Breastfeeding FAQs

Common Breastfeeding Conditions

• This can include sore, flat, or inverted nipples
• Letdown failure, hyperactive letdown, hyperlactation and engorgement can happen
• Low milk supply, plugged duct, or mastitis are also conditions

Sore Nipples

• These may be prevented by proper positioning of the baby on the breast
• The mother's nipple should be at the junction of the hard and soft palate
• This ensures it’s beyond the reach of the tongue compression wave

Flat or Inverted Nipples

• These should not impact breastfeeding if the latch is correct
• Roll the nipple between the fingers or use a breast pump prior to feeding if latching is difficult
• This helps to draw out the nipple

Letdown Failure

• This is where milk does not eject from the breast and it’s not common
• Oxytocin nasal spray may be prescribed
• Relaxation techniques may help enhance letdown

Hyperactive Letdown

• Streams of milk come from the breast
• The infant may cough, choke, or gulp if milk flow is too active
• Wait for the milk flow to slow down before putting the infant to the breast
• Express milk until the flow slows, then allow the infant to nurse

Hyperlactation

• Milk volume produced exceeds intake
• Symptoms in the mother include breasts not being drained completely or plugged ducts
• Further symptoms are leaking between feedings and pain with letdown or deep in the breast
• Symptoms in the baby include spitting up, poor weight gain, and difficulty maintaining latch
• Cabbage leaves or cold compresses may be used to decrease production
• Nurse the baby on one side only and express for comfort on the other

Engorgement

• This is where the breasts are overfilled with milk
• It results when the supply-and-demand process is not yet established
• Nurse frequently as the best prevention
• Newborns may nurse every hour and a half
• Cabbage leaves may be used to reduce discomfort

Plugged Duct

• Localized blockage of milk happens as a result of milk stasis
• Milk staying in the ducts causes it
• A painful knot may form in the breast
• Massage and a warm compress are the right treatment
• Prevent it by completely emptying breasts and changing the infant's position while feeding

Mastitis

• Inflammation of the breast may be infective or non-infective
• It affects 1-33% of breastfeeding women
• It is most common 2-3 weeks after birth
• It may result from sore or cracked nipples or missing a feeding

Low Milk Supply

• This is the most common reason for the cessation of breastfeeding
• It may be real or perceived due to ineffective emptying of the breast or stress
• Try nursing or pumping every 2-3 hours during the day and once at night
• A galactagogue may be prescribed

Maternal Medications

• Most medications are excreted in breast milk
• Variables like pharmacokinetic properties of the drug must be considered
• Time-averaged breast milk/plasma drug concentration ratio is another variable
• Drug exposure index, dose, strength, and duration are crucial to consider
• The ability to absorb, detoxify, and excrete the drug matters
• Variables such as age, feeding pattern, total diet, and health are also relevant
• The milk/plasma drug concentration ratio (M/P Ratio) is the ratio of the concentration of a drug in milk to the concentration of a drug in maternal plasma
• Exposure index is the average infant milk intake per kilogram of body weight per day, times 100

Drug categories

• Cytotoxic drugs, drugs of abuse, and radioactive compounds have to be considered
• Medications compatible or those with no effect on breastfeeding should be preferred
• Drugs with unknown or significant effects are also a category
• Evidence suggests combined oral contraceptives (OCs) may reduce breast milk volume
• It is recommended to avoid use of combined OCs from six weeks to six months postpartum

Herbal Remedies

• Scientific information about herb use during lactation is sparse
• Medicinal herbs should be viewed as drugs
• Many items are considered not appropriate during lactation
• Specific herbs used in the United States include Echinacea, which has insufficient data
• Ginseng root is not advisable
• St. John's wort may reduce milk supply
• Fenugreek and Goat's rue/milk thistle/blessed thistle are also options
• Fenugreek may increase milk supply, but infants may have reactions
• Goat's rue and milk thistle or blessed thistle are increasingly being used as a galactagogue

