The What and How to on breastfeeding Problems

Introduction

Breastfeeding problems  (breastfeeding difficulties), refers to challenges that arise during breastfeeding. It includes problems to both mother and baby that occur as a result of engaging in breastfeeding as well as conditions in them that can hamper breastfeeding. All experienced nursing mothers know that breastfeeding can turn sour if totally handled with a happy go lucky attitude. It is more of a ‘reap what you sow’ arrangement. That, however, does not mean that a mother and all other concerned parties should get neurotic over how to handle breastfeeding. In fact, that in itself, can worsen the experience and eliminate the prospects of success since it’s always associated with attempts to ‘mechanize’ the process. Therefore, the best way to prepare for and handle breastfeeding is to look into how to support the natural. There can be a need to possibly correct the unfavorable natural. That said, even the best preparation and practice of breastfeeding won’t surely go without some difficulties which will have to be addressed along the journey. As aforementioned, those problems or difficulties arise as a result of breastfeeding itself, concerns with in the mother, or the child. Here, we shall categorize them into two, namely; Maternal and child categories.

 

The Maternal category of Breastfeeding difficulties.

Mothers can have problems that contribute to difficulty with breastfeeding  ranging from the physical to the psychological as briefly elucidated below.

The sore nipple

Is a general and casual description given to any condition that causes pain on the nipple. A lump-sum of those undeniably occur to the nursing nipple. We give attention to the most common which include;

The cracked nipple; known to occur in nursing mothers with poor latch or poor positioning of the nipple in the suckers mouth mainly arises as a result of continual abrasion with eventual breach of skin integrity.  In a good latch with all things going well, the infants jaws nimble over the areola (the dark portion of skin on the breast just around the nipple) and the nipple is totally sucked in, so that it’s freely stretched out and it’s tip smoothly glides below the soft palate and the base of the tongue.

With a poor latch, the infant literally sucks the nipple and since this doesn’t deliver milk, are preempted to suck at higher pressures which only brings damage to the skin with resultant pain. The correction for this is proper re-latching if  the mother knows what to do or has that kind of support around her, otherwise a visit to a lactation consultant will be imperative.

Areola engorgement is another source of nipple pain. A mother holding the breast between her thumb and fingers to enable good latch is a common practice especially in the early stages of breastfeeding. Occasionally this is done wrongly by applying disproportionate pressures on either sides of the breast. This results into the nipple tip misdirection (being directed to the roof of the mouth -hard palate or  tongue surface) with subsequent abrasion during suck motions. Infants put to artificial nipples develop a sucking pattern which can produce a similar hurt to the nipple since their sucking pattern is different.  Holding the breast  a few centimeters from the areola with proportionate pressures from the thumb and fingers so that it’s horizontal helps abate the problem. Use of dummies on bottle feeders should be restricted to specific times with the greater feeding periods on the actual breast to prevent confusion in the  infant. Institution of any artificial teats should be done not earlier than 4 weeks of age.

Areola engorgement, which is swelling with mild firmness over the areola, causes the infant to suck on the nipple alone due to difficulty latching on. The mother can express some milk from the areola to make it pliant and enable good latching. Basically, she holds the areola between two of her fingers, then pushes and compresses it towards her chest in a rhythmic fashion. If this doesn’t suffice, use of  a hospital grade electric breast pump with a silastic flange will solve the problem. A doctor’s/lactation consultant’s visit will be necessary if things don’t workout with the above.

Some environments can contribute to nipple soreness given the relevant circumstance. The areola has pimple like bumps (Montgomery tubercles) through which a few milk ducts permeate. This is naturally  designed to enable lubrication of the area during breast feeding. Occasionally these get plugged or desiccate and obliterate due to use of nursing creams and extremes in humidity, resulting into a dry nipple/areola area, increased sensitivity and proneness to cracks. Dryness can be abated by always smearing small amounts of expressed breast milk in the area before nursing. After nursing, the area is partly wiped just to remove the drip and allow for a small dump which should air dry. In dry environments, use of  vitamin A and D creams can be used after nursing to prevent desiccation and cracking (useful in healing cracked nipples as well), Lansinoh “allergy free” cream can be used as well. In a high humidity,  a hair dryer set to warm held about 15-20cm can be used to condition the breasts. Dry skin can sometimes be associated with redness  in the surrounding breast area in which a steroid or hydrocorticoid  cream is recommended. Halobetasol proprionate is most recommended with 1-3 day course being sufficient. Mometasone furoate or Elocon ointment are the synthetic hydrocorticoids of choice. But this is only to be attempted by one who knows how to eliminate the presence of an infection. Outside that, see the doctor.

