of the feed. Pain often improves during the first few weeks of breastfeeding. Common causes of breastfeeding problems that may require management are discussed below.^1,6,8

Engorgement

Engorgement may occur in the first few days after birth when there has been no or insufficient milk removal. Pain typically starts in the first few days after birth, is often in both breasts, and is worse before a feed. Infant attachment may be difficult due to breast fullness. The woman may have a mild, short-lived fever. The whole breast is typically swollen and may appear shiny with some redness. The nipple may be stretched and look flat in appearance. Engorgement can also occur when breastfeeding becomes restricted or infant demands have decreased. Engorgement is more common in women who have had breast implants.

The woman should be advised to feed her infant with no restrictions on the frequency or length of feeds. She should wear a well-fitting bra and clothing that does not restrict the breasts. Advice should be given on self-management techniques such as simple analgesia (for example paracetamol) for pain relief, breast massage after feeds and expressing milk to relieve full breasts. Heat packs or a warm shower before feeding or expressing milk can stimulate milk let-down, and cold packs after feeding or expressing can be used to relieve pain and swelling.

Nipple pain 

Inefficient positioning and attachment typically causes nipple pain at the start of a breastfeed that continues throughout the feed. Pressure from suckling may cause blanching and compression of the nipple, and fissuring across the top of the nipple or around the base. There may be flattening of the nipple from side to side, with a pressure line across the tip.

Advise the woman to continue breastfeeding wherever possible, and that reducing the duration of feeds is unlikely to relieve nipple pain. A thin layer of white soft paraffin or expressed breast milk can be used if the nipple skin is cracked or fissured.

If symptoms persist, consider the possibility of nipple infection. Bacterial infection may present with nipple discharge, crusting, redness, and fissuring. Candida infection typically causes burning pain in both nipples, itching and hypersensitivity, especially during and soon after feeds. 

There may be deep breast pain radiating into the breast and chest. Typically, the pain does not resolve despite improved positioning and attachment, or follows a period of pain-free breastfeeding. If bacterial infection is suspected antibiotics should be given such as fusidic acid 2% cream to be used after every breastfeed for five to seven days. For severe infections 500mg flucloxacillin should be prescribed for use four times a day for seven days (erythromycin should be given for women who are allergic to penicillin). 

Mastitis and breast abscess  

Mastitis may be infectious or non-infectious and is usually secondary to milk not being removed effectively from the breast. Non-infectious mastitis is more likely where there is no nipple damage  and poor drainage of one part of the breast due to external pressure such as tight clothing, car seat belts, or extended intervals between feeds. Infectious mastitis is more likely if there is a nipple fissure or damage, which may become infected. Engorgement or blocked ducts may lead to mastitis, which may then develop into a breast abscess.

Mastitis may present with a hard painful swelling in a wedge-shape in one breast, with redness of the overlying skin. The woman often has a fever and appears unwell. A breast abscess may present with a worsening painful breast lump, and the overlying skin is often red and warm. There may be a persistent fever.

Women should continue to feed from the affected breast if possible. Pain relief and antibiotics should be given. If the woman is showing signs of serious infection she should be admitted to hospital with her infant to allow for continuation of breastfeeding. If a breast abscess is suspected the woman should be referred urgently to a surgeon. 

Low milk supply

Low milk supply can be caused by insufficient access to the breast which can be indicated by short or infrequent feeds; no night feeds, use of a pacifier, or giving supplementary feeds other than breast milk. Maternal depression, stress, and/or anxiety may result in a reduced response to infant feeding cues and a reduced frequency of feeds, which leads to reduced stimulation of milk production.

Ineffective infant positioning and attachment suggested by frequent feeding more than every two hours; no long intervals between feeds; feeding for less than five minutes or longer than 40 minutes’ duration may also indicate a low milk supply. The infant may be generally unsettled, have faltering growth, or show signs of dehydration.

Advise on increasing skin-to-skin contact; to feed her infant with no restrictions on the frequency or length of feeds; offering both breasts at each feed; and alternating between breasts. The woman may also wish to express milk after feeds to stimulate milk production.

Milk oversupply

If a woman has an oversupply of milk her breasts may be very full with possible engorgement or blocked ducts. She may have a painful, forceful milk let-down reflex and milk leakage and/or milk spraying from the opposite breast when feeding. The infant may choke or splutter while on the breast, suffer from colic or frequent, explosive loose stools and they may have rapid or excessive weight gain. 

Milk oversupply can be caused by ineffective infant positioning and attachment during which the infant may not remove milk efficiently so suckles a lot, stimulating the breast to produce excessive milk. Swapping sides too early and not allowing the infant to finish feeding from the first breast can also lead to supply issues.

Ensure that the woman is aware of early feeding cues that suggest an infant is hungry, so that breastfeeds are initiated at appropriate times. Advise that if the infant is unable to attach effectively to the breast due to breast fullness, it may be helpful to express a small amount of milk until the flow slows down, and then try to attach the infant to the breast. Advise on feeding from one breast for each feed, to help reduce milk supply.

General information

Advice on continuing breastfeeding should be given wherever possible. Provide advice on optimal infant positioning and attachment to the breast, simple analgesia, massage, and expression of milk, if appropriate and advise the woman to wear a well-fitting bra and clothing that does not restrict the breasts.^1,8

Further information on breastfeeding support is available from: 

• Breastfeeding.ie: www.breastfeeding.ie/

• La Leche League of Ireland: www.lalecheleagueireland.com

• Cuidiú: www.cuidiu-ict.ie/supports_ breastfeeding

References

1. World Health Organization. Infant and young child feeding. Published 2009. Available from: http://www.who.int/maternal_child_adolescent/documents/9789241597494/en/

[Accessed January 31, 2017]. 

2. University of Sheffield. Benefits of breastfeeding. Published 2017. Available from: https://www.shef.ac.uk/scharr/sections/ph/research/breastmilk/benefitsofbreastfeeding

[Accessed January 31, 2017].

3. Institute of Public Health in Ireland. Breastfeeding in Ireland – A 5-year strategic action plan 2005-2010. Published February 2014. Available from: https://www.breastfeeding.ie/Uploads/files/Breastfeeding-in-Ireland-Review-and-Evaluation.pdf [Accessed January 31, 2017] 

4. Field F. (2015) The Foundation Years: preventing poor children becoming poor adults. Published December 2010. Available from: http://www.bristol.ac.uk/media-library/sites/ifssoca/migrated/documents/ffreport.pdf [Accessed January 31, 2017].

5.Layte R, and McCrory C. Growing up in Ireland. National longitudinal study of children. Published October 2014. Available from: https://www.esri.ie/pubs/BKMNEXT286.pdf [Accessed January 31, 2017].

6. Amir, LH. (2014) Managing common breastfeeding problems in the community. BMJ. 348: g2954.

7. Buck ML, Amir LH, Meabh C. et al. (2014) Nipple pain, damage, and vasospasm in the first 8 weeks postpartum. Breastfeeding Medicine. 9(2): 56-62.