ROLE OF PHYSIOTHERAPIST IN
HOW BREASTFEEDING WORKS
• The breast is made of a network of ducts, fatty and
glandular tissue containing small ducts and alveoli.
The milk is produced within the alveoli.
• Milk is produced by the glandular tissue contained
within the fatty and fibrous supporting tissue of the
breast. Prolactin is the hormone responsible for
milk production. Small nerves in the areola, the
coloured area surrounding the nipple, are
stimulated as the baby suckles the nipple. This
causes the release of the hormone prolactin which
stimulates milk production.
• The ‘let-down reflex’ gets the milk from the breast
tissue to the nipple for the baby to drink. Nipple
stimulation signals the brain to trigger the release
of oxytocin. This hormone causes cells surrounding
the alveoli in the glandular tissue to contract and
release milk into the ducts. The milk is transported
through the ducts to openings in the nipple.
Oxytocin also stimulates the uterus and it is quite
common to have uterine cramps and increased
blood flow during or following breastfeeding in the
first days and weeks after giving birth.
• Babies suckle in a two phase pattern. As the
baby starts to feed they suckle in a shallow and
fast suck pattern. This progresses to a deeper
suck and swallow action as let-down occurs. The
stimulation of the nipple triggers further
oxytocin and prolactin to be released so further
milk is produced and let down. In this way the
more the baby suckles, the more milk you make,
so supply usually equals demand.
• Early breast milk is liquid gold.-Known as liquid gold,
colostrum (coh-LOSS-trum) is the thick yellow first breast
milk that you make during pregnancy and just after birth.
This milk is very rich in nutrients and antibodies to protect
• Your breast milk changes as your baby grows.-
Colostrum changes into what is called mature milk. By the
third to fifth day after birth, this mature breast milk has just
the right amount of fat, sugar, water, and protein to help
your baby continue to grow. It is a thinner type of milk than
colostrum, but it provides all of the nutrients and
antibodies your baby needs.
• Breast milk is easier to digest.- For most babies –
especially premature babies – breast milk is easier
to digest than formula. The proteins in formula are
made from cow’s milk, and it takes time for babies’
stomachs to adjust to digesting them.
• Breast milk fights disease- The cells, hormones, and
antibodies in breast milk protect babies from
illness. This protection is unique; formula cannot
match the chemical makeup of human breast milk.
In fact, among formula-fed babies, ear infections
and diarrhea are more common.
Mothers Benefit from Breastfeeding
• Breastfeeding may take a little more effort than formula
feeding at first. When you breastfeed, there are no bottles
and nipples to sterilize. You do not have to buy, measure,
and mix formula. And there are no bottles to warm in the
middle of the night.
• Breastfeeding can feel great. Mothers can benefit from this
closeness, as well. Breastfeeding requires a mother to take
some quiet relaxed time to bond.
• Breastfeeding is linked to a lower risk of these health
problems in women:
-Type 2 diabetes
Learning to Breastfeed
Initiate breastfeeding immediately after birth preferably during the
first 30 minutes. Place the infant skin to-skin on her chest
uninterrupted, until the first breastfeeding is accomplished. The
baby may only lick and smell the breast and may not necessarily
actively suck in the early stages of breastfeeding.
Breastfeed when the baby is showing Early Feeding Readiness
Cues before the baby gets too hungry and is too eager to feed
or is crying. Early Feeding Readiness include:
• Rapid eye movements, under the lids.
• Soft cooing or sighing sounds.
• Sucking or licking movement.
• Sucking sounds.
• Hand-to-mouth movements
• Allow the baby to breastfeed on the first breast
until the baby is no longer sucking and swallowing
effectively (e.g., deep and slow sucks) .The second
breast should then be offered. The average time of
a breastfeeding is usually 20-40 minutes. Babies
should effectively suck and swallow for at least 10-
20 minutes in total at each feeding.
• Avoid supplementation with other fluids or foods in
the first 6 months of life, unless medically indicated
LATCHING And POSITIONING
• When feeding your baby it is important to maintain
a good posture. This positions your nipples straight
ahead, which is easier for the baby to attach to.
Bring the baby to your nipple height, and prop up
their weight with pillows You should not feel you
are taking the weight of the baby in your arms;
rather you are guiding the baby into the correct
position. It is tempting to lean forward and drop
your nipple into the baby’s mouth. This is more
difficult for the baby to attach to and feed from and
can result in neck and back pain for you
• The baby should have good hold of your areola and
the nipple well within his mouth. The baby draws
the nipple and breast tissue into his mouth a long
way. His tongue comes forward over the gums and
the bottom lip rolls out. It should feel comfortable if
the baby is well attached. Poor attachment is
painful due to abnormal pressure on the nipple
which can cause cracking or open areas.
