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Management of Common
Breastfeeding Problems
Breastfeeding Residency Curriculum
Prepared by
Andrew Hsi MD, MPH
and
Larry Leeman MD, MPH
University of New Mexico School of Medicine
Breastfeeding Assessment
• Before being able to address breastfeeding problems, the
physician needs to assess breastfeeding by observing the
infant feeding at the breast.
• See the Basic Breastfeeding Assessment presentation
• The following presentation discusses how to further
assess for a particular problem and administer treatment
to the breastfeeding dyad.
Objectives
At the end of this presentation the learner will be able
to discuss:
• Assessment of ineffective breastfeeding due to causes associated
with the newborn oral cavity, breast anatomy, disorganized suckle,
ankyloglossia, and milk transfer
• Assessment of ineffective breastfeeding due to less common
causes including disorganized suckle and ankyloglossia
• Monitoring of hyperbilirubinemia and jaundice
• Assessment of dehydration in context of poor feeding and/or
low milk supply
• Diagnosis and management of the delay or failure of lactogenesis II
• Galactogogue use
• Evaluation for blocked nipples, engorgement, and milk oversupply
• Diagnosis and treatment of mastitis, breast abscess, and
candidal breast infections
Assessment of Newborn Oral Cavity
• Palpation for hard and soft palate defects
• Visual of gingivae, sublingual areas including
– Attachment of sublingual frenulum
– Movement and elasticity of tongue
• Gloved finger in baby’s mouth assesses function
– Nail bed placed at lower gum ridge to
assess excursion
• Rule out inability to compress milk ducts
Assessment of Breasts
• Breasts should be assessed during a prenatal visit
to prepare the mother for any issues that may arise due
to breast anatomy
• Rule out uncommon breast abnormalities
– Breast enlargement/reduction surgery
– Breast hypoplasia: tubular breasts, unilateral hypoplasia
– Gigantomastia
• Awareness of potential anatomic mismatch
– Large nipple with small baby
– Perceived problems influence feedings
Reference 19, 27
Breast Assessment —
Uncommon Conditions
Primary Hypoplasia:
Secondary Displasia:
- insufficient mammary glandular tissue
- nulliparous state (adopted infant)
- unilateral or bilateral breast anomalies
s/p radiation Rx
s/p breast surgery
s/p severe mastitis/abscess
Breast Injury and Surgery
• Reduction Mammoplasty — likely to have difficulty producing
enough milk, especially with periareolar incisions
• Augmentation Mammoplasty — compatible with successful
breastfeeding
• Lumpectomy — may affect breastfeeding if significant nerves
or ducts have been removed
• Previous Treatment for Breast Cancer — radiation after
lumpectomy may interfere with lactation. Mother can usually
breastfeed on an unaffected breast
• Trauma and Burns — varies, but many people with severe trauma
and burns to the breast have been able to breastfeed with success
• Pierced Nipples — not associated with breastfeeding difficulties.
