Breastfeeding

The common challenges of breastfeeding

As you get more practice and become more proficient with the skill of breastfeeding, it will become easier and more enjoyable. It is very common that along the way you and your baby may experience some problems that can lead to early weaning if not dealt with a combination of good knowledge, patience and support.

Here you will find information and tips to help you work through any difficulties you might have.

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Finding good help and support for breastfeeding difficulties

My number one choice for breastfeeding support is your local support group. In Australia this is the Australian Breastfeeding Association for most other countries it is LaLeeche Leauge . You can find a huge amount of encouragement and support from other mothers who are going through difficulties themselves or from those who have been there and done that and made it to the other side. You will also have access to trained breastfeeding counsellors either by phone or through your local group. These counsellors have current and extensive breastfeeding knowledge as well as their own personal experience to draw from. These counsellors are not medically trained; they are mothers who know a lot about the anatomy, physiology and psychology of breastfeeding and are trained to provide support, information and encouragement to other mothers.

A lactation consultant is my first choice for breastfeeding help when you suspect that there may a problem with attachment, the baby's sucking technique or you feel you need the support of a health professional. A lactation consultant is trained extensively in every aspect of breastfeeding and will have the most up to date knowledge of breastfeeding currently available. They can provide a more hands on and a more medical approach to breastfeeding problems if required.

I encourage mothers to be wary when seeking breastfeeding help from their GP, natural health practitioner, obstetrician, paediatrician or infant health nurse unless you know for sure that they have good sound training in breastfeeding management. I say this is because I have heard so much incorrect information given out by health professionals who think they are giving good advice. Many health professionals still tell mothers that baby's only need to be fed no more than every 3-4 hours, that baby's should be sleeping through the night by 12 weeks and that a good solution to low supply or a stressed out mother is to give a bottle. This is out dated information and in many cases will lead to early weaning.

Obviously there are times when you need to see a doctor for help while breastfeeding such as if you have mastitis and need antibiotics to treat it. I encourage you to find a doctor that supports breastfeeding and who has a sound knowledge of how it works. I have found that a good screening question is: Is there a female doctor that has children that I can see? These doctors are likely to have breastfed their own children and are more likely to have taken an interest in breastfeeding management. You might also find that a friend or family member can recommend someone they have found to be helpful.

Management of common breastfeeding problems

Low supply

Nipple pain

It is possible to avoid pain during the early days of breastfeeding. Sore nipples are a sign that something is not right and you need to make a change.

You can expect some tenderness in your nipples when you first start to breastfeed. As your baby latches onto the nipple and stretches the breast tissue, you may feel a pulling sensation that is uncomfortable. However as baby begins to suck and you have a let down, it should become more comfortable. This initial soreness should improve within two to four days after birth, if your baby is positioned well at the breast and is properly attached.

If baby is having difficulty learning to latch-on, you can expect that your nipples will be sore. Pain that lasts throughout the breastfeed or soreness that is still there after the first week tells you that something needs to be changed about your baby's attachment.

It's important to do something about nipple soreness before it gets worse and your nipples develop painful cracks. If you are dreading the next feed because your nipples hurt, you may benefit from some time with a lactation consultant.

Sore nipples in the first days and weeks postpartum are usually the result of poor attachment or the inexperienced baby's sucking technique. If you experience sore nipples past the first few weeks or if you suddenly develop the problem after weeks or months of pain-free breastfeeding, there is probably another cause, such as nipple thrush. Again, my advice is too see a lactation consultant.

If your nipples are very sore, your baby is probably not getting enough breast tissue in the mouth. A horizontal red stripe across the tip of your nipple or a temporary indentation at the base of your nipple are signs that the nipple is not far enough back in the baby's mouth while sucking. The baby's tongue may be rubbing against the tip of the nipple or the baby's gums might be chomping at the base of the nipple instead of on the areola over the milk sinuses. This kind of sucking is painful for mothers and inefficient for babies. Your Baby will not be able to empty the breast properly if sucking only on the tip of the nipple. Of course this not only means pain for Mum but passably a hungry frustrated baby and supply problems.

How you can prevent sore nipples

Paying careful attention to how your baby takes the breast will prevent, or at least reduce the problems associated with sore nipples.

See Tips for proper attachment and Tips for Happy Breastfeeding to teach your baby to breastfeed correctly. If you have problems with attachment, you may need hands-on help from a lactation consultant before your nipples get terribly sore and your baby develops bad habits.

What to do..

- Again, ensure your baby is attached properly.

- Always break the suction before taking baby off the breast.

- Pulling the baby off the breast hurts and can leave your nipples hurting for a long time. Slip a clean finger into the corner of baby's mouth to release the suction before taking baby off the breast. Or, try pressing down gently on the breast near baby's mouth.

- Avoid bottles and dummies or pacifiers during the time that your baby is learning to breastfeed. Getting milk from bottles requires a different technique than breastfeeding. Using the bottle technique at the breast leads to attachment and sucking problems. Babies who get both the bottle and breast in the early days are likely to have problems learning good sucking technique.

- In the early days of breastfeeding, you'll have to keep working at getting your baby attached properly, even if it means taking the baby off the breast and starting over several times at the beginning of a breastfeed. If you do this, you'll soon be rewarded with pain-free breastfeeding. If you are struggling with attachment or your nipples are painfully cracked or bleeding get help. The sooner you get help, the easier it will be to fix the problem. Call a lactation consultant or a breastfeeding counsellor.