Nipple sensitivity; though not an unusual experience in the early stages of breast feeding, is a concerning cause of ‘sore nipple’ in some mothers if persistent and no other physical explanation for the pain can be given. The nipple is the only region of breast tissue loaded with both pain and pressure nerve fibers. The latch will have to be re-examined before any other remedy is considered. Usually, the problem corrects with proper latching. Maternal anxiety can be a contributor and the right support eg from Doula will be useful. Some mothers have inherent nerve function disorders which bring pain by causing dysfunction in small vessels. The most famous among these is Raynod’s phenomenon and can occur in nipple tissue as well. Caution; don’t run for topical anesthetics or any cream/ointment containing them. It will make matters worse for both the baby and mothers!

The white dot; clinically known as white bleb, is a solitary lesion which arises through a milk duct at the nipple tip. This is known to be sore indeed. Relief comes with a spontaneous burst. Unfortunately, that rarely happens, necessitating a medical consult in which cannulation with a suture can be done.

For the above discussed causes of sore nipples, proven remedies have been suggested. However if the condition persists or worsens, a doctor’s visit is warranted.

Other nipple anomalies of concern.

Small or flat nipples; make breastfeeding troublesome especially with an engorged areola. Moderate compression just at the areola helps draw out the nipple and enable latching. patience has to be exercised here. Use of an electric breast pump to suck out and elongate the nipple can be performed for at least 2 days till the infant adapts.

Large Nipples; can be difficult for little infants or those with indecisive suck. working patiently with the infant is what is encouraged. Use of an electric pump with a thin latex shield or silastic shell is a means to draw out the nipple into a teat, making it easier for the infant to suck.

Nipple blanching;

The swollen and painful breast

Breastfeeding can be associated with pain and/or breast swelling caused by a cluster of conditions most of which include those discussed below.

Breast engorgement; also referred to as peripheral engorgement is a situation in which the breasts “fill up” causing discomfort. It occurs when there is a rump up in milk production, an increase in  blood flow to the breast and a mild edema. The mother is typically a first timer, usually has both breasts affected and might have a low grade fever. This is commonest in the first 3-7 days of lactation when milk production is reaching it’s peak and breast feeding is not yet fully established. It also occurs when breastfeeding is suddenly reduced. The condition can be very painful and discomforting. The solution is “to get the Breasts empty”. Use of warm compresses before nursing and cold compresses afterwards can help with the discomfort. Pumping briefly before feeds can help soften the breast and better the nursing experience.  Manual expression can be done in the absence of a pump, but that can be a new source of pain. Cabbage Leaves are  an age old celebrated remedy for the above condition, they can be cooled and applied to the breasts for a number of hours, relief is known to occur in about 6 hours. A cabbage gel (interestingly has no cabbage component in it) can be used to help keep the leaves in place. This is an effective remedy proven by research! Pain medications like ibuprofen and paracetamol can be used in some circumstances. It’s advisable the medicines are taken just when starting to feed or pump so that by the time the medication reaches the blood stream, the  session has expired.

Mastitis; Infection in the breast characterized by breast pain & associated physical changes, with a high grade fever and other symptoms associated with systemic illness. The condition usually affects one breast and can be localized to just a portion of it. Predisposition is from milk stasis with a super infection. The common offender in this case is a bacterium called staphylococcus ( others include E. coli and streptococcus). Therefore, antibiotics will be needed and the treatment process should be overseen by a health professional. Keeping the breast empty is an important part of treatment and breastfeeding is the best way to do it (it’s safe). Occasionally, mastitis is caused by non bacteria, predominantly a fungus known as candida. This usually follows a period of  antibiotic treatment and presents with a characteristic pain of ‘fire in the milk ducts’.

Breast abscess; is a condition that usually follows untreated mastitis. The infection is contained with in a focus where pus is formed, with characteristic severe ache. The patient has high grade and spiking fevers with all other features of systemic infection. It’s discouraged to breastfeed at this point with pumping as a means to keep the breast empty. Treatment involves letting out the pus and should only be done in healthcare settings. So, see the doctor if you suspect this.

The breast milk-retention cyst (galactoceole); sometimes, a lactiferous duct gets occluded and production with in that small unit continues for a while. This results into a small pocket of walled off milk, which with time, turns greasy  then clear due to re-absorptive processes. The condition is ultimately corrected by surgery. Breastfeeding is okay and should be continued.

Plugged milk duct; at times milk collecting ducts get obstructed due to non infectious causes. One identified in particular is “calcium sand grains” due to high dietary calcium and poor fluid intake. The nursing mother has breast pain with a lump, no features suggesting other causes and occasionally excreting “grains of salt” from the breast. Breastfeeding with deliberate efforts to keep the breast empty should be made. Warm compresses can be used to keep down pain before nursing. Oral hydration should be stepped up and dietary calcium reduced.

