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Common problems of breastfeeding and weaning

Common problems of breastfeeding and weaning
Literature review current through: Jan 2024.
This topic last updated: Sep 21, 2023.

INTRODUCTION — Breastfeeding is universally recognized as the normative and preferred method of infant feeding. Breastfeeding has important short- and long-term health benefits for both infant and mother. (See "Infant benefits of breastfeeding" and "Maternal and economic benefits of breastfeeding".)

For many women, difficulties in breastfeeding result in early termination of breastfeeding before the recommended period of time. However, with accurate advice and treatment, most of these difficulties can be overcome, and breastfeeding can be successfully sustained for longer periods.

Common problems associated with breastfeeding and their management are reviewed here. Other aspects of breastfeeding are discussed in the following topics:

(See "Initiation of breastfeeding".) – Includes breastfeeding technique and issues related to maternal medications

(See "Breastfeeding: Parental education and support".)

(See "Breastfeeding: Parental education and support", section on 'Contraindications to breastfeeding'.) – Includes considerations for maternal infectious diseases

(See "Maternal nutrition during lactation".)

(See "Breastfeeding the preterm infant".)

INADEQUATE MILK INTAKE — Inadequate milk intake or the perception of inadequate milk production is the most common reason for early termination of breastfeeding. Inadequate milk intake may be due to insufficient milk production or failure of the infant to extract milk or a combination of these factors. In many cases, the problem can be solved by optimizing breastfeeding frequency and technique, with close monitoring and lactation support.

Diagnosis of inadequate intake — The diagnosis of inadequate milk intake is made clinically by demonstrating insufficient feeding based on a nursing history, decreased infant urine and stool output, and excess weight loss of the infant. (See "Initiation of breastfeeding", section on 'Assessment of intake'.)

Clinical signs and behaviors – For healthy term newborns, assess intake by clinical signs of hydration and feeding (table 1). During the first week of life, mothers with term infants should nurse when the infant exhibits hunger cues, which usually occurs 8 to 12 times in 24 hours. By four weeks after birth, nursing usually decreases to seven to nine times per day. By the fifth day of life, infants with adequate intake urinate at least six to eight times daily and have three or more pale yellow and seedy stools daily.

Some mothers perceive that the infant is not ingesting adequate milk, because the infant seems hungry and is nursing more frequently. If the infant is gaining weight appropriately, the infant may be undergoing a growth spurt or is having difficulty removing milk, leading to more frequent feeding. Growth spurts typically occur at two to four weeks, six weeks, three months, and six months.

Infant weight – To determine whether caloric intake is adequate, infants must be weighed naked at each office visit and at any time a parent is concerned about having enough milk.

Term infants generally lose weight in the first three to five days of life with an average loss of 7 percent of their birth weight. They typically will regain their birth weight by one to two weeks of life and gain approximately 30 grams per day. Once the mother's breasts feel full with milk by day three to five, the infant should not continue to lose weight. If an infant has lost 10 percent of its weight or fails to regain birthweight appropriately, inadequate intake should be considered and further assessment should be performed, including direct observation of breastfeeding. (See 'Observed feeding' below.)

Late preterm infants (born between 34 and 37 weeks gestation) or infants with underlying medical problems are at increased risk for feeding problems and inadequate milk intake. As a result, they often need additional breastfeeding support and monitoring, often including scheduled feedings and after-feeding pumping, and sometimes test weighing (before and after a feed) to determine actual milk intake. (See "Breastfeeding the preterm infant", section on 'Late preterm infants' and "Breastfeeding the preterm infant", section on 'Test weighing'.)

Management — Inadequate milk intake is most commonly related to or worsened by ineffective breastfeeding technique In some cases, specific maternal and/or infant factors contribute to the problem, which may warrant specific interventions, depending on the cause (table 2).

Optimize breastfeeding technique – Inadequate milk intake is most commonly related to or worsened by ineffective breastfeeding technique. The first step is a careful assessment of breastfeeding technique, including direct observation of feeding, and providing maternal education and support to increase breastfeeding frequency and optimize technique. Proper latch-on is illustrated in the figure (figure 1) and further detailed in videos available here. (See "Initiation of breastfeeding", section on 'Optimize mechanics of feeding'.)

Assess and address contributing factors – In some cases, specific maternal and/or infant factors contribute to the problem, which may warrant specific interventions, depending on the cause (table 2).

If the mother reports nipple or breast pain, the breast should be examined for evidence of nipple injury or dermatitis, engorgement, or narrowed (blocked) ducts, all of which cause pain and may interfere with breastfeeding and/or milk transfer. The most common cause of nipple pain and injury is an ineffective latch. Diagnosis and management of these problems are discussed below. (See 'Nipple and breast pain' below.)

During the first weeks after birth, an important marker of milk production is the timing of lactogenesis II (also called secretory activation), which is the transition from making concentrated drops of colostrum to larger quantities (ounces) of breast milk; this transition typically occurs by 72 hours postpartum. Lactogenesis II is delayed if has not occurred within three to four days postpartum; this occurs in approximately 20 percent of women and is more common in those who are primiparous, in those with obesity or insulin resistance, or after cesarian birth [1,2]. In most cases, this problem can be addressed by optimizing technique, increasing breastfeeding frequency, and ensuring complete breast emptying to stimulate milk production.

Increased maternal stress has been associated with decreased let-down and, thus, less effective breastfeeding. Mothers who are overly stressed may benefit from relaxation techniques or other interventions to help them remain calm [3]. Unfortunately, as the mother becomes more stressed, breastfeeding may worsen and a vicious circle can ensue.

Supplementation (if medically necessary) – Supplementation of feeds with formula or donor human milk should be avoided if possible. If supplementation reduces breast milk removal, it may decrease milk production and exacerbate the breastfeeding problem. However, supplementation may be necessary in some cases to provide adequate nutrition to the infant, including a delay in lactogenesis II. When supplements are medically necessary, they are ideally given in small volumes and only for a brief period while addressing the breastfeeding technique and ensuring signaling to improve the mother's milk production (ie, increased frequency and thorough milk removal of the breast). When possible, the supplemental formula should be given via one or more alternative techniques, including use of a syringe, cup, spoon, or a supplemental nursing system at the breast, rather than using a bottle and artificial nipple [4]. To ensure safety, methods other than bottle feeding should be guided by appropriately trained clinical staff. Indications and techniques for supplementation are outlined separately. (See "Initiation of breastfeeding", section on 'When and how to supplement with formula'.)

If the mother chooses to supplement with donor human milk, it should be obtained from an established human milk bank that follows safety regulations for optimal milk collection, pasteurization, storage, and shipping. (See "Human milk feeding and fortification of human milk for premature infants", section on 'Use of donor milk'.)

Galactagogues (not recommended) – Galactagogues (or lactagogues) are medications or other substances believed to augment maternal milk production. The most commonly used prescription agents are dopamine receptor antagonists, primarily metoclopramide and domperidone. We do not recommend the routine use of galactagogues, because there is limited evidence to support their efficacy and because of potential safety concerns [5,6]. These agents should never be used in place of an evaluation and correction of any modifiable factors such as frequency and thoroughness of milk removal [5,7,8]. If galactagogues are considered in selected patients who have not responded to lactation support, they should be used with caution, and mothers need to be aware of potential side effects and the lack of data supporting their use.

Most studies suggest limited efficacy of galactagogues in increasing milk production [6,9-15]. In small randomized trials of metoclopramide given to mothers of term or preterm infants at a dose of 10 mg every eight hours, there was no difference in the amount of milk production between mothers who received metoclopramide compared with mothers who received placebo [9,14,15]. A systematic review concluded that domperidone may increase the volume of expressed breast milk in mothers pumping for their preterm infants, but the findings may not be generalizable, because the two included studies involved mothers greater than 14 days postpartum and who had full lactation support [16-18]. In another trial of 80 mothers who were expressing breast milk to feed their infants in the neonatal intensive care unit, 10-day courses of domperidone and metoclopramide appeared to be equally effective in increasing milk production [19]. Although 15 percent of mothers reported side effects (eg, headaches, diarrhea, and mood swings), this may be an underestimation, as a significant number of mothers withdrew from the trial (n = 15). Another trial in mothers of preterm infants under 29 weeks gestation found that domperidone appeared to increase milk volume, at least in some of the subjects, although the absolute increase in milk volume was modest [20].

