Breastfeeding is a learnt skill; mothers and babies need appropriate support and encouragement if they encounter problems. Many families have no problems at all with breastfeeding but research has shown that accessing breastfeeding classes before giving birth can help a mother and baby be more successful with breastfeeding. It is important that you are not made to feel a 'failure' or bad parents if you are unable to, or choose not to breastfeed your baby.

A good place to access information is your local breastfeeding support groups such as the La Leche, Breastfeeding network or the National Childbirth Trust. Professionals such as your midwife or health visitor can also help.

This is intended for use as a quick reference guide. It is extremely important that this is not intended to undermine mothers' confidence, or conflict with advice given by the mothers’ health professional.

Your breastfeeding history can be very important; How often does the baby feed, day and night and for how long? Are both breasts offered at a feed? Is the baby allowed to finish the first breast? Babies do not need both breasts at a feed but many choose to have 'the second side'. It is most important not to time the baby at your breast and let him/her finish spontaneously and then offer the second side if it seems he/she wants more. Are any supplements given – water, formula or solids, are they given before or after breastfeeds, and how much does the baby take. Supplements can alter how the baby feeds at the breast and ultimately the amount of milk the mother produces.
Is a dummy used, or nipple shield, are you mother expressing milk?

The Baby

• Did the baby breastfeed soon after birth?
• The baby's appetite: Does he wake for feeds or have to b

e woken, does he root for the breast (look for it) and feed eagerly?

• Does the baby look well and handle well, is he/she well hydrated (not short of fluids, urine pale coloured and copious) and free from infection jaundice etc?
• What colour are the stools and how many wet nappies in a day? (It is normal for a breastfed baby to have approximately 6-10 wet nappies a day (sometimes more) and yellow loose stools after the first few days.
• Is the baby on any medication?

The Mother

Common problems

Full breasts

This is normal in the first few days, the breasts can feel hot and full, but the milk flows well. It can also occur when a feed is delayed - such as the mother going out, the baby goes through the night or also if the baby is not attached well at the breast.
If problems with attachment are promptly dealt with then this is unlikely to become a problem (when the baby is not attaching correctly at the nipple leading to sore nipples, unsettled babies, poor weight gain and ultimately poor milk supply.

• Get support from a breastfeeding specialist if there are signs the baby is not correctly feeding at the breast - such as sore nipples.
• If the breasts become full it can be appropriate to wake the baby for feeds.
• Expression of a small amount of milk before feeds can assist with attachment by softening the area around the nipple to help the baby grasp the breast more effectively.
• Let the baby spontaneously release the breast at the end of a feed( do not time feeds), and maximise the use of one breast at a feed. If the baby only takes one breast at a feed then hand expression can relieve the fullness in the other breast.
• Warmth before feeds and cold after in the form of warm and cool packs applied to the breast can be soothing and assist with oedema.

Engorged breasts - different from just full breasts

This can be mistaken for mastitis, and can be the result of full breasts being mismanaged. It is extremely important to react quickly to this situation. If left, it can result in reduced milk supply.

The breasts appear shiny due to oedema( swelling of the tissues), veins are dilated and the breasts are over full with milk. They are often painful, red and the mother can be feverish. The milk does not flow well due to increased pressure in the breast.

Methods to help

• Optimise positioning and attachment, get help if needed.
• Milk needs to be removed by frequent feeding and expressing if necessary
• Expressing prior to feeds to aid correct positioning of baby, release the pressure in the breast and promote a good flow of milk
• Hand expression is ideal and usually less traumatic, ask a health professional for help if needed to teach this skill
• Warmth before feeds or expressing
• Cold compresses following a feed to reduce oedema and provide some relief
• It is essential to ensure good attachment and maximise the emptying of at least one breast and express the other if required to soften.
• Mild pain killers such as Paracetamol or Ibuprofen taken as directed on the packet
• Antibiotics are best avoided as they can lead to Candida infections
• Prevention is preferred, by ensuring early feeds after delivery, the support with optimal positioning, baby led feeding.
• Poor management can lead to mastitis and arise in the feedback inhibitor of lactation and the subsequent reduction in milk supply.
• there are many other methods of relieving the discomfort of full/engorged breasts such as the outdated cabbage leaf method, and various others out there( it would take forever to mention them all). Research has shown that the majority cause no harm but as in the case of cabbage leaves a cold compress can be as effective.
  Check with your breastfeeding supporter or health professional before using any other methods, but as said before the majority are harmless and some mothers do find they can give relief in their particular case.

Reluctant feeder

This applies to ‘sleepy’ babies who do not wake for feeds, do not attach and suck at the breast well.
This can often be the result of sedated, ill or premature babies or the separation of the mother and baby and hence ‘feeding cues’ have been missed. A feeding cue from a young baby can be a subtle as just 'mouthing' for a feed, or a gentle cry. Often advice is given to wait until the baby is'really hungry' until offering a feed, this can result in a baby just 'giving up' for want of a better word.. Many of these babies have not had the opportunity for ‘skin to skin’ contact and early feeding cues have been missed and the first breastfeed after birth was delayed.

