Clinical Review Management of Common Breast-feeding Problems Joy Melnikow, Ml), MPH, and Joan M. Bedinghaus, MD Sacramento, California, and Cleveland, Ohio The benefits of breast-feeding have been well docu­ Poor weight gain in the infant is managed by more mented in the literature: it reduces morbidity from frequent nursing. Neonatal jaundice or infant gastro­ many illnesses and is considered the ideal nutrition for enteritis rarely requires discontinuation of breast-feed­ the newborn infant. This paper reviews common breast­ ing. feeding problems that family physicians may be called Although physicians frequently recommend that upon to manage: maternal problems, infant problems, women discontinue breast-feeding because of the ad­ and problems related to the need for maternal medica­ ministration of some maternal medications, maternal ill­ tion. ness can often be managed with medications that do not Ensuring proper position of the infant at the breast interfere with nursing. and attention to the let-down reflex is the recom­ Given proper advice and support, many mothers con­ mended method for prevention and treatment of nipple tinue to breast-feed even after returning to work. soreness. Prompt identification and treatment of blocked ducts, mastitis, and mondial infection of the Key words. Breast-feeding; hyperbilirubinemia; mastitis; nipple can prevent complications and allow uninter­ abscess, review literature. rupted nursing. ( / Fam Pract 1994; 39:56-64) Breast-feeding, which is recognized as the ideal nutrition offer little guidance to physicians regarding the manage­ for newborn infants,1 3 has been proven effective in reduc­ ment of patients with breast-feeding problems. A study of ing morbidity from lower respiratory infections, gastroin­ family practice residents in the southeastern United States testinal disease, and otitis media for infants in developed showed that many physicians-in-training lack adequate countries.4 6 Although Healthy People 2000 set a goal of knowledge or training about breast-feeding.10 In addi­ 75% of women breast-feeding at hospital discharge,7 the tion, a recent editorial called attention to the need for percentage of women in the United States breast-feeding improved education for physicians and physicians-in- at discharge actually declined from 60% in 1984 to 52% in training regarding breast-feeding.11 1989.8 This paper reviews common breast-feeding problems Many women leave the hospital planning to breast­ that family physicians may be called upon to manage in feed but discontinue in the first few weeks because of the process of caring for mothers and newborns. Maternal problems that arise after discharge. Some women discon­ problems, infant problems, and problems related to the tinue breast-feeding on the advice of their physicians, need for maternal medication are covered in sequence. even though their problems may have been successfully Articles on specific breast-feeding problems were managed while they continued to breast-feed.9 General identified by MEDLINE searches from 1966 through textbooks of family medicine, obstetrics, and pediatrics 1992. Additional articles were identified through artide references, reference texts, and knowledgeable individu­ Submitted, revised, January 31, 1994. als. When available, evidence from randomized clinical From the Departments o f Family Practice of the University of California at Davis, trials is cited. However, few trials have been conducted Sacramento (J.M.), and at the Mctrohealth Medical Center, Cleveland, Ohio that address the many questions related to breast-feeding. (J.M.B.). Requests for reprints should be addressed to Joy Melnikow, MD, MPH, Department o f Family Practice, University o f California at Davis, Sacramento, CA In light of their limited power, randomized trials with a 95S26. small sample size that showed no effect of an intervention © 1994 Appleton & Lange ISSN 0094-3509 56 The Journal of Family Practice, Vol. 39, No. l(Jul), 1994 Common Breast-feeding Problems Melnikow and Bedinghaus were interpreted cautiously. Nonrandomized trials, case trial compared the effects of limited nursing time with that series, and expert recommendations in published review of unrestricted nursing time.27 No difference in nipple articles and textbooks are included as well. The type of soreness between groups was found, but women in the evidence used to derive recommendations is specified in unrestricted group were more likely to still be breast­ each section. feeding at 6 weeks postpartum. Two smaller observational studies also found no relationship between early restric­ tion of nursing time and nipple soreness.28-29 Frequency Problems and Recommendations of breast-feeding (demand vs scheduled intervals) does not appear to affect nipple soreness.30 Current recommendations based on the published Maternal Problems clinical impressions of experts focus on the importance of proper positioning of the infant’s mouth on the nipple to Sore N ipples prevent and treat nipple soreness.31 