The use of metoclopramide and domperidone is also limited by concerns about possible adverse effects and because the long-term effects of these medications on offspring are unknown [5,21].

For metoclopramide, no definite adverse effects on the infant have been demonstrated. However, there are theoretical concerns about the use of this drug during lactation because of its known effects on the central nervous system [18].

Domperidone is excreted in low concentrations in breast milk and does not cross the blood-brain barrier. However, because of important concerns about arrhythmias due to QT prolongation, domperidone is not approved for marketing in the United States [22,23]. Moreover, the quality of product available from compounding pharmacies cannot be assured. Domperidone use is most risky in mothers with a history of arrhythmias or who are at risk for prolonged QT syndrome, are on other medications that increase the QT interval, on CYP3A4 inhibitors such as grapefruit juice or fluconazole, or who take domperidone doses over 30 mg daily [24]. Severe psychiatric side effects have been reported with high doses and abrupt weaning of domperidone [25].

Data on the use of herbal galactagogues are even more limited. Fenugreek is the most widely used herbal agent, including in many "lactation cookies," but data are insufficient to determine its efficacy and safety [6,26-30]. Reported side effects include diarrhea, flatulence, allergic reactions, and hypokalemia. In addition, it is not known whether components of the herb are transferred to the infant via breast milk. As with all herbal supplements, manufacturers are not required to demonstrate efficacy, and the contents of individual products vary. Further information about fenugreek and other herbal galactagogues is available from the LactMed database, which is maintained by the National Library of Medicine.

NIPPLE AND BREAST PAIN — After insufficient milk intake, nipple and breast pain are the most common causes of premature discontinuation of breastfeeding.

Etiology — Causes of nipple and breast pain include:

Nipple injury from breastfeeding (eg, due to improper latch or suck) or pumping (eg, due to poorly fitted breast shield)

Nipple vasoconstriction

Engorgement

Narrowed (blocked) ducts

Nipple and breast infections (see 'Breast infections' below)

Excess milk production

Nipple dermatitis/psoriasis

Evaluation — Evaluation of breast pain begins with a thorough history, examination of the infant and mother's breasts, and observation of feeding.

History — The following are key elements in the history:

The onset of breast pain, as breast pain in the first days of breastfeeding is most often caused by poor latch, whereas infectious causes of breast pain occur later.

Description of the pain including the clinical setting. For example, pain that occurs in a mother who feels fullness of her breasts may be due to excessive milk production. Whereas pain that occurs only with pumping may be due to trauma from the pump.

Feeding history that includes the frequency and duration of feedings, when the milk "came in," and how well the infant latches onto the breast.

Previous breastfeeding experience.

Maternal breast surgeries including breast reduction, piercings and implants, or the presence of inverted nipples.

Maternal history of skin conditions including sensitivities, eczema, and psoriasis.

History of nipple pain or extreme sensitivity during pregnancy.

History of Raynaud syndrome or autoimmune disease, which may be associated with nipple vasoconstriction. (See 'Nipple vasoconstriction' below.)

Physical examination

Infant — Physical examination of the infant should focus on the head and neck:

Torticollis commonly causes a unilateral sore nipple.

A tight lingual frenulum may cause sore, traumatized nipples.

Cleft lip and/or palate, retrognathia, large adenoids with mouth-breathing, and oral defensiveness are other reasons for difficulty achieving a nontraumatic wide latch with good milk transfer.

Mucocutaneous candidiasis that involves the oral cavity (eg, thrush) or diaper area may be associated with breast pain. (See 'Candidal infection' below.)

Maternal breast examination — The mother's nipples should first be inspected for swelling, rash, vasospasm, impetiginized nipple pores, blocked pores, abrasions, ulcers, and open cracks. A thorough breast examination should also be done to identify engorgement, masses, abscesses, tenderness, or areas of erythema indicating mastitis; details of these disorders are discussed below.

Observed feeding — An episode of breastfeeding should be observed because most causes of breast pain in the lactating mother are due to incorrect breastfeeding technique. The latch and feeding technique should be directly assessed (figure 1 and figure 2). A poor latch may result in injury to the nipple and may interfere with the infant's ability to empty the breast, which may result in engorgement, narrowed (blocked) ducts, mastitis, and breast abscess. Details on breastfeeding technique and lactation support are discussed separately. (See "Initiation of breastfeeding", section on 'Principles of breastfeeding'.)

The observation and education can be performed by either the primary care provider or a lactation consultant, and supplemented with educational videos, such as this one demonstrating effective latch-on technique.

Nipple pain — Sore nipples are one of the most common complaints by mothers in the immediate postpartum period. Pain due to nipple injury needs to be distinguished from nipple sensitivity, which normally increases during pregnancy and peaks approximately on the fourth postpartum day. Normal nipple sensitivity can be differentiated from the pain due to nipple trauma by differences in their timing and course [31].

Normal sensitivity typically subsides approximately 30 seconds to 1 minute after suckling begins. It also diminishes after the fourth postpartum day and completely resolves approximately seven days after delivery.

In contrast, pain due to trauma persists at the same or an increasing level throughout the nursing episode. Severe pain or pain that extends beyond the first postpartum week is more likely to be due to nipple injury.

Normal nipple sensitivity — As noted above, most mothers experience nipple discomfort with breastfeeding initiation. This nipple sensitivity is usually limited to the first few suckles of the feed and is thought to be related to the negative pressure on the ductules that have not yet filled with milk [31]. This "latch-on pain" should not persist throughout the whole feeding and should resolve completely after the first week or two. In addition, some mothers find the "pins and needles" sensation of let-down to be uncomfortable, but this discomfort often improves in the first weeks of breastfeeding. In any case, the pain is not severe.

If needed, the mother can use acetaminophen before the feeding. Nipple toughening procedures during pregnancy have not been shown to be beneficial in preventing nipple sensitivity as breastfeeding is initiated [32].

Nipple injury — Nipple pain due to trauma persists at the same or an increasing level throughout the nursing episode. Severe pain or pain that extends beyond the first postpartum week is more likely due to nipple injury.

Nipple injury usually is due to incorrect breastfeeding technique, particularly poor position or latch-on. Nipple abrasion, bruising, cracking, and/or blistering may result when an infant fails to achieve a proper latch-on. (See "Initiation of breastfeeding", section on 'Positioning and effective (asymmetric) latch'.)

Other contributing factors for nipple trauma include eczema or other maternal dermatitis, harsh breast cleansing, use of potentially irritating products including breast pads, and infant biting or oromotor problems [8]. Nipple injury also is associated with areas of breast inflammation, bacterial infections, engorgement, or use of a breast pump with poorly fitted breast shield. (See 'Ductal narrowing' below and 'Breast infections' below and 'Engorgement' below.)

Nipple trauma is sometimes related to mouth abnormalities in the infant, such as ankyloglossia or a palatal anomaly [33,34]. Ankyloglossia, also known as "tongue-tie," occurs when the frenulum connecting the tongue to the floor of the mouth is tight and limits mobility of the tongue (picture 1). Many infants with ankyloglossia can breastfeed without difficulty and/or do well with lactation support; a minority will require frenotomy. (See "Ankyloglossia (tongue-tie) in infants and children", section on 'Breastfeeding problems'.)

General management – Management includes prevention of nipple injury and healing of traumatized nipples.

Prevention:

-The most effective techniques for preventing nipple trauma are proper positioning and latch of the infant.

-Anticipatory guidance should be given prior to hospital discharge, regarding prevention and management of engorgement. Engorgement interferes with proper latch-on, which contributes to nipple injury. Conversely, nipple pain contributes to poor milk extraction, resulting in engorgement.

-Avoidance of excessive moisture of the nipples and irritating cleansers. The nipples should be allowed to air dry gently after breastfeeding, and pads that prevent drying should be avoided.

-Nipple abnormalities detected in the prenatal period should be evaluated by a lactation consultant. (See "Initiation of breastfeeding", section on 'Flat or inverted nipples'.)

-Abnormalities of the infant's oral cavity (eg, ankyloglossia) should be evaluated during the birth hospitalization. (See "Ankyloglossia (tongue-tie) in infants and children".)

Care of the traumatized nipple consists of the following:

-Assessment of infant positioning and latch-on and correction of improper technique. She should nurse first on the unaffected side. If the mother is unable to achieve appropriate latch and positioning such that nursing continues to be traumatic, she should seek lactation consultation and consider just pumping or hand expressing and supplementing the baby with expressed breast milk until the infant feeding problem is alleviated.

