Breast Problems

Breastfeeding her child is the most natural thing for every mother. It is a unique experience to be cherished and protected by maternity and neonatal caregivers. Sometimes certain simple problems faced by the mother add to her apprehension and anxiety. This may result in stoppage of breastfeeding or addition of supplements of animal milks/commercial infant formula. Problem may be like flat nipples, inverted nipples, breast engorgement, mastitis, sore nipples or not enough milk etc. These can be overcome by careful guidance, reassurance, encouragement and simple measures. These problems are preventable and women should be helped & supported from the antenatal period to prepare for breastfeeding and avoid these problems. Research has clearly shown if mothers are given assistance it helps to increase duration of exclusive breastfeeding.

1. Flat or Inverted Nipples
Flat nipples
The size of the resting nipple is not important. It is just a guide to show where the baby has to take the breast. The areola and the breast tissue beneath should be capable of being pulled out to form the teat. Occasionally on attempting to pull out the nipple it goes deeper into the breast, this is true inverted nipple.

Nipple protractility test should be done during pregnancy if there is any doubt. The nipple usually becomes more protractile (capable of being pulled out) as pregnancy progresses and mother should be reassured that she would be able to breastfeed.

Treatment of inverted nipples during postnatal period.
Normally, the nipple corrects itself as the child suckles. But in a few cases, the problem persists even after that. In such cases following should be tried:

• Cut the nozzle end of a disposable syringe (10- 20 ml).
• Introduce the piston from the ragged cut end side.
• Ask the mother to apply the smooth side of the syringe on the nipple and gently pull  out the piston and let her wait for a minute.
• Nipple would then protrude into the syringe. Ask the mother to slowly release the suction and put the baby to breast, at this time it helps the nipple to erect out and baby is able to suckle in the proper position.
• After feeding the nipple may retract back, but doing it each time before feeding over a period of few days will help to solve the problem.

2. Fullness and engorgement of the breast
Fullness of the breast is a frequent problem. However, milk flow continues and the baby can feed normally. If enough milk is not removed, engorgement of breasts may result.

Breast engorgement is an accumulation in the breast of increased amounts of blood and other body fluids, as well as milk. The engorged breast becomes very full, tender and lumpy. The common causes of engorged breasts are: giving prelacteal feeds, delayed initiation of breastfeeds, early removal of the baby from the breast, bottle-feeding and any restriction on breastfeeding.

Engorgement may cause the nipple to flatten, making it difficult for the baby to suckle effectively. The mother too avoids feeding because of a tight and painful breast. This leads to inadequate emptying, decreased production of milk and sometimes infection. Engorgement of the breast can be prevented by avoiding prelacteal feeds, keeping the baby on mother's milk both in hospital and home, unrestricted and exclusive breastfeeding on demand, and feeding in the correct position.

Treatment
Once engorgement occurs, the baby should be breastfed frequently followed by expression of breastmilk
The following measures will help relieve the problem usually within 24 to 48 hours:

To prevent soreness and cracking of the nipples, attention should be paid to teaching correct feeding positions and techniques to the mother. (see Fig. 3)  

Treatment
If there is pain in the nipple area during breastfeeding, mother should wait until the baby releases the breast, or insert her finger gently into the baby’s mouth to break the suction first, so as to avoid injury to the nipple. Then the mother should be helped with attachment and repositioning the baby, it will not cause pain. This is the test of correct attachment.

Breastfeeding should be continued on the affected breast as it usually heals after correcting the sucking position. Medicated creams are best avoided as they may worsen the soreness and draw away the attention from the crucial issue.

If the infant has oral thrush, 1% gentian violet should be applied over the nipple as well as inside the baby’s mouth. If the oral thrush in the baby leads to maternal fungal infections causes and itching in  mothers breast, then give systemic antifungal drugs to the mother (Miconazole or Fluconazole tablets 250 mg Q.I.D. for 10 days).

For cracked nipples, treatment consists of feeding in correct position, washing the nipple once daily only with water, exposure of nipple to air and sun as much as possible. Application of hind milk drop on the nipple after each feed may also help. If mother is not able to feed because of pain she should express milk frequently.

4. Blocked duct
If the baby does not suckle well on a particular segment of the breast, the thick milk blocks the lactiferous duct leading to a painful hard swelling. This ‘blocked duct’ is not associated with fever.

Treatment
Treatment requires improved removal of milk, and avoiding any obstruction to milk flow.

Ensure that the infant is sucking in good position. Some authors recommend holding the infant with the chin towards the affected part of the breast, to facilitate milk removal from that section, while others consider generally improved attachment is adequate.

