Common problems of breastfeeding and weaning Authors Richard J Schanler, MD Debra C Potak, RN, BSN, IBCLC Section Editors

Steven A Abrams, MD Jan E Drutz, MD Deputy Editor Melanie S Kim, MD Disclosures Last literature review version 19.2: mayo 2011 | This topic last updated: marzo 21, 2011 (More) INTRODUCTION Breastfeeding a healthy infant is often accompanied by challenges. Some may be predictable, while others are unexpected. These problems may accompany the normal anxiety of first-time parents, who rarely appreciate the intensity of care infants require. Reassurance and guidance often will enable mothers to continue breastfeeding. Common problems associated with breastfeeding and their management in the postpartum period are reviewed here. The initiation of breastfeeding and immediate postpartum evaluation of mothers and infants are discussed separately. (See "Initiation of breastfeeding".) BREAST PAIN Breast pain is a common manifestation of the following conditions during lactation:

Engorgement Sore nipples Plugged ducts Mastitis Breast abscess

These conditions are commonly due to incorrect breastfeeding technique, particularly the inability of the infant to form a good latch-on and empty the breast. Latching on refers to the formation of a tight seal of the infant's lips around the nipple and a sufficient portion of the areola to allow efficient removal of milk during nursing. A poor latch-on may result in injury to the nipple (eg, sore nipples) and may interfere with the infant's ability to empty the breast, which may result in engorgement, plugged ducts, mastitis, and breast abscess. Latch-on is discussed in greater detail separately. (See "Initiation of breastfeeding", section on 'Latch-on'.) Engorgement Engorgement refers to swelling of the breast and is due to ineffective or infrequent removal of milk from the breast. It can be quite painful for some women, whose breasts become hard and warm to the touch. Engorgement can occur early or late in the postpartum period.

Early engorgement typically occurs with the onset of copious milk production (ie, lactogenesis stage II) usually between 24 and 72 hours postpartum. It is secondary to edema, tissue swelling, and accumulated milk. Early engorgement resolves spontaneously in the majority of cases but may be persistent and more severe if the infant does not latch on well and nurse frequently and efficiently. During engorgement, latch-on may be more difficult because of breast tissue swelling and reduced protractility of the nipple. Late engorgement is usually due only to milk stasis. It may be generalized or limited to a single lobe of the breast. Late engorgement can result from missed feedings or failure to empty the breast thoroughly.

Management Frequent emptying of the breast is critical to both prevent and treat engorgement. The initial step is to ensure that the infant can achieve a satisfactory latch-on. This may require softening the areola by hand expression of milk. Thereafter, frequent and thorough breastfeeding is mandatory. Many interventions have been used for symptomatic pain relief. It remains unknown if one is more effective compared to others. They include the following:

Cool compresses or ice packs. Breast massage [1]. Ejection of milk between feedings. One intervention is a warm shower taken several times a day that allows the spray to fall on the breasts promoting milk release. Mild analgesics, such as acetaminophen or ibuprofen, may provide effective pain management. These are considered safe in breastfeeding women by the American Academy of Pediatrics Committee on Drugs [2].

In contrast, the following should be avoided, as they may exacerbate the problem or are not effective.

Use of breast pumps for more than 10 minutes at a time should be avoided. Pumps are often inefficient for removing milk during early engorgement. Furthermore, the additional stimulation can exacerbate engorgement by promoting excess milk production. When pumps are used during engorgement, concurrent hand massage may help promote rapid milk removal. Although heat application may provide temporary relief from discomfort, it should be used with caution during early engorgement because heat may exacerbate swelling [3]. In contrast, heat packs may be used in cases of late engorgement because tissue swelling usually is not present.

Cabbage leaves or cabbage leaf extracts, ultrasound treatments, and oxytocin are not beneficial compared to routine care, and should not be used in women with breast engorgement [4].

Sore nipples Sore nipples are one of the most common complaints by mothers in the immediate postpartum period. Pain due to nipple injury needs to be distinguished from nipple sensitivity, which normally increases during pregnancy and peaks approximately on the fourth postpartum day [5]. Normal nipple sensitivity can be differentiated from the pain due to nipple trauma by differences in their timing and course.