-Traumatized nipples should be treated with moist wound-healing principles. If the nipple is cracked or abraded, an antibiotic ointment such as bacitracin or mupirocin is applied and a nonstick pad is used to cover the affected area. This will help to prevent nipple infection and prevent the abraded open areas of the nipple from sticking to the breast pad and bra.

-If the nipples appear to be infected, a culture of any drainage should be obtained to check for bacterial infection (eg, Staphylococcus aureus). If candidal infection is suspected, a Gram stain to confirm is recommended. Candidal infection is often overdiagnosed. Dermoscopy can also be helpful in these situations [35]. (See 'Breast infections' below and "Office-based dermatologic diagnostic procedures", section on 'Potassium hydroxide preparation'.)

-Cool or warm compresses, the application of expressed breast milk to the nipple, and mild analgesics such as acetaminophen or ibuprofen may be helpful.

-There is probably no benefit to applying lanolin or other substances to the nipple. A systematic review evaluated the effectiveness of glycerine gel dressings, breast shells with lanolin, lanolin alone, or the all-purpose nipple ointment containing mupirocin, miconazole, and hydrocortisone. The review concluded that none of these interventions were clearly effective in alleviating nipple pain in lactating women, and that nipple pain decreased significantly by 7 to 10 days postpartum regardless of the intervention [36]. Despite this, lanolin is frequently recommended by health care professionals. Highly purified lanolin (Lansinoh) is purported to have enhanced safety and reduced allergic potential compared with other lanolins because residual pesticides and detergent residues are removed and the natural free alcohols are reduced [37]. Nonsterile honey may contain botulism spores and so should be avoided on the nipple. Medical grade honey should not have the risk of botulism in the infant but its efficacy has not been researched.

-Highly concentrated vitamin E oil should not be applied to the nipples, because it is readily absorbed by the infant and may be toxic at high levels [38].

Infants with mechanical feeding problems may need special interventions:

-For infants with ankyloglossia, lingual frenotomy has been shown to decrease nipple pain and may facilitate breastfeeding [39]. This is because effective breastfeeding requires coordinated anterior and vertical motion of the tongue [40,41]. (See "Ankyloglossia (tongue-tie) in infants and children", section on 'Breastfeeding difficulties'.)

-The maxillary labial frenulum rarely interferes with breastfeeding, and frenotomy of this frenulum is rarely indicated [42,43]. (See "Ankyloglossia (tongue-tie) in infants and children", section on 'Upper lip tie'.)

Biting – Some infants cause pain to their nursing mothers by biting.

Biting that occurs in the first few weeks postpartum is typically due to a tonic bite reflex that often occurs due to infant oral defensiveness, retrognathia, and tight lingual frenulum. Natal teeth can rarely present at birth. In these neonates, the incisal edge may need to be smoothed to decrease maternal discomfort, or if they are causing great discomfort or pain they may need to be removed. (See "Developmental defects of the teeth", section on 'Natal and neonatal teeth'.)

Biting may also occur due to teething after the normal teeth eruption at 3 to 12 months and may cause nipple pain and trauma. Infants usually bite more at the end of the feeding since their tongues cover the teeth during active feeding. Biting is often avoided by keeping the baby close to the breast while feeding with the mouth wide open, which prevents the baby's latch from becoming shallow onto the nipple. Once swallowing is over and the baby is nursing for comfort, taking the baby off the breast prevents biting. If these steps are not helpful, and the baby continues to bite, the mother should say "no" firmly, break the suction with her finger, and put the infant on a safe surface. Mothers should avoid expressing too much emotion over the event to discourage the infant from repeating it [32]. Most infants learn quickly not to bite. They should be offered teething rings as more suitable objects for teething.

Areolar dermatitis — Eczema and psoriasis of the nipple/areolar complex typically present as itchy and painful burning of the areola and nipples, with a red, scaly rash (picture 2). This is more common in women with a history of either of these two skin conditions. Other contributing factors include irritant dermatitis due to soaps or fragrances, solid foods in the infant's diet, or allergic reaction to topical agents such as lanolin, antifungals, or antibiotics. During an acute presentation, vesicles, crusting, and erosions are seen in the affected areas, whereas in the chronic state, the areas are generally dry, erythematous, lichenified, and scaling [44].

Management begins with avoidance of potential irritants and allergens. Medium potency topical steroids are generally effective and should be applied after feeding [44]. Ointments are more easily absorbed, but can expose the infant to mineral paraffins, which may be of concern [45,46]. Visible topical agents should be removed from the nipple/areolar area before the next feeding. Expressed breast milk applied before the feeding is often effective in their removal.

Other conditions that may present with similar skin manifestations include:

Herpes simplex and herpes zoster – Women with herpes simplex and herpes zoster breast lesions should not breastfeed from the affected breast until the lesions resolve, because direct contact with the lesions may transmit the herpes viruses to her infant [47]. Mothers should use careful hand hygiene and cover any lesions with which the infant might come into contact. Mothers can pump and the expressed milk that does not come into direct contact with open herpetic lesions can be given to the infant. Herpes simplex is diagnosed by viral culture, serology, or skin scrapings. Herpes zoster is usually diagnosed based on clinical examination, although laboratory confirmation may be needed if the presentation is atypical. If an antiviral treatment for these infections is indicated, they are generally compatible with breastfeeding. (See "Epidemiology, clinical manifestations, and diagnosis of herpes simplex virus type 1 infection" and "Epidemiology, clinical manifestations, and diagnosis of herpes zoster".)

Impetigo – Eczema can predispose a mother to impetigo. A culture should be obtained in mothers with pustules and thick adherent crusting with a characteristic golden appearance of the affected area. (See "Impetigo", section on 'Diagnosis'.)

Nipple vasoconstriction — Cutaneous vasospasm of the nipple due to arteriolar vasoconstriction can occur in mothers who have Raynaud phenomenon, unusual cold sensitivity, milk overproduction, or nipple trauma (picture 3) [31,48,49]. (See "Clinical manifestations and diagnosis of Raynaud phenomenon", section on 'Clinical features'.)

Clinical manifestations – Mothers with nipple vasoconstriction typically experience pain, burning, and paresthesias with cold exposure, nursing, or nipple trauma; the pain may radiate into the breast as a sharp or deep aching sensation. The vasoconstriction can be reproduced with exposure of the nipple to cold air or compresses [50]. Between episodes, the mother is asymptomatic, and the nipples are normal in appearance. In patients with Raynaud phenomenon or cold sensitivity, vasoconstriction is responsible for the classic tricolor change of pallor, followed by cyanosis, and then erythema as the circulation returns.

Diagnosis – The diagnosis is made by the history of nipple vasoconstriction occurring during cold exposure and/or breastfeeding. Many patients also complain of a constant burning sensation of the nipples between feeding. Because of the intensity of the pain, a diagnosis of candidiasis of the nipple is often made; however, the trigger of cold exposure for the onset of pain and changes in nipple appearance should differentiate between the two conditions [49].

Management – In mothers with cold sensitivity, warming the entire body appears to be helpful in reducing nipple vasoconstriction, so affected mothers should breastfeed in warm conditions (if possible) and wear warm clothing or use a heating source applied over the bra. Other interventions include avoidance of vasoconstricting medications (eg, nicotine and caffeine), warming the nipple at the onset of symptoms, and managing milk overproduction [48].

Case reports suggest that the administration of nifedipine, a potent vasodilating calcium channel blocker, relieved symptoms of nipple vasoconstriction [48-50]. Low levels of nifedipine are found in breast milk, but no adverse effects have been observed in nursing infants whose mothers have been treated with nifedipine [21,48].

Engorgement — Engorgement occurs either from interstitial edema with the onset of lactation after birth, or at other times during lactation with accumulation of excess milk.

Clinical manifestations – Engorgement results in breast fullness and firmness, which is accompanied by pain and tenderness. Among mothers, the affected area varies with primarily areolar involvement in some mothers, more peripheral involvement in others, and in some mothers both peripheral and areolar involvement. If the areola is engorged it can impair the baby's ability to latch and worsen the engorgement [31].

Engorgement can occur at varying times postpartum:

Primary engorgement occurs with the onset of copious milk production (ie, lactogenesis stage II), usually between days three to five after delivery. It is due to interstitial edema of the breast prompted by the decrease in progesterone levels after the placenta is delivered [51].

