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New York, NY, USA
8.1 Common Breastfeeding Problems
There’s an old saying that every story has three sides: My side, your side, and the truth. When it comes to breastfeeding problems, it is critical to examine three potential sources: The mother, the baby, and the interconnection of the mother—baby relationship. Most commonly, there will not be a solitary cause or “fix.” Rather, there are usually overlapping and symptoms and treatments.
Keep in mind that since there are so many variables, similar diagnoses can present in a plethora of ways. In this chapter, I present common case scenarios that illustrate this point, followed by recommended treatments.
Note: Regardless of symptoms, never tell a mother who is struggling to nurse to wait it out. If a mother has concerns, then they are real, and must be addressed immediately. There is always a solution.
Here is a list of common problems that come up in nursing. We will incorporate all of these difficulties into the scenarios, as they are usually overlapping and interdependent.
Infant Difficulties
1.
Inability to latch
a.
Structural
b.
Behavioral
2.
Poor or shallow latch
3.
Excessive gas/reflux
a.
Poor latch
b.
Food (dairy and other) allergies
c.
Structural causes
4.
Falling asleep at the breast/frustration
a.
Hunger—not getting milk, low milk supply
b.
Medications
5.
Poor intake—comes from low supply or poor transfer and results in
a.
Constant feeding/poor satiety
b.
Poor weight gain or weight loss
c.
Jaundice
6.
Breast Aversion
Maternal Difficulties
1.
Nipple pain/trauma
a.
Infectious
b.
Trauma
c.
Raynaud’s
2.
Reasons for Inadequate supply
a.
Gestational diabetes
b.
Hypoplasia
c.
Other hormonal causes
3.
Oversupply
4.
Breast pain
a.
Engorgement
b.
Plugged ducts/engorgement
c.
Mastitis—yeast or bacterial
5.
Medications
8.2 Case 1
Baby is 10 days old. He was born vaginally and full term to a first time mother. The mother has a negative medical history, is 30 years old, and takes only prenatal vitamins—no medications or other supplements. Baby was put to the breast and skin-to-skin contact was established immediately at birth. Baby seemed to try to latch but could not. He bobbed his head up and down and tried to open his mouth but couldn’t open it very wide. He suckled a little then fell asleep quickly.
Later that same day, the mother worked with the nursing staff in the hospital to try to latch the baby on. When the baby was brought to the breast, he was able to latch on, but it was very painful for the mother. She was told that pain is normal at first and to keep nursing every 2 h. She continued nursing every 2 h. Baby had adequate wet diapers and slept most of the time. They were discharged home.
At home, the mother’s nipple pain continued. She developed cracks in her nipples with bleeding, which was much worse on the right side. The baby seemed to be hungry all the time and preferred the right breast. He nursed continuously and “ravenously” and only slept for an hour at a time. When he awoke, he cried and was hungry. He still had wet diapers, but only one soiled diaper. Mom was not pumping because she was in too much pain from nursing, and had no time to pump even if she could. She had not yet experienced engorged breasts. She did not want to give her baby a bottle because she was determined to breastfeed and felt that formula was bad for her baby.
At 1 week, the baby was seen by his pediatrician and weighed. He had lost 9 % of his birth weight and had slightly elevated bilirubin.
On evaluation, the mother has large breasts with inverted nipples, and nipple trauma with damage and scabbing. Her breasts are tender and erythematous but not engorged. They are not widely spaced and have no stretch marks.
Baby has a slightly retrognathic jaw and normally arched palate. He has a strong, coordinated suck. His left sternocleidomastoid (SCM) muscle is tight and he tends to turn his head to the left. His nose is slightly congested but clear. There is no anterior lingual frenulum. His labial frenulum is normal.
What is the diagnosis?
Relevant Facts:
Maternal pain and nipple damage
Large breasted mother with inverted nipples
Possible low supply, as evidenced by lack of engorgement
Small infant gape
Tight left SCM muscle/torticollis
Continuously hungry baby who wants to nurse all the time
Excessive infant weight loss and mild jaundice
Diagnoses:
1.