Normal sensitivity typically subsides approximately 30 seconds to 1 minute after suckling begins. It also diminishes after the fourth postpartum day and completely resolves approximately seven days after delivery. In contrast, pain due to trauma persists at the same or an increasing level throughout the nursing episode. Severe pain or pain that extends beyond the first postpartum week is more likely to be due to nipple injury.

Nipple trauma usually is due to incorrect breastfeeding technique, particularly poor position or latch-on. Nipple abrasion, bruising, cracking, and/or blistering may result when an infant fails to achieve a proper latchon. Infants with ankyloglossia are at increased risk for inadequate latch-on. Ankyloglossia, also known as "tongue-tie", occurs when the frenulum connecting the tongue to the floor of the mouth is tight and limits extension of the tongue (figure 1). (See "Ankyloglossia (tongue-tie) in infants and children", section on 'Breastfeeding problems'.) Other contributing factors to sore nipples include plugged ducts, infections (eg, candidiasis), harsh breast cleansing, use of potentially irritating products, and skin disorders [6]. (See 'Plugged ducts' below.) Women with injured nipples are at increased risk for developing a skin or breast infection. Common causative agents are Candida albicans and Staphylococcus aureus, although others may be involved. Management The most effective techniques for preventing nipple trauma are a good latch-on, and proper positioning. In general, prenatal preparation of the nipple with nipple exercises or devices to correct inverted nipples (Hoffman's shells) does not help and may actually shorten breastfeeding duration [7]. Nipple abnormalities detected in the prenatal period should be evaluated by a lactation consultant. (See "Initiation of breastfeeding", section on 'Inverted nipples'.) Normal nipple sensitivity resolves spontaneously, and mothers should be reassured that this will occur.

The management of mothers with nipple trauma includes the following [6]:

Identification of any underlying nipple condition and, if present, treatment for the specific problem. In particular, assessment of infant positioning and latch-on with correction of improper technique should be performed. Use of purified lanolin (eg, Lansinoh, Purelan) or hydrogel dressing (eg, Comfortgels, Soothies) to provide moisture to the nipples to facilitate healing Use of breast shields to protect the nipples from friction between feeds.

For sore nipples that are refractory to initial measures, some experts recommend an antibiotic ointment, such as mupirocin (Bactroban), plus a combination antifungal and antiinflammatory agent (Mycolog) because of concerns of skin/breast bacterial or candidal infection [8]. A combination ointment that includes a mixture of mupirocin, steroid (betamethasone 0.1 percent), and antifungal powder (miconazole), known as "All purpose nipple ointment" (APNO), is also available. The mixture should be applied after each nursing. It does not need to be removed before the next feeding. Highly concentrated vitamin E oil should not be applied to the nipples because it is readily absorbed by the infant and may be toxic at high levels [9]. Biting After eruption of the primary teeth, which normally begins at 6 to 10 months of age, biting during breastfeeding can cause trauma to the nipple. Mothers can usually teach their infants not to bite the nipple by immediately removing the breast from his or her mouth as soon as a bite begins and placing the infant immediately on a safe surface. If the mother is consistent, the baby usually learns quickly not to bite. Plugged ducts Plugged ducts are localized areas of milk stasis with distention of mammary tissue. Symptoms include a palpable lump with tenderness. They are distinguished from mastitis and breast abscess by the absence of systemic findings, such as fever >38.3 C, myalgia, chills, malaise, and flu-like symptoms. (See 'Breast infections' below.) Predisposing factors for plugged ducts are similar to those for engorgement. They include poor latch-on that results in inadequate emptying of the breast, an overabundant milk supply, an abrupt change in feeding frequency, or a poorly fitting brassiere [3]. Galactoceles Unrelieved plugged ducts may lead to galactoceles, milk retention cysts (picture 1) [5]. Initially, these are milk filled, but gradual fluid resorption results in the formation of a thick, creamy, cheesy, or oily material that may be extruded from the nipple when the nodule is compressed.