Secondary engorgement typically occurs later when there is a mismatch between milk production and removal as the mother's milk production exceeds the amount of milk removed by her infant. This may occur from excessive stimulation of milk production via pumping, taking medications that increase milk production, or decreased milk extraction from not feeding the baby as often (eg, weaning or when the infant is ill). (See 'Routine weaning' below.)

Management – Effective management hinges on adequate removal of the milk. For primary engorgement, it is important to ensure implementation of good feeding techniques with a satisfactory latch and optimal nursing positioning.

If the areola is involved, manual expression of small amounts of milk before the feeding will soften the areola and facilitate latching. Hand expression is accomplished by placing the thumb and forefingers well behind the areola toward the chest wall and then compressing them together and toward the nipple in a rhythmic fashion. Using the fingers in a similar position, the mother can present the nipple in a way that is easier to latch. Mothers can also use this rhythmic compression while the infant is suckling to enhance milk transfer (Stanford video link on hand expression of breast milk).

Some mothers may find use of a breast pump or hand expression to be helpful. However, this use should be limited to immediately before a feeding to soften the breast because overuse will stimulate milk production and could increase the engorgement.

For others, applying pressure toward the chest wall softens the edema and facilitates the latch.

Evidence for other supportive measures is limited because engorgement usually resolves over time; therefore, it is difficult to see the effect of specific interventions. In addition, studies of these measures have included only small numbers of patients and were poorly controlled. This was best illustrated in a systematic review that found possible benefits of interventions including hot/cold packs, gua sha (breast massage or scraping therapy), acupuncture, and cabbage leaf application, but insufficient evidence to justify widespread use [52]. Results from the two studies using acupuncture showed improved symptoms in the days following treatment, but there was no difference in outcome by six days after treatment. In the single study using cold gel packs, there appeared to be improvement in symptoms, but differences between the control and intervention groups made it difficult to interpret the results.

Nevertheless, the following interventions are often used for pain relief associated with either primary or secondary engorgement:

Applying warm compresses or a warm shower enhances let-down and may facilitate milk removal either by hand expression or with suckling

After or between feedings, cold compresses may decrease the swelling and discomfort

Analgesics such as ibuprofen and acetaminophen may decrease the discomfort

Topical application of cool green cabbage leaves is soothing, inexpensive, and unlikely to be harmful [52,53]

Ductal narrowing

Localized duct narrowing — Ductal narrowing (commonly called blocked milk ducts) are localized areas of edema due to high milk production with insufficient removal. If the predisposing factors are not reversed, this condition can evolve into lactational mastitis. (See "Lactational mastitis".)

Clinical manifestations – Localized duct narrowing presents as a tender and often painful palpable lump, without systemic findings [31]. Obstruction of the nipple pore ducts may also occur and presents as a white bleb at the end of the nipple. (See 'Nipple blebs' below.)

Contributing factors – In many cases, the narrowing is related to engorgement, localized compression of the breast due to wearing tight or unsupportive brassieres, or scarring from previous breast surgery or biopsy [31,32]. Pumping can contribute to the problem by causing engorgement or trauma. Other contributing factors include use of a nipple shield or problems with feeding technique (eg, ineffective latch-on and positioning), both of which can lead to insufficient milk removal, leading to localized edema [54].

Diagnosis – The diagnosis is made clinically on typical presentation and response to management. Localized duct narrowing is distinguished by the absence or minimal localized redness and no systemic findings from other conditions (lactational mastitis and breast abscess) that present with a tender area of breast inflammation. Lactational mastitis and breast abscess are usually accompanied by systemic findings (eg, fever >38.3°C, myalgia, chills, malaise, and flu-like symptoms). (See 'Breast infections' below.)

Management – Management is focused on relieving the inflammation that is narrowing the ducts and allowing the milk to flow freely (table 3). Because of the low quality of evidence regarding some of these interventions, an individualized approach is suggested.

Optimize feeding technique – Encourage regular feeding (on-demand), but avoid efforts to completely empty the breasts. The infant's positioning and latch should be assessed and corrected if needed (figure 1 and figure 2). The mother should try several comfortable positions to ensure that milk flows from each area of the breast. The La Leche League website provides patient information on feeding techniques for a mother with a blocked duct.

Mothers should be counseled not to stop breastfeeding, since this could lead to engorgement and worsen the problem.

A nipple shield may be helpful in some circumstances (eg, to manage nipple pain) but should be used judiciously because they can cause uneven and inadequate breast milk removal. Nipple shields are best used with good lactation support [55].

Other measures that may facilitate drainage include cool compresses and very gentle manual massage, consisting of lightly sweeping of the skin [54]. By contrast, deep massage or use of vibrating devices should be avoided because they can increase inflammation and edema, thus exacerbating the problem.

Analgesics such as ibuprofen and acetaminophen may decrease the discomfort and inflammation.

Minimize use of breast pump. Pumping frequently and completely emptying the breast may contribute to hyperlactation and engorgement in some women. Excessive pump pressure or poor flange fit can cause trauma to the nipple or areolar complex. Gentle hand expression or gentle breast compression while pumping may be helpful. An individualized approach is appropriate.

The vast majority of blocked ducts resolve in 48 hours. If the symptoms do not resolve with the above measures within 48 hours, or if fever develops, the patient should be further evaluated for lactational mastitis or related complications (bacterial mastitis, abscess, or galactocele). (See 'Lactational mastitis' below and 'Breast abscess' below and 'Galactocele' below.)

Nipple blebs — A nipple bleb (or "milk blister") is a white bleb or dot on the nipple (picture 4). It is caused by obstruction of the nipple pore ducts due to ductal inflammation (figure 3).

A nipple bleb can cause pain with latching. Relief may be obtained by soaking the nipple in warm water or applying olive oil and then wiping the softened area with a clean washcloth. If this fails, topical 0.1% triamcinolone cream may reduce the inflammation [31]. Unroofing should generally be avoided as this procedure can be painful and may lead to scarring, especially when repeated [56]. Oral lecithin supplementation has also been suggested, but this is based on very low-quality evidence, consisting of case reports and the unsubstantiated hypothesis that it may reduce inflammation and emulsify the milk, causing it to be less prone to blockage [57,58]. Caution should be used in obtaining lecithin supplements because they are not regulated by the US Food and Drug Administration (FDA). The effect of maternal lecithin supplements on the breastfed infant has not been studied, but seems unlikely to be of concern (see record in the LactMed database) [59].

Galactocele — Galactoceles are milk retention cysts (image 1). They are more common when there is breast inflammation or edema causing external pressure on milk ducts, thus blocking the ducts. They present as cystic, sometimes very large masses during pregnancy, lactation, and after weaning. Unless they are infected, they are usually painless. Initially, they contain milky fluid, but over time, contents become thicker, more creamy, or oily as the fluid is reabsorbed [31].

Diagnosis – Ultrasound is the primary diagnostic imaging modality to distinguish galactoceles from other breast masses including adenomas, fibroadenomas, papillomas, lipomas, abscesses, and fibrocystic disease [60]. In addition, although uncommon, breast malignancies can present as breast masses during lactation. (See "Diagnostic evaluation of suspected breast cancer", section on 'Ultrasonography'.)

On ultrasound, galactoceles appear as a well-defined lesion with thin echogenic walls [61]. The internal appearance consists of either homogeneous contents with medium-level echoes or heterogeneous contents with fluid clefts and anechoic rims, especially in galactoceles of longstanding duration. Focal echogenic areas with distal shadowing are sometimes seen [61]. On mammography, they may also appear cystic, contain an air fluid level, or appear heterogeneous.

Aspiration demonstrating the characteristic milky contents confirms the diagnosis of galactocele and excludes malignancy [62].

Management – In mothers with a diagnosis of galactocele confirmed by aspiration, repeated needle aspiration or surgical excision is only necessary if the galactocele is bothersome to the mother. Breastfeeding generally can continue during aspiration or excision. Preoperative discussion with the surgeon regarding plans to continue breastfeeding is essential. In some cases, surgery can be postponed until after the infant is weaned.

