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JohannaKoivisto
OutiTammela

Breastfeeding: Advice and Difficulties

Essentials

  • Frequent breastfeeding on demand (infant-led feeding) during the first days is important for the success of breastfeeding: frequent breastfeeding promotes milk production.
  • When estimating the success of breastfeeding the following should be considered: the frequency and duration of feeding sessions, the infant's positioning on the breast, the latch-on technique, the efficacy of sucking, swallowing sounds and the mother's experiences about breastfeeding.
  • An exclusively breastfed neonate is at risk of developing hypernatraemic dehydration if the amount of breast milk is not adequate. The parents should be advised to recognize efficient sucking and to observe how often their baby feeds, the frequency of urination and defecation and, if necessary, to keep a close eye on the baby's weight.
  • If a newborn infant feeds less than 6 times in 24 hours (the feeding interval repeatedly over 4 hours) during exclusive, on-demand breastfeeding, enhanced monitoring of the infant's weight is indicated.
  • If complementary feeds are needed, the breast should always be offered first followed by a complementary feed. The complementary feed of choice is the mother's own expressed milk.
  • Skin-to-skin contact will improve the success of breastfeeding Early Skin-to-Skin Contact for Mothers and Their Healthy Newborn Infants.

General remarks Supplementation with Long Chain Polyunsaturated Fatty Acids to Breastfeeding Mothers for Improving Child Growth and Development, Early Additional Food and Fluids for Healthy Breastfed Full-Term Infants, Maternal Health Advantages of Breastfeeding

  • At the time of birth, the mother will have already produced protein-rich colostrum. Colostrum is sufficient to fulfil the early nutritional needs of a healthy, full-term infant, if the infant is allowed to feed on demand.
  • A healthy, full-term infant has a good store of fat and hepatic glycogen.
  • A few days after the birth, the amount of progesterone in the mother's blood decreases and that of prolactin increases. The second phase of lactation starts and the milk ”comes in”.
  • Frequent on-demand breastfeeding will hasten the increase of milk production.
  • Should this phase be delayed, the cause for the delay should be identified and the infant given supplementary feeds as needed.
  • It must be ensured that an exclusively breastfed infant receives an adequate amount of nutrition: the number of wet nappies at the ages of 0-24 hours, 72-96 hours and 7 days are, respectively, approximately 2, 5 and 7 per 24 hours. The number of soiled nappies at the same ages is usually 3, 4 and 6 per 24 hours. According to international guidelines, a newborn infant who is successfully breastfed will have at least 3 bowel movements each day after day 1 and at least 6 wet nappies each day by day 4.
  • Prophylactic measures are important in neonates who are at risk of developing hypoglycaemia (see the list below), including breastfeeding at frequent intervals and ensuring an adequate intake of nutrients by monitoring the weight of the newborn and the sucking efficiency, by giving supplementary feeds if necessary and by feeding breast milk to premature and/or sick newborns via a nasogastric tube, if indicated.
  • Risk factors for hypoglycaemia of the newborn
    • Maternal (gestational) diabetes or toxaemia
    • SGA/LGA (small/large for gestational age)
    • Prematurity (under 37 weeks)
    • Asphyxia
    • Large doses of maternal beta blockers
    • Maternal sodium valproate
    • Low temperature
    • Neonatal dehydyration (dehydration fever)

Breastfeeding advice Optimal Duration of Exclusive Breastfeeding, Interventions for Promoting the Initiation of Breastfeeding, Separate Care for New Mother and Infant Versus Rooming-in for Increasing the Duration of Breastfeeding, Early Skin-to-Skin Contact for Mothers and Their Healthy Newborn Infants

Good breastfeeding position

  • There are many good positions. The mother should be in a relaxed and comfortable position that facilitates an effective latch-on. The mother and infant must face each other (body/abdomen) and be sufficiently close. The mother guides the infant by supporting his/her back and shoulders. The infant's ears, shoulders and hips are aligned (not twisted). In challenging situations it is worthwhile to try laid-back position, which activates the baby's instinctive behaviour.

Correct latch-on

  • The infant should search for the breast, turn his/her head towards the breast and open his/her mouth wide.
  • Initially the infant's nose is against the nipple.
  • The infant lifts his chin and grasps the nipple deep into his/her mouth.
  • Both the nipple and some of the surrounding area should be drawn into the mouth.
  • The infant's lips should be slightly flared and the cheeks should not be hollow (indicating that the negative pressure within the mouth is adequate)
  • The latch should be sustained whilst the infant sucks-swallows-breathes rhythmically.
  • Breastfeeding should not be a painful experience for the mother.