- Experiment with different breastfeeding positions; find what works for you and your baby. It can be very helpful to change positions from one feeding to the next so as to change the distribution of pressure on your areola and nipple during sucking.

- Feed your baby on the side that is least sore first and change to the more painful side after you have had a let down. The pain from sore nipples is usually less intense after the milk is flowing and your baby will be more calm and patient if it is not so hungry.

- Feed your baby before it becomes impatiently hungry. This way the sucking will be less vigorous and baby is likely to be more co-operative with re-positioning and re-attaching.

- Try shorter more frequent breastfeeds, these are easier on your nipples than longer feeds spaced farther apart.

- Pad your nipple. As you're putting baby to the breast, use your thumb and fore finger to slide the skin of the areola forward with gentle compression. This forms a wrinkle at the base of the nipple, which adds extra padding to protect the sore nipple.

- If your baby needs to suck for comfort and your nipples are too painful to allow it, give your baby a finger to suck on. This will avoid having to use a dummy or pacifier. Long periods of comfort sucking at the end of a breastfeed are great for building a good supply but they can be feeding hard to endure when you have recovering traumatised nipples. Mum or Dad can use a clean finger instead of a dummy so as to avoid allowing baby to learn a poor sucking technique.

- Avoid engorgement. It is more difficult for a baby to latch on to a breast that is swollen and engorged. Feeding often will help to prevent this. While you may want to limit the amount of comfort sucking your baby does when your nipples are very sore, make sure that you breastfeed often enough and long enough for your baby to get the milk out of your breasts. Engorgement can make problems with attachment and sore nipples worse.

- Numb your nipples. If your nipples are really tender, try numbing your nipples before breastfeeding by applying ice wrapped in a damp cloth.

Helping the nipples to heal faster

- After each breastfeed, manually express a few drops of colostrum or milk and gently rub this into your nipples. This stimulates circulation and promotes healing. Colostrum is the best nipple cream.

- Keep your nipples dry when you are not breastfeeding. Pat your nipples dry with a soft cotton cloth after feedings. If it hurts to this, just let your nipples air-dry. Leave your bra flaps down and your shirt open until the nipple is no longer moist. Or, go without a bra, especially at night. You can sleep on a towel to absorb any leaking milk. Use fresh, dry breast pads after feedings, avoid disposable breast pads as these have plastic backs on them which hold the moisture against the skin.

- Don't use quick drying methods, such as a hair dryer (even on a low setting) to dry your nipples. While some nipples tolerate this technique, it can cause more delicate nipples to crack because it dries the skin itself, not just the surface of the skin.

- Try exposing your nipples to a few minutes of sunshine during the day. This will help to heal damaged nipples, stop the growth of bacteria or thrush and can help to toughen them up. You only need to do this for a few minutes at a time. Don't get sunburnt nipples, OOCH!

- Avoid using soap on your nipples. The little bumps on the areola around your nipples are the Montgomery glands that secrete a natural antibacterial and lubricating oil. Soaps remove these natural oils, causing dryness and cracking.

- Wear a properly fitting bra. Be sure your bra is not so tight that it compresses your nipples or so rough that it irritates them. Your nipples may feel better if you go without a bra and wear a soft t-shirt or cotton crop top instead.

When nothing is working

If your nipples are still very sore after using the above measures, you may need to take more drastic action. If you haven't seen a lactation consultant yet, now is the time. You may need expert help in fixing the cause of the pain. A lactation consultant can show you how to teach your baby to suck more effectively so as not to traumatise your nipples. If your nipples really need a rest, try the following suggestions:

Try a nipple shield. This is a soft, flexible silicon artificial nipple that fits over your nipple and areola. The baby sucks on the shield to get milk out of the breast. Nipple shields can ease the pain during vigorous sucking and can also provide a temporary solution to some attachment difficulties.

Nipple shields should be used with caution because your nipples will receive less stimulation and the baby will require a different sucking action to the milk out. This is not so much a concern with the very thin silicone shields but it is still something to keep in mind. Ensure your baby's lips are turned out and positioned high on the part of the shield that covers the areola - and not just on the nipple. Try to use the nipple shield only temporarily, since some babies develop problems with attachment if they are used for too long.

To wean your baby from the shield, try using it only at the beginning of feedings. Once the baby is attached and feeding, quickly slip the shield off and get baby directly onto the breast. Eventually, your baby will take the breast without the shield at the start of the breastfeed.

You can obtain a nipple shield from a lactation consultant, who will also help you resolve the problems that have made the use of a nipple shield necessary. They can also be bought from a pharmacy, but be sure to follow the directions in the packet and ask for help if you are having trouble using them. They can be a little tricky until you get used to using them and following the instructions really does help- I learnt the hard way.

Rest the breast with a pump. Let baby suck on the nipple that is less sore while you express the milk from the sore side for a day or so. But be careful. Pumping can irritate the nipples if you use too much suction pump for too long, or if the nipple rubs against the pump. Offer the milk that you pump to your baby using a cup, a feeding syringe, or a spoon. Avoid giving your breast milk to your baby in a bottle. Feeding expressed milk with a bottle will often make it more difficult to solve the attachment problems that caused the sore nipples in the first place.