• Good attachment looks like this:
• The baby’s mouth is wide open and the lips are
turned outwards. The lower lip especially can be
seen to be curled right back and the baby’s chin is
touching the mother’s breast.
• The nipple will be deep into the baby’s mouth, with
the tip touching the baby’s palate.
• The baby suck by making two simultaneous
movements: the lower jaw goes up and down and a
muscular wave (like peristalsis) goes from the tip to the
back of the tongue. You can sometimes see the tongue
above the lower lip. This action presses the milk out of
the lactiferous sinuses, through the nipple into the back
of the baby’s mouth.
• The baby suckles with short quick movements at first,
but changes the rhythm to a more continuous deep
suckling as the milk flows. The baby pauses throughout
with the pauses getting longer as the feed continues.
• The baby’s cheeks will be rounded and not drawn in
and sometimes the baby’s ears will move as it suckles.
• The baby sucks or “chews” on
the nipple only, with lips, gums
• The mouth is not wide open
and the lips are sucked in.
• The lips and gums press against
the nipple instead of the areola.
• The tongue may be misplaced,
blocking the protrusion of the
nipple into the baby’s mouth.
• The cheeks are pulled in.
signs of a good latch:
• Baby’s mouth is opened wide.
• Baby’s lips are curled out and cover about 1-1½ inches of the
area below the nipple (this may be less for a small or
• Baby’s lower lip covers more of the areola than the upper lip.
• Baby’s chin is pressed into the breast.
• Tip of baby’s nose lightly touches the breast.
• Baby’s cheeks appear to be full and rounded (not dimpling in)
• Baby’s mouth does not slip off the breast.
• Baby is supported in chest-to-chest position and baby’s neck
is not turned.
• Mother feels a strong tugging sensation with no pain.
• Breastfeeding is pain-free.
• Baby shows signs of sucking and swallowing breast milk
Interrupting the Latch
• Press down on her breast near to the baby’s
• Bring the baby in closer to the breast so that
the nose is covered with breast tissue.
• Pull down on the baby’s chin.
• Insert a finger into the corner of the baby’s
Breastfeeding Holds and positioning
Checkpoints - For each position encourage the mother to
• She is relaxed and comfortable with good posture. She
has correct body alignment.
• Her back and arms are well supported.
• Baby’s head and body are supported.
• The baby’s head is at the level of the breast.
• Baby’s ear, shoulder, and hip are in a straight line.
• Baby’s chest is facing the mother’s chest (chest-to-
• Baby’s nose is facing the nipple. Baby’s chin touches
• CRADLE HOLD – an easy, common hold that is
comfortable for most mothers and babies. Hold your
baby with his or her head on your forearm and his or
her whole body facing yours.
• Sit in a chair that has supportive armrests or on a bed
with lots of pillows. Rest your feet on a stool, coffee
table, or other raised surface to avoid leaning down
toward your baby. Hold her in your lap (or on a pillow
on your lap) so that she’s lying on her side with her
face, stomach, and knees directly facing you. Her pelvis
should line up with your stomach, and her nose should
line up with your nipple. Tuck her lower arm under your
own. If she’s feeding on the right breast, rest her head
in the crook of your right arm. Extend your forearm and
hand down her back to support her neck, spine, and
bottom. Secure her knees against your body, across or
just below your left breast.
• Best for: The cradle hold often works well for full-term
babies who were delivered vaginally. Some mothers say
this hold makes it hard to guide their newborn’s mouth
to the nipple, so you may prefer to use this position
once your baby has stronger neck muscles at about 1
month old. Women who have had a caesarean section
may find it puts too much pressure on their abdomen.
• The Cross-Over Hold or Cross cradle or transitional
hold -this position differs from the cradle hold in
that you don’t support your baby’s head with the
crook of your arm. Instead, your arms switch roles.
If you’re feeding from your right breast, use your
left hand.and arm to hold your baby. Turn her body
so her chest and tummy are directly facing you.
With your thumb and fingers behind her head and
below her ears, guide her mouth to your breast.
• This position allows the mother to have maximum
control of the baby’s head while latching.
• Best for: This hold may work well for small
babies and for infants who have trouble
• If baby is premature or small.