Galactoceles can be visualized by ultrasound and appear as a well defined lesion with thin, echogenic walls [10]. The internal appearance consists of either homogeneous contents with medium-level echoes or heterogeneous contents with fluid clefts and anechoic rims. Focal echogenic areas with distal shadowing are sometimes seen. Management The initial management of plugged ducts is to assess the infant's positioning, latch-on, and ability to thoroughly empty the affected breast during each feeding, and to correct any improper technique. Positioning the infant with the chin close to the lump may facilitate drainage of the affected lobe. Frequent feedings or expressing milk using a breast pump should begin with the affected breast in order to optimize emptying. Massage and application of heat (warm showers) may also be useful. Plugged ducts that do not resolve within 72 hours require additional evaluation and treatment.

In some women with a plugged duct, a white area the size of a pin is visible on the nipple. This may occur when skin has grown over the duct opening. In some cases, relief may be obtained by gently opening the skin covering with a sterile needle and expressing the white cheesy substance from the nipple pore. However, this procedure can be exquisitely painful and should be performed by experienced clinicians with sensitivity and caution. Some clinicians recommend treatment for plugged ducts with ultrasound, although there are no data supporting their use [11]. Therapy consists of a dose of 2 watts/cm2 applied continuously for five minutes to the affected area once daily for one to two days. We do not think there is sufficient evidence to recommend this approach. Galactoceles that do not resolve can be treated with needle aspiration without interruption of breastfeeding. They tend to refill after aspiration, and may require repeated drainage or surgical removal under local anesthesia. Galactoceles that are not aspirated may persist after weaning.

BREAST INFECTIONS Lactational mastitis Mastitis is inflammation of the breast and is thought to be infectious in nature. It typically presents as a hard, red, tender, swollen area of one breast associated with fever >38.3 C (picture 2). Other systemic complaints include myalgia, chills, malaise, and flu-like symptoms. Common infectious agents include Staphylococcus aureus, streptococcus, and Escherichia coli. Lactational mastitis and its management are discussed separately. (See "Lactational mastitis".)

Breast abscess Breast abscess is an uncommon problem in breast feeding women, with a reported incidence of 0.1 percent [12]. The presentation of breast abscess is similar to mastitis, with breast pain and systemic symptoms, along with a fluctuant, tender, palpable mass. Breast abscess in lactating women and its management are discussed separately. (See "Breast abscess".) Candidal infection Candidal skin infections are usually treated with topical antifungal therapy, typically nystatin. In a lactating woman with candidal skin infection, systemic absorption of nystatin from intact skin and mucosal surfaces is low, and there should not be any nystatin detected in either maternal serum or milk [13]. However, there are no published reports on the use of nystatin during lactation [14]. To avoid infant contact with topical nystatin, care should be taken to wash the affected skin before breastfeeding or cover these areas during breastfeeding. If there is concern that the infant's mouth might come in contact with the treated area, an option would be to have a pharmacy prepare a topical gel of nystatin using a base that can be safely ingested by the infant by mouth to treat a mild infection. The usual excipients/carriers (polyethylene glycol, mineral oil, petrolatum, sorbitol, others) are not considered to be safe for infant ingestion. Topical application of the oral nystatin suspension might also be considered, although there are no data available on its use on surfaces other than oralesophageal mucous membranes. The oral suspension is used in neonates and infants for thrush and are therefore, safe to use on maternal skin [15,16]. For breastfeeding women with candidal infection, oral fluconazole can be considered as the American Academy of Pediatrics classifies fluconazole as compatible with breastfeeding. Treatment with an oral agent should generally only be used when a mother has failed topical therapy or has a particularly severe presentation. Fluconazole is distributed to breast milk at a ratio (0.9) similar to maternal serum, thus the infant receives a minimal amount of drug through breast milk [17]. As a result, dosing for the affected mother is not modified. (See "Candidal intertrigo", section on 'Oral antifungal agents'.) From a safety perspective, we suggest that a mild candidal infection not involving the nipples be treated initially with nystatin powder and/or ointment, provided it can be kept away from the baby's mouth during breastfeeding. INADEQUATE MILK INTAKE Inadequate milk intake may be due to insufficient milk production or failure of the infant to extract milk. The inability to fully and regularly empty the breast will ultimately result in

decreased milk production. Causes of inadequate milk intake include the following [18]:

Inappropriate early feeding routines are the most common cause of insufficient milk intake. They include infrequent feeding, poor latchon, maternal-infant separation, and the use of supplements. A delay in the progression of lactogenesis to stage II prevents the anticipated increase in milk production that occurs within the first five days of life. This may be due to retained placental fragments, primary pituitary insufficiency (eg, prolactin deficiency), or previous breast surgery. (See "Physiology of lactation", section on 'Lactogenesis'.) In some infants, oral-motor or neurologic abnormalities may lead to insufficient emptying and milk transfer.

Management The goal of management is to increase milk production and milk transfer. Initial management is focused upon determining the cause of inadequate milk supply:

A thorough breastfeeding history may identify contributing maternal and/or neonatal factors. Direct observation of breastfeeding may reveal either maternal or neonatal anatomical difficulties or improper breastfeeding technique (eg, position and latch-on). Determination of milk volume before and after feeding either by manual expression or breast pump will determine whether there is inadequate production or failure of milk transfer.

The primary intervention depends upon the cause but most often involves increasing the effectiveness and frequency of breastfeeding [18]. Use of breast pumps after each feed increases stimulation and emptying of the breast. Galactogogues Galactogogues (or lactogogues) are medications or other substances believed to assist initiation, maintenance, or augmentation of maternal milk production. The agents most commonly used are dopamine receptor antagonists (eg, metoclopramide, anddomperidone). However, there are no data demonstrating that these agents are more effective than interventions focused upon increasing the frequency of breastfeeding and improving breastfeeding technique [19-21]. In the one randomized trial of mothers of fullterm infants with inadequate milk production, there was no difference in the amount of milk production between mothers who received metoclopramide at a dose of 10 mg every 8 hours compared to mothers who received placebo [19]. In addition, the long-term effects of these medications are unknown. We do not recommend the routine use of galactogogues. These agents should never be used in the place of an evaluation and correction of any

modifiable factors such as frequency and thoroughness of breast emptying [6,22]. These agents should be used with caution and mothers need to be aware of the lack of data supporting their use. BLOODY NIPPLE DISCHARGE A small percentage of women have bloody nipple discharge in the first few days postpartum, resulting in bright red, pink or brown colostrum (also known as "rusty pipe syndrome"). The condition is related to vascularization of ducts during pregnancy. It typically resolves within a few days. Another rare problem is bloody milk during lactation that is often detected when the infant's stool becomes bloody or guaiac positive. The color of the milk can range from pale pink to bright red. If no obvious source is identified, such as cracked nipples that bleed during nursing or pumping, the presumptive diagnosis is intraductal papilloma (tumor derived from the lining of the breast duct). A milk specimen should be sent for cytology; expectant management is appropriate if cytology is negative. The bleeding usually resolves spontaneously and nursing should continue. (See"Nipple discharge", section on 'Pathologic (suspicious) nipple discharge' and "Overview of benign breast disease", section on 'Intraductal papillomas'.) OVERACTIVE MILK EJECTION REFLEX Milk production increases rapidly from the onset of lactogenesis stage II until approximately two to four weeks postpartum. The volume achieved is determined by the infant's demand. (See "Initiation of breastfeeding" and "Physiology of lactation".) Copious milk production may be accompanied by ejection of milk that is too rapid for the infant to swallow as it is presented. This results in gagging, coughing, and pushing away from the breast shortly after latch-on. Mothers may interpret the behavior as rejection of the milk or of breastfeeding. Management The management of an overactive milk ejection reflex includes the following options:

Nurse the infant in a semi-upright position, and allow the infant to interrupt nursing frequently. Reduce the flow of milk by gently compressing the base of the nipple during the first several minutes of nursing to slow the initial milk flow. Hand express until the initial let-down occurs, and then allow the baby to latch onto the breast. Nurse frequently to minimize the amount of milk that collects. Having less milk collected in the breasts will reduce the force of milk flow. Use a nipple shield to create a reservoir for the milk. Avoid pumping because this will further stimulate milk production and exacerbate the problem.