Consider other causes. If you have tried everything and you still have exquisitely tender and painful nipples, you could have thrush of the nipples. Sore nipples that appear after weeks or months of comfortable breastfeeding are almost always caused by this. Other causes of persistent sore nipples include eczema or Reynaud's syndrome. These problems will need to properly diagnosed and the best person to this is a lactation consultant.

Low supply

Breastfeeding is a supply and demand system. Whatever your baby needs, your body will produce. Your milk is made fresh each feed in response to the suckling stimulus. The more your baby breastfeeds, the more milk you will produce. If your baby acts hungry, feed more frequently for a few days. Your supply will increase and your baby will settle into a new feeding pattern.

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, see 'How do I know my baby is getting enough milk?'

If you notice there are signs that your baby is not getting enough milk, the following suggestions should help your supply meet your baby's needs..

Increase the frequency of breastfeeds

Breastfeed your baby at least every two hours during the day. If your baby has been sleeping for more than two hours, wake it up for an extra feed. Consider waking your baby for at least one extra night feed, especially if you have a baby who sleeps for more than a four or five hour stretch at night.

Don't wait for your breasts to "fill up" to tell you when it's time for another breastfeed

There is always milk in your breasts for your baby, and more milk is made while you breastfeed. Studies have shown that fat levels in milk are higher when the time between feedings is shorter. This means when you offer the breast again minutes after the last feeding when your breasts may still feel "empty", your baby is getting the high-fat milk that makes those cute chubby babies.

Offer the breast more often

The first golden rule of breastfeeding 'Supply=Demand' implies that babies will demand the milk they need. Like every rule, there is always the exception. Some babies, especially sleepy babies and those that are naturally undemanding, may not breastfeed as frequently as they need to without Mum forcing the issue a little. If this sounds like your baby, you need to take the lead and give your baby more frequent opportunities to breastfeed. Lots of skin-to-skin contact, night breastfeeds, breastfeeding in a sling or having a bath together will help to stimulate longer, more frequent feedings. If your baby has really long sleeps and doesn't appear to be getting enough milk you will need to wake your baby up for extra breast feeds. What? Wake a sleeping baby, are you crazy? Afraid so. If you need to give extra feeds and your baby doesn't care, you will need to wake your baby up.

Waking a sleeping baby

These are based on Dr. Sears recommendations for waking a Sleeping baby found at askdrsears.com. They are fabulous, gentle and natural techniques.

- Try to wake your baby during REM sleep. You can recognise this by fluttering eyelids, little smiles, clenched fists, and limbs that are not limp. A baby in deep sleep is harder to wake up.

- Prod and poke your baby a bit. Undress your baby down to the nappy, get yourself top less and place your baby skin-to-skin against your tummy and breast, while you drape a towel or lightweight blanket over baby's exposed back and head. Your own body heat should keep him toasty warm (a mother's skin temperature automatically goes up a bit while breastfeeding) but not so toasty that your baby falls asleep.

- If that doesn't work, hold your baby upright and talk encouraging him to open the eyes.

- Instead of the usual bonding positions (which relaxes babies), straighten out your baby's body and extend the arms - these postures perk up the brain- Nifty!

- Stroke the palms of the hands and soles of the feet to help your baby wake up.

- Rub your baby's face with a cool washcloth- O.K this ones not so gentle, but it generally works.

- Hand express a few drops of colostrum or milk. Using your tantalising leaking nipple, tickle the lower lip to stimulate your baby to open the mouth. Talk to your baby while you are breastfeeding to keep him stimulated. If he nods off, stroke the legs or pat the back.

- Get in the habit of changing sides as soon as your baby begins to nod off.

- If your baby drifts off after only a few minutes of breastfeeding, take baby off the breast and help him wake up again before changing sides. Wake your baby several times if you have to, until there has been at least ten or fifteen minutes of good sucking.

Have long breastfeeds

Don't limit the length of your baby's breastfeeds to a predetermined number of minutes on each side. Allow your baby to finish the first breast before changing sides. This will give your baby an opportunity to fill up on the high-fat milk brought down by the later let-downs. If you change your baby to the second breast too soon, you won't completely empty the first breast which means that next time the breast won't make as much milk.

Change side often

The advice in the previous point about finishing the first breast first may not work well for babies who suck at a leisurely pace or who fall asleep a few minutes into a breastfeed. Changing sides often will encourage a baby to suck more vigorously for a longer period of time allowing more nutritive sucking time. You can try to let the baby feed on the first breast until the intensity of the suck and swallow diminishes. Before baby drifts off into comfort sucking, swap over to the other breast. This will encourage another letdown and baby will have to drink vigorously again.. When the sucking action slows again go back to the fist breast, and keep doing this until your baby has had enough milk and you feel that your breasts are empty.

Give top up feeds

Some mothers find this a good adjunct or alternative to changing sides often. After you finish the feed and baby seems content, hold or carry baby upright and awake for 10 to 20 minutes, allowing any burping that needs to take place. This makes room for more milk. Feed your baby again from both breasts. This will stimulate more let-downs which will increase the volume and energy content of your milk.

