“Breastfeeding

difficulties”
and

Common
Maternal
 ‘Not enough milk’
One of commonest reasons for stopping
breastfeeding

 Mother thinks she does not have

enough breast milk (can produce for
twins)

 Baby does not get enough breast milk.

(ineffective suckling.
mother cannot produce enough )
Reasons why a baby may not get enough
breast milk
1. Breastfeeding factors
 Delayed start  Poor attachment
 Feeding at fixed time  Bottles, pacifiers
 Infrequent feeds  Other foods
 No night feeds  Other fluids
 Short feeds

2. Baby’s condition : Illness

Abnormality
 Reasons why a baby may not get enough breast
milk

3. Mother: 4. Mother: Physical

Psychological factors Condition

 Lack of confidence  Contraceptive pills

 Worry, stress  Pregnancy
 Dislike of  Severe malnutrition
breastfeeding  Alcohol
 Rejection of baby  Smoking
 Tiredness  Retained piece of
placenta
 Poor breast
development
Reliable signs that a baby is not getting
enough milk

 Poor weight gain

< than 500 grams per month
check growth chart

 Small amount of concentrated

urine
< than 6 times per day
strong smelling
dark orange in color
 The Crying Baby
Possible reasons:

 Discomfort – dirty / cold / hot

 Tiredness – too many visitors
 Illness / pain- changed pattern of crying
 Hunger – not getting enough milk / growth
spurt (2 weeks ,6 weeks , 3mos )
 The Crying Baby -
reasons

 Mother’s food – some food substance

pass into her milk
 Drug mother takes – caffeine ,
cigarette etc
 Colic – may have very active gut …
lessen after 3 mo old
 “high needs” babies – “KSP”/ needs to
be carried more
The Crying Baby
m
a
y

Unnecessary introduction of food / fluids

Can upset relationship between mother &

baby
Some Different Ways to Hold a
Colicky Baby
 Babies refuse to breastfeed
Reasons

1. Baby ill, sedated or in pain

 Infection
 Brain damage
 Pain from bruise (forceps /
vacuum)
 Blocked nose
 Sore mouth (thrust / teething)
 Reasons why babies refuse to
breastfeed

2. Difficulty with breastfeeding technique

 Use of bottles, pacifiers whilst
breastfeeding
 Poor attachment

 Pressure on back of head

 Mother shaking breast

 Restricting length of feeds

 Difficulty co-ordinating suckle

 Reasons why babies refuse to
breastfeed

3. Change which upsets the baby

(especially aged 3-12 mos)

 Separation from mother (work)

 New carer or too many carers
 Change in family routines
 Mother ill / breast problem (mastitis)
 Mother menstruating
 Change in smell of mother
 Reasons why babies refuse to
breastfeed

4. Apparent refusal

 Newborn – rooting
 Age 4-8 mos – distraction

 Above 1 year – self weaning

 Helping a mother & baby
to breastfeed again

Help her do these things:

 Keep her baby close to her
 Offer breast whenever baby is willing
 Feed by cup
 Help baby to take your breast
 How to help mother

 Listening & learning  Good counseling skills

skills  Assess
 Confidence & support  Praise when relevant
skills  Empathize
 Assessing a breastfeed  Give relevant
 Helping mother to information
position & attach her  Give practical help
baby
 Taking a detailed
feeding history
Establish the confidence of
the mother that

she
CAN DO IT
 Nipple / Breast Forms

 Large / small breasts

various positions

 Flat / inverted /
retracted nipple
syringe / pump / cup
feeding EBM

Baby sucks from

breast not from
 Long or big nipples
use football hold , C position
/ cup feeding using expressed
breastmilk (EBM)

Reassure mother… baby’s

mouth will grow, nipples will
not
What do you think
of the nipple ?
What breast condition do you see ?
Sy ri nge meth od f or retr act ed ni pple

Pull plunger to maintain

steady gentle pressure
Do it for 30 sec to 1 min
several x a day
Push plunger back to reduce
suction – if there is pain
 Causes of sore nipple

