this lecture is one of my lectures for the lactation specialists diploma at Benha University it involves easy and simple explanation for the common difficulties and problems during breast feeding these difficulties include maternal, fetal problems and problems in special situations maternal problems during breast feeding include: (Full breast and breast engorgement Sore, painful, cracked or fissured nipple Flat or inverted or non-protractile nipple Mastitis or breast abscess Sick mothers and breast feeding) newborn problems include: (Baby refuses the breast or unable or unable to suck Birth injuries especially cephalohematoma Jaundice or hypoglycemia Sick baby who is taken to the neonatal care unit (NCU) or baby with congenital anomaly that disables him or her from breastfeeding as cleft lip or choanal atresia or a tracheoesophageal fistula) twins and multiple gestations breast feeding support Discharge Care for Continued Breastfeeding

1. By
Dr. Ahmed Mohamed Amin Nasef
Assistant lecturer in Obstetrics & gynecology department
Benha University

2. Objectives
• Common Breast-Feeding difficulties in
the Postpartum Period
• Maternal problems during breast
feeding
• Infant problems during breast feeding
• Breast feeding in special situations
• Discharge Care for Continued
Breastfeeding

3. Common Breast-
Feeding difficulties in
the Postpartum Period

4. Common Feeding Difficulties in the Postpartum
Period
There are several conditions may arise in the immediate postnatal period that are
usually prevented by optimal early feeding practices
They include:
• Maternal Problems
• Infant Problems
• Breastfeeding in special situations

5. Breastfeeding in special situations
These are conditions that necessitate additional help and include:
• Mothers delivered by CSD
• Multiple births
• Preterm and Low Birth Weight (LBW)

6. Maternal
Problems

7. Maternal problems
They are most related to the breast (i.e., local breast problems) They include:
• Full breast and breast engorgement
• Sore, painful, cracked or fissured nipple
• Flat or inverted or non-protractile nipple
• Mastitis or breast abscess
• Sick mothers and breast feeding

9. Breast
engorgement

10. Breast engorgement
Predisposing factors
• Normal fullness of the breasts which occurs with the “coming in” for the milk around the third day
• If the baby is not put early at the breast
• Separated from the mother
• Infrequent feeding
Symptoms
• Both breasts becomes distended, tense, tender and reddened
• Maternal fever
D.D
Serious postpartum infections as puerperal sepsis or infection of the wounds of CSD
Complications
In severe cases the baby becomes unable to suckle (cannot stretch the nipple to form a teat because of the tense areola), he can only hold the
nipple in his mouth pressure by gums on the nipple causing fissuring
In neglected cases, mastitis and breast abscess occurs

12. Breast engorgement
Prevention
• Early initiation and frequent suckling at the breastfeeding
• Rooming in and guiding mothers to her baby’s feeding cues
• Teaching mothers how to express her milk and teaching her partner how to
massage her back to stimulate milk flow
• Assisting mother in positioning her baby at the breast and the correct latch

13. Sore and Fissured
Nipple

14. Sore and Fissured Nipple
The nipples are very sensitive at birth and when the
newborn latches incorrectly, the overly sensitive nipples
may feel sore and may even get cracked or fissured from
the strong suckling and hard grasp of the gums on the
thin overly sensitive nipples
In most of the cases, when mother receives help with
achieving a good latch, the pain is relieved, and
breastfeeding becomes comfortable again.
However, when babies are left for a long interval between
the feeds, the baby get hungry, and the breast fill up and
this stretches the nipple, so when the baby latches, the
mother feels pain again
Teaching mothers how to express milk before and a feed
and to soften her nipples and areola may assist the baby
to latch without causing her pain

15. Sore and Fissured Nipple
Prevention and management
• Teach the mother how to relax and how to bring the baby to the breast from below ensuring a wide gap
• Continue breastfeeding but make feeds short and frequent (to speed recovery)
• Let the baby suckles first from the least-affected breast (initial suckling is the strongest, thus most painful)
• Correct suckling position during feeding
• Local applications to the nipple (e.g., edible oil, lanolin, wetting with HBM; gentian violet 1% (disinfectant) may be used
• Exposure of the nipple to sunlight may promote healing
• If pain is very severe discontinue breastfeeding temporarily from the affected side until healing with milk expression (to
maintain milk production, prevent engorgement and breast abscess)

16. Flat or retracted
(too short nipple)
or Non-protractile
nipple

17. Flat or retracted (too short nipple) or
Non-protractile nipple
Most of flat or non-protractile nipples correct at birth with the release of the
elastin hormone that causes the fibromuscular tissue to stretch during birth to
assist birth
Mothers who deliver by CSD may not have had enough time for the hormone
to be released and so may need some assistance
This problem should be no longer diagnosed during the antenatal period Such
nipples were found to improve immediately before delivery or as the baby
starts to suckle

