Breastfeeding difficulties

# Overview
Breastfeeding is the feeding of an infant or young child with milk from a woman's breasts. Babies have a sucking reflex that enables them to suck and swallow milk. With few exceptions, human breast milk is the best source of nourishment for human infants. There are circumstances under which breastfeeding can be problematic, however, or even in rare instances contraindicated.  This article looks at some of the difficulties that can arise in breastfeeding.
Broadly speaking, difficulties can arise in connection with the act of breastfeeding, on one hand, and the health of the nursing infant, on the other.

# Breastfeeding
While breastfeeding difficulties are not uncommon, putting the baby to the breast as soon as possible after birth helps to avoid many problems. The policy of the American Academy of Pediatrics on breastfeeding says, "delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed."  Many breastfeeding difficulties can be resolved with proper hospital procedures, properly trained nurses and hospital staff, speech pathologists and lactation consultants.
Several factors can interfere with successful breastfeeding:
- Formula feeding
- Artificial teats (nipples) or dummies (pacifiers)
- Thrush
- Distractions or interruptions during feeds
- Long separations from the mother
- Tachypnea (rapid breathing) such as in transient tachypnea of the newborn, surfactant deficiency, respiratory distress syndrome or other infant medical conditions
- Presence of an actual physical barrier between mother and infant
- Swallowing difficulties such as with prematurity and coordination of sucking, swallowing and breathing, or gastro-intestinal tract abnormalities like tracheo-oesophageal fistula.
- Pain resulting from surgical procedures like circumcision, blood tests, or vaccinations.
- Difficulties latching onto the breast
- Poor sucking reflex
- Hypoplastic Breasts/Insufficient Glandular Tissue
- Agalactia (absence of lactation)
- Polycystic Ovarian Syndrome
- Diabetes
- Severe maternal stressors
- Insufficient rest/support of the mother during the first 6 weeks post-partum
- Early return to work due to lack of financial support/maternity leave of mother
- Cleft palate
- Ankyloglossia (tongue tie)
- Hypoglycemia or hyperglycemia
- Hypotonia, or "low-tone" infant disorder
- Hyperlactation syndrome
- Overactive let-down
- Oversupply of breast milk with or without an overactive let-down.
- Premature babies can have difficulties coordinating their sucking reflex with breathing. They may also tire during feeds. Premature infants unable to take enough calories by mouth may need enteral or gavage feeding - inserting a feeding tube into the stomach to provide enough breast milk or a substitute. This is often done together with Kangaroo care (prolonged skin-to-skin contact with the mother) which makes later breastfeeding easier. For some suckling difficulties, such as may happen with cleft lip/palate, the baby can be fed with a Haberman Feeder.
- Dysphoric Milk Ejection Reflex (D-MER) is a newly recognized condition affecting lactating women that is characterized by an abrupt dysphoria, or negative emotions that occur just before milk release and continuing not more than a few minutes. Preliminary testing tells us that D-MER is treatable and preliminary research tells us that inappropriate dopamine activity at the time of the milk ejection reflex is the cause of D-MER.

## Breast Pain
Pain often interferes with successful breastfeeding. It is cited as the second most common cause for the abandonment of exclusive breastfeeding after perceived low milk supply.

## Engorgement
Breast engorgement is the sense of breast fullness experienced by most women within 36 hours of delivery. Normally, this is a painless sensation of "heaviness". Breastfeeding on demand is the primary way of preventing painful engorgement.
When the breast overfills with milk it becomes painful. Engorgement comes from not getting enough milk from the breast. It happens about 3 to 7 days after delivery and occurs more often in first time mothers. The increased blood supply, the accumulated milk and the swelling all contribute to the painful engorgement. Engorgement may affect the areola, the periphery of the breast or the entire breast, and may interfere with breastfeeding both from the pain and also from the distortion of the normal shape of the areola/nipple. This makes it harder for the baby to latch on properly for feeding. Latching may occur over only part of the areola. This can irritate the nipple more, and may lead to ineffective drainage of breast milk and more pain. Engorgement may begin as a result of several factors such as nipple pain, improper feeding technique, infrequent feeding or infant-mother separation.
To prevent  or treat engorgement, remove the milk from the breast, by breastfeeding, expressing or pumping. Gentle massage can help start the milk flow and so reduce the pressure. The reduced pressure softens the areola, perhaps even allowing the infant to feed. Warm water or warm compresses and expressing some milk before feeding can also help make breastfeeding more effective. Some researchers have suggested that after breastfeeding, mothers should pump and/or apply cold compresses to reduce swelling pain and vascularity even more. One published study suggested the use of "chilled cabbage leaves" applied to the breasts. Attempts to reproduce this technique met with mixed results. Non-steroidal anti-inflammatory drugs or paracetamol (acetominophen) may relieve the pain.

