BREAST AND NIPPLE CONDITIONS
2. Engorgement, blocked ducts and mastitis 20 minutes One of the mothers in our story, Fatima, has heard that breastfeeding mothers can
have sore breasts. She is worried this might happen to her, as her breasts seem to be getting swollen.
Ask: What can you explain to a mother about normal breast changes during breastfeeding and changes that may indicate a difficulty?
Wait for a few responses.
Engorgement
What is engorgement?
- Slide 12/2:Picture of full breast
• Normal breast fullness: When the milk is "coming in,” there is more blood supply to the breast as well as more milk. The breasts may feel warm, full, and heavy. This is normal. To relieve fullness, feed the baby frequently and use cool compresses between feeds. In a few days, the breasts will adjust milk production to the baby’s needs.
- Slide 12/3:Picture of engorgement
• Engorgement: If the milk is not removed, the milk, blood and lymph become congested and stop flowing well, which results in swelling and oedema. The breasts will become hot, hard and painful, and look tight and shiny. The nipple may be stretched tight and flat, which makes it difficult for the baby to attach and which can result in sore nipples.
• If engorgement continues, the feedback inhibitor of lactation reduces milk production.
• Causes of breast engorgement include:
- Delay in starting to breastfeed soon after baby’s birth.
- Poor attachment, so that milk is not removed effectively.
- Infrequent feeding, not feeding at night or short duration of feeds.
Do your practices help to avoid engorgement?
• If much engorgement is seen in a maternity facility, the pattern of care for mothers should be reassessed. Implementation of the Ten Steps to Successful Breastfeeding prevents most painful engorgement. If you can answer “yes” to all of the following questions, there should be very little engorgement in your facility.
• Ask yourself:
- Is skin-to-skin care practiced at birth? (Step 4).
- Is breastfeeding initiated within one hour after birth? (Step 4).
- Do staff offer help early and make sure that every mother knows how to attach her baby at the breast? (Step 5).
- If the baby is not breastfeeding, is the mother encouraged and shown how to express milk from her breasts frequently? (Step 5).
- Are babies and mothers kept together 24 hours a day? (Step 7).
- Is every mother encouraged to breastfeed whenever and for as long as her baby is interested, day and night (at least eight to twelve feeds in 24 hours)? (Step 8).
- Are babies given no pacifiers, artificial teats, or bottles that would replace suckling at the breast? (Step 9).
Help mothers to relieve engorgement
• To treat engorgement, it is necessary to remove the milk from the breast. This will:
- Relieve the mother’s discomfort.
- Prevent further complications such as mastitis and abscess formation.
- Help to ensure continued production of milk.
- Enable the baby to receive breast milk.
• How to help a mother to relieve engorgement:
- Check attachment: Is baby able to attach well at the breast? If not:
- Help the mother to attach her baby at the breast well enough to remove the milk.
- Suggest that she gently express milk54 from her breasts herself before a feed to soften the areola and make it easier for the baby to attach.
- If breastfeeding alone does not reduce the engorgement, advise the mother to express milk between feeds a few times until she is comfortable.
- Encourage frequent feeds: if feeds have been limited, encourage the mother to breastfeed whenever and for as long as her baby is willing.
- A warm shower or bath may help the milk to flow.
- Massage of the back and neck or other forms of relaxation may also help the milk to flow.
- Help the mother to be comfortable. She may need to support her breasts if they are large.
- Provide a supportive atmosphere; build the mother’s confidence by explaining that soon the engorgement will be resolved.
- Cold compresses may lessen pain between feeds.
Blocked milk ducts and mastitis (breast inflammation)
• Milk sometimes seems to get stuck in one part of the breast. This is a blocked duct.
• If milk remains in a part of the breast, it can cause inflammation of the breast tissue or non-infective mastitis. Initially there is no infection, however the breast can become infected with bacteria and is then infective mastitis.
• Blocked ducts and mastitis can be caused by:
- Infrequent breastfeeding – maybe because the baby wakes infrequently, hunger signs are missed, or the mother is very busy.
- Inadequate removal of milk from one area of the breast.
- Local pressure on one area of the breast, from tight clothing, lying on the breast, pressure of the mother’s fingers on the breast, or trauma to the breast.
• A woman with a blocked duct may tell you that she can feel a lump, and the skin over it may be red. The lump may be tender. The mother usually has no fever and feels well.
• A woman with mastitis may report some or all of the following signs and symptoms:
- pain and redness of the area;
- fever, chills;
- tiredness or nausea, headache and general aches and pains.
• The symptoms of mastitis are the same for non-infective and infective mastitis.