18. Flat or retracted (too short nipple) or
Non-protractile nipple
Prevention and management
• Encourage natural childbirth
• SSC immediately after birth
• Allow prefeeding reflexes to develop and for baby to take time to develop a good gape response, licking and
sucking at fists before attempting to suck at the areola
• Use techniques to pull nipple manually and by the inverted syringe method and massaging and expressing
milk before a feed
• Ensure correct feeding position
• Nipple shield is no longer recommended and should be used with caution and for short periods

20. Blocked-duct, Acute
Mastitis and Breast Abscess

21. Blocked-duct, Acute Mastitis
and Breast Abscess
Sequalae
Blocked duct if not cleared, infection may occur
& lead to acute mastitis
Mastitis may lead to breast abscess
These conditions are very painful and can cause
the mother to refuse to feed her baby
Pain killers and antibiotics given may pave the
way to superimposed candida infection

22. Management
Prevention and Management In case of blocked duct:
Increase frequency of feeding from the affected breast
Gentle massage of the lump towards the nipple before and during feeding
These two measures usually clear the duct in a day or two
Mastitis management
Continue breastfeeding from the affected side and the other side
If the mother does not want to feed her baby, stop feeding from the infected breast and continue it from the other healthy one (Infected breast
should be expressed several times per day)
Systemic antibiotics together with a safe analgesic and antipyretic (Ibuprofen) and local application of cloth soaked in warm water or kaolin poultice
(to relieve pain)
Abscess management
refer to hospital for incision and drainage
Refeeding from the infected breast should be started as early as possible (to avoid dryness of HBM) with measures to increase HBM supply

23. Sick mothers
& breast
feeding

24. Sick mothers & breast feeding
Sick mothers comprise 10-15% of the mothers in a maternity ward They are
usually placed in the critical wards of the maternity unit
Most of medical problems are compatible with breastfeeding and may improve
with breastfeeding e.g., diabetics go into remission or may lead less insulin,
heart and renal patients can reduce dose of diuretic as breastfeeding is a
natural diuretic

25. Medications and breast
feeding

26. Medications instructions with breast
feeding
Most medications are compatible with
breastfeeding
If a medication is not suitable alternative
are available
Less than 1% of the drug passes to HBM and
their levels can be monitored in the infant
It is safer to take the drug in widely spaced
doses and just before the longest sleep of
the baby. This allows the infant to handle
and excrete the drug and prevent
accumulation in baby's systemic circulation

27. Infant
problems

28. Infant Problems
These are problems that present in the early hours or days of life and include:
• Baby refuses the breast or unable or unable to suck
• Birth injuries especially cephalhematoma
• Jaundice or hypoglycemia
• Sick baby who is taken to the neonatal care unit (NCU) or baby with
congenital anomaly that disables him or her from breastfeeding as cleft lip
or choanal atresia or a tracheoesophageal fistula

29. Infant problems and management
during breast feeding
Blocked nose (by mucus or cold) clean the nose, use saline nasal drops
Sore mouth (e.g., oral thrush) oral Nystatin drops or gentian violet 1% with examination of nipple
and areola for monilial infection and treatment as above if present
Sick baby (e.g., septicemia, intracranial he or Kernicterus) require treatment of the cause
Emergency as choanal atresia or TEF may require immediate referral for surgical intervention
The mothers should express their milk for the baby and to keep up milk supply until the baby to
breastfeed again

30. Infant problems
In lip or palate anomaly (cleft lip and/or palate), dental plate "obturator" may be used If the baby
cannot suck, mother gives him EMB by cup and spoon
If ORS is required, it should also be given by cup and spoon
When the baby recovers from illness
he must be put on the breast and breastfeeding is continued
If the baby refuses at first, help him to start again
Measures to help mother to build up her milk supply may be needed (e.g., increased frequency of
feeding, plenty of fluids, use of locally known galactagogues or drugs, feed on breast with nursing
supplement to nourish baby while increasing nipple stimulation and skin contact)

31. Multiple pregnancies and feeding
twins

32. Multiple pregnancies incidence
Multiple-gestation pregnancies have increased in the past decades because of
the increased use of assisted reproductive technology (ART) such as in vitro
fertilization (IVF) and embryo transfers, and increasing maternal age
Approximately 3% of all live births in the US are multiples
Most multiples are twins and approximately one fourth of twins are
monozygotic, and two thirds are dizygotic (resulting from the fertilization of
two eggs)

33. Risks of multiple pregnancy
Pregnancy risk factors, such as discordant growth and twin to-twin transfusion
syndromes, arise from carrying more than one fetus who share the placenta
The mother with a multiple gestation is also at higher risk for many of the
complications of pregnancy such as preterm labor, intrauterine growth
retardation (IUGR), preeclampsia, and antepartum hemorrhage