Explain the need to avoid anything that could obstruct the flow of milk, such as tight clothes, and pinching or scissoring the breast too near the nipple.

Encourage the mother to breastfeed as often and as long as her infant is willing, with no restrictions, including night feeds.
Suggest that she applies wet heat (e.g. warn compresses or a warm shower) over the breast.

Occasionally, these techniques do not relieve a woman’s symptoms. This may be because there is particulate matter obstructing the duct. Massage of the breast, using a firm movement of the thumb over the lump towards the nipple may be helpful.

However, this should be done gently, because when breast tissue is inflamed, massage can sometimes make the situation worse.

Unfortunately, blocked ducts tend to recur, but once a woman knows what they are due to, and how to treat them herself, she can start treatment early and avoid progression to mastitis.

5. Mastitis and Abscess
If the blockage of the duct or engorgement persists, infection may supervene. The breast becomes red, hot, tender and swollen. Mastitis must be treated promptly and adequately. If treatment is delayed or incomplete, recovery is less satisfactory. There is an increased risk of developing breast abscess and relapse. A breast abscess may occur sometimes without mastitis.

Treatment
The main principles of treatment are:

Supportive counselling
Mastitis is a painful and frustrating condition, and it makes many women feel very ill. In addition to effective treatment and control of pain, a woman needs emotional support.  She may have been given conflicting advice from health professionals. She may have been advised to stop breastfeeding, or given no guidance either way. She may be confused and anxious, and unwilling to continue breastfeeding.

She needs reassurance about the value of breastfeeding; that it is safe to continue; that milk from the affected breast will not harm her infant; and that her breast will recover both its shape and function subsequently. She needs encouragement that it is worth the effort to overcome her current difficulties.

She needs clear information and guidance about all measures needed for treatment, how to continue breastfeeding or expressing milk from the affected breast. She needs follow up to give continuing support and guidance until she has recovered fully.

Effective milk removal
This is the most essential part of treatment. Antibiotics and symptomatic treatment may make a woman feel better temporarily, but unless milk removal is improved the condition may become worse or relapse despite the antibiotics.

Help the mother to improve her infant’s attachment at the breast. Encourage frequent breastfeeding, as often and as long as the infant is willing, without restrictions. If necessary express breast-milk by hand or with a pump until breastfeeding can be resumed.

Antibiotic therapy
Antibiotic treatment is indicated if either;

If possible, milk from the affected breast should be cultured and the antibiotic sensitivity of the bacteria determined. To be effective against Staph.aureus a b-lactmase resistant antibiotic is needed. For gram-negative organisms, cephalexin or amoxicillin may be the most appropriate. The chosen antibiotic must be given for an adequate length of time (10-14 days). Shorter courses are associated with a higher incidence of relapse.

Symptomatic treatment
Pain should be treated with an analgesic. Ibuprofen is considered the most effective, and it may help to reduce inflammation as well pain. Paracetamol is an appropriate alternative.

Rest is considered essential and should be in bed if possible. Helping the woman to rest in bed with the infant is a useful way to increase the frequency of breastfeeds, and thus improve milk removal.

Other measures recommended are the application of warm packs to the breast, which both relieve pain and help the milk to flow. Also ensure that the woman drinks sufficient fluids.

Incision and drainage should be done if abscess forms. Breastfeeding should be restarted from the infected breast as soon as possible.
 

Commonly asked questions

There are some questions that are commonly asked by the mothers. The following are suggested responses, which you can use while counselling mothers. However, you can individualise your decisions. These are suggestions only.

Q 1. I have developed a painful lump in my right breast, and have high fever. Is it safe to feed my baby, as I am worried about infecting him?
Response: Maintaining lactation is important for your own       recovery, and for the health of your infant. Stopping breastfeeding during an attack of mastitis will not help you to recover; on the contrary, there is a risk that it can make your condition worse. Furthermore, if you stop breastfeeding before you are emotionally ready, you may suffer considerable emotional distress.
 

Q 2. I had a very bitter experience with my first baby when I developed mastitis and breast abscess. How do I prevent such problems, as my 2nd baby is due and I am very scared?
Response: It is very heartening to know that you are so eager to breastfeed your 2nd baby.

Important points to rember for effective breastfeeding are:

You should particularly avoid the following:

Following publications are available at BPNI Resource Center, in case you need to order,  please send your payments through DD in favour of  "BPNI Delhi".
 

Dr. J.S. Bhasin, Dr. Jagdish C. Sobti and Dr. Rita Gupta