QuestionSBA
QuestionChoice
Difficulties in breastfeeding are common in the first few days and weeks. Women should be supported and encouraged to continue breastfeeding where possible.
50016
e
She should switch to bottle feeding indefinitely
QuestionChoice
Ideally the women should continue either breastfeeding or expressing milk by hand to encourage further milk production.
50013
b
She should stop breastfeeding for three days and re-attempt
QuestionChoice
There is no indication of abscess or breast pathology that merits imaging in this case.
50015
d
Refer to hospital for an ultrasound of both breasts
QuestionChoice
This is the treatment for a thrush infection. There is no indication here of a thrush infection, and the discomfort is likely caused by poor attachment.
50014
c
Clotrimazole 1% applied to the nipples twice daily
QuestionChoice
In most cases, nipple discomfort in the first few days is due to poor nipple attachment, in which case breastfeeding support can benefit.
50012
a
Speak to her midwife for breastfeeding support
Concept
Chapter
# Summary
 
Breastfeeding provides many health benefits for both infant and mother. It is recommended by the WHO for infants until 6 months, with continued breastfeeding alongside solid foods until age 2 or beyond. It provides key benefits to both infant and mother, such as immunity support and reduced disease risks. Despite this, many infants are not breastfed for the recommended duration. Common breastfeeding issues include nipple pain, engorgement, mastitis, and insufficient milk. Management often involves pain relief, continued breastfeeding, and antibiotics when necessary. For mothers who choose not to breastfeed, formula is a suitable alternative.

# Definition

Breastfeeding is the process of feeding an infant or young child with breast milk directly from the breast. It is advised by the World Health Organisation (WHO) that an infant is exclusively breastfed until 6 months, followed by gradual introduction of solid food and breastfeeding until age 2 or longer. 
 
Benefits of breastfeeding include:
 
- To the infant:
     - Antibodies and protection against infection
     - Reduced atopic eczema and asthma 
     - Reduced rates of obesity later in childhood
- To the mother:
     - Reduced risk of diabetes mellitus and heart disease 
     - Protective against breast and ovarian cancer

# Epidemiology

Globally, nearly 66% of infants are not exclusively breastfed for the recommended 6 months – a rate that has not improved in 2 decades. Breastfeeding rates in the UK are low - approximately 34% of infants are breastfed at 6 months. 

# Common issues
 
- Cracked/sore nipples: pain, discomfort, visible cracks or sores on nipples.
- Blocked duct and breast engorgement: pain, swelling, warmth, redness, lump in the breast.
- Mastitis/abscess: fever, intense breast pain, red, swollen, warm breast, malaise, pus or discharge from the nipple.
     - This can be managed using antibiotics and analgesia
- Thrush: white patches on the tongue or inside of the mouth, pain, discomfort, and difficulty feeding.
- Insufficient milk: slow weight gain, fewer than six wet diapers a day, persistent hunger, no night feeds 

#  Investigations
 
For any individual with breastfeeding problems:
 
 - Take a breastfeeding history and complete the UNICEF UK Baby Friendly Initiative Breastfeeding assessment form 
 - A health visitor or breastfeeding specialist may be needed to observe to ensure optimal breastfeeding technique 
 - Consider skin swab or breast milk sample for microscopy and culture if suspected bacterial or candida infection is present 

# Management 

Management of problems with breastfeeding may include:

- For breast engorgement and blocked ducts:
    - Encourage continued breastfeeding
    - Analgesia (see below) and warm compress for pain relief 
    - Wear comfortable and non-restrictive clothing 
- For mastitis or breast abscess:
    - Manage conservative management as for breast engorgement 
    - Breastfeeding should be encouraged 
    - Oral antibiotics can be used for symptoms not improving after 12-24 hours or if breast milk culture is positive 
- For nipple damage:
    - Consider review by health visitor for advice and support 
    - Consider ankyloglossia (tongue tie) in infant 
- For low milk supply:
    - Reassure the mother and manage any underlying cause (i.e. stress, hypothyroidism)
    - If continuing or concerns about the child's growth, refer for further treatment and investigations
- Milk oversupply
    - Encourage breastfeeding
    - Avoid expressing milk by hand or breast pump between feeds to reduce overstimulation 