BREAST INFECTIONS

Lactational mastitis — Lactational mastitis is a localized inflammation of the breast associated with breastfeeding. It typically presents as a firm, red, and tender area of one breast (picture 5). In the early stages of breast infection, the presentation can be subtle with few clinical signs, while patients with advanced infection may present with a large area of breast swelling with overlying skin changes (eg, erythema). Systemic symptoms may include fever, malaise, and flu-like symptoms. (See "Lactational mastitis", section on 'Clinical manifestations'.)

Although mastitis can occur any time during lactation, it is most common during the first three months postpartum. The primary event appears to be ductal narrowing that leads to poor drainage and subsequent inflammation, edema, and compression of additional milk ducts. It tends to occur in the setting of breastfeeding problems that result in prolonged engorgement or poor drainage, including partial blockage of milk duct, inefficient milk removal or infrequent feedings, nipple trauma, and pressure on the breast [63]. Because engorgement can contribute to the problem, complete emptying of the breast and use of a breast pump may contribute to and exacerbate the problem [54]. Incomplete breast emptying may result in organisms growing and proliferating into infectious mastitis. Details on diagnosis and management of lactational mastitis are discussed separately. (See "Lactational mastitis".)

Breast abscess — Breast abscess is a localized collection of pus within the breast tissue that is often preceded by mastitis. It is an uncommon problem in breastfeeding with a reported incidence of 0.1 percent [64] that increases to 3 percent of women with antibiotic treated mastitis [65]. The presentation of breast abscess is often similar to mastitis, with breast pain and systemic symptoms, but in addition there is a fluctuant, tender, palpable mass (picture 6). Breast abscesses may also occur without fever or breast redness.

Breast abscess in lactating women and its management are discussed separately. (See "Primary breast abscess".)

Candidal infection — Many women are diagnosed with a "candidal" infection when they complain of sore nipples, especially when associated with deep sharp shooting and/or burning pains in the breasts, particularly when these symptoms occur in association with infant thrush.

Limitations of evidence — Although this is a common clinical diagnosis, there is considerable controversy about whether candidal infection is associated with pain during breastfeeding. On one hand, several studies reported that Candida was more likely to be recovered from breast milk samples of symptomatic versus asymptomatic women [66-69]. On the other hand, at least one-third of the symptomatic women had no detectable candida in their breast milk, even when polymerase chain reaction was used for testing. Moreover, other studies found no such association. Instead, some of these studies found an association between symptoms and staphylococci and streptococci species [70-72].

Pending more definitive information, it is reasonable to use the common practice of clinical diagnosis and empiric management, as outlined below, since it is often effective. However, it is important to be aware of the limited evidence for an association between these symptoms and candidal infection.

Diagnosis — Diagnosis of a candidal infection of the breast is challenging [68,70,73]. In general, mammary candidiasis is diagnosed clinically based on the following:

Breast pain out of proportion to physical findings

History of infant oral or diaper candidal infection or maternal vaginal candidal infection

Physical finding of shiny or flaky skin of the affected nipple

A positive skin scraping of nipple or areolar region demonstrating Candida or positive breast milk culture for Candida

The signs and symptoms may be confused with those of areolar dermatitis and/or nipple injury from breast pump use [74]. (See 'Areolar dermatitis' above.)

Management — It is reasonable to treat the mother with nipple/breast pain for a candidal infection of the nipple/breast if the mother has confirmed evidence of a candidal infection on her nipple/breast and/or if other causes of pain are ruled out and the infant has definite oral candidiasis. In such patients, we use the following approach, which is based on clinical experience and used by lactation specialists [31]. Selection of therapy depends on the clinical suspicion of candidal infection and other patient-specific factors, as outlined below.

Initial treatment of women with nipple/breast pain – Initial treatment consists of topical miconazole or clotrimazole applied to the nipple. These agents are preferred rather than topical nystatin since there is less resistance of Candida species [73]. Topical ketoconazole should be avoided due to potential hepatotoxicity for the infant [46]. Combination topical antifungal and antiinflammatory agent (Mycolog) may also be effective. Although the effects of maternal use of topical antifungal agents in breastfed infants have not been studied, it is unlikely to represent a safety problem. However, prior to each feeding, visible residual medication should be removed using oil (eg, olive oil or coconut oil) rather than soap and water, which can irritate the nipples. After feeding, the antifungal agent should be reapplied. If fissures are present, a topical antibiotic such as mupirocin or bacitracin is often added. These agents are also removed prior to and reapplied after each feeding.

Gentian violet is not recommended in areas where other alternatives are available. It is associated with toxicity to the mucous membranes and can cause tattooing of the skin. It is also potentially carcinogenic and may cause allergic hypersensitization. (See "Candida infections in children", section on 'Oropharyngeal candidiasis'.)

Refractory symptoms or breast pain associated with strong evidence of candidal infection of the nipple/breast – If the mother's symptoms fail to respond to topical treatment, oral fluconazole is an alternative. In our practice, we also use oral fluconazole as initial therapy if there is clinical evidence of candidal infection, ie, other causes of nipple pain are ruled out and if the infant has definite thrush. If possible, a breast milk culture also should be done at the time of treatment to document whether Candida is present in the breast milk. Other experts in the field only use fluconazole after confirmation of candidal infection, based on a positive breast milk culture or a potassium hydroxide (KOH) examination of skin scraping, because of the controversy about whether candidal infection is responsible for these clinical symptoms, as outlined above. (See 'Limitations of evidence' above and "Intertrigo", section on 'Diagnosis'.)

Dosing of oral fluconazole for lactating mothers is 400 mg the first day followed by 200 mg per day for 14 days. At this dose, the peak level in breast milk is 4.1 mg/L, which is considered to be a safe level for breastfeeding infants, as the amount of drug an infant would receive from the milk is less than the amount given to treat an infant with a Candida infection [21]. In addition, this level in the milk is insufficient to treat yeast in the infant. The dose used to treat vaginal candidiasis (a single dose of 150 mg) is too low to be effective for candidiasis of the breast or nipple.

Infant care – Although there is a lack of supportive data, some clinicians treat the infant for oral candidal infection with the same regimen used to treat oral mucocutaneous candidiasis. This is administered as an oral suspension of nystatin (100,000 units/mL) at a dose of 0.5 mL to each side of the mouth, given four times a day. Others in the field administer nystatin only if the infant is clinically diagnosed with oral thrush. More detailed discussions on the diagnosis and treatment of neonatal mucocutaneous candidiasis are presented separately. (See "Clinical manifestations and diagnosis of Candida infection in neonates", section on 'Oropharyngeal candidiasis (thrush)' and "Treatment of Candida infection in neonates".)

BLOODY NIPPLE DISCHARGE — Some women have bloody nipple discharge during the first days of lactation (this has been called "rusty pipe syndrome") [75]. This is more common with the first pregnancy, and it is thought to be caused by the increased vascularization of the alveoli and ducts with the onset of milk production. The color of the milk varies from pink to red or brown and generally resolves within a few days. This should be differentiated from Serratia marcescens colonization of breast milk, which can cause a bright pink discoloration, usually not in the early postpartum period [76]. (See "Nipple discharge", section on 'Pathologic nipple discharge during pregnancy and lactation'.)

For patients with bloody nipple discharge for more than one week, other causes of bloody milk should also be considered, including cracked nipples or subacute mastitis. These disorders should be evaluated with a thorough breast examination and breast milk culture. If no explanation is found and the discharge persists, the possibility of an intraductal papilloma (tumor derived from the lining of the breast duct) should be entertained. Evaluation for this can include mammography, breast ultrasound, and magnetic resonance imaging (MRI), usually with surgical consultation. (See "Overview of benign breast diseases", section on 'Intraductal papillomas' and "Nipple discharge", section on 'Clinical evaluation' and "Nipple discharge", section on 'Diagnostic evaluation'.)

In settings when the infant spits up blood-tinged milk or has blood in the stool, an Apt test is used to confirm whether the source of bleeding is from the mother or infant. (See "Lower gastrointestinal bleeding in children: Causes and diagnostic approach", section on 'Swallowed maternal blood'.)

MILK OVERPRODUCTION — Some mothers experience milk overproduction, also known as hypergalactia or hyperlactation. Generally, the production of milk is determined by the infant's demand, but in this case, the production exceeds demand. Milk overproduction occurs early in lactation and may worsen in affected mothers with successive pregnancies [77].