NIPPLE VASOCONSTRICTION Women who have Raynaud phenomenon or unusual cold sensitivity may develop cutaneous vasospasm of the nipple (picture 3). In a series of five affected women, the nipple blanched during, immediately after, and between feeds [23]. Cold exposure induced blanching of the nipple and pain in all of the women. Three had biphasic color change (white and blue), and two had the classic tricolor change (white, blue, and red) of Raynaud phenomenon. (See "Clinical manifestations and diagnosis of the Raynaud phenomenon".) Management Vasoconstriction associated with the Raynaud phenomenon should be differentiated from blanching of the nipple caused by compression due to poor positioning and latch-on. The latter is a much more common cause of blanching and nipple pain, and can be addressed by adjusting the infant's position and latch-on. Other palliative and preventive measures include increasing the environmental temperature and wearing warm clothing, and avoiding tobacco, oral contraceptives, and sympathomimetic medications (eg, pseudoephedrine), which can exacerbate vasoconstriction. Nipple pain due to vasoconstriction that is not responsive to these measures may benefit from pharmacologic treatment. We recommend a trial ofnifedipine (initial dose 10 mg orally three times daily) for two weeks [24]. If pain returns after the drug is discontinued, therapy may be resumed for a two-week period (see "Pharmacologic and surgical treatment of the Raynaud phenomenon"). JAUNDICE Breastfeeding is associated with hyperbilirubinemia as two distinct entities, breastfeeding failure jaundice and breast milk jaundice, which are discussed separately. (See "Pathogenesis and etiology of unconjugated hyperbilirubinemia in the newborn", section on 'Breastfeeding failure jaundice' and "Pathogenesis and etiology of unconjugated hyperbilirubinemia in the newborn", section on 'Breast milk jaundice'.) WEANING Exclusive breastfeeding is recommended for the first six months after birth, and the introduction of complementary feedings after six months of age along with partial breastfeeding up to at least 12 months, and thereafter for as long as mutually desired [25,26]. Adequate intake of human milk meets all the known nutritional requirements for infants in the first six months of life. Thereafter, solid foods help to supplement energy, iron, vitamins, and trace elements, and prepare the infant for a more diversified diet [3]. Ideally, weaning is accomplished gradually by eliminating one breastfeeding session every two to five days. The midday feeding is a good time to start because babies tend to be more attached to the first and last feedings of the day, when their need for comfort is greater. The use of drugs to inhibit

milk production postpartum is generally not recommended. (See "Principles of medication use during lactation", section on 'Decrease'.) Expressed milk may be given, or iron fortified formula, cow's milk, or solids may be introduced as an alternative food source, depending upon the age of the infant. Cow's milk can be substituted for formula in infants over 12 months of age [25]. (See "Introducing solid foods and vitamin and mineral supplementation during infancy", section on 'Cow's milk'.) The infant can be weaned to a bottle then a cup, or directly to a cup. When introducing a bottle, it helps if the baby is not extremely hungry, so he/she may be more patient when trying it out. It also helps if another caregiver introduces the bottle, as some babies initially refuse the bottle when the mother's breast is available. After bottle-feedings have started, some babies get frustrated with breastfeeding because milk flow is not as fast from the breast as from a bottle. It may help to select a bottle nipple with a slow flow and offer the breast before the baby gets very hungry and impatient. Weaning directly to a cup avoids the problems associated with bottlefeeding (eg, falling asleep while bottle-feeding can lead to tooth decay, the bottle can become a security object, and the infant's frustration with subsequent breastfeeding). A trainer cup with two handles and a snap-on lid with a spout is easiest to manage. If engorgement occurs, it can be managed as described above. (See 'Engorgement' above.) Once breastfeeding has stopped entirely, the breasts will stop producing milk quickly. INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.)