• If baby has low muscle tone.
• If baby has a weak rooting reflex or weak suck.
• THE CLUTCH OR RUGBY BALL HOLD OR FOOTBALL
POSITION- in this position you tuck your baby under
your arm (on the same side that you’re feeding from)
like a rugby ball or handbag. First, position your baby at
your side, under your arm. She should be facing you
with her nose level with your nipple and her feet
pointing toward your back. Rest your arm on a pillow in
your lap or right beside you, and support your baby’s
shoulders, neck, and head with your hand. Using a C-
hold, guide her to your nipple, chin first. But be
careful—don’t push her toward your breast so much
that she resists and arches her head against your hand.
Use your forearm to support her upper back.
• Best for -useful for mothers who had a c-section and
mothers with large breasts, flat or inverted nipples, or a
strong let-down reflex and for mothers of twins. . It is
also helpful for babies who prefer to be more upright.
This hold allows you to better see and control your
baby’s head and to keep the baby away from a c-
• The Reclining Position or Side-Lying Position-To
breastfeed while lying on your side in bed, ask your
partner or helper to place several pillows behind
your back for support. You can put a pillow under
your head and shoulders, and one between your
bent knees, too.
• The goal is to keep your back and hips in a straight
line. With your baby facing you, draw her close and
cradle her head with the hand of your bottom arm.
Or, cradle her head with your top arm, tucking your
bottom arm under your head, out of the way. If
your baby needs to be higher and closer to your
breast, place a small pillow or folded blanket under
her head. baby shouldn’t strain to reach your
nipple, and you shouldn’t bend down toward baby.
Best for - If mother finds it too painful to sit.
• If mother wants to rest when breastfeeding
(e.g., night feedings).
• If mother had a caesarean birth.
• If mother has large breasts.
• Baby Upright- Helpful for older babies who want to
nurse sitting bolt upright because of congestion,
reflux, or an ear infection. (Use pillows to prop
babies too young to sit up on their own.) Sit the
baby on your lap, facing you, and bring his head to
• Australian Hold -It’s best to do this in the family bed. Lie in
bed with the baby latched onto your breast, and her feet near
your ears, and her belly opposite your chin. This position
works well when the baby is little.
• Upside down -Best for older babies with some head and neck
control, and good for overactive letdown at any age. Lying flat
on your back, latch the baby onto your breast, holding the
baby at an angle to your body. He will be halfway on your
chest, with his bottom and legs trailing into the air or onto
Nutritive vs. Non-nutritive Sucking:
Nutritive sucking promotes the transfer of breast milk.
Non-nutritive sucking promotes little or no breast
milk transfer but has other purposes.
• Increases peristalsis.
• Increases the secretion of digestive fluids.
• Decreases crying; increases calming and comforting
for the infant. e.g., an infant sucking on a finger is
using non-nutritive sucking as a self-directed,
Guidelines for Assessing Effectiveness
• Alignment - Correct positioning; baby facing mother, and
nose at level of nipple.
• Areolar Grasp - Latch. Peristaltic motions of tongue result in
effective areolar compression.Mouth wide, lips flanged,
complete seal, covers areolar and surrounding tissue.
• Areolar Compression - Removal of breast milk from the
breast. Mandible moves in rhythmic motion. Cheeks are full
and rounded when sucking.
• Audible Swallowing
- Quiet sound or pause is noted during suck cycle.
- May increase after breast milk ejection reflex occurs.
- Co-ordinated pattern of suck-swallow-breathe (1:1:1).
- May be preceded by several sucking motions during initiation
COMMON PROBLEMS AND
• Sore Nipples-Sore nipples is one of the most
common complaints of new mothers and is one of
the most frequent reasons that mothers stop
breastfeeding sooner than they intended Sore
nipples may have one or more underlying causes
that may be mother and/or baby related. The two
most common causes of sore nipples are incorrect
latching and incorrect positioning.
OBSERVATION AND ASSESSMENT
Assess the pain and appearance of the nipples:
• Nipples that feel sore, painful, burning and/or itchy.
• Nipples that appear to be pink or red, bruised,
blistered, cracked, shiny, flaky and/or bleeding.
• Discharge from cracks or sores on the nipple.
• A white blister at the opening of one of the ducts on
• Timing of the pain. Nipple pain that may decrease after
the initial latch and/or may persist throughout the
breastfeeding and between breast feedings.
• Nipples that appear blanched and are painful after
• Location of the nipple pain.