Clinical features and evaluation — In some cases, the rush of the milk with the mother's ejection reflex may be too forceful and the infant may have trouble feeding. Infants may choke, cough, and become irritable with feeding and may bite to clamp the nipple. Infants may either have an increased weight gain or, paradoxically, poor weight because of inadequate intake as they cannot handle the flow of milk or because the infant is not receiving hind milk with its higher caloric content. Overproduction of milk typically resolves over the first few weeks of lactation.

Mothers with milk overproduction should be evaluated for drugs that increase milk production (eg, psychiatric medications that may be dopamine antagonists or herbs like fenugreek) [78].

Management — The management of milk overproduction and/or an overactive milk ejection reflex is based on clinical experience and consists of the following (La Leche League: Oversupply):

Nursing position – Mothers should nurse with the infant in a more upright position and the mother leaning back or in the side lying position; this allows the infant to better control the flow of milk.

Manual reduction of flow – Using a scissors-hold on the areola or pressing on the breast with the heel of the hand may restrict flow.

Feeding strategies – Infants should be allowed to interrupt feeding as needed, and often need frequent burping. Block feedings are often successful. In these, the mother uses only one breast for a planned interval (usually three hours). The resulting milk stasis in the other breast should decrease milk production. For the subsequent three hours, the other breast is used [79].

Pumping – Avoid pumping to prevent continued stimulation of milk overproduction. However, some mothers may find it necessary to hand express some milk at the beginning of a feeding.

Discomfort – Cold compresses can be helpful.

Medications – Any galactagogues, including herbal forms such as fenugreek, should be stopped. The use of pharmacologic intervention is not well studied. Low-dose oral contraceptives or pseudoephedrine may be helpful [31,77]. The LactMed database maintained by the United States National Library of Medicine considers both agents to be safe in lactating mothers, although they should be used with caution due to their diminishing effect on milk production and should be avoided for the first two weeks until milk production is well established. Pseudoephedrine may cause irritability in the infant.

DYSPHORIC MILK EJECTION REFLEX — Dysphoric milk ejection reflex is an uncommon condition characterized by unpleasant feelings that occur only with letdown and last a few minutes. It is thought to be related to hormonal fluctuations. Mothers describe feeling anxious, hopeless, nervous, sad, or other negative emotions. Stress, fatigue, and dehydration often worsen the sensation. The condition often improves as the infant ages. Distraction such as eating or watching television while breastfeeding may help. Often, simply identifying the condition and explaining that it is a physiologic response to letdown is therapeutic [80,81]. In some mothers, the condition recurs with subsequent pregnancies.

Dysphoric milk ejection reflex is distinct from postpartum depression. (See "Postpartum unipolar major depression: Epidemiology, clinical features, assessment, and diagnosis".)

NEONATAL JAUNDICE — Breastfeeding is associated with hyperbilirubinemia as two distinct entities: breastfeeding (lactation) failure jaundice (exclusive breastfeeding with suboptimal intake) and breast milk jaundice, which are discussed separately. (See "Unconjugated hyperbilirubinemia in neonates: Etiology and pathogenesis", section on 'Inadequate milk intake' and "Unconjugated hyperbilirubinemia in neonates: Etiology and pathogenesis", section on 'Breast milk jaundice'.)

MATERNAL USE OF MEDICATIONS — Most, but not all, therapeutic drugs are compatible with breastfeeding. Considerations are discussed in a separate topic review. (See "Breastfeeding: Parental education and support", section on 'Maternal medications'.)

In addition, the LactMed database, produced by the National Library of Medicine is a free, authoritative reference for lactation compatibility for prescription and over-the-counter drugs.

WEANING — The timing of weaning is a personal decision made by the mother in the context of her social setting. This decision is influenced by factors including subsequent pregnancies, career choices, and maternal health. Exclusive breastfeeding is recommended by the American Academy of Pediatrics (AAP) for the first six months of life [82]. At approximately six months of age, iron-rich complementary foods should generally be offered to infants. The AAP recommends breastfeeding be continued for at least one year and supported for two years and beyond, as mutually desired by the mother and child [82]. (See "Introducing solid foods and vitamin and mineral supplementation during infancy", section on 'When to initiate complementary foods'.)

Abrupt weaning — Abrupt weaning is not recommended. When abrupt weaning occurs because of unanticipated maternal-child separation or severe maternal illness, engorgement is likely and steps should be taken to diminish it. The mother may experience "milk fever" (a condition of a flu-like illness with fever chills and malaise). This is thought to be caused by maternal reabsorption of milk products [31]. Rapid weaning results in a rapid decrease in prolactin, and this may cause an increase in depressive symptoms. (See 'Engorgement' above.)

If rapid weaning is necessary, such as due to maternal illness, the following steps may be helpful:

Wear a tight-fitting bra night and day

If milk is leaking, change breast pads often to keep nipples dry

Apply cold compresses or cold cabbage leaves

Express small amounts of milk for comfort

Take acetaminophen or ibuprofen if needed for discomfort

Routine weaning — Routine weaning of the infant after six months of age is most easily accomplished following the child's lead. After the child starts solid foods, the child will diminish breastfeeding, and gradually the weaning process begins. If the weaning is gradual, engorgement is not likely to occur.

Strategies for weaning include dropping a breastfeeding session every two to five days, shortening each breastfeeding session, and increasing the time between breastfeeding sessions. Midday feedings are often ideal to eliminate first since the child is often active at this time and so may not become fussy. Persons other than the mother may have more success offering other feedings [32]. During the weaning process, it is important that the mother continue to maintain closeness.

It may be challenging for exclusively breastfed infants to accommodate to bottle feeding. Older infants may be directly weaned to a cup. For infants being weaned to a bottle, varying the type of nipple may be helpful in those who are having difficulty adjusting to bottle feeding.

If engorgement occurs during the weaning process, mothers should try to avoid pumping any more than is necessary to relieve engorgement as this will increase milk production.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Breastfeeding and infant nutrition".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Common breastfeeding problems (The Basics)" and "Patient education: Mastitis (The Basics)" and "Patient education: Weaning from breastfeeding (The Basics)" and "Patient education: Breastfeeding (The Basics)" and "Patient education: Pumping and storing breast milk (The Basics)")

Beyond the Basics topics (see "Patient education: Common breastfeeding problems (Beyond the Basics)" and "Patient education: Weaning from breastfeeding (Beyond the Basics)" and "Patient education: Breastfeeding guide (Beyond the Basics)" and "Patient education: Pumping breast milk (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Inadequate milk intake – Inadequate milk intake may be due to failure of the infant to extract milk or insufficient milk production (table 2). For healthy term newborns, assess intake by clinical signs of hydration and feeding (table 1) and by tracking the infant's weight. In many cases, the problem can be solved by providing maternal education and support to increase breastfeeding frequency and optimize technique, with close monitoring of the infant's weight and hydration. In some cases, specific maternal and/or infant factors contribute to the problem, which may warrant specific interventions, depending on the cause.

We do not suggest the use of galactagogues to increase milk production (Grade 2C). The available data suggest that galactagogues are not more beneficial than interventions focused upon improving breastfeeding technique. (See 'Inadequate milk intake' above.)

Nipple and breast pain

Common causes – Conditions that typically present with nipple and breast pain include nipple injury or vasoconstriction, engorgement, blocked ducts, and breast infections. These problems are usually due in part to incorrect breastfeeding techniques. (See 'Nipple and breast pain' above and 'Breast infections' above and "Initiation of breastfeeding", section on 'Evaluating a latch for effectiveness'.)

General measures – For conditions that present with breast pain, the primary intervention is to identify and correct any improper breastfeeding technique to ensure that the infant is achieving a satisfactory latch-on (figure 1) and is thoroughly emptying the breast on a regular and frequent basis. (See "Initiation of breastfeeding", section on 'Principles of breastfeeding'.)

Additional interventions – Other interventions of breast pain depend upon the specific condition as follows:

-Nipple injury – Nipple injury presents with nipple pain, abrasion, bruising, cracking, and/or blistering. It is usually is due to incorrect breastfeeding technique, such as improper latch-on, or pumping with a poorly fitted breast shield. Women with nipple injury should be assessed for breastfeeding technique and for an underlying nipple condition. Pain due to nipple injury needs to be distinguished from nipple sensitivity, which peaks during the fourth postpartum day and then resolves. (See 'Nipple pain' above.)