Undress your baby during breastfeeds

Skin-to-skin contact helps to wake up a sleepy baby and stimulates less enthusiastic feeders. Undress your baby down to the nappy. To maximize skin contact, take off your bra and wear a shirt that you can unbutton all the way down the front, better still take off your shirt all together. To prevent your baby from getting chilled you can place a blanket around the two of you. Remember also, that warm fuzzy feelings make milk and skin to skin contact makes warm fuzzy feelings. This is the effect of the bonding hormone oxytocin.

Sleep with your baby

One of the most powerful ways to stimulate increased milk production is to take your baby to bed and breastfeed at will. This relaxes both you and your baby and stimulates longer and more frequent breastfeeds. It also increases your levels of prolactin and oxytocin, the hormones that make milk and that make breastfeeding an enjoyable experience.

Sling feed, topless

Naturally, keeping baby nice and close to your breasts will entice him to eat more. Wear your baby in a baby sling between breastfeeds, even while your baby is sleeping. In fact, some babies feed better and more often when on the move. Again, this is skin to skin contact, the easiest hormone producing, milk making method there is.

Focus on breastfeeding

Expect nothing of your self except to breastfeed your baby. What activities and worries are draining away energy that could be better spent looking after yourself and your baby? Are you trying to do too much, are you taking enough time to sit down to feed and enjoy your baby? To make more milk for your baby, you have to make breastfeeding and taking care of yourself a priority. Let go of other responsibilities for a while. Have your partner share in non-feeding baby care, so that you can rest, take a walk, or take a shower.

Get household help

Get help with laundry, dishes, cooking, and cleaning. If you have a demanding toddler, get someone to come to your house after school to entertain your older child and give you a few hours of relief so you can sit and relax and breastfeed your baby. If possible you could ask your partner to take time off work for a few days so that you can concentrate only on breastfeeding and making milk.

No bottles, No dummies (or pacifiers)

When there are concerns about weight gain, all of your baby's sucking needs to be done at the breast. Bottles of formula will interfere with the delicate balance between your milk supply and your baby's need, as will satisfying your baby's need to comfort suck with a dummy or pacifier. If it is medically necessary to give your baby supplementary formula feeds, speak to a lactation consultant about a supplemental nursing system. Also ask the lactation consultant to show you how to use it. I've spoken to a few mothers who have managed to tangle themselves and their babies up in the tube.

Enjoy your baby

While you are feeding, stroke and calm your baby using a lot of skin-to-skin contact. Enjoy looking at and feeling your baby. This will help your let down reflex. Between breastfeeds and immediately before a feeding, imagine your baby breastfeeding and your breasts pouring out milk to satisfy your baby.

Get professional help

Contact your local breastfeeding counsellor and/or a professional lactation consultant for help increasing your milk supply. A lactation consultant can help you evaluate your baby's attachment and suck so you can be certain that baby is breastfeeding effectively. Support from a breastfeeding counsellor will help you feel more confident about your ability to breastfeed your baby.

Trust your body

If you're breastfeeding often enough, and you baby is sucking effectively, you will make enough milk. It's rare that a mother is unable to produce enough milk for her baby. And while it may seem that your life is stressful, mothers throughout history have breastfed their babies through war and famine. There's no reason to think that you won't succeed at breastfeeding.

Massage and heat

These can encourage your let down reflex. If you are having trouble getting a let down try this before you feed your baby.

Apply a warm compress to your breast, such as a warm towel or cloth nappy soaked in warm water. Then, with your fingertips, stroke from the top of the breast down and over the nipple, using a light touch. This helps you to relax and helps to stimulate the milk making hormones. Massage the glands and ducts by pressing the breast firmly with the flat of the fingers into the chest wall, beginning at the top and working in a spiral down toward the areola. Massage in a circular motion a few strokes at a time before moving to another spot. While leaning forward, gently shake your breasts, allowing gravity to encourage the stimulation to release milk.

Engorgement

Two to four days after birth, your 'milk will come in', it will come in a dramatic fashion. You may wake up to find that you have rock hard breasts that are two bra sizes bigger than they were the last time you were awake.

This dramatic increase in breast size and fullness is called physiologic engorgement. It is caused by the changes in hormone levels after the birth of your baby. These hormone changes begin the process of milk production and also increase blood circulation to the breasts.

Physiologic engorgement is usually more dramatic and uncomfortable in first-time mothers and lessens in intensity the more times you go through the process.

The fullness and tightness can be quite uncomfortable. Many mothers find that their breasts fill up faster than baby can empty them. Some mothers can even develop a slight fever when their breasts are engorged. This has more to do with the increase in blood flow rather than an infection.

Frequent breastfeeding is the best way to prevent and treat engorgement. Relief comes when baby gets the milk flowing and empties the breast. Once you and your baby find the delicate balance between supply and demand, the discomfort will pass. The swelling will subside, you'll stop feeling like you will pop right out of your skin and your breasts won't look like they belong to a porn star. Rest assured, once all this passes, your breasts are still making enough milk for your baby.

Preventing and coping with engorgement

Engorgement can lead to other problems, so it's important to treat it quickly. When the breasts swell with fluid and milk, the nipple may flatten out, making it more difficult for your baby to get a good mouthful of breast. The baby can suck on only the end of the nipple and often can't get enough of the areola tissue into the mouth to compress the milk sinuses and empty the breast. This causes further engorgement and a hungry baby. As the hungry baby sucks harder but incorrectly, the nipple gets damaged and painfully sore. Eventually, your breasts make less milk because to match the amount of milk that the baby has been taking from breast. This will put a stop to the engorgement, but may lead to problems with milk supply if your baby is still not attaching properly and sucking well.