## Nipple Pain
Sore nipples (nipple pain, or thelalgia) are probably the most common complaint after the birth. They are generally reported by the second day after delivery but improve within 5 days. Pain beyond the first week, severe pain, cracking, fissures or localized swelling is not normal. The mother should see a doctor for further evaluation. Sore nipples, a common cause of pain, often come from the baby not latching on properly. Factors include too much pressure on the nipple when not enough of the areola is latched onto and an improper release of suction at the end of the feeding. Improper use of breast pumps or topical remedies can also contribute. Nipple pain can also be a sign of infection. When the baby bites the nipple it can also be painful.
Treatment with botulinum toxin has been described.

## Candidiasis
Symptoms of candidiasis of the breast include pain, itching, burning and redness, or a shiny or white patchy appearance. The baby could have a white tongue that does not wipe clean. Candidiasis is common and may be associated with infant thrush. Both mother and baby must be treated to get rid of this infection; first-line therapies include nystatin, ketaconacole or miconazole applied to the nipple and given by mouth to the baby. Strict cleaning of clothing and breast pumps is also required to eradicate the infection.
Another effective treatment of candidia is the use of gentian violet. When the nursing mother has a Candidal infection of the nipple, she may experience severe nipple pain, as well as deep breast pain.   Please note: Gentian violet 1% in water also contains alcohol.   Apparently some pharmacists are now dissolving it in glycerin, thus avoiding the use of alcohol. It is believed that gentian violet  is the best treatment of nipple soreness due to Candida albicans for the breastfeeding mother.   This is because it usually works, and relief is rapid.   It is messy, and will stain clothing (actually, it will usually wash out), but not skin.   The baby's lips will turn purple, but the purple will disappear after a few days.   Gentian violet is available without prescription but is not available at all pharmacies.   Call around before going out to get it.

## Milk Stasis
Milk stasis is when a milk duct is blocked and cannot drain properly. This may affect only a part of the breast and is not associated with any infection. It can be treated by varying the baby's feeding position and applying heat before feeding. If it happens more than once, further evaluation is needed.

## Mastitis
Mastitis is an inflammation of the breast. It causes local pain (dolor), redness (rubor), swelling (tumor), and warmth (calor). Later stages of mastitis cause symptoms of systemic infection like fever and nausea. It mostly occurs 23 weeks after delivery but can happen at any time. Typically results from milk stasis with primary or secondary local, later systemic infection. Infectious organisms include Staphylococcus sp., Streptococcus sp. and E. coli. Continued breastfeeding, plenty of rest and adequate fluid supply is the best treatment for light cases.

## Overactive Let-down
Overactive let-down (OALD) is the forceful ejection of milk from the breast during breastfeeding. The forceful spray of milk can cause the baby to consume too much milk too quickly as well as to swallow air during the period of rapid swallowing following the let-down.

## Raynaud's of the Nipple
Very rarely, nipple pain can be caused by vasospasm of the nipple. In essence, blood does not flow properly to the nipple which causes the nipple to blanch. This can be caused by trauma to the nipple through early breastfeeding or candidal infection of the nipple. The pain is intense during the latch stage and in between breastfeeding sessions there is a throbbing pain when the nipple is blanched. The nipple can be massaged to help blood flow return to reduce pain, as well as avoiding cold. In some instances, heart medication, nifedipine, is used to help the blood flow return to the nipple.

# Health of the Infant
Infants with classic galactosemia cannot digest lactose and therefore cannot benefit from breast milk. Breastfeeding might harm the baby also if the mother has untreated pulmonary tuberculosis, is taking certain medications that suppress the immune system. has HIV, or uses potentially harmful substances such as cocaine, heroin, and amphetamines. Other than cases of acute poisoning, no environmental contaminant has been found to cause more harm to infants than lack of breastfeeding. Although heavy metals such as mercury are dispersed throughout the environment and are of concern to the nursing infant, the neurodevelopmental benefits of human milk tend to override the potential adverse effects of neurotoxicants.

## Transmission of Infection

### Tuberculosis
It is not safe for mothers with active, untreated tuberculosis to breastfeed until they are no longer contagious. According to the American Academy of Pediatrics 2006 Redbook:
In areas where BCG vaccination is the standard of care, the WHO provides treatment recommendations and advises mothers to continue breastfeeding. TBC may be congenital, or perinatally acquired through airborne droplet spread.