Ways to help

• Optimise position and attachment - ask for breastfeeding specialist support
• Stimulate lactation be hand expressing
• Give the baby skin to skin contact and give the baby time to prepare for feeding
• Cup / syringe feeding may be necessary ( ask for help) to allay concerns with the time between feeds( mother needs to express at least 6-8 times in 24 hours, to stimulate milk supply if baby not feeding at the breast)
• Babies who remain unwilling to feed may be unwell and should be assessed / examined regularly.
• In the continued absence of illness the baby can be fed by cup or syringe and continued assessment and support is needed. Specialist feeding support will be required.

Breast Refuser

This is the baby who cries or 'fights at the breast'. This is commonly caused by the baby being 'forced' onto the breast or a reluctant feeder who has been mismanaged. A poorly attached baby may become a breast refuser after a few days if not correctly attached.
Babies may be in pain from delivery trauma, oral thrush, teething etc.
There may be some nipple confusion from the use of dummies, teats, restriction of feeds, poor attachment or the rapid switching of breasts - not finishing one breast at a feed or timing feeds, resulting in high lactose feeds(mostly fore milk) causing pain in the baby.

The baby who comes off the breast crying or choking may be suffering from the rapid 'letdown' of milk – too much, too fast. The mother could express a little milk before feeds as a temporary measure and use one breast at a feed. Support for correct attachment and positioning can help.

Sometimes it is only a very efficient 'let down' reflex. Differing feeding positions can help – feeding lying down, or sit the baby up more when feeding.

An older baby may go on feeding strike if in pain, upset, with distractions or with unfamiliar smells or tastes such as perfume, deodorant.

Try to keep the baby calm, skin to skin contact can help –return to familiar routine and surrounding if appropriate. Good attachment and baby led feeding can prevent this problem. Mothers can often become anxious, expressing in the short-term may be needed to feed the baby and maintain lactation. Babies who continue to refuse feeds will need to be seen by a doctor to exclude other physical causes.

Unsettled baby

This is often seen in a baby under a week old. It is normal for a baby to feed often and for varying times as breastfeeding becomes established and the baby is learning good attachment. There are a number of reasons for this becoming a problem. In new babies it can be a sign of delayed milk production but more commonly is the result of poor attachment, a misunderstanding of normal newborn behaviour or missed breastfeeding cues as mentioned before.

Be reassured that this behaviour is normal and it is important to feed on demand.
If unsettled behaviour or prolonged feeding continues then some support may be required. Is the baby ill?
The most common causes are poor attachment or a strong let down. Frothy, sweet smelling, frequent stools are a sure sign of a poor feeding technique or over supply.
This can result in the baby taking large amounts of foremilk which can also result in positing or vomiting after feeds. The mother feels that the baby is unsettled because he is hungry after the feed and is not getting enough milk. The babies’ weight gain may or may not be normal. The true sign of insufficient milk supply is poor weight gain, but there are other causes of poor weight gain that need reviewing, ask for professional help.

In the majority of cases learning correct feeding cues( do not wait until the baby is crying hard for a feed), correct feeding technique, and comforting babies will resolve the problem. Co-sleeping is a good way of calming babies, but up to date advice following guidelines should be sought
Poor attachment and restricting feeds can result in high lactose feeds; do you let the baby finish the first breast spontaneously before offering the second breast?
Mothers often feel that ‘colic’ is the problem and wish to give medication inappropriately. There is no evidence for their efficiency – you need to make an informed choice as to their use.
If a forceful let down appears to be the cause then expressing a small amount of milk before feeds and altering the feeding position may help.
If you have concerns as to the babies well being or the symptoms persist then refer to a Doctor.

There is a lot of pressure on mothers to 'return to normal' and start a 'routine' soon after birth. The mother's expectation of newborns behaviour is often quite different to reality. The reality of newborn behaviour is that they often do feed 8 – 12 times in 24 hours and they tend to 'cluster' feed particularly in the early evening. There can frequently be well meaning advice from friends and relatives to have a scheduled feeding programme and sleeping for long periods at night.

Commonly it is thought that putting the baby back on the same side after feeds means that the baby ‘will get more hind milk and sleep longer. This is not the case; the baby usually tires, gets less milk and wakes sooner for a feed. When the baby spontaneously removes himself from the breast or he starts to ‘flutter’ suck then he should be offered the second breast. Demand feeding in this way with correct attachment usually improves the baby's behaviour and weight gain.

If experiencing problems advice from a lactation consultant, breast feeding advisor or similar would be advised.

References