You can keep normal physiologic engorgement from becoming a problem. Here are some suggestions for coping with breast fullness:

Teach your baby good attachment technique in the first days after birth. It's easier for a baby to learn to latch on correctly on the first and second day after the birth when your breasts are softer, before your milk comes in. Check out our tips for correct attachment.

Keep your baby with you immediately after birth and breastfeed frequently . This will minimize problems with engorgement and get your milk supply meeting your baby's needs more quickly. Don't let the well meaning nurses take your baby to the nursery so that you can get some rest. Keep your baby close and start off as you intend to continue. Feed according to your baby's need.

Breastfeed often during the night as well as during the day. In the first month or two, a baby who sleeps for four or five hours at a time is a mixed blessing. Mum gets a chance to rest, but she may suffer from frequent bouts of engorgement. If you find yourself in this situation you might need to wake your baby up if you feel too uncomfortable. This is preferable to expressing the excess milk because eventually supply and demand will even out. If you are tipping breast milk down the sink or putting it in the freezer, your breasts will start to make enough for your baby and enough to tip down the sink.

Do not limit the length of breastfeeds to protect your nipples. Protect your nipples by being sure that your baby has good technique. Limiting the length of breastfeeds will increase engorgement. In the beginning most babies can not adequately empty the breasts in five or ten minutes.

Express a little milk. If you are becoming uncomfortably engorged and your baby is not breastfeeding well or often enough, you may need to express a little milk for your own comfort and to allow good feeding technique from your baby. Express only enough milk to make you feel more comfortable. Expressing too much milk may stimulate the production of more milk. Remember, the delicate balance of supply and demand.

Soak your breasts in a warm shower just before expressing your milk or feeding your baby. Direct the shower spray from the top of your breast toward your nipple as you massage your breasts. This warmth can help trigger a let down, which gets the milk flowing more quickly when you begin to express or your baby begins to feed. Other ways to apply warmth and moisture to your breasts include leaning over a sink or bowel of warm water (gravity will help you express milk in this position) or applying a warm towels or cloth nappies.

If baby is unable to breastfeed well, you may need to express your milk with an electric pump every 2 to 3 hours, to prevent problems with engorgement. Basically, do whatever you need to do to get the milk out of your breasts. Frequent emptying of the breasts in the early stages of breastfeeding will help you have a good milk supply in the weeks and months to come. And if expressing too much leads to over supply, that is a problem that is easier to fix than the other problems that can come from engorgement.

Don't stop breastfeeding . Unrelieved engorgement can lead to a breast infection, and a baby who breastfeeds well can empty the breasts more efficiently than any pump.

Between breastfeeds, apply cold compresses to your breasts to relieve the pain and reduce swelling. Wrap small plastic bags filled with crushed ice in a tea towel or a cloth nappy. Frozen peas are good too.

Wear a loose fitting bra. Avoid bras that are too tight or those with seams that compress the lower part of your breast against your body. This traps milk and sets you up for engorgement and possible mastitis.

Get plenty of rest. Lie down with your baby and snooze and breastfeed together.

Cabbage leaves can be helpful . If engorgement is particularly bad, cabbage leaves can be a real help if you can put up with the smell of cabbage cooking on your breasts. Keep the leaves in the refrigerator and take the big veins out before putting the leaves on the breasts, you can use your bra to keep them in place. Change the leaves once they lose the coolness. Just the cool feeling alone can be relieving for engorgement. Don't use these for any longer than you need to. There is some concern that they may work too well and reduce supply beyond what is required although controlled studies have not confirmed any special benefits or problems with this treatment.

Engorgement after the early weeks

If you have enjoyed weeks of trouble-free breastfeeding and then suddenly begin to suffer from engorgement, take this as a sign that something is interfering with the delicate balance between your milk supply and your baby's needs: Is your baby going too long between breast feeds, has you baby changed it's feeding pattern, has something changed about the way your baby is sucking (sometimes teething can do this), has your baby been sick or are you feeling stressed. These things can all throw a good breastfeeding relationship out of wack for a short time. Often the only thing required to help you though this is take a few days off from other responsibilities to reconnect with your baby. Many mothers find it helpful to go back to the early rules of breastfeeding. Feed you baby according to its unique needs and get plenty of rest. Don't use dummies or bottles, avoid stress, eat well and keep your self hydrated. And if possible, get some extra help for a few days.

Blocked ducts

Sometimes a milk duct leading from the alveoli to the nipple can become blocked, resulting in a tender lump beneath the areola. There may also be a wedge-shaped area of redness extending from the lump back towards the wall of the chest. Unlike mastitis, the pain comes and goes with a blocked duct, and unless the duct is infected, you will not feel sick. If left untreated a blocked duct is likely to become infected, resulting in mastitis, infection, or a breast abscess.

Removing the blockage

Continue to breastfeed on the affected side. Get the milk out however you can. This is the golden rule of preventing engorgement, blocked ducts and mastitis. Use a breast pump or express by hand if your baby is unwilling to breastfeed. It will be painful to continue to feed or express from the affected breast, but removing the milk is the only way to prevent a blocked duct from making you really sick with mastitis. Generally if a blocked duct is left untreated for more than 18 hours you will get an even more painful breast infection.

