Breastfeeding complications

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 milk. With few exceptions, human breast milk is the best source of nourishment for human infants.cite journal |author=Picciano M |title=Nutrient composition of human milk |journal=Pediatr Clin North Am |volume=48 |issue=1 |pages=53–67 |year=2001 |pmid=11236733 |doi=10.1016/S0031-3955(05)70285-6] There are circumstances under which breastfeeding can be difficult, however, or even in rare instances contraindicated. This article looks at some of the complications that can arise in breastfeeding.

Broadly speaking, complications can arise in connection with 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."cite journal | author=Gartner LM, "et al" | title=Breastfeeding and the use of human milk | journal=Pediatrics | year=2005 | pages=496–506 | volume=115 | issue=2 | url=http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496 | doi = 10.1542/peds.2004-2491 | pmid= 15687461] Many breastfeeding difficulties can be resolved with proper hospital procedures, properly trained nurses and hospital staff and lactation consultants.cite book | author = Newman J | authorlink = Jack Newman (doctor) | coauthors = Pitman T | title = Dr. Jack Newman's guide to breastfeeding | publisher = HarperCollins Publishers | date = 2000 | isbn = 0006385680]

Several factors can interfere with successful breastfeeding:

*Formula feeding
*Artificial teats (nipples) or dummies (pacifiers)cite journal |author=Sanches MTC |title= Clinical management of oral disorders in breastfeeding |journal=J Pediatr (Rio J) |volume=80 |issue=5 Suppl |pages=S155–62 |year=2004 |doi=10.1590/S0021-75572004000700007 | pmid=15583766] cite journal | author=Marmet C | coauthors=Shell E, Aldana S | title=Assessing infant suck dysfunction: case management | journal=Journal of Human Lactation | volume=16 | issue=4 | pages= 332–6 | year=2000 | pmid=11188682]
*Thrushcite journal |author=Brent N |title=Thrush in the breastfeeding dyad: results of a survey on diagnosis and treatment |journal=Clin Pediatr (Phila) |volume=40 |issue=9 |pages=503–6 |year=2001 |pmid=11583049]
*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
*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.cite journal |author=Hagan J Jr, etal. |title=The assessment and management of acute pain in infants, children, and adolescents |journal=Pediatrics |volume=108 |issue=3 |pages=793–7 |year=2001 | url=http://aappolicy.aappublications.org/cgi/content/full/pediatrics%3b108/3/793 |pmid=11533354 |doi=10.1542/peds.108.3.793]
*Difficulties latching onto the breast
*Poor sucking reflex
*Poor staminaFact|date=February 2007
*Hypoplastic Breasts/Insufficient Glandular Tissue
*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)cite journal | author = Genna CW | title = Tongue-tie and breastfeeding | journal = LEAVEN | year = 2002 | volume = 38 | issue = 2 | pages = 27–9 | url=http://www.lalecheleague.org/llleaderweb/LV/LVAprMay02p27.html ] cite journal |author=Ballard J, Auer C, Khoury J |title=Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad |journal=Pediatrics |volume=110 |issue=5 |pages=e63 |year=2002 | url=http://pediatrics.aappublications.org/cgi/content/full/110/5/e63 |pmid=12415069 |doi=10.1542/peds.110.5.e63]
*Hypoglycemia or hyperglycemiaFact|date=February 2007
*Hypotonia, or "low-tone" infant disordercite journal | author = Genna CW | title = Tactile Defensiveness and Other Sensory Modulation Difficulties | journal = LEAVEN | year = 2002 | volume = 37 | issue = 3 | pages = 51–3 | url=http://www.lalecheleague.org/llleaderweb/LV/LVJunJul01p51.html ]
*Hyperlactation syndromecite journal | author = Livingstone V | title = Too much of a good thing. Maternal and infant hyperlactation syndromes | journal = Canadian Family Physician | year = 1996 | volume = 42 | pages = 89–99]
*Overactive let-downcite book | last= Mohrbacher | first= Nancy |coauthor=Stock, Julie | title = The Breastfeeding Answer Book | edition = 3rd ed. (revised) | publisher = La Leche League International | year = 2003 | id = ISBN 0-912500-92-1 ]
Premature babies can have difficulties coordinating their sucking reflex with breathing. They may also tire during feeds.Fact|date=February 2007

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.

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.cite journal |author=Woolridge M |title=Aetiology of sore nipples |journal=Midwifery |volume=2 |issue=4 |pages=172–6 |year=1986 |pmid=3643398 |doi=10.1016/S0266-6138(86)80042-0]

Engorgement

"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.cite journal |author=Hill P, Humenick S |title=The occurrence of breast engorgement |journal=J Hum Lact |volume=10 |issue=2 |pages=79–86 |year=1994 |pmid=7619260 |doi=10.1177/089033449401000212] 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.cite journal |author=Nikodem V, Danziger D, Gebka N, Gulmezoglu A, Hofmeyr G |title=Do cabbage leaves prevent breast engorgement? A randomized, controlled study |journal=Birth |volume=20 |issue=2 |pages=61–4 |year=1993 |pmid=8240608 |doi=10.1111/j.1523-536X.1993.tb00418.x] Non-steroidal anti-inflammatory drugs or paracetamol (acetominophen) may relieve the pain.