Nipple devices should be removed before feeding
Reference 38
Disorganized Suckle
• Term babies have because:
– Coordination problems
– Hypotonia
– Hypertonia
• Preterm babies may have:
– Neurologic immaturity
– Disorganized sucking excessive external stimulation
– Weaker muscles in mouth and tongue
Suckle Problems: Ankyloglossia
• Presents as ineffective latch or nipple pain
• Lactation specialist consult if possible
• Assessment by Hazelbaker Tool
• Significant ankyloglossia when:
– Appearance score < 8 and Function score < 11
• Attention to changing position on breast
• Care of mother’s nipples to prevent injuries
Reliability of Assessment
• Hazelbaker Tool in research
– Appearance items “moderate” reliability
– First 3 function items “substantial” agreement
• Lateralization, lift, and extension of tongue
• The items for infant sucking; low reliability
– Suggest using first 3 function items only
• Clinical agreement high for frenulotomy
Reference 5
Frenulotomy Studies
• Study using well designed enrollment
• Frenulotomy improved feeding
– Mothers reported relief from pain
– Improved latching
• Study of 24 older babies (33 + 28 days)
– Ultrasound studies found
• Better position of nipple against palate
• More milk transfer, less maternal pain
Reference 5,7,23
Breastfeeding and
Hyperbilirubinemia: Guidelines
• All infants routinely
monitored for jaundice
• Accurate gestational age;
intensively monitor late
preterm
• Jaundice while breastfeeding
• Kernicterus would be largely
preventable
Reference 2,3
Breastfeeding Preterm or Late Preterm
Infants and Hyperbilirubinemia
• Jaundice in late preterm infants results from:
– Increased bilirubin due to increased bilirubin production
– Decreased bilirubin elimination
– Insufficient breast milk intake even when mom’s milk
established
– Inability to ingest larger volumes of breast milk
• Hyperbilirubinemia in late preterm infants:
– Increased incidence
– Increased severity
– Longer course
– Increased risk of deleterious consequences
Reference 12,13
Management for Early Jaundice in
Breastfeeding Infants
• Close clinical observation for jaundice
• Largely related to insufficient breast milk
intake
• Initiate early and frequent breastfeeding
• Discourage water, dextrose water, and
unnecessary formula supplements
• If supplementing with formula, consider
using SNS or finger feeding to continue
the establishment of lactation
• Monitor weight, breastfeeding,
urine, and stool
• Refer to AAP guidelines for management
of jaundice
Reference 3,27,21
Management of Breastmilk Jaundice
• Cause not defined
• Breastfeeding successfully established yet hyperbilirubinemia
persists beyond the fourth week of life
• No clear reason to intervene if baby thriving
• Recommendation 7.3 – AAP guidelines for management of
jaundice
– If infant requires phototherapy, breastfeeding should be
continued if possible
– Option to temporarily interrupt breastfeeding and substitute
formula to reduce bilirubin levels and enhance efficacy of
phototherapy
– Breastfed infants being treated with phototherapy can be
supplemented with expressed breast milk or formula if needed
Reference 3, 17, 27
Summary for Early Detection of Risk
for Hyperbilirubinemia
• Good gestational age assessment
• Review of physiologic risk factors
• Early breastfeeding initiation
• Monitoring of latching on; feed every 2–3 hours
– Use of LATCH score, similar objective tool
– Direct observation of latching for near term
• Screen every baby for jaundice
Assessment of Milk Sufficiency
• “Not enough milk” stops breastfeeding
• Visual cues for feeding interaction
– Baby eagerly seeks breast, latches on, feeds
– Baby body tone relaxes
– Mother’s body tone relaxes
• Auditory confirmation of swallowing
• Weight gain around arrival of mother’s milk
– 0–90 days; median gain 26–31 g
– 90–180 days; median gain 17–18 g
Reference 15, 27
Assessment for Slow Weight Gain
Versus Failure To Thrive
• Slow weight gain
– Generally alert and healthy
– Good skin turgor and muscle tone
• Failure to thrive
– Generally apathetic, crying, not satisfied
– Poor tone, constant rooting
– Weight loss continued or no weight gain
Reference 16, 27
Test-weighing To Assess Nutritive
Breastfeeds in Failure To Thrive Infant
• Weigh naked baby
– Before and after breastfeeding
episode
– May help assess adequacy of
breast milk intake
• Rationale for diagnostic test
• Review of 32 studies found
– “Regardless of whether the
clinical assessments were performed by nurses,
mothers, or lactation educators, the differences
between the clinical estimates and the test weight
estimates of milk intake were large and random.”