Breastfeed on the affected side first

Your baby's sucking will be the strongest at the beginning of the feed, so you have more chance of dislodging the blockage when your baby starts on the affected breast.

Vary the baby's position at the breast

Doing this ensures that all of the milk ducts are drained. Be sure that your baby has a good attachment at the breast, so that the sucking will be more efficient. Experiment with different positions.

Massage the affected area

Before each breastfeed, give the affected breast a good massage by kneading it gently from the top of the breast down over the affected area toward the nipple.

Point the baby's chin to the sore spot

Drain the affected breast better by positioning your baby so that the chin "points" to the area that is sore. For example, thinking if the breast like a clock face; if the lump is around 4 o'clock , position your baby's chin around this point on the nipple clock. The lower jaw is often most effective at getting milk out of the breast. You may have to get creative with positioning here. I found a nifty trick when I was suffering from recurrent blocked ducts, give it a try.

Lay your baby on its back on your bed. Get yourself positioned on your knees and lower the breast into the baby's mouth ensuring that the chin is positioned to the affected part of the breast. You may have to be positioned above your baby's head or at an awkward angle to the side to get the chin in the right position, but its well worth temporary discomfort. You also have the advantage of working with gravity using this method. I've found it very effective.

Apply moist hot compresses

Apply the warmest water you can stand without burning yourself for a few minutes before breastfeeding or expressing, or soak the affected breast in warm water or in the shower.

Rest

Lie down and snooze with your baby allowing baby to feed when ever it is willing.

Pressure massage

Try a pressure massage on the area of your breast that is swollen and painful. This may help to loosen the blockage. With pressure massage, you do not actually move your hand over the skin as you would with a normal massage. You simply press more and more firmly with the heel of your hand to move the blockage in the duct down closer to the nipple.

To do pressure massage, start at the edge of the lumpy area closest to your chest wall. Apply pressure to that area with the heel of your hand to the point just before it becomes too painful. Hold the pressure at that level until the pain eases off. Then increase the pressure again, without moving your hand and hold it until the pain eases. Continue to gradually increase pressure at that same site until you are pressing as hard as you can. Then pick your hand up, move it down toward your nipple a little further and repeat the procedure. Continue moving your hand a little closer to the nipple each time and repeat the massage until you get all the way down to the nipple.

You may see the congealed milk come out from an opening in your nipple. Even if the blockage doesn't actually come out, you will at least have dislodged it and moved it toward the nipple so that when your baby goes to the breast and sucks, it can easily be removed. It is always a good idea to put you baby on the affected breast first, when the sucking will be the strongest.

Preventing recurring blocked ducts

Feed your baby in different positions. This will help you to empty all the milk sinuses and ducts.

Make sure your bra is not too tight. You may find it best to wear a bra with no seams. These can be more expensive but are worth the extra money. Some mothers find that crop tops are a good alternative to a bra for smaller breasts.

Pay attention to anything that may put pressure on the milk ducts. Some women find that sleeping on their side or on their stomach is the cause of recurrent blocked ducts. Sometimes it can be the way you hold your baby when you feed. Sometimes it can be the way the baby holds its arm against the breast. Generally for a recurrent problem like this the cause is something that you are doing regularly, so pay attention for a couple of days and see what you discover.

Mastitis

Mastitis is inflammation of the breast, usually due to a bacterial infection. It is excruciatingly painful and can make you feel very sick very quickly.

Since this is likely to be a bacterial infection and can make you feel very ill and can have far reaching consequences such as surgery and early weaning, I recommend that you consult a trusted and breastfeeding savvy GP to determine whether or not an antibiotic is necessary. Mastitis can become a breast abscess that may require surgical draining, but this can almost always be prevented by quick and proper treatment.

What are the signs of mastitis?

The breast is intensely painful, hot, tender, red, and swollen. Some mothers can pinpoint a definite area of inflammation, while at other times the entire breast is tender.

You will likely feel tired, run down, achy, have chills or fever and you may think you have the flu. Mothers with mastitis will sometimes experience these flu-like symptoms, even before they get a fever or notice breast tenderness.

If you have mastitis you will feel progressively worse, your breasts become more tender, and you will continue to experience fever. If you are experiencing engorgement, a blocked duct or mastitis without infection, you will gradually feel better instead of worse.

You chances of suffering from mastitis are greater if you have recently experienced any of the following: cracked or bleeding nipples, stress or getting run down, missed breastfeeds or longer intervals between breastfeeds.

Preventing mastitis

The best way to prevent mastitis is to avoid the situations that predispose you to it.Here are my tips for preventing mastitis.

- Relieve engorgement as quickly as possible - Milk that doesn't flow gets thicker and can cause blocked ducts, which can easily lead to mastitis

- Breastfeed frequently

- Don't restrict the length of breastfeeds

- If you feel your breasts getting full, encourage your baby to breastfeed. You don't have to wait for your baby to be hungry

- Avoid sleeping on your stomach or so far over on your side that your breasts are squashed

- Take care of yourself and get plenty of rest

Recurrent mastitis

The usual suspects

- Missed breastfeeds
- Giving bottles in place of breastfeeds
- Not expressing enough if separated from the baby
- Compromised immune system due to being run down tired and stressed

Recurrent mastitis can be taken as a sign that you need to take a closer look at your lifestyle and breastfeeding relationship and make some adjustments.