-Areolar dermatitis – Eczema and psoriasis of the nipple/areolar complex can present as itchy and painful burning of the areola and nipples, with a red, scaly rash (picture 2). This is more common in women with a history of either of these two skin conditions. Other contributing factors include irritant dermatitis due to soaps or fragrances, solid foods in the infant's diet, or allergic reaction to topical agents such as lanolin, antifungals, or antibiotics. (See 'Areolar dermatitis' above.)

-Engorgement – Interventions for symptomatic pain relief for engorgement include cool compresses, hand expression of breast milk, and use of analgesics (eg, acetaminophen or ibuprofen). However, there are no data regarding their comparative efficacy. (See 'Engorgement' above.)

-Narrowed (blocked) ducts – The initial management of a narrowed (blocked) milk duct (picture 4) is to ensure milk drainage through regular on-demand and effective feeding, while avoiding excessive pumping and complete emptying of the breast (which can induce hyperlactation and engorgement) (table 3). Other interventions include very gentle hand expression of breast milk and cold compresses. If there is no resolution after 72 hours, further assessment (and possible intervention) is required. Unrelieved ductal narrowing may result in lactational mastitis, which may require antibiotics, or galactoceles (image 1), which may need to be aspirated. (See 'Ductal narrowing' above.)

-Lactational mastitis – Lactational mastitis is a condition in which the breast becomes painful, swollen, and red (picture 5); it is most common in the first three months of breastfeeding. It tends to occur in the setting of breastfeeding problems that result in prolonged engorgement or poor drainage, including nipple trauma, inefficient milk removal, excessive pumping, or infrequent feedings and overproduction of milk. The condition occasionally evolves into a breast abscess. Diagnosis and management of lactational mastitis and breast abscess are discussed separately. (See "Lactational mastitis" and "Primary breast abscess".)

-Candidiasis – Candidal infection of the breast or nipple should be considered in mothers with pain out of proportion to the physical examination, especially if the infant has oral thrush. There is substantial variation in practice regarding its diagnosis and management, but the condition is probably uncommon and overdiagnosed. (See 'Candidal infection' above.)

Other problems – Other breastfeeding problems include bloody nipple discharge, milk overproduction, and neonatal jaundice. (See 'Bloody nipple discharge' above and 'Milk overproduction' above and 'Candidal infection' above and 'Neonatal jaundice' above.)

Maternal medications – Most, but not all, therapeutic drugs are compatible with breastfeeding. The LactMed database is a valuable free online database for medication compatibility. (See "Breastfeeding: Parental education and support", section on 'Maternal medications'.)

Weaning – Weaning can be accomplished gradually by eliminating one breastfeeding session every two to five days. The infant can be weaned to a bottle and then a cup or directly to a cup. (See 'Weaning' above and "Introducing solid foods and vitamin and mineral supplementation during infancy", section on 'Self-feeding'.)