Dummy and feeding bottle Avoidance of Bottles during the Establishment of Breast Feeds in Preterm Infants, Pacifier Use in Breastfeeding Term Infants

  • In addition to nutrition, suckling gives the infant a feeling of pleasure. During the first few weeks, a dummy should not be used to replace frequent breastfeeding sessions since this reduces the stimulation of the breasts. This is turn might result in insufficient amounts of milk being produced to meet the infant's needs.
  • The sucking technique needed for a dummy or feeding bottle is different from that for a breast (moreover, less suction is needed to draw milk from a bottle). The use of a dummy is therefore not recommended until the infant has learned the correct sucking technique for breastfeeding.
  • The use of a dummy at a later stage does not hinder successful breastfeeding Pacifier Use in Breastfeeding Term Infants.

Breastfeeding difficulties

  • Flat nipples. There are two types of inverted nipples:
    • retracting nipples that can be pulled or drawn out
    • truly inverted nipples that cave inwards and cannot be made to protrude.
  • Flat and retracting nipples can correct themselves during pregnancy due to hormonal changes. There is no study data to show the benefit of exercise or the use of various devices during pregnancy.
  • Advice regarding the correct latch-on techniques and positioning is important Support for Healthy Breastfeeding Mothers with Healthy Term Babies.
    • Stimulating the nipple by massage may help it to protrude.
    • A nipple shield is beneficial in some cases.

Cracked nipples

  • Nipple soreness and redness with some blistering may occur at the beginning of breastfeeding. Nipples can be looked after by rubbing them with a few drops of milk after feeding. It is also possible to use proprietary nipple creams that do not need to be washed off before the next breastfeeding session.
  • If the nipple does not enter the infant's mouth deep enough
    • the skin will crack at the base of the nipple or over the top
    • a moist fissure with discharge may develop
    • breastfeeding becomes painful.
  • Treatment
    • Check the breastfeeding position and latch-on.
    • Brestfeeding positions should be alternated.
    • Breasts should be washed with only water about once daily.
      • Too much washing removes the natural oils of the skin and breast tenderness becomes worse.
    • Bra pads made of fabric or wool are worthwhile to use. These are more suitable for tender breasts than pads made of paper.
    • If the nipple skin is broken, the wound may become scarred and tear open again during the next breastfeeding session. This can be prevented by lubricating the nipples with breast milk before and after sessions, and even between them. Hence the nipples remain moist. A gauze dressing may be dampened with sodium chloride solution or breast milk. Dressings are applied on the tips of the nipples to keep them moist.
    • Breasts should be exposed regularly to air
  • A tongue tie (short lingual frenulum) must be excluded because, if present, it will prevent the correct latching on to the breast.

Insufficient milk supply Methods of Milk Expression for Lactating Women

  • Breasts should be sufficiently stimulated either by breastfeeding (baby properly latched on and sucking efficiently) or by expressing milk (at least 8 times a day, even more often when aiming at increasing the milk amount).
  • A breastfeeding mother must receive encouragement and support Support for Healthy Breastfeeding Mothers with Healthy Term Babies. The mother's family and partner play a very important role. Advice given to the mother by a primary care physician/public health nurse within two weeks of the birth prolongs the duration of breastfeeding and significantly reduces the incidence of breastfeeding problems.
  • There is no evidence on the efficacy and safety of drugs that increase breast milk secretion.

Breast engorgement

  • Engorgement may develop a few days after birth as the milk ”comes in”.
    • The breasts are red, swollen and painful and the mother may experience chills. The peak engorgement rarely lasts for longer than 24 hours, and the condition gradually improves within a fortnight.
    • Engorgement can be prevented by frequent breastfeeding started during the first 24 hours after birth using the correct technique.
    • Cold compresses and chilled (refrigerated) cabbage leaves can be used to relieve the feeling of heat Treatments for Breast Engorgement during Lactation.
  • Treatment consists of emptying the affected breast, either by breastfeeding (more than 8 sessions/24 hours) or by expressing milk (if the infant is not suckling) as often as possible. Removing just 5-10 ml of milk will relieve the tightness and the infant will be better able to get hold of the breast. Effective positioning and latch must be ensured.
  • Engorgement may also be caused by the following:
    • delayed breastfeeding, irregular or infrequent feeding, time-dictated feeding schedules (e.g. 10 minutes/breast) or changing the infant from breast to breast halfway through feeding.
    • supplemental feeds or the use of a dummy
    • breast implants
    • in some cases stress, tight clothing, overabundant milk production.
  • A warm shower, warm compresses and breast massage will stimulate the oxytocin reflex. Analgesia if considered necessary.