- Show slide 12/4:Picture of mastitis. Note that an area is red and there is swelling. This is severe. Participants and mothers need to learn to recognise blocked ducts and mastitis in an earlier stage so that it does not progress to this severity.
53 Relieving engorgement when a mother is not breastfeeding is discussed in the Additional Information section for this session.
54 See Session 11 for details of how to express milk.
Assessment of a mother with a blocked duct or mastitis
• The important part of treatment is to improve the drainage of milk from the affected part of the breast.
- Observe a breastfeed. Notice where the mother puts her fingers and if she presses inwards, perhaps blocking the milk flow.
- Notice if her breasts are very heavy. If the blocked duct or mastitis is in the lower area, lifting the breast while feeding the baby may help that part of the breast to drain better.
- Ask about frequency of feeds and if the baby is allowed to feed for as long as the baby wants.
- Ask about pressure from tight clothes, especially a bra worn at night, or trauma to the breast.
Treatment of mastitis
• Explain to the mother that she MUST:
- Remove the milk frequently (if not removed, an abscess may form).
- The best way to do this is to continue breastfeeding her baby frequently.
- Check that her baby is well attached.
- Offer her baby the affected breast first (if not too painful).
- Help the milk to flow.
- Gently massage the blocked duct or tender area down towards the nipple before and during the feed.
- Check that her clothing, especially her bra, does not have a tight fit.
- Rest with the baby so that the baby can feed often. The mother should drink plenty of fluids. The employed mother should take sick leave if possible.
Rest the mother, not the breast!
• If the mother or baby is unwilling to feed frequently, it is necessary to express the milk55. Give this milk to the baby. If the milk is not removed, milk production can cease and the breast becomes more painful, possibly resulting in an abscess.
Drug treatment for mastitis
• Anti-inflammatory treatment is helpful in reducing the symptoms of mastitis. Ibuprofen is appropriate if available. A mild analgesic can be used as an alternative.
• Antibiotic therapy is indicated if:
- The mother has a fever for twenty four hours or more.
- There is evidence of possible infection, for example an obviously infected cracked nipple.
- The mother’s symptoms do not begin to subside within 24 hours of frequent and effective feeding and/or milk expression.
- The mother’s condition worsens.
• The prescribed antibiotic56 must be given for an adequate length of time. Ten to fourteen days is now recommended by most authorities to avoid relapse.
55 See Session 11 for details on expressing milk.
56 Generally oral antibiotics are used - erythromycin, flucloxacillin, dicloxacillin, amoxacillin, cephalexin. See Mastitis: causes and management WHO/FCH/CAH/00.13 for further information.
Mastitis in the woman who is HIV-positive
• In a woman who is HIV-positive, mastitis or nipple fissure (especially if bleeding or oozing) may increase the risk of HIV transmission.
• If an HIV-positive woman develops mastitis, an abscess or a nipple fissure, she should avoid breastfeeding from the affected breast while the condition persists. She must express milk from the affected breast, by hand or pump, to ensure adequate removal of milk. This is essential to prevent the condition becoming worse, to help the breast recover, and to maintain milk production. The health worker should help her to ensure that she is able to express milk effectively.
• Antibiotic treatment is usually indicated in a woman with HIV. The prescribed antibiotic must be given for an adequate length of time. Ten to fourteen days is now recommended by most authorities to avoid relapse.
• If only one breast is affected, the infant can feed from the unaffected side, feeding more often and for longer to increase milk production. Most infants get enough milk from one breast. The infant can feed from the affected breast again when the breast has recovered.
• If both breasts are affected, the mother will not be able to feed from either side. The mother will need to express her milk from both breasts. Breastfeeding can resume when the breasts have recovered.
• The health worker will need to discuss other interim feeding options (AFASS). The mother may decide to heat-treat her expressed milk57, or to give home prepared or commercial formula. The infant should be fed by cup58.
• Sometimes a woman may decide to stop breastfeeding at this time, if she is able to give another form of milk safely. She should continue to express enough milk to allow her breasts to recover and to keep them healthy, until milk production ceases.
3. Sore Nipples 10 minutes
• Breastfeeding should not hurt! Some mothers find their nipples are slightly tender at the beginning of a feed for a few days. This initial tenderness disappears in a few days as the mother and baby become better at breastfeeding. If this tenderness is so painful that the mother dreads putting the baby to the breast, or there is visible damage to the nipples, this soreness is not normal, and needs attention.
• The most common early causes of nipple soreness are simple and avoidable. If mothers in your facility are getting sore nipples, make sure that all maternity staff know how to help mothers get their babies attached to the breast. If babies are attached well at the breast and breastfeed frequently, most mothers do not get sore nipples.
57 This milk can be heat treated and used for the baby. Small lumps may form in the milk after heating, but these lumps can be removed and the milk used.