Reference 29, 37
Dehydration and Breastfeeding
• Rare, but severe condition
• Among exclusively breastfed term infants
–
–
–
–
Weight loss > 10% in first 3 days of life
1/3 with hypernatremia
Maternal factors
Infant factors
• Close follow up breastfeeding dyads required
– Daily weight evaluation
– Careful breastfeeding assessment
Reference 16
Management of Dehydration Associated
with Breastfeeding Problems
• Review maternal history, medications
• Assess infant feeding history, urine and stool output
• Examine infant, skin turgor, capillary refill
• Observe infant on breast
• Stat lab studies
Reference 32
Lactogenesis II
• Lactogenesis I : Initiation of milk production which
occurs in second trimester of pregnancy
• Lactogenesis II: Postpartum initiation of high volume milk
production which occurs as transition from low volume
colostrum
– Usually at 30–40 hours postpartum
– Subjective feeling of breast fullness
– Day five term infant receive 500 to 750 cc of milk
compared to < 100 cc/day prior to lactogenesis II
– If lactogenesis II has not occurred by postpartum day 5,
then delay or failure is present
Reference 11, 24, 34, 35
Problems with Lactogenesis II
• Delayed: extended time between colostrum and full
milk production
• Failed: unable to achieve full lactation due to either
primary inability to produce or issues with breastfeeding
or infant health
• Can lead to hypernatremic dehydration which can rarely
progress to neurologic injury, seizures, renal failure,
thrombosis, and death
Reference 33, 42
Causes of Delayed Lactogenesis II
Any circumstance that leads to delayed, infrequent, or
ineffective milk removal
•
•
•
•
Delay in first breastfeeding: oral or IBV infant feeding
Low breastfeeding frequency-poor stimulation
Psychosocial stress/pain
Unscheduled cesarean or stressful labor/delivery
Less common etiologies secondary to maternal disease
• Maternal obesity
• Maternal diabetes or hypertension-etiology unknown
Reference 24
Causes of Failed Lactogenesis II
• Breast surgery or injury
• Retained placenta
• Hypothyroidism
• Theca lutein ovarian cysts
• Mammary hypoplasia (congenital)
• Polycystic ovarian syndrome
• Sheehan’s syndrome secondary to postpartum
hemorrhage
Reference 24, 33
Galactagogues
• Used to increase breast milk supply
• Need to attempt to determine the etiology of low milk
supply prior to initiation
• Ensure proper breastfeeding technique prior to use
• Only use galactogogues with adequate milk removal
by nursing or electrical pumping or milk stasis will occur
• Consider need to evaluate for medical co morbidities
e.g., hypothroidism, retained placental fragments,
theca lutein ovarian cysts
Reference 41
Galactagogues
• Metoclopramide — most commonly used
• Domperidone — not approved in USA. Similar to
metoclopramide but less side effects as little crosses
blood brain barrier
• Fenugreek and other herbal medicines — no scientific
data except anecdotal reports
Reference 9, 14, 18, 22
Metoclopramide
• Benefit shown in small placebo controlled crossover
study with increase of 50 cc per feed with dose of at least
30 mg per day
• Effect is to increase prolactin level
• Side effects: gastrointestinal, anxiety, sedation, and rare
dystonic reactions
• No documented neonatal reactions
• Short term: 1–3 weeks is common. No evidence
supporting long-term use. Usually wean after 10–14 days
• A common dosing regimen is 10 mg po qd first day, then
10 mg po bid, then 10 mg po TID
Reference 9, 25
Excess Milk Supply
• Much less common problem than low milk supply
• Minimal medical literature
• Maternal symptoms; continual engorgement, leaking and
increased mastitis risk
• Infant: regurgitation and reflux symptoms. Development
of poor sucking technique
Management of Excess Milk Supply
Attempt to offer just 1 breast at each feeding to decrease
stimulation and produce milk stasis in the other breast to
decrease production
Reference 43
Plugged Ducts
• Tender lump
• Predisposing factors
– Positions that don’t empty breast
– Underwire bras
• Predispose to mastitis with possible continuum from
engorgement to blocked ducts to inflammatory mastitis
to bacterial mastitis
• Treatment
• Ensure complete drainage
– Massage
– Warm packs
– Position changes
Reference 1
Mastitis
• Infection of the breast usually caused by Staphylococcus
aureus
• Risk factors: plugged ducts, untreated engorgement,
cracked nipples, missed feedings, excessive fatigue,
decreased resistance to infection
• Common occurring in 5%–10% of breastfeeding women
• Most common in first month
• Recurrences occur in 8%–19% of women and commonly