Mastitis Interventions for Preventing Mastitis after Childbirth

Breast milk jaundice in the newborn

  • Some breastfed infants develop breast milk jaundice after the initial neonatal period. The jaundice is caused by breast milk interfering with bilirubin excretion Jaundice in the Newborn.
  • These infants are healthy and alert. Breast milk jaundice is not harmful and not an indication for stopping breastfeeding.
  • Conjugated hyperbilirubinaemia, infections and other systemic illnesses in the infant should, however, be excluded. Examine at least the conjugated-to-total bilirubin ratio, chemical urinalysis, CRP.
  • Monitor: colour, general condition, alertness, eating, weight. Alarming symptoms and signs (refer urgently to specialized care):
    • fatigue, inactivity, sleepiness, poor weight gain, grey colourless stools
    • plasma conjugated bilirubin HASH(0x2fcfe80) 17 µmol/l, if plasma bilirubin < 85.5 µmol/l
    • plasma conjugated bilirubin share HASH(0x2fcfe80) 20%, if plasma bilirubin HASH(0x2fcfe80) 85.5 µmol/l.

Breast refusal (nursing strike)

  • Is the infant ill and unable to suckle? Encourage the mother to express milk.
  • Nasal congestion? Instill physiological saline into the infant's nostrils.
  • Sore mouth? Check the infant's mouth, and treat possible candidiasis. Teething may cause tenderness; in this case, administration of milk from a beaker/spoon can be tried.
  • Feeding sessions should be as calm and relaxed as possible and skin-to-skin contact maintained.

Incorrect sucking technique

  • Is the infant not allowed to suckle on demand, does the mother perhaps steer the infant's head by pressing it from the back, is the latch-on technique incorrect or does the mother limit the time of a breastfeeding session? Give advice to the mother.
  • Insufficient milk production? Increase the frequency of breastfeeding sessions.
    • How is the mother coping? Ensure the mother gets enough rest, eats well and is well hydrated.
  • Overabundant milk production
    • If the initial milk flow is so abundant that the infant is not able to feed properly, the suction should be broken for a while and the initial spurt caught in a towel or similar.
    • Laid-back (semi-reclining) and upright breasfeeding positions help the infant to cope better with the abundant oozing of milk.
    • Is the mother willing to donate breast milk? Give advice about local breast milk banks.
    • If the milk production needs to be slowed down, the mother is advised to use the same breast for two consecutive feeds or only feed every 4-6 hours. If no milk is expressed from the other breast it receives less stimulation and will thus produce less milk (the fuller the breast, the slower the milk production).
    • If breasts are so painful that expressing milk becomes necessary, the milk supply should be gradually reduced: only one breast is offered at a feed and only enough milk is expressed from the other one to relieve the worst of the pressure.

Special situations

  • Breastfeeding twins
    • Breastfeeding small twins one at a time is very time consuming. Breastfeeding the twins both at the same time may save some time. Particular attention should be paid to the mother's coping.
  • Cleft palate or lip Feeding Infants with Cleft Lip, Cleft Palate or Cleft Lip and Palate
    • An infant with a cleft palate often cannot grasp the breast or a standard teat effectively, but a long specially designed teat usually solves the problem.
    • If the mother is motivated to feed her own milk, she must be taught right from the beginning how to express milk in order to both initiate and maintain her milk supply.

    References

    • Nommsen-Rivers LA, Heinig MJ, Cohen RJ, Dewey KG. Newborn wet and soiled diaper counts and timing of onset of lactation as indicators of breastfeeding inadequacy. J Hum Lact 2008 Feb;24(1):27-33. [PubMed]
    • International Lactation Consultant Association. Clinical guidelines for the establishment of exclusive breastfeeding. 3rd edition, 2014 http://www.ilca.org/i4a/pages/index.cfm?pageid=3933
    • Labarere J, Gelbert-Baudino N, Ayral AS, Duc C, Berchotteau M, Bouchon N, Schelstraete C, Vittoz JP, Francois P, Pons JC. Efficacy of breastfeeding support provided by trained clinicians during an early, routine, preventive visit: a prospective, randomized, open trial of 226 mother-infant pairs. Pediatrics 2005 Feb;115(2):e139-46. [PubMed]
    • Colson SD, Meek J, Hawdon JM (2008), Optimal Positions triggering primitive neonatal reflexes stimulating breastfeeding Early Human Development. Journal of Human Lactation, Volume 84, Issue 7, Pages 441-449
    • Cable B, Stewart M, Davis J. Nipple wound care: a new approach to an old problem. J Hum Lact 1997;13(4):313-8. [PubMed]