Possible Causes or Contributing Factors
• Incorrect latching and positioning techniques
• Poor latching or tongue thrusting may result in
soreness on the top or tip of the nipple.
• Pressure from the mother’s hand on the breast may tip
up the nipple which then rubs the hard palate.
• The position of the mother’s hands on the breast may
tip the nipple so that the infant ‘strokes’ the underside
of the breast with the tongue.
• Baby is not facing the breast and has to turn his head
• Baby’s nose is not level with the nipple and cannot tip
his head back to latch correctly.
• Engorged breast or Inverted or flat nipples
• Washing the nipple with soap or with water before every
• Menstruationor Extremelysensitivenipples.
• Dermatitis, eczema, impetigo, scabies, herpes, or other skin
• Nipple vasospasm ( when the baby comes off the breast the nipple
is blanched and has a burning pain. After several minutes the nipple
returns to its normal colour and the burning sensation changes to a
throbbing pain. Further assessment is needed to determine if the
Assess the baby for possible causes:
• Ineffective suck
• A very aggressive and strong suck. This may be
associated with hypertonicity.
• High, arched palate.
• Receding chin.
• Use of artificial nipples and other devices (e.g.,
bottle nipples, soothers, nipple shields).
• Teething and biting down on the breast by an older
What you can do
• A good latch is key, If your baby is sucking only on the
nipple, gently break your baby’s suction to your breast
by placing a clean finger in the corner of your baby’s
mouth and try again. (Your nipple should not look flat
or compressed when it comes out of your baby’s
mouth. It should look round and long, or the same
shape as it was before the feeding.)
• Ensure that the letdown or milk ejection reflex is
initiated. The baby’s rooting and sucking are the natural
stimuli for letdown when breastfeeding is initiated
early and the baby is calm, before the baby is overly
hungry, and begins crying
• Try changing positions each time you breastfeed. This
puts the pressure on a different part of the breast.
• After breastfeeding, express a few drops of milk and gently rub it
on your nipples with clean hands. Human milk has natural healing
properties and emollients that soothe. Also try letting your nipples
air-dry after feeding, or wear a soft cotton clothes.
• Avoid wearing bras or clothes that are too tight and put pressure
on your nipples.
• Avoid using soap or ointments that contain astringents or other
chemicals on your nipples. Washing with clean water is all that is
needed to keep your nipples and breasts clean.
• If necessary gently massage the breasts. Apply moist or dry heat to
the breasts for a few minutes before or during massage until
• If only one nipple is sore and the breastfeeding is to be started on
that side, breastfeed on the pain free side first until letdown
occurs then switch to the sore side.
• Numb the nipple just before latching by applying ice wrapped in a
cloth on the sore nipple for a few seconds. Avoid prolonged
exposure to the ice as this can inhibit the letdown reflex or
damage the nipple.
• Engorgement can occur when your milk comes in.
This is uncomfortable swelling of your breasts that
tends to happen between 2 to 4 days after delivery.
The swelling may restrict the flow of milk by
compressing the ducts. The breast may be very hard
making it difficult for the baby to attach and feed
• Engorgement can lead to plugged ducts or a breast
Possible Contributing Factors or Causes
Assess the mother for:
• Poor latching and positioning techniques
• Use of supplements and pacifiers.
• Restricting the frequency and length of breast feedings.
• Temporarily stopping breastfeeding without expressing
for the missed breastfeeds.
• Weaning abruptly.
• Underlying abnormal breast pathology (e.g., non-patent milk
• • Stress and Fatigue.
Assess the baby for:
• Ineffective suck
• Use of pacifiers.
• The best management of engorgement is prevention
• Check first for incorrect latching and positioning
• Compress the breast when the baby’s sucking becomes
• Apply cold to the softened breasts for a few minutes
• Hand express or pump a little milk to first soften the
breast, areola, and nipple before breastfeeding
• Wear a well-fitting, supportive bra that is not too tight.
• Demand feeding and using heat just before
feeding to help the milk flow, and cold
between feeds to reduce swelling is helpful.
Cabbage leaves are said to be comforting,
especially if kept in the freezer and slipped
into your maternity bra between feeds.
• Plugged or blocked ducts occur when one or more of
the collecting ducts within the breast become plugged
with cells and other breast milk components.
Contributing factors may include milk stasis or external
pressure applied on specific areas of the breast.