Repeated plugging; milk ducts can get recurrent obstruction every now and then. Identified factors include; maternal fatigue, high saturated fat in diet, and diminished breastfeeding (of which pumping can be associated).  When expressed, fatty-oily discharge is obtained with no grains. Breastfeeding with massage and warm compresses are encouraged to help ameliorate the problem. Pay attention to the  nursing Bra; Underwire Bras, molded plastic cups, and the unusually tight type can fuel the pathology. An appropriate Bra should be sought in this instance.  Limiting the mother to polyunsaturated fats and adding lecithin (one spoon or capsule a day) to the diet has been shown to be helpful. Some doctors think the problem could be associated with deficiency of type A antibodies (immunoglobulin A).

Breast milk expression; can be a cause of severe pain if done over long periods especially where engorgement is involved. Breast milk pumping is the ultimate effective and palatable alternative. In case a breast pump can not be used, application of lubricant jelly to prevent abrasion during the process can be greatly helpful.

Eczema; this ‘skin demon’ can once again haunt a mother with the condition sitting in her system. Attacks or flares can come along or be worsened or first noticed during breastfeeding. The classical picture is an “oily rash”, redness, skin flaking, pain or even burning mostly over the nipple and areola. For mothers with prior diagnosed eczema on treatment, continuation of the regimen is encouraged. Breastfeeding and/or breast pumping is continued, persistence or exacerbation of  the ailment is addressed with a steroid cream ( halobetasol proprionate after nursing sessions). Temporary discontinuation of  nursing is hardly necessary.

Problems with milk production.

Insufficient milk production;

Milk over production;

Psychological issues associated with nursing

As nursing turns over a mothers physical in various ways, it rarely leaves her psyche unscathed. Maternity, especially around birth (also known as peripartum period) poses the highest risk for a woman to develop mental illness in her lifetime. As a matter of fact, a third of all new mental illnesses in  females are diagnosed just around this time. Before any one mocks, please remind them that WHO estimates 1 in 4 individuals at any one point in time and 1 in 5 in a life time to be suffering from some form of mental ill health, and that most of them are men! Much as pregnancy has an unusually broad range of normal, there are certain “lines that should never be crossed”. A mother is deemed to be needing mental health care if she presents outside that scope, set a side those who are already on chronic treatment.

It is not unusual to have mild feelings of anxiety over child birth and motherhood, emotional lability, mild depression or even obsessional thoughts while pregnant as long as those don’t produce physical symptoms or impairment in personal function. After birth, there are two major emotional spectra, deviant from normal which are regarded non pathological. Those include;

  • The ‘pinks’; a mild form of anxiety occurring up to about 48 hours after birth. Major features include; excitement, over activity, elevated mood and  difficulty sleeping. This “new mom thrill” is non worrisome and spontaneously resolving.
  • The ‘Blues’ (maternal/post-natal blues); which basically is a very mild form of depression not entirely fitting the criteria. It is characterized by difficulty sleeping, ‘fatigue’,  low mood, short temper, tearfulness and negative thoughts about the baby. This occurs and resolves within the first 2 weeks after birth. Support from a Doula or Spouse is adequate good enough.

These, fortunately, resolve spontaneously and do not produce physical symptoms or inability of the woman to function. Any of these mental aberrations shouldn’t last more than two weeks. Otherwise, medical attention is warranted. In good healthcare systems, the mother is screened for mental ill health during pregnancy, and at least twice after delivery, more opportunities are provided during home visits and infant routine care.

A few mental illness are note worthy due to their high incidence and  tendency to cause severe impairment in function.

Major depressive illness; has a gradual onset with marked symptoms about 6 wks from delivery, with social support spontaneously resolves by 6 months. Few cases will require dedicated psychiatric care. Important to note is low appetite in the mother affecting milk production and suicidal ideation potentially culminating into infanticide or suicide.

Pueperal psychosis; is a severe form of mental illness always warranting dedicated psychiatric care, can be devastating to nursing. Specialized units have a means to promote bonding and nursing, though the infant might have to be withdrawn for a time. The most notable features here are disordered sleep and seeing/listening to non existent people or objects (hallucinations). It tends to manifest as early as 3 days after birth. The illness is closely related to a history of ‘manic depression’ (bipolar affective disorder) in the family.

Schizophrenia;  a mental illness severely detrimental to a mothers breastfeeding self-efficacy should be closely monitored. It is advised women with a history of this consult with their doctor before conception. The most glaring of features are; a radical disconnect with reality, paranoia, and hallucinations.