34. Measures to improve BF for twins
Multiple pregnancies are often associated with prematurity and low or very
low birthweight infants. Premature infants are prone to develop postnatal
complications including recurrent episodes of sepsis (16–30% of very low
birthweight; 1500 g), necrotizing enterocolitis (1– 12%), and retinopathy of
prematurity (20–50%)
Early initiation of breastfeeding through SSC and feeding only HBM decreases
the incidence of many of these complications

35. Measures improve BF for twins
Breastfeeding initiation of multiples has increased over the past years to 70 to
90%
• Research showed that the main reasons for breastfeeding was
• mother’s knowledge about the benefits of breastfeeding to the mother
Prior counseling increased the rate of early initiation of breastfeeding
Extensive education on the benefits of breastfeeding must be provided to
parents from their doctor, nurse, or other sources before pregnancy or within
the first trimester

36. Lactation specialist counselling for twins
feeding
Lactation specialists (LS) can provide guidance through counseling and support to mothers of twins by explaining to them that
they can produce enough milk to meet the needs of either baby
HBM volume increases with twin feeding because more sucking leads to more HBM secretion
The stronger baby usually brings more milk for the weaker baby
Mothers also benefit from family and social support networks in the early weeks to cope with the increased responsibilities
The LS needs to emphasize the following
• Ensure mother gets enough fluids, rest, social support (help) and nutrition
• Avoid smoking or exposure to smoke as it decreases HBM supply
• Avoid tight bras, sleeping prone and taking antihistaminic medications
• Taking herbal drinks will help her relax to increase her HBM production. Fenugreek drinks, fennel and galactagogues as
metoclopramide or Domperidone increase HBM production but mint, chamomile, lavender and rose drinks can be relaxing

37. Breastfeeding techniques for twins
• Twins can be put on the two breasts at the same time this can be stimulate more HBM production. Positions
used can be “double cradle”, “double football” or “combination of cradle and football”
• It is preferable to alternate breasts when breastfeeding twins. This ensures that each breast receives balanced
stimulation from the different babies and that the HBM yield for each baby will be the same
• Reassure the mother that she does have enough HBM for her multiples and she does not need to give
supplements. Support and teaching may be needed at first
• Monitor weight curve by regular follow up of both babies is necessary to monitor their progress in weight
gain and their development and reinforce mother’s self-esteem and build her self-efficacy. If the weight gain
is inadequate, expressed HBM can be given to each one immediately after breastfeeding until babies are
strong enough to get their own needs

38. Discharge Care
for Continued
Breastfeeding

39. Discharge instructions
At discharge from the hospital the following instructions should be given to the mother in oral
and written form:
• Information about the benefits of EBF
• Hazards of any supplementation whether decoctions or formula with breastfeeding
• Hazards of pacifiers or using bottles with teats to feed babies in the first six months of thereafter
• The hazards of supplementation and artificial nipples (whether for soothing the baby as pacifiers or feeding as in bottles) must
include the negative effect on breastfeeding and the superiority of HBM and breastfeeding
• Where or who to contact when the mother has any worries or faces any difficulties
• Provide mothers access to mother support groups and hotlines that can be useful for resolving any query she may have
• Mother-to-mother support groups are an opportunity for the mother to vent her feelings and relieve her worries and give her
confidence that she is doing the right thing for her baby

40. Discharge instructions
• Health care provider needs to assess breastfeeding and make sure that mothers know how to express
their HBM (if they want to relieve the fullness that happens when “milk comes in” or to express and
store milk for later use when she goes for work or to do any errands
• She needs to be reassured that she can breastfeed anywhere and be given access to shops that sell
maternity wear that facilitate breastfeeding whether at home or in public
• Mothers need to reassured that personal hygiene by daily showering (running water) and washing
her clothes especially her support bras is important for the care for her breasts and nipples to
prevent clogging and infection
• It is important to avoid using excessive soap or alcohol on her breasts or nipples
• After bathing with soap and water she can wipe her breasts with an acidic solution (as potassium
permanganate or diluted vinegar or lime). The latter prevents the overgrowth of monilia (candida) on
the nipple area

41. Discharge instructions
• Wiping her nipple with a drop of milk can also be useful as it is acidic and helps to lubricate
and prevent dryness of the nipple and areola
• The presence of her partner and other family members as mothers or mothers in law is
important to give them instructions about EBF and feeding on demand (to infant feeding
cues) and avoidance of artificial nipples and pacifiers
• They are also taught how to burp the baby and how to do SSC for soothing the baby instead
of giving pacifiers
• They can be also taught on how to cup feed if the mother needs to leave the baby with
them when she goes out for work or other errands