• A plugged milk duct feels like a tender and sore lump in
the breast. It is not accompanied by a fever or other
symptoms. It happens when a milk duct does not
properly drain and becomes inflamed. Then, pressure
builds up behind the plug, and surrounding tissue
becomes inflamed. A plugged duct usually only occurs
in one breast at a time.
Possible Contributing Factors or Causes
• Ineffective removal of breastmilk and inadequate
drainage of the breast
• Engorgement (
• Overabundant breast milk supply
• External pressure on a specific area of the breast
e.g., - mother’s finger pressing the breast
- constrictive bra or clothing
- straps on a baby carrier
- always sleeping on the same side or
- always holding the baby the same way.
• Positioning difficulties.
• Poorly managed plugged ducts can develop into
What you can do
• Breastfeed often on the affected side, as often . as
every two hours. This helps loosen the plug, and keeps
the milk moving freely.
• Massage the area, starting behind the sore spot. Use
your fingers in a circular motion and massage toward
• Use a warm compress on the sore area.
• Get extra sleep or relax with your feet up to help speed
healing. Often a plugged duct is the first sign that a
mother is doing too much.
• Physiotherapy treatment consists of ultrasound and
effleurage or draining massage to clear the ducts.
• Mastitis is an inflammatory condition of the breast,
which may or may not be accompanied by infection.
• Assess the mother for possible symptoms:
• Unilateral symptoms most often in the upper, outer
quadrant but may occur anywhere, including under
• Red, hot, swollen.
• Intense pain.
• Flu-like symptoms (e.g., chills, aches, fatigue).
• Possible sudden onset.
Promote Effective & Regular Milk Removal.
• Do not stop feeding the baby.
• Promote milk flow with a hot bath or a warm compress or
pack. Follow this (or during a bath or shower) with gentle
massage towards the chest, ensure blocked areas are covered.
• Start the feed on the affected breast.
• If pain inhibits let down, feeding may begin on unaffected breast,
then switch to the affected side once let down is achieved; breast
feeding is often more comfortable once the milk is flowing
• If pain prevents breast-feeding, remove milk by hand or pump
• Position the baby on the breast so the chin is over the blockage
• Vary the baby's position on the breast so that all ducts are
• Ensure breast is fully drained after baby has finished feeding
• Once the breast is drained massage the breast toward the nipple
Decrease Pain & Swelling
• Cold Packs (specifically after feeding) and/or
Cold Cabbage leaves
• Identify and effectively massage blocked
• Ultrasound opens the ducts and promotes
• In addition to effective breast milk removal of
the breast, infectious mastitis may also need
treatment with antibiotics
Flat and Inverted Nipples
• Some women have nipples that turn inward instead of
protruding or that are flat and do not protrude. Nipples
can also sometimes be flattened temporarily due to
engorgement or swelling while breastfeeding. Inverted
or flat nipples can sometimes make it harder to
• The nipple pinch test can be done to clarify if a nipple is
flat or inverted.
• Nipple pinch test: Gently compress the areola about
one inch from the base of the nipple, placing the
thumb on one side of the areola and the index finger
on the opposite side. nipple may appear to be
protruding, flat, or inverted before the nipple pinch test
Possible Contributing Causes or Factors
• An areola that is non-elastic and difficult to
compress. This type of areola will make it more
difficult for the baby to latch on the breast.
• An engorged areola that may flatten a normally
protruding nipple. This is most likely the case if the
mother did not have a flat nipple until after birth.
• Adhesions that connect the nipple to the inner
• Less dense connective tissue located beneath the
• History of breast surgery or nipple piercing.
• Breast shells and nipple preparation (the Hoffman Technique)
are often recommended to help evert flat or inverted
• Hoffman Technique is intended to loosen adhesions. Place
your two thumbs opposite each other at the base of your
nipple. Press firmly and at the same time, pull the thumbs
away from each other. Rotate the thumbs around the base of
• Breast Shells – Breast shells are two-piece plastic devices that
may be worn over the nipple and areola to evert flat or
• Nipple Shields-A nipple shield is an artificial nipple and areola
shaped like a floppy sun hat and is made of a synthetic
material like silicone.
Possible contraindications to breastfeeding
related to the mother
• active herpes lesion on her breast or nipple.
• HIV positive
• Mothers who have severe psychosis, eclampsia or
shock may not be able to manage breastfeeding for
a period of time.
• Mothers who are taking a medication which is
contraindicated when breastfeeding (e.g. cytotoxic
drugs, radioactive drugs, and anti-thyroid drugs
other than propylthiouracil) cannot breastfeed
while the drugs are present and active.