Successful breastfeeding is a combination of patience, good technique, and support. As you become more proficient in the skill of breastfeeding, it will become easier and more enjoyable. However, along the way you and your baby may experience some problems or discomforts. The following are tips that may help prevent/or treat any that might occur:

• Inverted or Flat Nipples
• Engorgement
• Sore Nipples
• Thrush
• Nipple Preference
• Decreased Milk Supply
• Plugged Ducts
• Mastitis

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Inverted or Flat Nipples

Babies nurse areolas, not nipples! Initial feedings may be more difficult with flat or inverted nipples, but successful breastfeeding is achieved by most women.

Prevention/Treatment

• Some women find that wearing special nipple cups called breast shells between feedings help draw their nipple out.
• After you have delivered, hand expression or pumping may help make the nipple more erect.
• It is not recommended to roll, twist or pull on your nipple. These actions can cause nipple trauma.
• Consult a lactation consultant for additional assistance.

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Engorgement

Breast fullness is a normal condition that occurs two to three days after birth and is caused by increased blood supply, fluids and milk in the breast tissue. Fullness is different from engorgement, and usually decreases within the first two to three weeks if the baby is nursing regularly. If, at any time, enough milk is not being removed, i.e., a skipped feeding, or limited feeding time at the breast, the breasts may become tender and engorged. An engorged breast may flatten your nipple and make it more difficult for your infant to latch-on.

Prevention/Treatment

• If breasts continue to be full and uncomfortable, apply cold compresses to both breasts as needed between feedings. The cold will feel good and decrease the swelling (baggies full of frozen peas or corn, or cold, raw green cabbage leaves work well as cold compresses).
• Try a warm shower; hot washcloths on your breasts; or lean over a sink or basin to let your breasts rest in the warm water prior to nursing.
• Massage your breasts to promote milk flow.
• An engorged breast may flatten your nipple, making it more difficult for your baby to latch-on. Use hand expression of milk to soften the areola just before latch-on.
• Feed your baby on demand, approximately every one to three hours for at least 15 minutes of suckling on each breast. Do not skip feedings.
• Wear a supportive bra and get in a comfortable and supported position for feedings. Avoid underwire bras.
• Consult a lactation consultant for additional assistance.

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Sore Nipples

Research supports the idea that the primary cause of nipple soreness is nipple trauma due to improper positioning of the baby on the breast. However, even with proper positioning, some women may experience temporary latch-on soreness.

Prevention/Treatment

• Make sure your baby's lips are not turned under and that your baby is not chewing on your nipple or sucking with his/her tongue up.
• Pull down firmly on your baby's chin to unhinge his/her jaw and widen the mouth allowing his/her lower lip to roll outward. (Use your index finger cupped under your breast or your thumb on the opposite hand.)
• If you feel your baby nipple-chewing, break the suction, remove your baby from your breast, and try attaching him/her again.
• If your baby is sucking her tongue, you may hear a smacking sound and see her cheeks caving in. Take your baby off your breast and reposition him/her.
• Make sure your baby's mouth is open wide (like a yawn) for a good latch-on.
• Direct your nipple down toward your baby's throat. (If nipple enters baby's mouth at an upward angle, sore nipples could develop.)
• Try different positions (see above) until your baby establishes a comfortable routine.
• Use hand expression to bring a little breast milk onto the nipple.
• Ensure proper release by inserting a finger between your baby's jaws to break the suction before removing him/her from your breast.
• Express some breast milk onto your nipples after a feeding and then allow your nipples to air dry completely.
• Consider applying a small amount of pure anhydrous lanolin (such as Purelan or Lansinoh) to your nipples if they have small abrasions. There is no need to wash the lanolin off before breastfeeding.

Keep Nipple Area Free from Irritation

• Avoid using drying breast creams, such as Masse or other creams that contain alcohol. Remember, the Montgomery Glands secrete a natural oil for lubrication and protection.
• Try more frequent and shorter nursing periods, rather than longer times between feedings.
• If you think you need a nipple shield, talk with your lactation consultant or health care provider.
• If using nursing pads, change them frequently. Consider using 100% cotton washable bra pads. Avoid pads with plastic or moisture-resistant liners.
• Wear clean, supportive 100% cotton nursing bras. Avoid underwires and tight bras.
• Discontinue use of any breast pump, which causes discomfort, and consult a lactation consultant.

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Thrush

Candida, or yeast organism, is normally present in the body in the mouth, gastrointestinal tract and vagina. The body also depends on our normal bacteria to prevent an overgrowth of yeast organism. This overgrowth of yeast causes a fungal infection called thrush, which grows in warm, moist conditions, and can affect any part of the
body, including the breasts and nipples in breastfeeding mothers.

Breastfeeding mothers are at risk for developing thrush if they have:

• Taken or are currently taking antibiotics
• Cracked nipples from poor latch-on or positioning

Symptoms

• PAIN!
• especially if it continues after an initial problem with poor latch-on or positioning was corrected
• occurs several weeks or months after successful breastfeeding
• is a burning or shooting/stabbing pain in the nipple, breast tissue or both
• is experienced during and after feedings. Sometimes the pain in between feedings is stronger
• its experienced with pumping the breasts
• Nipple itching, flaking, redness, shininess or sometimes white patches are present.
• The baby has white patches on his/her tongue or inside the mouth.
• The baby has a yeast diaper rash and may be gassy and fussy.

