by Dr Clare Macdonald, General Practitioner
I had major feeding issues with my youngest. I suffered recurrent deep ductal thrush, which was far more painful than giving birth, which was eventually attributed to a deep posterior tongue tie. My GP could not have been more helpful. He was open to looking at web links that I had found and at one point thanked me for educating him on issues with breastfeeding.
Around 30% of women will experience at least one breastfeeding problem in the first two weeks after delivery, and many of these will consult their GP1. The most common reasons for early cessation of breastfeeding are reported as ‘baby would not suck/rejected breast’ and ‘painful breast/nipples’2. After the first weeks the most common reason for cessation of breastfeeding is reported as ‘insufficient milk’3, which may include the perception of insufficient milk. In the UK Infant Feeding Survey 2010 most mothers who stopped breastfeeding would have liked to have carried on for longer2, 3.
Appropriate management and breastfeeding support for these problems is therefore key to achieving ongoing breastfeeding.
GPIFN Guide to Essentials when Supporting Breastfeeding Mothers A guide for the GP
Included here are summaries and resources for managing the breastfeeding problems typically seen in primary care. The diagnosis often lies within the history, and the following are useful, key questions to help determine the cause of the problem:
1. “How many times has the baby fed in the last 24 hours?”
It is useful to find out how many feeds per 24 hour period so this question is better than, for example “how often is baby feeding?”
2. “How long does each feed last?”
Be aware that in very young babies one feed may run into the next at times, but the mother should be able to give a range of typical feed duration e.g. “10-30 minutes”
3. “Do you have any pain or discomfort in your breasts or nipples?”
This really is a ‘catch all’ question and is likely to need some further clarification and distinction. If the answer is “yes”, the following should be ascertained
- Where is the pain?
- When does the pain occur? (e.g. at initial latch, throughout the feed, after the feed)
- Is the pain so severe it has caused you to avoid or delay any feeds?
4. “Does the baby settle well during and after a feed?”
5. “ What has been the nappy output in the last 24 hours?”
- Clarifying number of wet and soiled nappies, and the colour and consistency of the stool
During a consultation with a mother experiencing breastfeeding problems, use of appropriate and supportive language is paramount.
Breastfeeding women presenting with a painless breast lump should be advised to continue breastfeeding and be managed in the same way as non-breastfeeding women – ie. with a Two Week Wait referral where indicated4.
Women with breastfeeding problems should be examined in the same systematic and sensitive manner as any woman requiring a breast examination. A chaperone should offered. Women with engorged breasts, or mastitis are likely to leak milk and may feel embarrassed by this. Similarly, breast stimulation on examination may trigger a let-down reflex and therefore milk ejection. Clinicians should bear this in mind and be ready to put the woman at ease, and reassure where appropriate.
The size and shape of women’s breasts and nipples is highly variable and this does not necessarily reflect their breastfeeding success. However, women with inverted nipples may be concerned about their ability to breastfeed and may report difficulties. Breast changes during pregnancy often cause inverted nipples to begin to protrude.
La Leche League: Inverted Nipples Includes useful information for patients with inverted nipples.
More detail on individual topics can be found on the dedicated GPIFN web pages:
NICE CKS: Breastfeeding Problems Revised January 2017
NICE CKS Breastfeeding Problems: Assessment Revised January 2017 – Details an assessment of both mother and infant.
BMJ CME/CPD module: Managing Common Breastfeeding Problems in the Community May 2014 – by Dr Lisa Amir IBCLC. Covers common problems including milk supply issues and causes of breastfeeding pain.
UNICEF Baby Friendly Initiative e-learning for GPs (RCGP accredited) Summarises the medical aspects of lactation, including information on managing breastfeeding problems.
- Amir L. Managing common breastfeeding problems in the community. BMJ. 2014;348(may12 9):g2954-g2954.
- UK Infant Feeding Survey 2010:Birth, Postnatal Care and the Early Weeks see section 4.3.2 p8-9
- UK Infant Feeding Survey 2010: Feeding and Health After the Early Weeks see section 6.3 p1 and p6
- NICE CKS: Breastfeeding Problems Last Revised January 2017