BREAST DISEASE: DIAGNOSIS AND

CONTEMPORARY MANAGEMENT 0889–8545/02 $15.00
.00

COMMON BREASTFEEDING
PROBLEMS
Gail K. Prachniak, RN, IBCLC

FLAT OR INVERTED NIPPLES

Ideally, the health care professional assesses nipple type during the third
trimester. Retraction or inversion is caused by adhesions at the base of the
nipple. No immediate action is required. Nipple stimulation during pregnancy
may precipitate labor. Mothers can be instructed to roll the nipple before
breastfeeding. This exercise will loosen the nipple tissue and help to separate
adhesions.41 Breast shells—plastic, dome-shaped, circular-vented, discs that fit
over the nipple and are held in place by the bra—may be worn postnatally
between feeding and pumping sessions. Gentle pressure is applied evenly
around the nipple base to diminish adhesions and improve nipple protraction.
To avoid pressure on the breast tissue, the woman should remove breast shells
before going to sleep. Controversy continues regarding the effectiveness of breast
shells.30, 41
Medications used during childbirth may cause nipples to be somewhat flat
and less responsive to stimulation temporarily after delivery. Pumping briefly
before breastfeeding can elongate the nipple and facilitate latch-on.
For some women, any implication that the breasts are ‘‘defective’’ may
decrease their confidence level and dissuade them from attempting to breastfeed.
Establishing good rapport and providing the mother with options increases her
confidence and emotional and physical comfort level.

From the Lactation Program, Women and Infants Hospital; the Rhode Island Breastfeeding
Coalition; and the WIC Peer Counselor Program, the Rhode Island Department of
Health, Providence, Rhode Island

OBSTETRICS AND GYNECOLOGY CLINICS OF NORTH AMERICA

VOLUME 29 • NUMBER 1 • MARCH 2002 77

78 PRACHNIAK

NIPPLE PAIN

Nipple pain is usually the result of improper position, incorrect latch-on

technique of the baby, or both. Other common causes include sustained negative
pressure, improper technique of breaking suction, disorganized or dysfunctional
suckling, incorrect use of the breast pump, a tight frenulum, and nipple candidia-
sis.
The best prevention for sore nipples is prenatal education. Mothers benefit
when they are instructed in positioning and correct latch-on technique, the
proper method for breaking suction, the use of a breast pump, and the avoidance
of plastic-backed breast pads that trap moisture and inhibit sufficient air circula-
tion. Care of the breast prenatally and postnatally involves a daily wash with
plain warm water. Soaps and chemicals can irritate the nipple. Expressed breast-
milk can be rubbed on the nipple to facilitate healing. Purified forms of lanolin,
(Lansinoh Laboratories, Oak Ridge, Tennessee), and PureLan (Medela, Inc.,
McHenry, Illinois) are available over the counter. These products do not prevent
sore nipples but may aid in the healing process if soreness or nipple damage
occurs. The cause of nipple trauma must be addressed.42
Disorganized suckling may be temporary. Many babies become more adept
at 24 hours postdelivery. Dysfunctional suckling typically requires intervention;
careful monitoring is recommended. Pumping may be necessary to sustain the
milk supply.
A tight frenulum may prevent sustained extension of the tongue over the
lower gumline, interfering with the baby’s ability to elicit milk transfer and
stimulate milk supply. In some situations, a tight frenulum can be stretched,
using a finger to stroke the tongue in a downward, outward motion. In the
event of nipple pain or inability to latch-on, additional intervention is indicated.
Clipping the lingual frenulum provides relief from nipple pain and improves
the infant’s suckling pattern.9, 36
A statistically significant correlation between nipple candidiasis, vaginal
candidiasis, previous antibiotic use, and nipple trauma has been noted.50 Treat-
ment of vaginitis during pregnancy is important to prevent the newborn from
becoming infected at birth.21
Little information is available in the medical literature concerning breast
and nipple pain as a result of a yeast infection.2a It is difficult to diagnose yeast
infections of the nipple and breast.1a Currently, internal breast yeast is a diagnosis
of exclusion; therefore, detection and treatment may be delayed. A detailed
history is necessary. Any family member with a fungal infection, such as a
vaginal yeast infection, ‘‘jock itch,’’ diaper rash, finger or toenail fungus, ring-
worm, or dandruff, requires immediate treatment. All family members and
caregivers should be educated regarding activities to decrease the spread of
yeast. Hoover21 recommends the following measures:
• Good hand washing is important. Wash the hands with warm soapy water
and use lots of friction for at least 15 seconds.
• Use paper towels for hand drying and then discard them because yeast
can live on a moist towel.
• Use a bath towel only once and then wash it. Wash towels and clothing
that come in contact with the yeast in hot water (above 50C or 122F).
Hang washed towels in the sun to dry, if possible. Ironing will help
kill yeast.
• Boil items used in the baby’s mouth (pacifiers, bottle nipples, teething
toys) and anything that comes in contact with the breast milk (pump kit
parts, breast shells) for 20 minutes once a day.
 COMMON BREASTFEEDING PROBLEMS 79