What to do about it

Treating mastitis is much like treating engorgement only more urgent.

The following suggestions may be helpful. You might also find it helpful to look at our information on engorgement and blocked ducts .

Get plenty of rest . Mastitis is an illness, so take a 'sicky'. Find someone else to take on all of your responsibilities other than breastfeeding. Take your baby to bed with you to breastfeed and try to arrange for your partner, a friend, relative or neighbour to look after older children or toddlers. Rest relieves stress and replenishes your immune system.

Use alternating warm and cold compresses on your breasts . Cold compresses relieve pain; warm compresses increase the blood flow to the area, which brings the infection-fighting white blood cells to the inflamed area. You can lean over a sink of warm water, stand in a warm shower, or soak in a warm bath. Warm water or a warm, wet towel is more effective than the dry heat of a heat pack. For cold compresses you can use crushed ice in plastic bags or bags of frozen peas, covered with a tea towel or a cloth nappy to protect your skin.

Gently massage the area of tenderness. This increases circulation, helps to loosen any blocked ducts in the area, and brings white blood cells to the area to fight the infection. Some mothers find it easiest to do this while soaking the breast in a warm shower or bath.

Breastfeed frequently on the affected side . If it hurts to breastfeed your baby, start the feed on the breast that is not sore, and change to the sore side as soon as you notice a let down. Breastfeeding is usually more comfortable when the milk is flowing. It's important to empty the affected breast. Your baby can empty your breast more efficiently than a breast pump but if your baby is not breastfeeding well, you may need to express the milk to empty the breast.

Use a variety of breastfeeding positions. This will ensure you empty all of the ducts.

Relive the pain. Paracetamol and ibuprofen are considered safe to take while breastfeeding. Unrelieved pain not only decreases your ability to produce milk, but suppresses your body's ability to fight infection. You can also try the reflexology routine for pain relief and or EFT.

Drink lots of fluids. Fever and inflammation increase your need for fluids.

Eat good, nutritious food . This will help your immune system fight the infection

Sleep without a bra . At other times, wear a looser fitting bra that does not put pressure on the affected area. Or if possible, go without a bra.

Keep on breastfeeding . During a bout of mastitis is not a good time to wean. Weaning increases the risk of a breast infection turning into an abscess that may require surgical draining. Continuing to breastfeed your baby is the best treatment for engorgement, blocked ducts and mastitis.

If your baby refuses to breastfeed on the affected breast, it may be because inflammation of the milk glands increases the salt content of your milk. Most babies either don't notice or don't mind, and continue to breastfeed with no dramas. Some may object to the change and fuss or refuse the breast from that side. If this happens you can try starting the feed on the unaffected side and finishing on the salty side. As you get better, your milk will soon return to its usual taste.

Antibiotics and mastitis

You can experience the pain and inflammation of mastitis without necessarily having a bacterial infection. Yet it is often difficult to tell whether mastitis has become a breast infection. Some believe it is O.K to wait a little while to make sure that you have a bacterial infection before treating with antibiotics, though most would recommend treating mastitis as a bacterial infection just in case. A moderate course of action would be to consult a trusted, breastfeeding friendly GP as soon as you suspect mastitis, take the prescription and wait to see if you are getting worse. That way you have it on hand if things get worse. Try all the herbal, homoeopathic, reflexology, acupressure, aromatherapy and EFT suggestions you can from my 'Breastfeeding help with Natural therapies'. If none of this seems to be helping after 24 hours or you are getting worse very quickly or you have a temperature that is getting higher, take the antibiotics.

There is a fair amount of research which suggests that it is better to give antibiotic treatment early in the course of mastitis. Mothers who are given antibiotics later are more likely to wean their babies, to have a more severe infection, and to have the infection recur.

The following guidelines can help you both determine whether or not antibiotics are necessary.

You may not need an antibiotic if:

- You do not have a history of frequent episodes of mastitis.
- You don't feel that sick.
- You have not gotten progressively sicker over the last few hours.
- You don't have a rising temperature
- The breast pain and tenderness is not increasing
- You can easily correct whatever factors may have set you up for engorgement in the first place

Signs suggesting you do need antibiotic treatment:

- A history of frequent mastitis
- A fever that is rising
- You are feeling progressively sicker as the hours go by
- You have cracked nipples, which allow bacteria to get into your breast tissue more easily
- Your baby has a bacterial infection that could be transmitted through the nipple such as a gooey green nasal discharge or bacterial conjunctivitis.

Breast abscess

Engorgement, mastitis, or blocked ducts can occasionally lead to a breast abscess. This is unlikely if you continue to breastfeed your baby frequently during an episode of mastitis or when you have a blocked duct. An abscess is a pus-filled area, like a boil under the skin. Your healthcare provider will suspect an abscess if you have a lump which remains tender and does not go away with the suggested treatments for blocked ducts and mastitis. An ultrasound of the breast may be necessary to find out where the abscess is and how large it is. An abscess may require surgical drainage because the infection is contained within a capsule and antibiotic therapy may not be able to reach the infection. Before taking this option you may find it helpful to try some of the natural therapy treatments for breast abscess outlined in 'Breastfeeding Help with Natural Therapies'.

