Breastfeeding problems

Published on 10/03/2015 by admin

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Last modified 22/04/2025

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Chapter 8 BREASTFEEDING PROBLEMS

Breastfeeding has numerous benefits to the child and mother. Breastfed infants have lower rates of respiratory tract infections, otitis media, allergies, necrotizing enterocolitis, and serious bacterial infections. They also have lower rates of sudden infant death syndrome, diabetes, lymphoma, leukemia, obesity, hyperlipidemia, and asthma. Children who were breastfed also perform better on cognitive development tests. Benefits to the mother include decreased postpartum bleeding, increased temporal spacing between pregnancies, weight loss, lower risk of breast and ovarian cancer, and decreased risk of osteoporosis. In addition, breastfeeding results in less employee absenteeism, lower health care costs, and lower costs to families.

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) recommend that infants should be exclusively breastfed for the first 6 months and that breastfeeding continue through the first year of life. Promotion of breastfeeding can be achieved by encouragement and education before and after delivery, rooming in (in which mother and newborn share a hospital room), skin-to-skin contact after delivery, avoidance of supplements, avoidance of pacifiers until after breastfeeding is well-established, and follow-up with a health care provider when the infant is 3 to 5 days of age and 2 to 3 weeks of age.

Breastfeeding problems can sometimes result in serious consequences such as dehydration, failure to thrive, and jaundice in the infant. It is important that newborns and mothers have close follow-up after discharge from the hospital to prevent and identify these problems.

In a few cases, breastfeeding is contraindicated. Mothers with active untreated tuberculosis, positive human T cell lymphotrophic virus, or herpes lesions on their nipples should not breastfeed. Mothers who are being treated with radioactive isotopes or chemotherapy also should not breastfeed. In addition, infants with classic galactosemia should not be breastfed. In the United States, human immunodeficiency virus (HIV) infection is a contraindication to breastfeeding. Phenylalanine intake must be reduced if the mother or infant has PKU. Partial breastfeeding is often recommended.

Medications That May Inhibit Lactation

Oral contraceptives

Thiazide diuretics

Causes of Breastfeeding Problems

Environmental Issues

Domestic violence

Early hospital discharge

Employment barriers

Hospital policies and practices that hinder breastfeeding

Poor postdischarge follow-up

Poor social support

Neonatal Causes

Cleft lip or cleft palate

Diseases such as cardiac disease or sepsis in the infant

Multiple infants

Poor latch-on or ineffective suck

Premature birth

Shortened frenulum

Maternal Causes

Key Historical Features

✓ Birth history

• Apgar scores

• Infant birth weight

• Gestational age at birth

• Complications at delivery, such as shoulder dystocia or surgical delivery

• Neonatal complications, especially if infant required treatment in the neonatal intensive care unit or if invasive procedures, such as aggressive suctioning, were performed

✓ Maternal factors

• Pregnancy complications

• Medication use

• Alcohol use

• Illicit drug use

• History of eating disorders

• Inadequate diet/fluid intake

• History or symptoms of depression

• Experiences with breastfeeding during previous pregnancies

• Inadequate support system

• History of breast surgeries

• Type of breast pump, frequency of pumping, and amount of milk pumped per 24 hours

• Pain while breastfeeding

• Breast engorgement

• Use of nipple shields, which can decrease milk production

• Use of pacifiers, bottles, or formula

✓ Neonatal factors

• Amount of urination (three to five times per 24 hours by age 3 to 5 days and four to six times per 24 hours by age 5 to 7 days)

• Bowel movements (three or four stools per 24 hours by age 3 to 5 days and three to six stools per 24 hours by age 5 to 7 days)

• Weight gain (infant should return to birth weight by 2 weeks of age)

• Sleep schedule

• Frequency of breastfeeding and duration at each breast

• Amount of pumped breast milk consumed

• Alertness of infant during feeding

Key Physical Findings

During the examination, both the mother and infant should be examined. In addition, it is very useful to observe the mother breastfeeding her infant.

✓ Neonatal examination

• Naked weight before and after feeding to document amount of breast milk consumed and to compare with birth weight

• Signs of dehydration (dry mucous membranes, loss of skin turgor, depressed anterior fontanelle)

• Sleepiness of infant during feeding

• Examination of the infant for cleft palate or tight frenulum

• Cardiovascular examination to evaluate for congenital cardiac disease

✓ Maternal examination

• Breasts should be evaluated for inverted/flat nipples, cracked/bleeding nipples, engorgement, mastitis, evidence of prior surgeries, and asymmetry

• Evaluation of the mother’s mood for evidence of depression

✓ Breastfeeding technique

• Adequate latch-on (infant’s mouth is wide open and covering the entire nipple and most of the areola)

• Position of the infant while breastfeeding (infant should be well supported with the chest and abdomen facing the mother’s chest and the infant’s mouth at the level of the nipple)

• Breast should be supported by mother with the “C-hold” (four fingers on underside of breast and thumb on top of breast)

• Swallowing sounds should be heard during feeding

Suggested Work-Up

In most cases, a careful documentation of history and physical examination, as well as observation of the mother breastfeeding, are adequate for managing breastfeeding difficulties. However, if the infant appears ill or significantly jaundiced, further work-up is necessary. Further work-up is also warranted if a low milk supply is thought to be caused by maternal illness.

Maternal Work-Up

Complete blood cell count	To detect anemia if milk supply appears low
Thyroid-stimulating hormone measurement	To detect hypothyroidism if milk supply appears low

Neonatal Work-Up

Total and direct bilirubin measurement	If significant jaundice is present
Complete blood cell count	If significant jaundice is present or if sepsis or infection is suspected
Blood cultures	If sepsis is suspected
Lumbar puncture	If sepsis is suspected
Urinalysis and urine culture	If sepsis is suspected

Additional Work-Up

Pelvic ultrasonography in mother	If retained placenta is suspected
Testosterone measurement	If gestational ovarian theca lutein cyst is suspected (testosterone level is elevated)

FURTHER READING

American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics. 2005;115:496-506.

Amir LH. Breastfeeding: managing “supply” difficulties. Austral Fam Physician. 2006;35:686-689.

Breastfeeding and Maternal Medication. Recommendations for Drugs in the Eleventh WHO Model List of Essential Drugs. Geneva: World Health Organization, 2002.

Neifert MR. Breastmilk transfer: positioning, latch-on, and screening for problems in milk transfer. Clin Obstet Gynecol. 2004;47:656-675.

Sinusas K. Initial management of breastfeeding. Am Fam Physician. 2001;64:981-988.

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