 Poor attachment
 Candidiasis
 Not properly positioned pump
 Too much stretching of nipple
caused by the pump / wrong
position
 Management of sore nipple
 Observe feeding session
 Reassure mother
 Help improve attachment / positioning
 Treat skin condition …
fungal ? Soreness ? Big /small lesion ?
 Short frenulum ?
What conditions are shown
here ?
Full Breast  Full breast
 Milk has “come in”
 Hot heavy and hard
 Milk flowing well
 Sometimes feels lumpy

 Normal fullness

 Treatment : frequent
feeds
 Breast is OVERFULL Engorged breast
 Partly filled with milk
 Partly with tissue fluid
and blood
 Interferes with milk flow
 Breast shinny –
edematous
 Painful
 Milk does not flow well
 Nipple – stretched tight
 Causes and Prevention of Engorgement
Causes Prevention

 Plenty of milk  Start BF soon after

 Delay starting to BF delivery

 Poor attachment to  Ensure good

breast attachment

 Infrequent removal of
milk  Encourage on
 Restriction of length of demand feeding
feeds
 Management of engorged breast
General procedure:

Stimulate her oxytocin reflex

 Warm compress

 Massage back / breast / nipple skin

 Make her relax

 Warm shower / bath

 After feed put cold compress to help

reduce edema
 Built mother’s confidence
Engorgement in an HIV infected woman who is
stopping breastfeeding

 SHOULD express milk ONLY to relieve

congestion and not to increase
production

 Express ONLY when breast are

OVERFULL to make her comfortable

 May give analgesic to relieve

inflammation and discomfort (ibuprofen
or paracetamol)
What condition
is this ?
 Causes of blocked duct and mastitis
 Poor drainage of whole breast:
• infrequent feeds / ineffective suckling
• pressure from clothes
• pressure from fingers during feeds
• (Scissors’ hold )
• Large breast draining poorly

 Stress, overworked reduces frequency of

feeds
 Trauma to breast damages to tissue
 Cracked nipple allows bacteria to enter
 Treatment of blocked duct and mastitis

 Most important – improve drainage of milk

 Look for cause and correct
 Suggest:
 FREQUENT feeds / rest with baby
 gentle breast massage towards nipple
 warm compress between feeds
 Start feed on unaffected side IF in pain
 Express if necessary
 vary feeding position
 Antibiotics, analgesics, rest (flucloxacillin,
erythro)
 Mastitis in an HIV
infected mother

 Mastitis
 Abscess AVOID
BREASTFEEDING
ON THAT
SIDE
 Fissure
 Mastitis in an HIV infected mother
 SHOULD AVOID breastfeeding on the
AFFECTED side
 Express the milk effectively
 to ensure adequate removal
 to help prevent condition from becoming worst

 to help breast recover n maintain production

 Can feed from the Unaffected side

Frequent and longer feeding increase
production
 Mastitis in an HIV infected
mother
 Discuss feeding options
• heat treat expressed breastmilk
• home-prepared formula
• feed by cup

 Give antibiotics 10-14 days to avoid

relapse / pain reliever if needed / rest
 If decided to stop BF, cont to express just
enough until production ceases
What do you notice
about the breasts ?
What condition is
this ?
Candida Infection
 Shiny red area skin sore
 flaky / itcy / whitish
 Burning / stinging sensation
 which continues after a feed / pain that
shoots deep into her breast
 Check baby for thrust inside the mouth
or rash at his bottom
 Treat BF dyad
 Nystatin cream
 Nystatin Suspension
 Stop using pacifiers, teats, nipple
shields

IN HIV infected women,

treat breast thrush and
infant oral thrush
PROMPTLY
Reminder Ensure
s privacy

Explain what you

want to do

Ask permission before

breast is exposed

Talk with mother and look

at breast without touching
Explain what you found Reminders

 Highlight the positive signs

 Don’t sound critical about her
breast
 Build her confidence in her
ability to breastfeed.
 Thank her for her cooperation
 Summary
 Not enough milk  Engorgement
 Crying baby  Blocked duct /
 Refusal to feed mastitis
 Breast abscess
 Nipple & breast  Candidiasis
forms
 Unequal breast
 Sore nipple
she CAN DO IT !