There may be no visible signs in either mom or baby and pain is the only symptom

Treatment
If you suspect thrush is present, contact you health care provider to be assessed and treated. It is wise to treat both the mother and the baby at the same time, even if there are no symptoms. If treatment is indicated, it should continue for two weeks even if symptoms are gone.

Home Care
Care of the environment that you and the baby are in is very important for the treatment of thrush. Any items that come in contact with baby's mouth or mother's nipples can harbor the yeast. The following are highly recommended while treating and preventing the return of thrush:

• All items that come in contact with the baby's mouth such as toys, pacifiers, bottle nipples, etc., should be boiled daily for 20 minutes.
• Pacifiers and nipples should be replaced weekly.
• Any breast milk that was expressed and then frozen during a thrush outbreak may re-infect the baby at a later time. To avoid this, boil the milk to destroy the yeast.
• Keep the breasts as dry as possible and exposed to air whenever possible.
• Use disposable bra pads.
• When laundering bra pads, bras or diapers, use hot, soapy water. One cup of bleach in the wash water or one cup of vinegar in the rinse water can be effective. All items should be thoroughly dried by line drying in the sun or a hot dryer.
• During an outbreak, use paper towels for hand drying and use bath towels only once before laundering.

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Nipple Preference

If possible, breastfeed your baby exclusively for the first four weeks without using bottles. Some babies reject the breast if given bottles while they are learning to breastfeed. The suckling mechanisms of breastfeeding and bottle-feeding are very different in the use of the muscles and the tongue. When bottle-feeding, the milk flows faster and your baby gets milk immediately with little effort, whereas more active suckling is necessary for breastfeeding.

Prevention/Treatment

• If a bottle must be given to supplement, offer it after breastfeeding. If a supplement is needed, check with your lactation consultant or health care provider for recommendations on alternatives to bottles and nipples, such as finger, syringe or cup feeding.

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Decreased Milk Supply

Breastfeeding is a supply and demand system. Whatever your baby needs, your body will produce. Your milk is made fresh each feeding in response to the suckling stimulus. The more your baby nurses, the more milk you will produce. If your infant is going through a growth spurt and acts hungry, feed more frequently for a few days. Your supply will increase and your baby will resume his/her old feeding schedule.

Generally, there is no need while breastfeeding to supplement your baby's feedings with formula or water. If you are concerned your baby is not getting enough milk, evaluate the following:

• Check your baby's position at the breast.
• Observe your baby's swallowing behavior. If your baby is swallowing along with sucking, then he/she is getting milk.
• Count the number of wet and stooled diapers. Refer to, "How Will I Know if My Baby Is Getting Enough Milk?"
• Keep track of your baby's weight gain. If he/she is gaining one ounce a day during the first months, then he/she is getting enough nourishment.
• Observe your baby's general temperament after feeding. Does he/she appear contented?

Prevention/Treatment

• Breastfeed your baby every 1 to 3 hours per 24 hours (8-12 times in 24 hours).
• Try to do nothing else but relax, sleep, and breastfeed initially. Rest when your baby sleeps. Remember, babies are "night creatures" for the first three weeks. This is normal! So you will have more opportunities for good nursing sessions at night. Try to sleep during the day when your baby sleeps.
• Drink fluids when thirsty.
• Eat a well-balanced diet.
• Limit visitors and responsibilities. Have friends, relatives or hired help do the household chores, cooking, shopping, etc.
• If you continue to be concerned about your milk supply, or if your baby does not gain weight, you or your health care provider can request a consultation with a lactation consultant.

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Plugged Ducts

Occasionally milk ducts become clogged as a result of incomplete emptying or continued pressure on one or more ducts. If this occurs, you may feel a hard, lumpy, painful area on your breast.

Prevention/Treatment

• Apply warm, moist towels to your breasts before feeding.
• Massage your breasts down toward the nipple paying special attention to the painful area.
• Nurse your baby more frequently, as often as every 1 and ½ hours if possible.
• Breastfeed in different positions. Place your baby's chin in the direction of the plugged duct.
• Breastfeed on the side with the plugged duct first. (Remember, babies suck hardest on the first breast.)
• Use a little lotion on your thumb and apply steady rolling pressure from behind the outer lump toward the nipple while your baby breastfeeds.
• Get plenty of rest and fluids.
• Avoid restrictive clothing. Look to see if your baby carrier or bra is rubbing the painful area.
• Avoid sleeping on your abdomen or the side that the plugged duct is on.

Once the plug has been resolved, the area may still be tender. Continue to examine your breasts daily to check for plugged ducts.

If the plug does not resolve in several days, contact a lactation consultant or your physician for assistance. However, if you develop fever and flu-like symptoms, you may have progressed to mastitis. Contact your health care provider immediately.
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Mastitis

Mastitis is a breast infection. Fatigue is a leading cause of mastitis. Occasionally, a plugged duct will become infected or bacteria will enter the breast through another route, such as an open sore on the areola or nipple.

Usually, a red, hard, hot and painful area will be present on the breast. Typically, the mother will have a fever greater than 100.4 F degrees and feel "flu-like."

Prevention/Treatment
Do not wait for the mastitis to go away by itself. Contact your health care provider immediately for treatment with antibiotics. It is very important that you continue frequent nursing during this time. Your milk is not infected and will not harm your baby. Also, complete the entire treatment of antibiotics (seven to10 days) to avoid a recurrence. Consider contacting a lactation consultant to assist you in learning how to prevent reoccurrence of the mastitis.

Read more information on Mastitis from our Health Information section.
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