Breastfeeding — common issues

Most issues are temporary and not a reason to stop breastfeeding. Give consistent, supportive advice. Talk with midwife or lactation consultant if not sure

Early, effective treatment of breast engorgement and blocked milk ducts can prevent mastitis

Ask

Check

  • Calculate REWS — AVPU, RR, O2 sats, pulse, BP, Temp
  • Weight, BGL 
  • Breasts and under arms for tender areas, redness, lumps, swelling, nipple or tissue damage
  • Check baby's history and neonatal check — see Postnatal care of baby

Mastitis

  • Inflammation of breast tissue
  • Always consider in breastfeeding woman with flu-like symptoms and/or fever
  • Usually only one breast or part of one breast is affected

Causes

  • Infection in breast due to
    • Cracked nipples with broken skin
    • Untreated engorgement or blocked milk ducts
  • Prolonged pressure on breasts — tight bra, holding or pressing on breast during feeding

Do

  • Medical consult for all women who may have mastitis
    • If very unwell — need to send to hospital, IV antibiotics
    • If doesn't need IV antibiotics — give cefalexin oral — adult 500mg, 4 times a day (qid) for 10 days
    • If allergy to penicillin — medical consult for clindamycin 
  • For pain relief — give paracetamol OR ibuprofen — see Pain management (acute) 
  • Encourage woman to continue breastfeeding to empty breast
    • Feed from affected breast first unless pus draining from nipple. If pus — hand-express to empty the breast
    • Advise to feed baby often and check baby is well-positioned and sucking well, especially on affected side to improve milk drainage from breast 
    • If baby doesn't feed well on affected side — encourage woman to express milk to empty the breast
  • Encourage rest, good diet and plenty of fluids
  • Assess daily until resolved
  • If not improved after 24 hours of treatment — medical consult

Breast abscess

  • Woman looks and feels very unwell and usually has fever
  • Localised swelling, redness, pain in one breast
  • May have 'pointing' swelling — like a boil on skin

Causes

  • May be caused by a bacterial infection that hasn't drained properly, localised collection of pus
  • Can develop into mastitis if not treated properly

Do

  • If febrile or flu like symptoms — medical consult about management, IV antibiotics, IV fluid, send to hospital
    • If doesn't need IV antibiotics — give cefalexin oral — adult 500mg, 4 times a day (qid) for 10 days
    • If allergy to penicillin — medical consult for clindamycin 
  • If not febrile and no flu like symptoms — use hot packs when feeding and cold packs after feeding
  • For pain relief — give paracetamol OR ibuprofen — see Pain management (acute) 
  • Advise mother to
    • Rest and drink plenty of water
    • Handle breasts gently
    • Breastfeed often — at the breast or if too painful or pus near nipple express by hand or pump on affected side — see Breastfeeding
  • If not improved after 24 hours — medical consult

Breast engorgement

  • Woman not unwell and may have low-grade fever
  • Both breasts and axilla become hard and often swollen, tender, warm

Causes

  • Increased blood supply to breast when milk 'comes in' around 3–5 days after birth
  • Breasts not emptied by regular feeding due to sleepy baby, restricted feeds or mother and baby separated

Do not

  • Do not restrict woman’s fluid intake — won't help engorgement and may be harmful

Do

  • Reassure mother that engorgement will improve after 24–48 hours
  • Pain relief for mother can include
    • Paracetamol OR ibuprofen — see Pain management (acute)
    • Ice packs to breasts after feeds
    • Expressing some milk between feeds to relieve tension in breast. Can do this in shower or after warm compress
  • Management is aimed at getting baby to feed well — see Breastfeeding
    • Allow baby to feed completely from first breast before offering other. Start next feed on breast that was offered last — will be the fullest
    • Allow breast that baby not feeding from to drip onto cloth or pad
    • Avoid ill-fitting bras
    • Teach mother to massage or compress breast while feeding
    • Apply warmth to the breast while feeding — may help with the flow of milk
  • Assess daily until resolved

Blocked milk ducts

  • Woman looks and feels well
  • Suspect blocked milk duct if tender lump or swollen area in breast

Do

  • Give paracetamol OR ibuprofen — See Pain management (acute). Give time to take effect before starting feed
  • Feed from affected breast first make sure breast emptied at each feed
  • Apply warmth to area before feed — hot water bottle, hot pack or shower
  • During feed gently but firmly massage lump toward nipple
  • Change feeding positions each feed to help drain breasts
  • Advise mother to come back to clinic straight away if fever or feels unwell — may be developing mastitis

Sore nipples

  • Sore nipples are common and especially in first 2 weeks after birth
  • If untreated — can lead to cracked or bleeding nipples OR mastitis

Causes

  • Usually poor attachment — often due to breast engorgement or poor positioning
  • Occasionally eczema, bacterial or fungal infections of skin — check mother's nipple and baby's mouth for oral thrush

Do

Before feed

  • Reassure woman that nipples heal well if care is taken with attachment
  • Give paracetamol OR ibuprofen  for pain relief — see Pain management (acute). Give time to take effect before starting feed
  • Express a little breast milk and rub onto nipple to soften areola and get milk flowing for feed
  • Hold a warm compress against breast to soothe and encourage milk flow
  • If fungal infection — medical consult about applying miconazole 2% cream, twice a day (bd) to nipples and rubbed onto baby's cheeks and tongue
    • If infection spread to baby’s mouth — give baby nystatin oral liquid — child 1mL, 4 times a day (qid)
  • If bacterial infection suspected — medical consult
  • Feed both breasts. Start on the side last finished

After feeds

  • Check nipple for blanching — indicates baby hasn't attached well
  • Rub expressed breast milk onto nipple between feeds and let air dry. Avoid use of creams
  • Assess daily until resolved
  • Talk with midwife/ lactation consultant

Milk supply

  • In early postnatal period, milk supply can be affected by
    • Retained products (part of placenta or membranes left inside uterus)
    • Poor attachment of baby to breast — due to positioning or preterm baby
    • Sore nipples making attachment challenging
    • Hormonal issues, breast surgery, some medicines 
  • Later mother may be concerned about low supply if breasts feel soft or baby feeding often. These can be normal. Baby will naturally want to feed more often during growth spurts or if unsettled

Do

  • If retained products suspected — medical consult
  • Reassure mother that baby is getting enough breast milk if bright eyes, wet mouth and tongue, 5–6 wet nappies a day, pale coloured urine and weight gain
  • Supply will usually increase within a few days if
    • Baby is fed when it wants to be fed
    • Frequency and duration of feeds are increased
    • Mother expresses breast milk — see Breastfeeding
  • Supply will decrease if baby has other drinks (eg formula or water)
  • If growth or hydration concerns — medical consult to consider domperidone tablets
    • Also need to keep expressing to ensure supply
    • Domperidone should be slowly reduced once supply established

Supporting resources