In addition to the medical treatment recommended by your doctor, it's important to continue to empty the breast with the abscess. Depending on the location and the extent of the abscess, you may or may not be able to breastfeed from the infected breast. Your healthcare provider can help you decide whether this will be possible. If you are temporarily unable to breastfeed on the breast with an abscess, use an electric breast pump to empty the breast and breastfeed your baby more frequently on the other breast. Many babies get by with only one breast.

It can also be very useful to apply moist heat to the affected area before breastfeeding or expressing to help the milk to flow more easily if you have a breast abscess.

Breast refusal

This refers to a baby who doesn't want to breastfeed. Often this will happen suddenly after a period of trouble free breastfeeding.

The usual suspects

Developmental .Your baby may be developing better eye sight and become generally more aware of what is happening around them. This is very common around three months; some babies continue to be easily distracted at the breast indefinitely. This can be a concern for parents, but keep in mind that by this age, your baby has become very good at milking the breast and your breasts will most likely be working very efficiently so you may be able to empty a breast in under 5 mins.

Illness . It is common for babies to refuse the breast if they are coming down with a cold or are unwell in other way. It's often the first sign that something is up.

Return of fertility or oral contraceptives. Often changes in hormone levels can change the taste of the milk and some babies don't seem to like the taste. This is most likely to happen at ovulation or premenstrually. It can also happen when beginning on the pill. Generally, baby will get used to the tastes change.

Hot weather. Feeding patterns tend to change during hot weather. You may find that your baby will want only short feeds and will compensate for that by having them more frequently. This can be a cause for concern for some parents if they are used to long feeds.

Teething. Some babies get sore in the mouth and don't want to feed, probably because it hurts. See Teething for natural therapy solutions for fussy teething babies.

What to do about it.

Offer the breastfeed in a less distracting environment. Find somewhere boring and quiet to breastfeed such as the bedroom. Some mothers find it helpful to sit in a rocking chair or propped up on pillows on the bed, this may help your baby relax enough to remember that its tucker time.

Breastfeed your baby in bed. Pick a couple times during the day when you are the most tired and lie down with your baby to enjoy some quiet and relaxing breastfeeding time.

Breastfeed in a sling . Distractible babies often settle down easily when they are in a sling, and the motion of your walking will further relax your baby. Most mothers find that once they discover their own unique method and place to breastfeed, you will find that your baby will eventually settle into comfortable breastfeeding and finish a feed without so much distraction.

Wait. Often breast refusal is a temporary and short lived problem, particularly if it is due to illness.

Keep offering. Offer breastfeeds as usual and express your milk if your baby is not being co-operative. You still need to empty your breasts regularly to maintain your supply for when your baby starts feeding again. This is also important so that you don't set your self up for engorgement, blocked ducts or mastitis.

Biting

This is a very common reason for weaning. Baby gets the first tooth, gets a bit bitey, hurts Mum and Mum decides enough is enough. Time to wean. What many mothers don't realise is that this is usually a problem that comes and goes within a few days. Baby's with teeth don't necessarily bite, it is usually only just as they are coming through. Having said this, I think it is important to acknowledge that it really, really hurts when a baby with new teeth decides to try them out on your nipples. It can also become a game or a habit, so it is important to think about how you are going to deal with the situation when it arises and to be prepared with an action plan which will keep the biting to a minimum so that it really does come and go quickly with a minimum of fuss allowing you and your baby to continue to breastfeed for as long as you are both

Here are some suggestions which may help to reduce biting:

Have an appropriate reaction. If it hurts, say "Ouch", loudly! Slip a finger into the mouth to break the seal. Once you've rescued your nipple, watch your baby's face. Some sensitive babies will cry at this kind of reaction. If your baby becomes upset, calm your baby and start the breastfeed again. If the baby bites again, react the same way. Eventually, your baby will associate biting with an undesirable reaction and will stop biting.

End the breastfeed. If your baby bites and you prematurely end the feeding, the baby associates biting with the end of the breastfeed, this may be the deterrent your baby needs to never try it again.

Pull baby close. This is a tough one because it is so counterintuitive but it works a treat. Instead of crying in pain and pulling the baby away, you can pull the baby close in to the breast as soon as you feel the teeth coming in for a chomp. The baby will immediately let go in order to open her mouth more and uncover the nose to breathe. After you do this a few times your baby will realize that biting triggers this uncomfortable response and will probably stop biting. Remember, your goal is to discourage her from biting, not to cause fear.

Keep a finger close by. Once you know your baby is in the biting phase, keep a finger in the corner of her mouth, ready to break the suction if you feel a bite coming on.

Take your baby off the breast and onto the floor. After a little time you can pick your baby up and try again. Try this with firmness and authority rather than anger and your baby should make the connection between biting and being down.

Provide an alternative. Teething creates the urge to chomp, and anything that goes into the mouth is fair game. Keep some teething toys in the fridge, or try some cold carrot or apple, and give your baby another way to deal with the urge. If you know from experience that biting comes at the end of the breastfeed, you can try taking your baby off the breast just before you think the feed is finished and give an chewing substitute.

See 'Teething' for homeopathic remedies and other natural solutions to help your baby through this time.

- How Does Breastfeeding Work?

- Tips For Happy Breastfeeding

- The Common Challenges Of Breastfeeding