# Medications and Breastfeeding
 
## Antibiotics
 

 - Antibiotics that are **safe** to use in breastfeeding mothers include: penicillin-based antibiotics, beta-lactam antibiotics, trimethoprim, azithromycin, cephalosporins, clarithromycin, erythromycin
 - IV gentamicin and meropenem can also be given
 - Tetracyclines although previously contraindicated - may be given in short courses, however, caution is advised
 - Most antibiotics can produce excessively loose motions in the baby, with the appearance of diarrhoea. Some infants appear more unsettled with tummy aches or colic. These effects are not clinically significant and do not require treatment.
 - Antibiotics which are **cautioned** or **contra-indicated** include: ciprofloxacin (potential joint problems), nitrofurantoin (G6PD deficiency), teicoplanin, clindamycin (antibiotic-associated colitis), co-trimoxazole. 
 

## Analgesia
  
  - Paracetamol and ibuprofen form the basis for safe analgesics for breastfeeding mothers.
  - NSAIDs are safe to use in breastfeeding mothers. 
  - Stronger drugs are available but should be taken with caution and babies observed for drowsiness.
  - Dihydrocodeine is the preferred opiate analgesic if mothers need stronger painkillers. This is because it has a cleaner metabolism than codeine and is less associated with adverse effects in the baby. It is frequently used as a drug after caesarean section.
  
  - Aspirin as a painkiller should be avoided because of the increased risk of Reye’s syndrome in paediatric viral infections.
  - Codeine is no longer recommended as routine medication for breastfeeding mothers (MHRA June 2013, BNF) with particular caution where the mother has never taken the drug before or has found that the drug causes her to be drowsy, dizzy or experience severe constipation.
 

## Alcohol and breastfeeding
 
Breastfeeding mothers can have occasional, small amounts of alcohol but should not drink regularly or heavily (e.g. binge drinking) without considering how to limit the baby’s exposure.


# Infection Transmission and Breastfeeding 

## HIV transmission
 

 - An HIV-infected mother can pass HIV to her infant during pregnancy and delivery 
 - Anti-retroviral drugs reduce the risk of transmission of HIV through breastfeeding
 - However, current recommendations advise that HIV-infected mothers should refrain from breastfeeding 
 

## Hepatitis B transmission
 
There is no risk for mother-to-child transmission of Hepatitis B provided the infant has received appropriate HBV vaccination after birth and the nipples are not cracked or bleeding. 

#  Alternatives

For mothers who prefer not to breastfeed, there are multiple types of formula available. Infants must have first infant formula when under 6 months, and that follow-on formula can only be used over the age of 6 months. It is important that infants under 1 year should not be given cow's milk as a drink alone, but can be used in cooking. 
 
 
#  NICE Guidelines
 
[NICE Guidelines on Breastfeeding problems](https://cks.nice.org.uk/topics/breastfeeding-problems/) 

# References 
 
[Patient Info on Infant Feeding](https://patient.info/doctor/infant-feeding)

[WHO Health Topics on Breastfeeding](https://www.who.int/health-topics/breastfeeding#tab=tab_1)

[Breastfeeding Network Drugs Factsheets](https://www.breastfeedingnetwork.org.uk/drugs-factsheets/)

[NHS Types of formula](https://www.nhs.uk/conditions/baby/breastfeeding-and-bottle-feeding/bottle-feeding/types-of-formula/)
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Breastfeeding
Topic
38
Obstetrics
10039
A 24-year-old woman calls her general practice with problems breastfeeding. She is three days postpartum, having delivered a baby boy by spontaneous vaginal delivery.

She describes both nipples as painful and it's uncomfortable for her to breastfeed. There is no unusual nipple discharge, swelling or redness, and the skin is intact. She is otherwise well.

What is the most appropriate advice?
a