58 Session 11 describes milk expression and cup feeding.
Observation and history taking for sore nipples
• Ask the mother to describe what she feels.
- Pain at the start of a feed that fades when the baby lets go, is most likely related to attachment.
- Pain that gets worse during the feed and continues after the feed has finished, often described as burning or stabbing, is more likely to be caused by Candida
albicans59.
• Look at the nipples and breast.
- Broken skin is usually caused by poor attachment.
- Skin that is red, shiny, itchy, and flaky, at times with loss of pigmentation, is more often seen with Candida.
- Remember Candida and trauma from poor attachment can exist together.
- Similar to other parts of the body, the nipple and breast can have eczema, dermatitis and other skin conditions.
- Show slides of sore nipples:
- 12/5:This nipple has an open sore in a line across the tip of the nipple. This is likely to be the result of poor attachment
- 12/6:This nipple is red and sore. Notice the red marks and bruising around the areola.
This is likely to be the result of poor attachment
• Observe a complete breastfeed. Use the Breastfeed Observation Aid.
- Check how the baby goes on the breast, and his or her attachment and suckling.
- Notice if the mother ends the feed or if the baby lets go himself or herself.
- Observe what the nipple looks like at the end of the feed. Does it look misshapen (squashed), red or have a white line?
• Check the baby’s mouth for tongue-tie and Candida.
• Ask the mother about previous history of Candida or anything that might contribute to Candida such as recent use of antibiotics.
• If a mother is using a breast pump, check that it is appropriately positioned and the suction is not too high.
• Decide the cause of the sore nipple. The most common causes of sore nipples are:
- Poor attachment.
- Secondary to engorgement, or both caused by poor attachment.
- Baby is ‘pulled’ off the breast to end a feed without the mother first breaking the seal between the baby's mouth and the breast.
- A breast pump that may cause excess stretching of the nipple and breast or rub against the breast.
- Candida that can be passed from the baby’s mouth to the nipples.
- The infant’s tongue-tie (short frenulum), which prevents the tongue reaching over the lower gum thus causing friction on the nipple.
• There are many other less common causes of sore nipples. Arrange for a mother to be seen by someone who has training to investigate these less common causes, if needed60.
59 Oral candida is also called thrush.
60 This course does not train participants to deal with complex or rare breastfeeding situations. Establish to whom participants could refer a mother if her breastfeeding difficulty is complex.
Management of sore nipples
• Reassure the mother that sore nipples can be healed and prevented in future.
• Treat the cause of the sore nipples:
- Help the mother improve attachment and positioning. This may be all that is needed. If necessary, show the mother how to feed baby in different feeding positions. This helps to ease any pain mother is experiencing because baby will be putting pressure on a different area of the sore nipple and allows her to continue feeding while the nipple heals.
- Treat skin conditions or remove source of irritation. Treat Candida both on the mother's nipples and in the baby's mouth.
- If the baby's frenulum is so short that the tongue cannot extend over the lower gum, and the mother's nipples have been sore for two to three weeks, consider if the baby should be referred and the frenulum clipped.
• Suggest comfort measures while the nipples are healing:
- Apply expressed breast milk to the nipples after a breastfeed to lubricate and soothe the nipple tissue.
- Apply a warm, wet cloth to the breast before the feed to stimulate letdown.
- Begin each breastfeed on the least sore breast.
- If the baby has fallen asleep at the breast and is no longer actively feeding but remains attached, gently remove the baby from the breast.
- Wash nipples only once a day, as for normal body hygiene, and not for every feed.
Avoid using soap on nipples, as it removes the natural oils61. What does not help sore nipples
• DO NOT stop breastfeeding to rest the nipple. The mother may become engorged, which makes it harder for the baby to attach to the breast. The milk supply will decrease if milk is not removed from the breast.
• DO NOT limit the frequency or length of breastfeeds. Limiting feeds will not help if the basic problem is not addressed. One minute of suckling with poor attachment can cause damage to the breast. Twenty minutes of suckling with good attachment will not cause damage to the breast.
• DO NOT apply any substances to the nipples that would be harmful for the baby to take into his or her mouth, which requires removal before breastfeeding, or which can sensitise the mother’s skin and make the nipple more sore. An ointment is not a substitute for correct attachment.
• (Include if nipple shields are available in the area) DO NOT use a nipple shield as a routine measure. A nipple shield may cause more problems. Some shields result in less stimulation of the breast and reduce the amount of milk transferred, which may lead to reduced production. It can affect the way the baby sucks resulting in more soreness when it is stopped. It also presents a health risk to the baby from the possibility of contamination.
61 This is normal washing procedure, not just for when nipples are sore.
4. Small group work 25 minutes