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Subscriber: null; date: 18 August 2018

  • Constituents of breast milk [link]

  • Advantages of breastfeeding [link]

  • Contraindications to breastfeeding [link]

  • Management of breastfeeding [link]

  • The 10 steps to successful breastfeeding [link]

  • Support for breastfeeding [link]

  • Practices shown to be detrimental to successful breastfeeding [link]

  • Expression of breast milk [link]

  • Breastfeeding and returning to work [link]

  • Discontinuation of breastfeeding [link]

  • Breastfeeding problems [link]

  • Breastfeeding in special situations [link]

  • Lactation and nutrition [link]

Constituents of breast milk


  • Provides complete nutrition for the healthy term baby until lactation is established, provided frequent feeds are offered and supplements are not considered medically necessary.

  • Produced in the first 3 days after delivery.

  • Volume: 2–10mL daily.

  • Transparent and yellow, due to high B-carotene content.

  • Easily digested and absorbed.

  • Energy content: 58kcal/100mL.

  • Rich in immunoglobulins responsible for passive immunity.

  • Contains higher levels of protein and vitamins A and K than mature milk.

  • Contains lower levels of sugar and fat than mature milk.

  • The presence of lacto bifidus factor provides favourable (acidic) conditions, which encourage colonization of the infant's gut with the beneficial microbe, Lactobacillus bifidus.

  • Stimulates the passage of meconium.

Breast milk

Breast milk is a complex fluid that contains above 200 known constitutents,1 and changes to meet the needs of the infant, from:

  • Colostrums to transitional then mature milk

  • The beginning to the end of the feed

  • Morning to evening.2

Nutritional composition

  • Carbohydrate: the main type being lactose, a disaccharide.

  • Fat: the most variable constituent. Provides 50% of the energy supplied by breast milk. Linoleic and linolenic acids are converted into long-chain polyunsaturated fatty acids, which are essential for development of the nervous system.

  • Protein: in the form of whey protein, required for growth and energy. Consists of anti-infective factors, including lactalbumin, immunoglobulins, lactoferrin, lysozyme and other enzymes, hormones and growth factors.3

  • Non-protein nitrogens: the three most important are taurine, nucleotides and carnitine. Taurine is important for bile acid conjugation, brain, and retinal development.2 Nucleotides are important for the function of cell membranes and for normal development of the brain.2 Carnitine plays an important part in lipid metabolism and is thought to be important in thermogenesis and nitrogen metabolism.4

  • Minerals and trace elements: the major ones are sodium, calcium, phosphorus, magnesium, zinc, copper, and iron. The quantities and ratios of these elements are species specific; human and cow's milk differ significantly.

  • Vitamins: human milk contains all the vitamins required for a term neonate, with the possible exception of vitamins D and K.

  • Enzymes: breast milk contains at least 70 enzymes.3 They contribute to digestion and development. Possibly the two most important are amylase and lipase. Their presence in breast milk compensates for the limited pancreatic amylase and lipase activity in the newborn and therefore aids digestion.

For a comprehensive breakdown of the composition of breast milk, see Henschel and Inch2 and Coad.4

Immunological properties of breast milk

Human milk also has a non-nutritive protective role for the infant and also for protecting the breasts from infection. Important constituents are as follows.

  • Immunoglobulins: IgA, IgG, IgM, IgD, and IgE, which are active against specific organisms, e.g. Salmonella species and poliovirus.

  • Cells: B lymphocytes, T lymphocytes, macrophages, and neutrophils. The actions of these cells include:

    1. Production of antibodies against specific microbes

    2. Killing of infected cells

    3. Production of lysozyme and activation of the immune system

    4. Phagocytosis of bacteria.

  • Lacto bifidus factor: promotes an acidic environment suitable for the growth of Lactobacillus bifidus and inhibits the growth of pathogenic organisms.

  • Lactoferrin: reduces iron availability for bacterial growth, by binding to iron. It also acts as a bacteriostatic agent.

  • Binding proteins: increase the absorption of nutrients, therefore reducing those available to be utilized by bacteria.