Spurious maternal conditions impacting on breast feeding.

Some conditions in a mother not specifically classified can affect her ability to nurse for instance;

  • Recreational drug use; severely lowers breastfeeding self-efficacy, and highly detrimental to mother and infant’s health.
  • Maternal fatigue; a plague of the “career woman”, has negative effects on milk production and coupled with reduced or no breastfeeding at all (which is often the case), results into insufficient milk production or conditions like peripheral engorgement. Breast pumping alone is associated with reduced breast emptying (~50%) compared to suckling (>70 %) and therefore, should never be used alone.

 

The child related problems of breast feeding.

Even with the mother all fine and performing at her peak, the duo can still fall short of the ultimate nursing outcomes and experience due to draw backs arising from the child. Those factors are clustered as discussed below.

Unfavorable anomalies…

The receding jaw; Known medically as Micrognathia, is a condition characterized by incomplete development of the lower jaw resulting into a subnormal size and defects with function. The chin is minute if recognizable and most times is not definable. This posses a great challenge with latching thus hampering smooth nursing. Adaptable infants are suckled. Pumping to supplement is done so as to boost intake since they tend to give the breast up early.

The fluttering tongue; prevents sucking in of the nipple and latching due to absence of the rhythmic coordination required for proper suckling.

Cleft lip and palate; in this situation, the contour at the roof of the mouth required to streamline the nipple and generate a suck is disordered. The whole process of suckling is not achievable. Breast pumping and feeding through tubes is carried till corrective surgery is performed.

Functional and structural anomalies of  the bowels; like pyloric stenosis and lactose intolerance are a significant barrier to infant feeding as a whole. These are attended to medically.

Prematurity; is a special barrier to breastfeeding due to weakness of their suck. Luckily, the Doctors will not let one out in that state. Controlled breast milk feeding (trophic feeding) to prime the gut is carried out as the little premie’s ability to suck is observed.

Unfavorable feeding habits…

Barracudas; are the group of infants wrongly described as having a ‘strong appetite’ due to their continuous strong suck lasting at least 10 minutes. They don’t dally! The truth is; the habit does not allow for the pauses which are required to gather and swallow milk; and can cause a sore nipple. Thankfully, it tends to occur in the early periods of nursing and kind of self corrects as they ‘gain experience’. Those with biting habits should be kept at bay by the mother deliberating pushing her finger in the way as they attempt to clump down on the nipple. This also tends to occur as teething sets in.

Excited ineffectives; these start off normally, kind of get distracted and start fiddling with the breast until they loose it with a final outcome of  screaming (and an inadequate feed). “Training” of the infant and mother with patience produces desired results. Quietening the infant serves before putting them back to the breast.

Procrastinators; these are ‘lazy feeders’ in the first few days of breastfeeding. Too much urging is discouraged though the mother should ensure a feed for every 4 hours. Breast pumping to boost milk production is encouraged. To mummy’s relief, this is self resolving and the infants “engage a higher gear” just at the right time ie when milk production first reaches it’s peak!

Gourmets or mouthers; are an interesting category with the habit of “tasting” the nipple. They eventually settle for real business when given time and do really well. Pumping after breast feeding is encouraged.

Resters; “the slow feeders”,  prefer to suck -rest- then suck again. They able to feed adequately but require prolonged nursing periods calling patience from the mother. As fro the rest, pumping after a feed is essential.

“Nursing Strikes”; the sudden refusal to breastfeed is usually caused by transient factors. Most mothers misinterpret this as absolution from breastfeeding delivered  by the baby it’s self! They then proceed to wean. When asked, they bluff their way out by saying, “the baby rejected the breast”. In real sense, this is an involuntary brief holiday the baby instinctively takes due perceived changes in breast milk flavor. In some circumstances, this is beneficial and can be life saving or revealing. So, a seasoned breast feeder should be aware of this temporary periods and the possible causes such as;

  • Onset of menses in the mother
  • Dietary indiscretion by the mother
  • Change in maternal soap, perfume, or deodorant.
  • Stress in the mother.
  • Earache or nasal obstruction in the infant.
  • Teething.
  • Episode of biting with startle and pain reaction
    by the mother

Breast milk pumping is encouraged to maintain supply.

 

Conclusion.

Of the long list of breastfeeding problems, a number of them have been elaborated on above with greatest attention given to the commonest. Remedies have been suggested where applicable. A healthcare providers consult should always be obtained where ever there is doubt or failure of the problem to resolve.

All the best in your nursing journey!

Appreciation to all readers and contributors. Questions, suggestions and comments are always welcome.

 

 

 

 

 

 

 

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