• Milk expressed during a yeast infection does not need to be discarded.

Because freezing does not destroy yeast,16 the milk could possibly be a
source of reinfection, but it is unlikely.
• After 1 week, discard all bottle nipples and pacifiers and purchase new
ones. Buy new toothbrushes for the whole family. One woman found her
dental retainer to be the source of reinfection.
• Check pets and farm animals for yeast, especially their ears.
• A bleach solution of 3/4 cup household bleach to 1 gallon of water (or 2
tablespoons of bleach to 2 and 2/3 cups of water) will disinfect surfaces
such as a diaper changing pad, baby furniture, and toys. Wipe with the
bleach solution, rinse, and air dry.
• If a yeast infection is not resolving, the mother can reduce sugar and dairy
products in her diet.22 Some women report that it helps to add acidophilus,
garlic, zinc, more water, or B vitamins (from a source other than nutritional
yeast) to their diets. Tests to rule out anemia and diabetes are a good idea.
Some women have found herbal or homeopathic remedies helpful.*
• Long fingernails or artificial fingernails may contribute to the spread of
yeast infections.18, 40, 56
Persistently sore nipples or shooting breast pain may be symptoms of
Candida albicans infection of the nipple, breast, or both.19, 23 The nipples may
appear erythematous or fissured. These effects can be remedied with topical
preparations. In some cases, oral antifungual treatment for the mother is neces-
sary. The infant’s mouth should also be treated to prevent reinfection.3, 4, 49
Candida infections can be extremely persistent. Initial management of the infec-
tion is crucial.18 Simultaneous treatment for the nursing couple is essential.5, 20, 41
A certified lactation consultant can provide assessment, education, and follow-
up care.
International Board Certified Lactation Consultants (IBCLC) are allied health
care providers who, by meeting eligibility requirements and passing an indepen-
dent certification examination, possess the necessary skills, knowledge, and
attitudes to facilitate breastfeeding. With a focus on preventive health care, these
individuals encourage self-care and parental decision making prenatally and
postnatally. IBCLCs use a problem-solving approach to provide appropriate
information, recommendations, and referrals in a variety of settings.24 Breastfeed-
ing management skills are critical in the prevention and proper treatment of
sore and cracked nipples.8 Providing information based on scientific research
reduces the risk of mothers receiving conflicting recommendations.19
Nipple pain often occurs with initial latch-on. Jaw massage, a gentle circular
massage in front of the baby’s ears, can relax his or her lower jaw. This activity
may be done before breastfeeding attempts to facilitate a wide-open mouth and
tongue extension over the lower gum to the lower lip. The mother should
place one finger on the baby’s chin and draw downward to encourage tongue
extension57 while the baby is at the breast. Elimination of nipple pain and
improved milk flow occurs when the tongue is properly positioned. Placing a
rolled cloth under the breast can provide adequate support for the breast tissue
and free one hand of the mother so she can assist the baby with latch-on. A hot