Shallow latch due to torticollis.
2.
Poor weight gain and mild jaundice.
3.
Risk of maternal low milk supply.
This baby cannot gape wide enough to fit over his mother’s breasts. He also has torticollis, which is a known cause of small gape. He is nursing constantly and losing weight. With a shallow latch, the teat will sit too anterior in his mouth. This causes friction on the nipple and does not allow the baby’s tongue to compress the breast against the palate. Since the mother has large breasts and inverted nipples, baby’s intraoral “shape” does not fit her well. Mom has not pumped, so she doesn’t know what her supply status is. Since she has not felt engorgement yet, it is probably on the low side. Also, the baby nurses all the time and he has mild jaundice and is losing weight, which also indicates a potentially low supply.
Treatment Recommendations:
Since the baby is only 10 days old, there is time to recover her milk supply and fix the situation: Mom’s supply can be fully developed, she can nurse painlessly, and the baby can eventually transfer milk efficiently from the breast to gain weight and avoid nipple aversion.
The baby was immediately sent for physical therapy and cranial osteopathy to resolve the torticollis. This treatment releases the SCM muscle so the baby can move his neck freely. This will also help release the tension in the jaw and tongue to allow for a wider gape. However, torticollis may take weeks to resolve, so that solution, on its own, is not timely enough to salvage breastfeeding. If the baby continues to nurse with a shallow latch, he will lose weight, cause more nipple damage, and prevent his mother’s milk supply from coming in fully. But if he is given another feeding source (such as bottle, syringe, etc.) and removed completely from the breast, he is at risk for developing nipple aversion because he has a low transfer rate from the breast. Therefore, the goal is to keep the baby happy on the breast while the torticollis is being resolved.
Since this is a first-time mother, referring her to an experienced lactation consultant (LC) is important. The LC can show her different nursing positions to optimize getting as much breast as possible into the baby’s mouth. This would include how she positions the baby and how she holds her breasts.
Since the baby prefers the right breast, that means he can transfer milk a little more easily from that side. The mother can be encouraged to continue nursing on that side, but for limited amounts of time. She could also use a supplemental nursing system so the baby makes the association of being fed from her breast so he has less risk of nipple aversion.
Pumping is vital until the torticollis is resolved since the breasts fill in response to complete emptying. Even if the mother is nursing on the right side, the baby likely cannot fully empty that breast until he is healed. After limited nursing on the right side to prevent nipple aversion, she should pump both breasts for 10 min, and repeat this every 2–3 h.
To heal her breasts and prevent mastitis, the mother can use ointments/salves and air out her nipples. She can also use nipple cups and do exercises to pull out her inverted nipples.
8.3 Case 2
Baby is 8 weeks old. He was born vaginally at 38 weeks without any medical problems. This is his mother’s second child, and she nursed her first child without a problem for 14 months. With this baby, the mother had some nipple pain and damage when he initially latched for the first 2 weeks. Her nipples healed, and she only has mild discomfort now. She was told that the latch “looked fine” when she was in the hospital. The baby nurses for variable amounts of time and cluster feeds overnight. He can nurse from 5 to 25 min on each breast. He also has excessive gas and colic. Because the baby is gaining weight, the pediatrician is not concerned. The doctor suggested Zantac for the gas, but it is not helping much. The baby is also getting more frustrated at the breast and sometimes bites.
The mother had an oversupply for the first month and did not pump. Over the last 2 weeks, her supply seems to be waning. She has not been pumping and has not yet given the baby bottles. She has no medical problems and takes only prenatal vitamins.
On evaluation, the mother has normal sized breasts with normal intra-mammary distance (no sign of insufficient glandular tissue). Her nipples are lipstick shaped but not otherwise damaged. There is no sign of infection or inflammation.
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