Alcohol and Other Drugs and Exposure

• Alcohol quickly passes to breast milk and the level is the same in breast milk as in maternal plasma
• Peak plasma levels occur in 30-60 minutes after consumption, if without food, or 60-90 minutes if with food
• Alcohol decreases oxytocin and letdown, affects the odor of milk, and decreases the volume consumed by the infant
• It also interferes with the infant's sleep pattern
• Nicotine poses many health risks to both the smoking mother and the infant
• Maternal smoking can cause otitis media, exacerbation of asthma, respiratory infections, and gastrointestinal dysregulation
• Nicotine levels are 1.5-3 times higher in breast milk than in the mother's blood
• Marijuana is transferred and concentrates in breast milk and is metabolized by the nursing infant
• It may change DNA/RNA formation and neurotransmitter systems needed for growth
• Moderate caffeine intake causes no problems for most breastfeeding infants and mothers
• Caffeine levels in breast milk are only 1% of that in maternal plasma
• It may accumulate in infants younger than 3-4 months (varies) and may interfere with sleep or cause hyperactivity and fussiness
• Amphetamines, cocaine, heroin, and phencyclidine (angel dust, PCP) are drugs of abuse that are contraindicated during lactation per the AAP
• The advantages of breastfeeding far outweigh potential risks from environmental pollutants

Neonatal Jaundice and Kernicterus

• Neonatal jaundice causes a yellow color of the skin and is seen in 40% of full-term and 80% of preterm infants
• Elevated bilirubin can cause permanent neurological damage if not resolved
• It is the most frequent cause for hospital readmission for newborns
• Severe hyperbilirubinemia risk factors include diabetes and Rh sensitization in the mother
• A previous child with phototherapy and the mother's race can be factors
• For the infant, prematurity and poor breastfeeding can be factors
• Blood group incompatibility and hemolytic disease are also factors
• Bilirubin is a byproduct of the normal physiologic degradation of hemoglobin
• After birth, released hemoglobin is broken down by the reticuloendothelial system
• Bilirubin is released into the circulation bound to albumin or another transport protein
• Bilirubin production in the neonate is double that of an adult due to the breakdown of fetal erythrocytes
• After the first day of birth, physiological jaundice rises steadily, peaking around the 5th day.
• Bilirubin is usually less than 12 mg/dL, and the condition resolves within a few days
• Pathological jaundice can begin within the first day after birth and rises fast lasting longer
• Bilirubin is greater than eight mg/dL in the first day
• Can be caused by medical intervention with phototherapy or it can be caused by various pathological conditions
• Early jaundice is either breast-nonfeeding or breastfeeding-related
• Infrequent/inefficiently nursing infants at risk for elevated bilirubin levels; usually resolves after 1-2 weeks
• Breast-milk jaundice syndrome becomes apparent after the third day
• A combination of factors causes this, including a substance in most mothers' milk increases intestinal absorption of bilirubin as well as individual variations in the infant's ability to process bilirubin
• The AAP guidelines recommend phototherapy using fluorescent lights and encourage continued breastfeeding in these patients

Information for Parents

• They should know that most breastfed infants will become jaundiced
• Most cases will be benign
• Only a small fraction will develop extreme hyperbilirubinemia and kernicterus

Infant Allergies

• At least four months of exclusive breastfeeding protects against dermatitis and wheezing
• Food allergies are influenced by genetics, and duration of breastfeeding
• The timing of the introduction of other foods, maternal smoking, and air pollution are further influences
• Exposure to infectious disease and maternal diet and immune system are other influencers
• There is no scientific evidence that shows gassy foods in the mother's diet produce gas in infants
• A low-allergen maternal diet is associated with a reduction in distressed behavior (colic)
• Cow's milk, eggs, peanuts, tree nuts, wheat, soy, and fish are allergenic foods that were eliminated