*A comprehensive article that includes descriptions of yeast infections, differential

diagnoses, medications that are effective in treatment, and medical references is available
in a four-page booklet entitled, ‘‘The Link Between Infants’ Oral Thrush and Nipple and
Breast Pain in Lactating Women,’’ written by Kay Hoover, MEd, IBCLC (see Appendix for
address). The booklet includes a two-page color photograph guide to assist with diagnosis.
80 PRACHNIAK

water bottle, heating pad, or ‘‘rice sock’’ (a tube sock filled with old-fashioned
white rice with the open end tied off that is placed in a microwave oven for 90
seconds on high, and then into a pillow case) applied to the mother’s upper
back and shoulder muscles while feeding or pumping promotes relaxation and
may facilitate milk flow.
If nipples are damaged, nursing pads may stick to the nipple. Soaking the
pads in warm water will ease their removal. Breast shells will protect the nipple
from the friction of clothing, prevent the nipple from sticking to fabric, and
allow air to circulate.

BREAST PAIN

Some women experience shooting pain within the breast during the milk
ejection reflex. Typically, this sensation occurs in the early weeks of breastfeeding
while the milk supply is being established. Pressure on the brachial plexus
caused by poorly fitted bras or heavy backpacks may lead to shooting breast
pains. Candida infections can also cause deep shooting pain in the breast.41

ENGORGEMENT

Approximately 36 hours postpartum, breast fullness is evident, reflecting an

increase in available milk volume and increased blood and lymph circulation.
Although the breasts may feel heavy, they remain soft and pain free. The breast
tissue is compressible, and effective latch-on can be achieved. Engorgement, or
stasis of milk, is demonstrated by hard, lumpy, painful breasts with taut skin;
the mother may be febrile. The breast tissue is not compressible, interfering
with proper latch-on. Intraductal pressure can cause atrophy of secreting and
myoepithelial cells, decreasing milk supply.30 Proper management of breastfeed-
ing can prevent engorgement. Mother–infant separation is a contributing factor
to milk stasis.
Treatment of engorgement includes reassurance that this state is temporary.39
To prevent permanent damage to alveoli, gentle handling of breast tissue is
recommended. Gentle massage assists with milk flow. The mother should be
advised to stand in the shower with her back to the water spray. It is often
painful to have the water hit the nipple and breast directly. Medication may be
necessary to alleviate pain.
After the initial pressure is relieved, breast compression is possible, and
latch-on can be achieved. Following an effective feeding or pumping session,
cold compresses can be applied to the breast to reduce swelling. Cold compresses
should be placed in a cloth before applying them to the skin. If uncomfortable
fullness remains after a feeding, it is advisable to relieve the fullness by pumping
or manual expression. A supportive bra is recommended. It is best to avoid
underwire bras while lactating, because compression of the milk ducts may lead
to plugged ducts or mastitis.

OBSTRUCTED MILK DUCT

An obstructed or ‘‘plugged’’ duct refers to stasis of milk, which creates a

blockage of the duct. Symptoms include localized tenderness, an area of redness
on the breast, and, possibly, a palpable lump. An exact cause has not been
 COMMON BREASTFEEDING PROBLEMS 81

documented. Contributing factors include constrictive clothing, fatigue, stress,

and inadequate drainage owing to a change in feeding frequency or duration.
Treatment measures include an increase in the frequency and duration of
feeds, rest, the application of moist heat, and massage behind the obstruction,
working toward the nipple. Pumping or manual expression prevents milk stasis.

