Common breastfeeding concerns

Some degree of breast fullness is expected and normal as your milk comes in but some women experience breast engorgement.

Breast engorgement is swelling, hardness, and an increased breast size. It happens about 3 to 5 days after birth when your milk is “coming in” or may occur later if you missed feedings or pump sessions. A congestion of blood and lymphatic fluids in the breast and increasing fullness from milk production can slow or stop drainage of these fluids and prevent milk from flowing out. Moderately severe engorged breasts are hard, full, tense, warm and tender with throbbing and aching pain.

The pressure in your breast from unrelieved engorgement can damage milk-producing cells and affect your ability to make milk enough milk for your baby.

To prevent or minimize engorgement

• Breastfeed often, every 1-2 hours, to avoid severe breast engorgement especially in the first 48 hours after birth.
• Alternate that breast you start breastfeeding with. Allow your baby to breastfeed on the first breast until it feels softer before offering the other breast.
• If you are pumping, pump often. Double pump at least every 3 hours or sooner during the daytime and nighttime. Pump long enough, until no more milk is dripping, at least 15” up to 30”.

What to do if your breasts become engorged

• Reverse pressure softening can be performed to soften the area around the areola to make it easier for the baby to latch.
• Using your fingertips, apply gentle firm pressure to your areola for 30 seconds. This will move some of the fluid back into your breast.
• If your baby cannot successfully latch and breastfeed, you can relieve breast engorgement by manually expressing milk or pumping, and then trying breastfeeding again.
• Wear a well-fitting supportive bra.
• Cold packs applied to the breast may reduce swelling and provide comfort.

Plugged or blocked milk ducts happen when milk is not moving well or backs up in a part of your breast. It is caused by a small blockage or poor drainage of a milk duct. It can happen from incomplete drainage, skipped feedings, or skipped pump session. Sometimes the symptoms happen quickly or may come on gradually. If the plugged ducts is not treated it can lead to mastitis or a breast infection.

Symptom of a plugged duct are

• A tender lump in one area of the breast that causes pain, but no fever
• Sometimes there are visible, tiny white milk plugs called blebs in an opening on the nipple

To prevent plugged milk ducts

• Breastfeed or pump often, at least 8-12 times per day
• Manually massage the breast during feeding or pumping to help milk drain
• Avoid tight clothing, underwire bras or tight straps on a baby carrier
• Avoid exhaustion and fatigue

What to do if you get plugged milk ducts

• Continue frequent breastfeeding or pumping
• Before a feeding or pumping
• Apply warm compresses or a heating pad to the area
• Take a warm shower and express some milk
• Lean over a sink or bowl of warm water
• Begin feeding on the affected side to help drain the breast
• Massage before and during feeding or pumping to help milk flow
• Apply firm pressure starting at the outside of the breast moving towards the plug
• Change breastfeeding positions
• Some women report that the dietary supplement lecithin prevents recurrence of plugged ducts
• To reduce pain, take acetaminophen or ibuprofen before breastfeeding or pumping
• Apply washed, cool cabbage leaves to the breasts for 20 minutes at a time or until the leaves wilt

Mastitis is a breast infection or inflammation and it can be infectious or non-infectious. Non-infective mastitis may progress to infective mastitis. Infectious mastitis is caused by a bacteria and may need to be treated with antibiotics. Bacteria may enter the breast through a crack in the nipple and spread through the ducts. Mastitis usually occurs within the first six weeks of breastfeeding, but can happen anytime. Often mastitis begins with engorgement and poor drainage of the breast could trigger mastitis especially when you are exhausted from lack of sleep and stress.

Symptoms of infectious mastitis are

• Redness, tenderness and heat in an area of the breast
• A fever and flu-like symptoms such as nausea, aches and chills
• Decreased milk flow in the affected breast
• Sudden onset with intense pain in one breast, rarely in both breasts

To prevent breast mastitis

• Massage any red or firm areas of the breast especially while breastfeeding
• Pump or express milk if you miss a feeding
• Pump or express milk if your breasts are engorged or still full after a feeding
• Breastfeed often, at least 8-12 times per day
•  Prioritize tasks and get help with chores, cooking and care for other children
• Reduce stress and fatigue
• Take naps when your baby sleeps
• Avoid underwire bras that block milk flow
• Delay return to work as long as possible
• If you’ve had mastitis before you are more likely to get it again - use preventive methods before it occurs

What to do if you get mastitis

• Keep nursing or pumping. Your baby will not get sick from your milk
• Begin breastfeeding with the unaffected breast to allow your milk to let-down in the affected breast to reduce pain
• Keep the affected breast as empty as possible
• Breastfeed often
• Hand express or pump after breastfeeding several times per day
• Call your healthcare provider and/or a lactation consultant to discuss your symptoms
• Your healthcare provider may prescribe antibiotics that are safe with breastfeeding to reduce reoccurrence, a worsening infection or abscess. Make sure to complete your full course of antibiotics
• Go to bed
• Take your baby to bed with you so you can breastfeed often
• Allow others to help with household chores and caring for your baby and other children
• Apply ice packs or hot packs to your breasts — whichever gives you the most comfort
• Drink lots of fluids
• To reduce pain, take acetaminophen or ibuprofen

Many women worry they don’t have enough milk for their babies, but it is rare to have an actual problem with making milk. Understanding normal milk production can help.

During the first few days after birth it is normal to produce very small amounts of the first milk, colostrum. New mothers notice more milk production after the day 4-6. In mothers who have a caesarian section it can take longer, another 1-2 days. By the end of the first 10-14 days, you will be producing around 500-1,000 ml (or 16-32 ounces) of milk per day.

Breastfed babies should breastfeed 8-12 times per day or more in the early days. Babies may feed from one or both breasts depending on how hungry or awake they are. If you are separated from your baby and are pumping, pump eight times or more every 24-hour hours.

Medical issues that can cause low milk supply

• Severe postpartum bleeding or hemorrhage (more than 1,000 ml). You can ask your healthcare provider about blood loss during labor and delivery
• Treatment with magnesium sulfate before birth for high blood pressure or preterm labor
• Placenta pieces still remaining in your uterus (usually you will have severe cramps and heavy bleeding) Call your health care provider if you think you have retained
  placenta
• No breast growth during pregnancy and after birth
• Breast reduction surgery
• Untreated hypothyroidism
• Polycystic ovarian syndrome (PCOS)
• Obesity
• Diabetes
• Smoking
• High blood pressure
• Steroids given during pregnancy for infant lung maturation for moms expecting to deliver prematurely 

Other causes of low milk supply

• Poor latch
• Sore nipples
• Flat nipples that make it difficult for the baby to latch
• Not breastfeeding or pumping often enough
• Change in feeding pattern (mom returns to work or baby sleeps through the night)
• Supplementing the baby with formula instead of breastfeeding
• Baby has a weak suck or poor endurance or is ill
• Baby has a significant tongue-tie

Treatment for low milk supply

• Hold the baby skin-to-skin as much as possible (diaper-only baby on your naked chest)
• Breastfeed or pump more often
• Use hand compression during breastfeeding to bring down more milk
• Use hand compression with pumping and hand express more milk after pumping
• Massage your breasts before, during and after feedings
• Relax during breastfeeding or pumping
• Hand-express and/or pump after feedings
• Improve latch with the help of a lactation consultant
• Medications such as Reglan® (metoclopramide) or Motilium®
• Some research says herbs used to increase milk supply like fenugreek can help