(25%) leads to lactation cessation
Reference 8, 44
Mastitis — History and
Physical Exam
• Fever, diffuse myalgias, “flu-like” symptoms, breast pain
• Wedge-shaped, tender, erythematous, usually unilateral
• Upper, outer quadrant most common
Mastitis Treatment
• DO NOT stop breastfeeding on the affected side, empty
the breast
• If mild, symptoms occur for less than 24 hours and
may attempt to resolve with frequent nursing or pumping
and supportive measures including bed rest, fluids,
analgesics
• Antibiotic options include dicloxicillin 500 mg po qid;
cephalexin 500 mg po qid, or clindamycin 300 mg po qid
for 10 to 14 days
• Observe carefully for signs of abscess formation
Reference 1, 20, 39
Breast Abscess
• ~3% of mastitis cases develop into an abscess
• P.E. — tender, hard breast mass, fluctuant, erythematous
• Incision and drainage, antibiotics, analgesia, frequent
emptying
• Alternative — needle aspiration every other day until pus
no longer accumulates. Recommended as first line
• Culture fluid from abscess
Reference 4
Methicillin Resistant Staph Aureus and
Breast Abscess in Lactating Women
• Incidence of mastitis and breast abscess from
community acquired MRSA appears to be increasing
with up to 50% in some studies
• > 95% are community not hospital acquired MRSA
• Most seem to resolve even when given antibiotic that
community acquired MRSA is resistant to
• Draining breast by manual pumping and/or
breastfeeding for mastitis or incision and drainage of
abscess may be most important part of treatment
Reference 26, 31, 36, 40, 46
Nipple Candidal Infections
• Not uncommon, but often misdiagnosed
• Nonspecific signs and symptoms
– Nipple pain, itching, or burning sensation or shooting
breast pains that radiate back towards the chest wall
(possibly ductal candidal infection; may persist or worsen
after feeding is complete and breast is drained)
– Nipple and areola may appear erythematous or shiny or
have white patches
– There could be NO external signs
Reference 38
Causes of Nipple Candida
• Predisposed factors
– Diabetes
– Steroid use
– Immune deficiency
– Antibiotic use
– Nipple trauma
– Use of plastic-line breast pads that trap moisture
Treatment of Candidal Nipple
Infections — General
• Difficult to prove that Candida is the causative organism in all
situations (milk or skin cultures are not helpful and should not
be performed routinely)
• Infant usually has thrush when mother has candidal infection
• Treat mother and infant simultaneously (the mother’s partner
may also need to be treated in some instances)
• Sterilize objects that contact breast or infants mouth: pumping
supplies, bottles, and pacifiers
• Maternal treatment: nystatin suspension/ cream or clotrimazole
applied after each nursing. No need to wash off before feeds
• Infant: nystatin (100,000 u/ml) 1 cc po qid inside mouth to breast
after each nursing
Reference 10
Treatment of Candidal Nipple
Infections — Other Options
• Gentian Violet — a topical treatment option that uses
0.25%–1% gentian violet swabbed on the affected
areas for up to 3 days
• Oral fluconazole — may be prescribed if nipples are
not significantly better after several days of topical
treatment, or in cases of reoccurrence
Correlation Between Breast Symptoms
and Candida in Breast Milk Cultures
• > 70% PPV for shiny skin of nipple areola with
stabbing breast pain OR flaky skin of nipple/areola
with breast pain
• > 50% PPV with 2 of the 6 symptoms (sore nipples,
burning nipple/areola, breast painful [nonstabbing],
breasts painful [stabbing], shiny skin, flaky skin)
Reference 16, 21
Ductal Yeast Infection
• Lack objective findings on exam as nipple and skin may
not be involved
• Lack reliable microbiologic tests
• Decision to treat based on deep burning/shooting breast
pain without other causes
• Potential for overdiagnosis
Reference 10, 45
Treatment of Ductal Yeast Infection
• Will not respond to topical medicines
• Treatment is usually fluconazole 100–200 mg po qd for
14–21 days, although not FDA approved for this
indication
• Need studies of diagnostic criteria and effectiveness
• Need to treat infant with oral nystatin as well for thrush
or colonization
Summary: Breastfeeding Problems
• Problems are common and treatable
• Assess adequacy of suckle and milk production/transfer
• Neonatal jaundice and dehydration are associated with
breastfeeding problems
• Treat engorgement and blocked nipples to prevent
mastitis and abscesses
• Bacterial and candidal infections can adversely affect
breastfeeding
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