MASTITIS

Acute nonepidemic mastitis, formerly called ‘‘puerperal mastitis,’’ refers to

breast soreness, fever, and flulike symptoms that may develop any time during
lactation.27 According to Kinlay and co-workers,27 ‘‘Mastitis is a bacterial cellulitis
of the interlobular connective tissue of the breast and of the mammary glands.
Milk stasis may predispose the breast to infection.’’ Disease-producing organisms
may gain access through a crack or an abrasion of the nipple. The most common
pathogens are staphylococci and Escherichia coli. On rare occasions, streptococci
are the infecting organisms.
New mothers need accurate information regarding the early signs and
symptoms of mastitis.2 Often, the initial manifestation is fatigue, followed by
localized tenderness of the breast and flulike symptoms, including an elevated
temperature and rapid pulse.12 The infection is usually unilateral and in the
upper outer breast quadrant, but bilateral infections are possible.
Typically, mastitis occurs 2 to 6 weeks following delivery. Approximately
one third of the reported cases occur after the infant is 6 months old. Treatment
includes bed rest, moist heat to the affected area, increased fluid intake, and
antibiotic therapy,10 and removal of additional milk from the affected breast after
a feeding.53 For staphylococcal infections, drugs of choice include amoxicillin,
dicloxacillin, and nafcillin. For streptococcal infection, penicillin is generally
recommended. If the infant is under 1 month of age, sulfa drugs should be
avoided by a breastfeeding mother.30 While taking antibiotics, the woman should
decrease sugar intake and take acidophilus capsules daily, according to package
instructions, to ward off yeast infections.30 Acidophilus capsules that require
refrigeration tend to be more potent. Horowitz and co-workers22 have reported
that, ‘‘Excessive lactose intake in the form of dairy products (yogurt) or of
commonly used artificial sweeteners increases the likelihood of yeast infections,
in their initial onset and particularly in their recurrence patterns.’’
During episodes of mastitis, breastfeeding should be continued. Milk from
the affected breast may have elevated sodium and chloride levels51 and de-
creased levels of lactose.38 If the infant objects to the taste, frequent pumping
should restore normal concentrations in the milk. Usually, symptoms are relieved
within 48 hours of antibiotic treatment. Most women continue to lactate success-
fully following an episode of mastitis.52 According to Fetherston,11 ‘‘Adverse
effects of mastitis on a mother’s breastfeeding experience are more likely to
depend on a mother’s perception of her experience rather than a clinician’s
interpretation of the severity of the symptoms.’’ One study noted a relationship
between the seasons and the incidence of mastitis. There was an increased
occurrence during the winter months.10
Recurrent mastitis may require long-term antibiotic therapy; however, a
breast abscess should be suspected. A breast abscess may result from an un-
treated episode of mastitis. Preventative measures include good breastfeeding
management, early identification, and antibiotics. Treatment includes surgical
incision and drainage, rest, and antibiotics. Depending on the location of the
abscess and the mother’s comfort level, breastfeeding may be continued. In-
82 PRACHNIAK

creased stimulation to the breast increases milk supply; therefore, the infant can
obtain an adequate quantity of milk from one breast. Any interruption of
breastfeeding at one or both breasts requires pumping of one or both breasts to
maintain the milk supply. The breasts function as separate glands. Each breast
responds directly to the stimulation it receives. Incision for a deep abscess may
result in a severed milk duct or nerve damage. Ductal abnormalities may be a
contributing factor of recurrent mastitis.53 In some situations, it is helpful to
culture the breastmilk as well as the infant’s nasopharynx and oropharynx.30
Table 1 compares the clinical findings of engorgement, an obstructed milk
duct, and mastitis.

BREASTFEEDING IN SPECIAL CIRCUMSTANCES

Maternal Factors

Cesarean Delivery
Immediate breastfeeding is compatible with cesarean delivery. With an
epidural anesthetic, the mother is awake and able to handle her infant with
assistance. Early and regular suckling of maternal milk has been shown to
increase breastfeeding rates among babies born via cesarean delivery.47

Maternal Infection
Few maternal infections actually require the cessation of breastfeeding.
In many cases, breastfeeding is uninterrupted or may be resumed following
appropriate therapy.31 Mothers who are HIV positive and wish to breastfeed are
faced with a dilema. HIV transmission from mother to child may occur during
pregnancy, childbirth, and breastfeeding. It is impossible to know exactly if, or
when, transmission will occur. Clearly, more research is necessary. Women need
to consult their obstetrician and pediatrician to review current data and to
facilitate an informed decision.37 According to Lawrence,29 ‘‘Women with known
AIDS who want their infant to receive human milk have two alternatives: (1)
pump their own milk and have it pasteurized at a local milk bank or hospital,
or (2) if that is not feasible, obtain milk from a breast milk bank, where milk is
donated by screened mothers and pasteurized.’’

