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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.

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Management of common breastfeeding problems

Management of CommonBreastfeeding Problems

Breastfeeding Residency Curriculum

Prepared by

Andrew Hsi MD, MPH


Larry Leeman MD, MPH

University of New Mexico School of Medicine

Breastfeeding assessment
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.


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

At the end of this presentation the learner will be able to discuss:

Assessment of newborn oral cavity
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
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


Awareness of potential anatomic mismatch

Large nipple with small baby

Perceived problems influence feedings

Reference 19, 27

Breast assessment uncommon conditions
Breast Assessment — Uncommon Conditions

Secondary Displasia:

s/p radiation Rx

s/p breast surgery

s/p severe mastitis/abscess

Primary Hypoplasia:

- insufficient mammary glandular tissue

- nulliparous state (adopted infant)

- unilateral or bilateral breast anomalies

Breast injury and surgery
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
Disorganized Suckle

Term babies have because:

Coordination problems



Preterm babies may have:

Neurologic immaturity

Disorganized sucking excessive external stimulation

Weaker muscles in mouth and tongue

Suckle problems ankyloglossia
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
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
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
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
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
Management for Early Jaundice in Breastfeeding Infants Hyperbilirubinemia

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
Management of Breastmilk Jaundice Hyperbilirubinemia

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
Summary for Early Detection of Risk for Hyperbilirubinemia 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
Assessment of Milk Sufficiency Hyperbilirubinemia

  • “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
Assessment for Slow Weight Gain Versus Failure To Thrive Hyperbilirubinemia

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
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
Dehydration and Breastfeeding Thrive Infant

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
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 II Problems

  • 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
Problems with Lactogenesis II Problems

  • 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
Causes of Delayed Lactogenesis II Problems

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
Causes of Failed Lactogenesis II Problems

  • 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 Problems

  • 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 Problems

  • 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 Problems

  • 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
Excess Milk Supply Problems

  • 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
Management of Excess Milk Supply Problems

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
Plugged Ducts Problems

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


Ensure complete drainage


Warm packs

Position changes

Reference 1

Mastitis Problems

  • 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
Mastitis — History and ProblemsPhysical Exam

  • Fever, diffuse myalgias, “flu-like” symptoms, breast pain

  • Wedge-shaped, tender, erythematous, usually unilateral

  • Upper, outer quadrant most common

Mastitis treatment
Mastitis Treatment Problems

  • 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
Breast Abscess Problems

  • ~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

Methicillin Resistant Staph Aureus and Breast Abscess in Lactating Women

Reference 26, 31, 36, 40, 46

Nipple candidal infections
Nipple Candidal Infections acquired MRSA appears to be increasing with up to 50% in some studies

  • 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
Causes of Nipple Candida acquired MRSA appears to be increasing with up to 50% in some studies

  • 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
Treatment of Candidal Nipple Infections — General acquired MRSA appears to be increasing with up to 50% in some studies

  • 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
Treatment of Candidal Nipple Infections — Other Options acquired MRSA appears to be increasing with up to 50% in some studies

  • 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
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
Ductal Yeast Infection Milk Cultures

  • 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
Treatment of Ductal Yeast Infection Milk Cultures

  • 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
Summary: Breastfeeding Problems Milk Cultures

  • 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

References Milk Cultures

  • Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #4: mastitis. Revision, May 2008. Breastfeed Med. 2008;3(3):177-180.

  • Alpay F, Sarici SU, Tosuncuk HD, Serdar MA, Inanc N, Gokcay E. The value of first-day bilirubin measurement in predicting the development of significant hyperbilirubinemia in healthy term newborns. Pediatrics. 2000;106(2): e16.

  • American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114(1):297-316.

  • Amir LH, Forster DA, Lumley J, McLachlan H. A descriptive study of mastitis in Australian breastfeeding women: incidence and determinants. BMC Public Health. 2007;7:62.

  • Amir LH, James JP, Donath SM. Reliability of the hazelbaker assessment tool for lingual frenulum function. Int Breastfeed J. 2006;1(1):3.

  • Andrews JI, Fleener DK, Messer SA, Hansen WF, Pfaller MA, Diekema DJ. The yeast connection: is Candida linked to breastfeeding associated pain? Am J Obstet Gynecol. 2007;197(4):424.e1-e4.

  • Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110(5):e63.

  • Barbosa-Cesnik C, Schwartz K, Foxman B. Lactation mastitis. JAMA. 2003;289(13):1609-1612.

  • Betzold CM. Galactagogues. J Midwifery Womens Health. 2004;49(2):151-154.

  • Betzold CM. An update on the recognition and management of lactational breast inflammation. J Midwifery Womens Health. 2007;52(6):595-605.

  • Betzold CM, Hoover KL, Snyder CL. Delayed lactogenesis II: a comparison of four cases. J Midwifery Womens Health. 2004;49(2):132-137.

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  • Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999;103(1):6-14.

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  • Cadwell K. Maternal and Infant Assessment for Breastfeeding and Human Lactation: A Guide for the Practitioner, 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2006.

References Milk Cultures

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  • Chou SC, Palmer RH, Ezhuthachan S, et al. Management of hyperbilirubinemia in newborns: measuring performance by using a benchmarking model. Pediatrics. 2003;112(6 Pt 1):1264-1273.

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  • Hurst NM. Recognizing and treating delayed or failed lactogenesis II. J Midwifery Womens Health. 2007;52(6):588-594.

  • Kauppila A, Arvela P, Koivisto M, Kiniven S, Ylikorkala O, Pelkonen O. Metoclopramide and breast feeding: transfer into milk and the newborn. Eur J Clin Pharmacol 1983;25(6):819-823.

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  • Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia, PA: Mosby, Inc.; 2005:46, 436-437, 538-540, 607.

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References Milk Cultures

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  • The Academy of Breastfeeding Medicine. Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Supply. 2004. Accessed October 13, 2008.

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