  1. Nommsen-Rivers LA, Wagner EA, Roznowski DM, et al. Measures of Maternal Metabolic Health as Predictors of Severely Low Milk Production. Breastfeed Med 2022; 17:566.
  2. Huang L, Chen X, Zhang Y, et al. Gestational weight gain is associated with delayed onset of lactogenesis in the TMCHC study: A prospective cohort study. Clin Nutr 2019; 38:2436.
  3. Mohd Shukri NH, Wells JCK, Fewtrell M. The effectiveness of interventions using relaxation therapy to improve breastfeeding outcomes: A systematic review. Matern Child Nutr 2018; 14:e12563.
  4. Kellams A, Harrel C, Omage S, et al. ABM Clinical Protocol #3: Supplementary Feedings in the Healthy Term Breastfed Neonate, Revised 2017. Breastfeed Med 2017; 12:188.
  5. Sachs HC, Committee On Drugs. The transfer of drugs and therapeutics into human breast milk: An update on selected topics. Pediatrics 2013; 132:e796.
  6. Foong SC, Tan ML, Foong WC, et al. Oral galactagogues (natural therapies or drugs) for increasing breast milk production in mothers of non-hospitalised term infants. Cochrane Database Syst Rev 2020; 5:CD011505.
  7. Brodribb W. ABM Clinical Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Production, Second Revision 2018. Breastfeed Med 2018; 13:307.
  8. Breastfeeding Challenges: ACOG Committee Opinion, Number 820. Obstet Gynecol 2021; 137:e42.
  9. Sakha K, Behbahan AG. Training for perfect breastfeeding or metoclopramide: which one can promote lactation in nursing mothers? Breastfeed Med 2008; 3:120.
  10. Lewis PA, Devenish C, Kahn C. Controlled trial of metocloproamide in the initiation of breast feeding. Brit J Clin Pharmacol 1980; 9:217.
  11. Anderson PO, Valdés V. A critical review of pharmaceutical galactagogues. Breastfeed Med 2007; 2:229.
  12. Forinash AB, Yancey AM, Barnes KN, Myles TD. The use of galactogogues in the breastfeeding mother. Ann Pharmacother 2012; 46:1392.
  13. da Silva OP, Knoppert DC, Angelini MM, Forret PA. Effect of domperidone on milk production in mothers of premature newborns: a randomized, double-blind, placebo-controlled trial. CMAJ 2001; 164:17.
  14. Hansen WF, McAndrew S, Harris K, Zimmerman MB. Metoclopramide effect on breastfeeding the preterm infant: a randomized trial. Obstet Gynecol 2005; 105:383.
  15. Fife S, Gill P, Hopkins M, et al. Metoclopramide to augment lactation, does it work? A randomized trial. J Matern Fetal Neonatal Med 2011; 24:1317.
  16. Donovan TJ, Buchanan K. Medications for increasing milk supply in mothers expressing breastmilk for their preterm hospitalised infants. Cochrane Database Syst Rev 2012; :CD005544.
  17. Campbell-Yeo ML, Allen AC, Joseph KS, et al. Effect of domperidone on the composition of preterm human breast milk. Pediatrics 2010; 125:e107.
  18. American Academy of Pediatrics Committee on Drugs: The transfer of drugs and other chemicals into human milk. Pediatrics 1994; 93:137.
  19. Ingram J, Taylor H, Churchill C, et al. Metoclopramide or domperidone for increasing maternal breast milk output: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2012; 97:F241.
  20. Asztalos EV, Campbell-Yeo M, da Silva OP, et al. Enhancing Human Milk Production With Domperidone in Mothers of Preterm Infants. J Hum Lact 2017; 33:181.
  21. LactMed database from the United States National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK501922/ (Accessed on November 25, 2019).
  22. Domperidone, in the LactMed database, maintained by the United States National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/books/NBK501922/ (Accessed on November 25, 2019).
  23. Sewell CA, Chang CY, Chehab MM, Nguyen CP. Domperidone for Lactation: What Health Care Providers Need to Know. Obstet Gynecol 2017; 129:1054.
  24. Anderson PO. Domperidone: The Forbidden Fruit. Breastfeed Med 2017; 12:258.
  25. Majdinasab E, Haque S, Stark A, et al. Psychiatric Manifestations of Withdrawal Following Domperidone Used as a Galactagogue. Breastfeed Med 2022; 17:1018.
  26. Zuppa AA, Sindico P, Orchi C, et al. Safety and efficacy of galactogogues: substances that induce, maintain and increase breast milk production. J Pharm Pharm Sci 2010; 13:162.
  27. Zapantis A, Steinberg JG, Schilit L. Use of herbals as galactagogues. J Pharm Pract 2012; 25:222.
  28. Turkyılmaz C, Onal E, Hirfanoglu IM, et al. The effect of galactagogue herbal tea on breast milk production and short-term catch-up of birth weight in the first week of life. J Altern Complement Med 2011; 17:139.
  29. Khan TM, Wu DB, Dolzhenko AV. Effectiveness of fenugreek as a galactagogue: A network meta-analysis. Phytother Res 2018; 32:402.
  30. Palacios AM, Cardel MI, Parker E, et al. Effectiveness of lactation cookies on human milk production rates: a randomized controlled trial. Am J Clin Nutr 2023; 117:1035.
  31. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Professions, 7th ed, Elsevier Mosby, Maryland Heights 2011. p.253.
  32. Meek J, Tippins S. American Academy of Pediatrics New Mother's Guide to Breastfeeding, Bantam Books, 2011. p.150.
  33. LeFort Y, Evans A, Livingstone V, et al. Academy of Breastfeeding Medicine Position Statement on Ankyloglossia in Breastfeeding Dyads. Breastfeed Med 2021; 16:278.
  34. Kent JC, Ashton E, Hardwick CM, et al. Nipple Pain in Breastfeeding Mothers: Incidence, Causes and Treatments. Int J Environ Res Public Health 2015; 12:12247.
  35. Naimer SA, Silverman WF. "Seeing Is Believing": Dermatoscope Facilitated Breast Examination of the Breastfeeding Woman with Nipple Pain. Breastfeed Med 2016; 11:356.
  36. Dennis CL, Jackson K, Watson J. Interventions for treating painful nipples among breastfeeding women. Cochrane Database Syst Rev 2014; :CD007366.
  37. Lanolin, in the LactMed database, maintained by the United States National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/books/NBK501922/ (Accessed on November 25, 2019).
  38. Marx CM, Izquierdo A, Driscoll JW, et al. Vitamin E concentrations in serum of newborn infants after topical use of vitamin E by nursing mothers. Am J Obstet Gynecol 1985; 152:668.
  39. O'Shea JE, Foster JP, O'Donnell CP, et al. Frenotomy for tongue-tie in newborn infants. Cochrane Database Syst Rev 2017; 3:CD011065.
  40. Geddes DT, Langton DB, Gollow I, et al. Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics 2008; 122:e188.
  41. Fauquier ENT. Breastfeeding ultrasound. Available at: https://www.youtube.com/watch?v=RNJr-EyEq1E.
  42. Towfighi P, Johng SY, Lally MM, Harley EH. A Retrospective Cohort Study of the Impact of Upper Lip Tie Release on Breastfeeding in Infants. Breastfeed Med 2022; 17:446.
  43. Messner AH, Walsh J, Rosenfeld RM, et al. Clinical Consensus Statement: Ankyloglossia in Children. Otolaryngol Head Neck Surg 2020; 162:597.
  44. Barankin B, Gross MS. Nipple and areolar eczema in the breastfeeding woman. J Cutan Med Surg 2004; 8:126.
  45. Noti A, Grob K, Biedermann M, et al. Exposure of babies to C15-C45 mineral paraffins from human milk and breast salves. Regul Toxicol Pharmacol 2003; 38:317.
  46. Anderson PO. Topical Drugs in Nursing Mothers. Breastfeed Med 2018; 13:5.
  47. American Academy of Pediatrics. Breastfeeding and Human Milk. In: Red Book: 2021-2024 Report of the Committee on Infectious Diseases, 32nd Ed, Kimberlin DW, Barnett ED, Lynfield R, Sawyer MH (Eds), American Academy of Pediatrics, Itasca, IL 2021. p.107.
  48. Anderson JE, Held N, Wright K. Raynaud's phenomenon of the nipple: a treatable cause of painful breastfeeding. Pediatrics 2004; 113:e360.
  49. Barrett ME, Heller MM, Stone HF, Murase JE. Raynaud phenomenon of the nipple in breastfeeding mothers: an underdiagnosed cause of nipple pain. JAMA Dermatol 2013; 149:300.
  50. Page SM, McKenna DS. Vasospasm of the nipple presenting as painful lactation. Obstet Gynecol 2006; 108:806.
  51. Czank C, Henderson JJ, Kent JC, et al. Hormonal control of thel actation cycle. In: Textbook of Human Lactation, 1st ed, Hale TW, Hartman PF (Eds), Hale Publishing, Amarillo, Texas 2007. p.90.
  52. Zakarija-Grkovic I, Stewart F. Treatments for breast engorgement during lactation. Cochrane Database Syst Rev 2020; 9:CD006946.
  53. Berens P, Brodribb W. ABM Clinical Protocol #20: Engorgement, Revised 2016. Breastfeed Med 2016; 11:159.
  54. Mitchell KB, Johnson HM, Rodríguez JM, et al. Academy of Breastfeeding Medicine Clinical Protocol #36: The Mastitis Spectrum, Revised 2022. Breastfeed Med 2022; 17:360.
  55. Chow S, Chow R, Popovic M, et al. The Use of Nipple Shields: A Review. Front Public Health 2015; 3:236.
  56. Mitchell KB, Johnson HM. Breast Pathology That Contributes to Dysfunction of Human Lactation: a Spotlight on Nipple Blebs. J Mammary Gland Biol Neoplasia 2020; 25:79.
  57. McGuire E. Case study: white spot and lecithin. Breastfeed Rev 2015; 23:23.
  58. Douglas P. Does the Academy of Breastfeeding Medicine's Clinical Protocol #36 'The Mastitis Spectrum' promote overtreatment and risk worsened outcomes for breastfeeding families? Commentary. Int Breastfeed J 2023; 18:51.
  59. Lethicin supplements, in the LactMed database, maintained by the United States National Library of Medicine. Available at: https://www.ncbi.nlm.nih.gov/books/NBK501922/ (Accessed on November 25, 2019).
  60. Baker TP, Lenert JT, Parker J, et al. Lactating adenoma: a diagnosis of exclusion. Breast J 2001; 7:354.
  61. Sawhney S, Petkovska L, Ramadan S, et al. Sonographic appearances of galactoceles. J Clin Ultrasound 2002; 30:18.
  62. Sabate JM, Clotet M, Torrubia S, et al. Radiologic evaluation of breast disorders related to pregnancy and lactation. Radiographics 2007; 27 Suppl 1:S101.
  63. Foxman B, D'Arcy H, Gillespie B, et al. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol 2002; 155:103.
  64. Dener C, Inan A. Breast abscesses in lactating women. World J Surg 2003; 27:130.
  65. Amir LH, Forster D, McLachlan H, Lumley J. Incidence of breast abscess in lactating women: report from an Australian cohort. BJOG 2004; 111:1378.
  66. Andrews JI, Fleener DK, Messer SA, et al. The yeast connection: is Candida linked to breastfeeding associated pain? Am J Obstet Gynecol 2007; 197:424.e1.
  67. Panjaitan M, Amir LH, Costa AM, et al. Polymerase chain reaction in detection of Candida albicans for confirmation of clinical diagnosis of nipple thrush. Breastfeed Med 2008; 3:185.
  68. Amir LH, Garland SM, Dennerstein L, Farish SJ. Candida albicans: is it associated with nipple pain in lactating women? Gynecol Obstet Invest 1996; 41:30.
  69. Kaski K, Kvist LJ. Deep breast pain during lactation: a case-control study in Sweden investigating the role of Candida albicans. Int Breastfeed J 2018; 13:21.
  70. Hale TW, Bateman TL, Finkelman MA, Berens PD. The absence of Candida albicans in milk samples of women with clinical symptoms of ductal candidiasis. Breastfeed Med 2009; 4:57.
  71. Jiménez E, Arroyo R, Cárdenas N, et al. Mammary candidiasis: A medical condition without scientific evidence? PLoS One 2017; 12:e0181071.
  72. Graves S, Wright W, Harman R, Bailey S. Painful nipples in nursing mothers: fungal or staphylococcal? A preliminary study. Aust Fam Physician 2003; 32:570.
  73. Wiener S. Diagnosis and management of Candida of the nipple and breast. J Midwifery Womens Health 2006; 51:125.
  74. Sadovnikova A, Fine J, Tartar DM. Nipple thrush or dermatitis: A retrospective cohort study of nipple-areolar complex conditions and call for coordinated, multidisciplinary care. J Am Acad Dermatol 2023; 88:1383.
  75. Virdi VS, Goraya JS, Khadwal A. Rusty-pipe syndrome. Indian Pediatr 2001; 38:931.
  76. Valle CA, Salinas ET. Pink Breast Milk: Serratia marcescens Colonization. AJP Rep 2014; 4:e101.
  77. Wilson-Clay B. Milk oversupply. J Hum Lact 2006; 22:218.
  78. Johnson HM, Eglash A, Mitchell KB, et al. ABM Clinical Protocol #32: Management of Hyperlactation. Breastfeed Med 2020; 15:129.
  79. Eglash A. Treatment of maternal hypergalactia. Breastfeed Med 2014; 9:423.
  80. Ureño TL, Berry-Cabán CS, Adams A, et al. Dysphoric Milk Ejection Reflex: A Descriptive Study. Breastfeed Med 2019; 14:666.
  81. D-MER.org. Available at: https://d-mer.org/ (Accessed on August 23, 2023).
  82. Meek JY, Noble L, Section on  Breastfeeding. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2022; 150.
Topic 4996 Version 87.0

References

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