Table 1. COMPARISON OF FINDINGS OF ENGORGEMENT, PLUGGED DUCT, AND

MASTITIS
Characteristics Engorgement Plugged Duct Mastitis
Onset Gradual, immediately Gradual, after Sudden, after 10 days
postpartum feedings
Site Bilateral Unilateral Usually unilateral
Swelling and heat Generalized May shift, little or Localized, red, hot,
no heat swollen
Pain Generalized Mild but localized Intense but localized
Body temperature ⬍38.4C (101F) ⬍38.4C ⬎38.4C
Systemic symptoms Feels well Feels well Flulike symptoms

From Lawrence R: Breastfeeding: A Guide for the Medical Profession, ed 5. Boston, Mosby, 1999,
p 276; with permission.
 COMMON BREASTFEEDING PROBLEMS 83

In many developing countries, the benefits of breastfeeding are considered

to outweigh the risks of HIV transmission. Formula prepared with contaminated
water leads to diarrheal disease. It may be socially awkward and conspicuous
for a mother to formula feed where breastfeeding is the norm.37, 45, 46

Mother and Infant Separation

At times, mother and infant separation is unavoidable. Whenever separation
is anticipated, a pumping regimen should be initiated, typically by pumping
every 2 to 3 hours during the day and once or twice at night. Pumping should
be comfortable. Information regarding the collection and storage of breastmilk
can be found in breast pump manuals and books on breastfeeding.

Medications
In most cases, maternal medication does not subject the infant to a signifi-
cant risk.6, 17, 25, 26 The American Academy of Pediatrics Committee on Drugs has
compiled a list of medications and any reported sign or symptoms in the infant
or effects on lactation.1

Infant Factors

Prematurity
With the increased use of in vitro fertilization, there has been an increase in
premature and multiple births. In such situations, breastfeeding is possible and
preferable. Human milk decreases the incidence of infection and necrotizing
enterocolitis.7 Low-birth-weight infants tolerate human milk more quickly than
formula.33, 55 A pumping regimen should begin as soon as possible.
Infants can receive expressed breastmilk in a variety of ways.15, 28 Initially,
gavage feeding may be necessary. Infants may go directly to the breast48; how-
ever, for successful oral feeding, the infant must be capable of coordinating
suckling, swallowing, and breathing reflexes.13 This coordination typically occurs
from 32 to 34 weeks’ gestation.35 Alternative feeding methods using an eyedrop-
per, spoon, or cup may ease the transition to breastfeeding.15, 28

Breastfeeding Multiples
Women have breastfed twins through the ages. It is increasingly common
for women to breastfeed triplets and even quadruplets.34 The benefits of
breastfeeding make it a worthwhile endeavor. Support groups provide encour-
agement and practical advice.

Cleft Lip and Cleft Palate

A simple cleft lip or cleft lip and alveolus does not interfere with breastfeed-
ing. Surgery is performed as early as possible.54 A cleft palate may cause
ineffective suckling. The infant may require the use of an orthodontic appliance
such as an obturator to close the gap and permit normal suckling.32, 43 Stimulation
of the milk supply is important.
84 PRACHNIAK

Breast Rejection
In most women, each breast and nipple varies at least slightly. The infant
usually adjusts to any differences and breastfeeds with no problems. If the infant
has been breastfeeding effectively and suddenly and consistently refuses one
breast, the mother and the involved breast should be evaluated to rule out local
disorders.14

References

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 COMMON BREASTFEEDING PROBLEMS 85

21. Hoover K: The Link Between Infant’s Oral Thrush and Nipple and Breast Pain in
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Address reprint requests to