Nipple pain

Sore nipples are probably the most common complaint after the birth. They are generally reported by the second day after delivery but improve within 5 days.cite journal |author=Ziemer M, Paone J, Schupay J, Cole E |title=Methods to prevent and manage nipple pain in breastfeeding women |journal=West J Nurs Res |volume=12 |issue=6 |pages=732–43; discussion 743–4 |year=1990 |pmid=2275191 |doi=10.1177/019394599001200603] 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.cite journal |author=Cable B, Stewart M, Davis J |title=Nipple wound care: a new approach to an old problem |journal=J Hum Lact |volume=13 |issue=4 |pages=313–8 |year=1997 |pmid=9429367 |doi=10.1177/089033449701300417] Nipple pain can also be a sign of infection.cite journal | author = Amir L | coauthors = Garland S, Dennerstein L, Farish S | title = Candida albicans: is it associated with nipple pain in lactating women? | journal = Gynecol Obstet Invest | volume = 41 | issue = 1 | pages = pp. 30–34 | publisher = Karger | date = 1996 | pmid = 8821881] When the baby bites the nipple it can also be painful.

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.cite journal |author=Tanguay K, McBean M, Jain E |title=Nipple candidiasis among breastfeeding mothers. Case-control study of predisposing factors |journal=Can Fam Physician |volume=40 |issue= |pages=1407–13 |year=1994 |pmid=8081120]

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 2–3 weeks after delivery but can happen at any time.cite journal |author=Evans M, Heads J |title=Incidence of mastitis in breastfeeding women during the six months after delivery: a prospective cohort study |journal=Med J Aust |volume=170 |issue=4 |pages=192 |year=1999 |pmid=10078195] 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.

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 had unusually excessive exposure to heavy metals such as mercury,cite journal | author = Amin-Zaki L | coauthors = Majeed MA, Greenwood MR, Elhassani SB, Clarkson TW, Doherty RA. | title = Methylmercury poisoning in the Iraqi suckling infant: a longitudinal study over five years | journal = Journal of Applied Toxicology | volume = 1 | issue = 4 | pages = pp. 210–214 | publisher = | date = 1981 | url = | doi = | pmid = 6892222 ] has HIV,cite web | title = HIV and Infant Feeding | publisher = Unicef | url = http://www.unicef.org/programme/breastfeeding/hiv.htm | accessdate = 2006-08-19 ] cite web | title = When should a mother avoid breastfeeding? | publisher = Centers for Disease Control and Prevention | date = 2006-08-26 | url = http://www.cdc.gov/breastfeeding/disease/contraindicators.htm | accessdate = 2007-03-04 ] or uses potentially harmful substances such as cocaine, heroin, and amphetamines..

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: cquote|Women with tuberculosis who have been treated appropriately for 2 or more weeks and who are not considered contagious may breastfeed. Women with tuberculosis disease suspected of being contagious should refrain from breastfeeding or any other close contact with the infant because of potential transmission through respiratory tract droplets (see Tuberculosis, p 678). "Mycobacterium tuberculosis" rarely causes mastitis or a breast abscess, but if a breast abscess caused by "M. tuberculosis" is present, breastfeeding should be discontinued until the mother no longer is contagious.

In areas where BCG vaccination is the standard of care, the WHO provides treatment recommendations and advises mothers to continue breastfeeding. [http://www.who.int/child-adolescent-health/New_Publications/NUTRITION/Breastfeeding_Tub.pdf The WHO] on Breastfeeding and maternal tuberculosis; acquired 2006-08-19] TBC may be congenital, or perinatally acquired through airborne droplet spread.cite journal |author=Nemir R, O'Hare D |title=Congenital tuberculosis. Review and diagnostic guidelines |journal=Am J Dis Child |volume=139 |issue=3 |pages=284–7 |year=1985 |pmid=3976610]

Medications

The vast majority of medicines are compatible with breastfeeding, but there are some that might be passed onto the child through the milk.cite journal | author = American Academy of Pediatrics Committee on Drugs | title = The Transfer of Drugs and Other Chemicals Into Human Milk | journal = Pediatrics | volume = 108 | issue = 3 | pages = pp. 776–789 | date = 2001 | pmid = 11533352 ]