33 Alternating nurs­ Sore nipples, a common reason reported by women for ing positions (cradle hold, football hold, lying down) with early discontinuation of breast-feeding, 12~14 are charac­ each feeding changes the location of maximum friction terized by pain that continues throughout feeding ses­ exerted by the infant’s mouth during nursing (Figure 1). sions. Often the nipples are cracked, bruised, or bleed­ Prolonged non-nutritive sucking, which may occur when ing.15 Sore nipples must be distinguished front the pain the baby is satiated and drowsy, leads to prolonged neg­ that, during latch-on, commonly occurs in the first few ative pressure and may also contribute to nipple trau­ postpartum weeks and is felt during the first seconds that ma.15-33 the infant closes his or her jaws on the breast. Although there is some evidence that prenatal prep­ Prenatal preparation of the breasts by nipple rolling, aration by nipple rolling may be helpful,18-19 it is not rubbing with a towel, applying cream or antiseptic spray, recommended by most experts.31-32 Nipple rolling should or expressing colostrum has been advocated to reduce not be initiated before 35 to 36 weeks’ gestation because nipple soreness associated with breast-feeding. Women of the possibility of stimulating uterine contractions. can perform nipple rolling by grasping the areola behind Proper positioning of the infant’s mouth on the nipple to the nipple, pulling gently but firmly outward, and rolling avoid trauma has been described in detail else­ the nipple between the thumb and finger. The thumb and where.31-33-34 Engorgement and mondial infections of the finger are then moved to another location at the base of nipple may also contribute to nipple soreness. the nipple and the exercise is repeated.16’17 Nipple rolling has been evaluated in two small studies, in which each Inhibited Let-D own subject served as her own control, preparing one breast but not the other.18*19 In one study, nipple rolling was Difficulty with the let-down reflex in the early days of combined with rubbing with a towel.19 In both studies, a nursing may compound the problem of sore nipples. statistically significant decrease in reported nipple tender­ Without significant let-down, the infant must nurse ness was noted. Application of creams, including com­ longer and more vigorously to obtain the same amount of mercial preparations,18 A and D Ointment (Schering- milk. The let-down reflex results from the release of oxy­ Plough Healthcare, Kenilworth, NJ), and lanolin20’21 has tocin by the posterior pituitary and is stimulated primarily been ineffective in studies on preventing nipple soreness. by nursing. The let-down reflex may be identified as a Lanolin may also contain pesticide residues.22-23 Applica­ tingling accompanied by an increased sensation of fullness tions of alcohol or soap solutions to the nipple have been in the breasts. In some women, milk may leak from the shown to increase soreness.20 One study claimed that a breast not being nursed. commercial antiseptic spray was beneficial in preventing To evaluate a patient’s let-down reflex, providers nipple trauma and soreness,24 but a reanalysis of the da­ may ask, “After the baby nurses for a minute or two, does ta25 casts doubt on that conclusion. Expression of co­ milk drip or squirt from both breasts? Do you feel a lostrum before giving birth has not been shown to have tingling sensation in the breasts or uterine cramping? any benefit.19 Breast shells (worn over the nipples when Does the baby seem to be swallowing a lot more milk after not nursing) did not reduce nipple pain in a small trial in the first couple of minutes?” Affirmative answers to any of which each of 20 subjects used the shell on only one these questions indicate an adequate let-down reflex. breast.26 Leaking of milk from the opposite breast, an infant’s in­ Limiting the length of breast-feeding sessions in the creased swallowing rate, or both, may be directly ob­ early postpartum period has been frequently recom­ served by providers during an office visit. Attention must mended for the prevention of nipple soreness. One large be paid to the provision of adequate privacy during nurs- The Journal of Family Practice, Vol. 39, No. l(Jul), 1994 57 Common Breast-feeding Problems Melnikow and Bedingham Figure. Positions for breast-feeding: cradle hold (top left), football hold (top right), side lying (bottom). ing, comfort and rest for the mother, and proper position­ Blocked D ucts ing and latch -on. Pain, anxiety, and cold are some of the factors shown to inhibit let-down.35 A blocked milk duct, identified as a persistent smooth, tender lump in the breast that does not change in size Local application of heat to the breasts or a warm with nursing, may result from an overly copious milk bath or shower before nursing may improve let-down. supply, a tight bra, incomplete emptying of the breast, or Oxytocin in nasal-spray form (Syntocinon, Sandoz Phar­ failure to vary position of the infant on the breast.