Gail K. Prachniak, RN
23 Earl Street
Lincoln, RI 02865

e-mail: gprachni@WIHRI.org

APPENDIX

The following offices and organizations provide breastfeeding information

for health care professionals:
Baby Friendly USA
8 Sebastian Way
Unit 22
Sandwich, MA 02563
Phone: (508) 888-8092
FAX: (508) 888-8050
e-mail: info@babyfriendlyusa.org
Information regarding yeast infections and thrush (four-page booklet), available
by sending a check (made out to Kay Hoover) of $5.00 for 1, $30.00 for 10,
$50.00 for 25, or $100.00 for 100 copies.
Kay Hoover, MEd, IBCLC
613 Yale Avenue
Morton, PA 19070–1922
Phone & FAX: (610) 543-5995
International Board of Lactation Consultant Examiners Office
7309 Arlington Blvd.
Suite 300
Falls Church, VA 22042
Phone: (703) 560-7330
FAX: (703) 560-7332
e-mail: iblce@erols.com
 COMMON BREASTFEEDING PROBLEMS 87

International Lactation Consultant Association Office

1500 Sunday Drive, Suite 102
Raleigh, NC 27607
Phone: (919) 787-5181
FAX: (919) 787-4916
e-mail: Ilca@erols.com
Lactation Study Center
Ruth A. Lawrence, MD
Linda R. Friedman, PhD
University of Rochester Medical Center
Department of Pediatrics
Box 777
Rochester, NY 14642
Phone: (716) 275-0088
La Leche League International Center for Breastfeeding Information
1400 N. Meacham Road
PO Box 4079
Schaumburg, IL 60168–4079
Phone: (847) 519-7730
FAX: (847) 519-0035
e-mail: CBI@Ill.org
Professional education and high-risk clinic for mothers and infants
The Lactation Institute
16430 Ventura Blvd.
Suite 303
Encino, CA 91436
Phone: (818) 995-1913
FAX: (818) 995-0634
e-mail: info@lactationinstitute@.org
National Organization of Mothers of Twins Clubs
PO Box 438
Thompson Station, TN 37179
Phone: (615) 595-0936
e-mail: nomotc@aol.com

WEB SITES

American Academy of Pediatrics breastfeeding resources

www.aap.org/visit/brres.htm
Baby Friendly USA (baby friendly hospital initiative)
www.babyfriendlyusa.org
Breastfeeding.com
www.breastfeeding.com
Center for Breastfeeding
www.healthychildren.cc
Centers for Disease Control
www.cdc.gov/breastfeeding/
88 PRACHNIAK

Hale, Thomas—information on drugs and lactation

www.perinatalpub.com
International Lactation Consultants Association
www.ilca.org
International Pediatric Chat
www.pedchat.org
Lactation Institute
www.lactationinstitute.org
Medline research published in professional journals
www.nlm.nih.gov
National Center for Education in Maternal and Child Health
www.ncemch.org
National Center for Health Sciences
www.cdc.gov/nchswww
National Healthy Mothers/Healthy Babies Coalition
www.hmhb.org
National Organization of Mothers of Twins Clubs
www.nomotc@aol.org
National Women’s Health Information Center
www.4women.org
Newman, Jack—lactation consultant
www.bflre.com/jn/biojack.htm
Office of Women’s Health
www.4women.org
Pediatric Journals
www.angelfire.com/in/pedscapes/index.html
Women and Infants Hospital
www.womenandinfants.com/bfeeding.html

MILK BANKS

Lactation Support Service Mothers’ Milk Bank

BC Children’s Hospital P/SL Medical Center
4480 Oak Street 1719 East 19th Avenue
Vancouver, BC Denver, CO 80218
V6H 3V4 (303) 869-1888
Canada
Mothers’ Milk Bank & Lactation Center
(604) 875-2345 x7607
Wake Medical Center
Mothers’ Milk Bank 3000 New Bern Avenue
c/o Professional Group Raleigh, NC 27610
PO Box 5730 (919) 350-8599
San Jose, CA 95150
Wilmington Mothers’ Milk Bank
(408) 998-4550
Christiana Hospital
PO Box 1665
Wilmington, DE 19579
(302) 733-2340