HIV

Research published in the Lancetcite journal |author= Coovadia, H. M.; Rollins, N. C.; Bland, R. M.; Little, K.; Coutsoudis, A.; Bennish, M. L. and Newell, M.|title= Mother-to-child transmission of HIV-1 infection during exclusive breastfeeding in the first 6 months of life: an intervention cohort study.|journal=The Lancet |volume=369| pages=1107–16 |year=2007|doi= 10.1016/S0140-6736(07)60283-9 ] [ [http://news.bbc.co.uk/1/hi/health/6507309.stm Breastfeeding alone cuts HIV risk] ] 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. [Nduati, R. et al. Effect of Breastfeeding and Formula Feeding on Transmission of HIV-1, A Randomized Clinical Trial. "Journal of American Medical Association". (2000) 283:9. ] 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. [World Health Organization. "Statement from the Consultation on Breast-feeding/Breast Milk and Human Immunodeficiency Virus (HIV)". Geneva, Switzerland: WHO; 1987.] [Global Programme on AIDS. Consensus statement from the WHO/UNICEF consultation on HIV transmission and breast-feeding. "Weekly Epidemiol Rec". 1992; 67:177-179.] 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. [Joint United Nations Program on HIV/AIDS. HIV and infant feeding. "Wkly Epidemiol Rec". 1996; 71:289-291.] 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 diahhrea. [Jelliffe, D., Jelliffe, E. Feeding Young Infants in Developing Countries: Comments on the Current Situation and Future Needs. "Studies in Family Planning" (1978). Vol 9, No. 8: 227-229 ] . 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. [Dettwyler, K., Fishman, C. Infant Feeding Practices and Growth. "Annual Review of Anthropology", Vol. 21 (1992), pp. 171-204.]

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.

Breastfeeding mothers must use caution if they smoke and therefore consume nicotine. 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. Research is ongoing to find out if the benefits of breastfeeding outweigh the potential harm of nicotine in breast milk. Sudden Infant Death Syndrome (SIDS) is more common in babies exposed to a smoky environment.cite journal |author=Gunn A, Gunn T, Mitchell E |title=CLINICAL REVIEW ARTICLE: Is changing the sleep environment enough? Current recommendations for SIDS |journal=Sleep Med Rev |volume=4 |issue=5 |pages=453–69 |year=2000 |pmid=17210277 |doi=10.1053/smrv.2000.0119] 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.cite journal | last = Villamunga | first=Dana | title = Smoking and Breastfeeding | journal = LEAVEN | year = 2004 | volume = 40 | issue = 4 | pages = 75–8 | url=http://www.llli.org/llleaderweb/LV/LVAugSep04p75.html ]

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.cite book | last = Gotch | first = Gwen | coauthors = Torgus, Judy | title = The Womanly Art of Breastfeeding | edition = 6th ed. | publisher = Plume |pages=p. 327 | year = 1997 | id = ISBN 978-0-452-27908-7 ] 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.Citation | author = Rosenstein S | coauthors = Bautis S, King B, Piercy M, Seeman MV, Wood W | title = Is It Safe for My Baby? | place = Toronto | publisher = Centre for Addiction and Mental Health | year = 2003 | url = http://www.camh.net/About_Addiction_Mental_Health/Drug_and_Addiction_Information/Safe_Baby/index.html | isbn = 0-88868-446-0 ]

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) 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.cite book | last = Lawrence | first = Ruth A | coauthors = Lawrence, Robert M | title = Breastfeeding: A Guide for the Medical Profession | pages= p. 369 | edition = 5th ed. | publisher = C.V. Mosby | year = 1999 | id = ISBN 978-0-815-12615-7 ]

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. [ [http://www.aap.org/policy/0063.html American Association of Pediatrics] on cannabis (see table 2); acquired 2006-08-19]

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.Tamborlane, et al. The Yale Guide to Children's Nutrition. Yale University Press. 1997. pg 33] Consumption of 1,500–1,800 calories per day could coincide with a weight loss of 450 grams (one pound) per week.cite web | title = How can I lose weight safely while breastfeeding?| work = |publisher=La Leche League International | url = http://www.lalecheleague.org/FAQ/diet.html | date= 2006-08-29 | accessdate = 2007-02-12] While mothers in famine conditions can produce milk with highly nutritional content, a malnourished mother may produce milk with decreased levels of vitamins A, D, B₆ and B₁₂.cite web | title = I am breastfeeding my baby and I want to lose weight. Is a low carbohydrate diet safe for a breastfeeding mother?| work = |publisher=La Leche League International | url = http://www.lalecheleague.org/FAQ/lowcarb.html | date= 2006-08-29 | accessdate = 2007-02-12] 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.

References

Unnumbered references

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External links

* [http://whyquit.com/whyquit/LinksBirth.html WhyQuit.com] – Anti-smoking site with numerous links in the "Known Breastfeeding Risk Factors" section
* [http://www.findarticles.com/p/articles/mi_qa3804/is_200404/ai_n9401756/print Antidepressants, Antipsychotics, Benzodiazepines, and the Breastfeeding Dyad] Perspectives in Psychiatric Care, Apr-Jun 2004, by Kirsten J. Malone. This article discusses the risks to both mother and child of formula feeding and attempts to weigh them against the risk to infants of absorbing psychotropic drugs through breast milk.
* [http://www.center4research.org/implantso.html Breast Surgery Likely To Cause Breastfeeding Problems] National Research Center for Women and Families