Basics topics (see "Patient information: Common breastfeeding problems (The Basics)" and "Patient information: Weaning from breastfeeding (The Basics)" and "Patient information: Breastfeeding (The Basics)")

Beyond the Basics topics (see "Patient information: Common breastfeeding problems" and "Patient information: Weaning from breastfeeding" and "Patient information: Breastfeeding guide")

SUMMARY AND RECOMMENDATIONS The most common problems of breastfeeding in the postpartum period are breast pain and inadequate milk intake by the infant.

Conditions that typically present with breast pain include engorgement, sore nipples, plugged ducts, mastitis, and breast abscess. These problems are usually due in part to incorrect breastfeeding techniques, particularly the inability of the infant to form a good latch-on and to empty the breast. (See 'Breast pain' above and "Initiation of breastfeeding", section on 'Latch-on'.) The primary intervention for conditions that present with breast pain is to identify and correct any improper breastfeeding technique or routine so as to ensure the infant is achieving a satisfactory latch-on and is thoroughly emptying the breast on a regular and frequent basis. Other interventions of breast pain depend upon the specific condition as follows: Interventions for symptomatic pain relief for engorgement include cool compresses, breast massage, milk ejection between feeds, and use of analgesics (eg, acetaminophen or ibuprofen). However, there are no data regarding their comparative efficacy. (See'Engorgement' above.) Pain due to nipple injury needs to be distinguished from nipple sensitivity, which peaks during the fourth postpartum day and then resolves. Women with nipple injury should be assessed (and if present, treated) for an underlying nipple condition, particularly for improper breastfeeding technique. Topical ointments may be applied for symptomatic relief and to provide moisture for cracked, dried nipples, and breast shields used to protect injured nipples between feeds. (See 'Sore nipples' above.) The initial management of plugged ducts is to assess breastfeeding technique and assure that the breast is thoroughly emptied with each feed. Other interventions include massage and heat application. If there is no resolution after 72 hours, further assessment (and possible intervention) is required. Unrelieved plugged ducts may result in galactoceles (picture 1), which may need to be aspirated. (See 'Plugged ducts' above.) The management of lactational mastitis and breast abscess are discussed separately. (See "Lactational mastitis" and "Breast abscess".)

Inadequate milk intake may be due to insufficient milk production or failure of the infant to extract milk. Management is focused upon determining the cause of inadequate milk intake based upon a thorough history, direct observation of breastfeeding, and determination of milk volume before and after feeding. Intervention is based upon the identified specific problem. We do not suggest the use of galactogogues to increase milk production (Grade 1C), because there are no data showing they are more beneficial than interventions focused upon improving breastfeeding technique. (See 'Inadequate milk intake' above.) Other common breastfeeding problems include bloody nipple discharge, overactive milk reflex, nipple vasoconstriction, maternal candidal skin infection, and neonatal jaundice. (See 'Bloody nipple discharge' above and 'Overactive milk ejection reflex' above and 'Nipple vasoconstriction' above and 'Candidal infection' above and 'Jaundice' above.) Exclusive breastfeeding is recommended for the first six months after birth, and partial breastfeeding for at least 12 months. Adequate intake of human milk meets all the known nutritional requirements for infants in the first six months of life and infants. After six months of age, the introduction of solid foods help to supplement energy, iron, vitamins, and trace elements, and prepare the infant for a more diversified diet. (See "Introducing solid foods and vitamin and mineral supplementation during infancy", section on 'Self-feeding'.) After six months of age, if desired, weaning can be accomplished gradually by eliminating one breastfeeding session every two to five days. Expressed human milk, iron fortified formula, cow's milk (after 12 months of age), or solids may be introduced as an alternative food source (see 'Weaning' above). The infant can be weaned to a bottle then a cup, or directly to a cup. (See "Introducing solid foods and vitamin and mineral supplementation during infancy", section on 'Self-feeding'.)

ACKNOWLEDGMENT The editorial staff at UpToDate, Inc. would like to acknowledge Dr. Judy Hopkinson, who contributed to an earlier version of this topic review. Use of UpToDate is subject to the Subscription and License Agreement. REFERENCES