### HIV
Research published in the Lancet has highlighted a lower risk of HIV transmission with exclusive breastfeeding by HIV positive mothers (4 percent risk), compared to mixed feeding (10-40 percent risk). Research on the timing of HIV transmission in 2000 revealed that a "substantial transmission occurs early during breastfeeding," concluding that 75% of all breast milk transmission had occurred within the first 6 months during a randomized control trial in Kenya. This research is of particular importance in developing countries where infant formula is not widely available or safe to prepare. In fact, the World Health Organization recommended breastfeeding in 1987 and 1992 for seropositive and seronegative women in areas where malnutrition and infectious diseases are the major cause of infant mortality. In 1996 UNAIDS issued a recommendation that women in developing countries consider the risks and benefits of each feeding practice on an individual level; they recommended women make an informed choice about infant feeding.  In the days before the AIDS epidemic was clearly understood, some researchers pointed to the need to increase breastfeeding rates and pointed to the risks of formula feeding, citing increased rates of marasmus and diarrhea. D. Jelliffe and E. Jelliffe also criticized the marketing of infant formulas by U.S. companies to resource-poor countries, something they termed "comerciogenic malnutrition." A more recent article from 1992 describes how the health of an infant can be compromised by water, which in many resource-poor countries holds the risk of environmental pathogens that are not present in breastmilk.

## Transmission of Drugs and Toxins

### Medications
The vast majority of medicines are compatible with breastfeeding, but there are some that might be passed onto the child through the milk.

### Tobacco Smoking
If one does continue tobacco smoking after giving birth, however, it is still more beneficial to breastfeed than to completely avoid this practice altogether. There is evidence that breastfeeding offers protection against many infectious diseases, especially diarrhea. Even in babies exposed to the harmful effects of nicotine through breast milk, the likelihood of acute respiratory illnessis significantly diminished when compared to infants whose mothers smoked but were formula fed.  Regardless, the benefits of breastfeeding outweigh the risks of nicotine exposure.
The main concern about smoking and breastfeeding is that infants may have smoking-induced reductions to the milk iodine content.  Smoking can adversely affect the lactation process by decreasing milk production and altering the milk composition. Smoking reduces daily milk output by roughly 250300 mL.  Not only will this be problematic on a daily basis for not producing enough milk, it will also cause the mother to wean her baby early.  The altered milk composition also caused infants to exhibit daily behaviors such as colic and crying which can promote early weaning, again something that is not beneficial to the infant.
Also, the nicotine obtained from smoking travels through a woman into her breast milk, thus giving nicotine to her child.
Heavy use of cigarettes by the mother (more than 20 per day) has been shown to reduce the mother's milk supply and cause vomiting, diarrhoea, rapid heart rate, and restlessness in breastfed infants. Sudden Infant Death Syndrome (SIDS) is more common in babies exposed to a smoky environment. Breastfeeding mothers who smoke are counseled not to do so during or immediately before feeding their child, and are encouraged to seek advice to help them reduce their nicotine intake or quit.

### Other Substance Abuse
The baby's risk from something unsafe in breast milk depends on how much of that substance the baby gets. The level of risk depends on the concentration of the substance in the breast milk and how much milk the infant consumes. Finally, that risk is weighed against the risks of using a substitute for breast milk, such as infant formula.
Heavy alcohol consumption harms the infant, causing problems with the development of motor skills and decreasing the speed of weight gain. There is no consensus on how much alcohol may be consumed safely, but it is generally agreed that small amounts of alcohol may be occasionally consumed by a breastfeeding mother. Considering the known dangers of alcohol exposure to the developing fetus, those mothers wishing to err on the side of caution should restrict or eliminate their alcoholic intake.
If the mother consumes too much caffeine, it can cause irritability, sleeplessness, nervousness and increased feeding in the breastfed infant. Moderate use (one to two cups per day of coffee, tea, or cola) usually produces no effect. Breastfeeding mothers are advised to restrict or avoid caffeine if her baby reacts negatively to it.  
Cigarette smoking is thought to increase the effects of caffeine in the baby.
Cannabis is listed by the American Association of Pediatrics as a compound that transfers into human breast milk. Research demonstrated that certain compounds in marijuana have a very long half-life.

# Diet
An exclusively breastfed baby depends on breast milk completely so it is important for the mother to maintain a healthy lifestyle, and especially a good diet. Consumption of 1,5001,800 calories per day could coincide with a weight loss of 450 grams (one pound) per week. While mothers in famine conditions can produce milk with highly nutritional content, a malnourished mother may produce milk with decreased levels of several micronutrients such as iron, zinc, and vitamin B12. She may also have a lower supply than well-fed mothers.
There are no foods that are absolutely contraindicated during breastfeeding, but a baby may show sensitivity to particular foods that the mother eats.