  • Complement, lipids, fibronectin, G-interferon, mucins, oligosaccharides, bile salt-stimulated lipase, epidermal growth factor, and many more.4

The immunological properties of breast milk are increased with better maternal nutrition.5

Advantages of breastfeeding

An ever-increasing amount of quality research has demonstrated the advantages of breastfeeding for both infant and mother.1

Advantages for the infant:

  • Optimal nutrition

  • Reduced risk of mortality from necrotizing enterocolitis and sudden infant death

  • Reduced infection: gastrointestinal, respiratory, urinary tract, ear, meningitis, intractable diarrhoea

  • Reduced atopic disease: eczema, asthma

  • Optimal brain development

  • Reduced risk of autoimmune disease

  • Enhanced immunity

  • Reduction in childhood obesity.

Advantages for the mother:

  • Convenience, cost, and lack of contamination

  • Reduced risk of maternal breast and ovarian cancer

  • Reduced risk of hip fractures in women over 65

  • Losing pregnancy weight gain if feeding for 6 months or longer,

Breastfeeding see also Health risks associated with formula feeding, [link].

For the infant breastfeeding also may have positive effects on:

  • Interpersonal relationships and sleep patterns2

  • Reduced crying if they stay close to the mothers and breastfeed from birth.3

Contraindications to breastfeeding

  • Drugs. Most drugs will pass into breast milk in a greater or lesser degree. The majority of drugs can be taken safely, but there some are drugs where breastfeeding is contraindicated.

  • Cancer. Anticancer treatments are normally highly toxic and will make it impossible to breastfeed without harming the baby. The mother could, if she wishes, express and discard her milk for the duration of treatment and resume breastfeeding later. If the mother has had a mastectomy, she may successfully breastfeed from the other breast. If the mother has had a lumpectomy, she should seek advice from her surgeon as she may be able to feed from the treated breast.

  • Breast surgery. Breast reduction and augmentation are not contraindications to breastfeeding, but this depends upon the surgical techniques used. Advice should be sought from the surgeon. Following unilateral mastectomy it is perfectly possible to breastfeed using the other breast.

  • Breast injury. Serious damage caused by burns and accidents may have caused scarring that makes breastfeeding impossible.

  • HIV infection. HIV may be transmitted in breast milk.

    1. Current WHO recommendations are that when breast milk substitutes are acceptable, feasible, affordable, sustainable, and safe, then mothers should be advised not to breastfeed. Therefore in the UK mothers would be advised against breastfeeding.1

    2. In developing countries, or in countries, where artificial feeding is a significant cause of infant mortality, exclusive breastfeeding may be less of a risk.

Management of breastfeeding

Initiation of breastfeeding

All mothers should be given their baby to hold with skin-to-skin contact in an unhurried environment for an unlimited period as soon as possible after delivery. All mothers should be offered help to initiate a first breastfeed when their baby shows signs of readiness to feed’.1

The need to suckle is common to all mammalian young and the human baby is no different. If the mother and baby are given a peaceful, unhurried environment and the baby is placed on the mother's abdomen following delivery, it will crawl to the breast and initiate suckling.2 A number of studies have shown that satisfying the infant's early urge to suckle positively influences the success and duration of breastfeeding.3 , 4

Skin-to-skin contact

  • Initiate as soon as possible after birth.

  • Place the naked, dried baby against their mother's skin.

  • Place a blanket around them both to ensure neither becomes cold.

  • Very small babies may also need a hat.

  • If the mother so wishes, place the baby inside her nightgown.

  • Provide a calm, unhurried atmosphere.

  • Ensure that the mother and baby are uninterrupted during this time.

  • Skin-to-skin contact should last until after the first breastfeed or until the mother chooses to end it.1

The midwife is responsible for ensuring that the mother and infant have a successful first feed. It is also their responsibility to provide information about breastfeeding, although the timing of this should be decided on an individual basis.

Positioning and attachment

Before commencing a feed, the comfort of the mother should be ensured. Talk the mother through the process as far as possible, to help develop her confidence and ability in breastfeeding. For the infant to suckle successfully at the breast, two processes need to be correct. These are positioning and attachment.

Positioning of the baby at the breast

Correct positioning is the secret of successful breastfeeding. Good positioning will enable the baby to achieve and maintain attachment at the breast. This, in turn, will enable the baby to feed effectively for as long as he or she needs. Good positioning is fundamental to successful breastfeeding and the prevention of problems. The mother should position the baby at the breast although some mothers may need guidance.

Principles of effective positioning

  • The baby's head and body should be in a straight line.

  • The mother should hold the baby's body close to hers. ‘Tummy to mummy’ may not be the appropriate position for all babies, as this will depend upon the shape and size of the mother's breasts.

  • The baby should face the breast with the nose opposite the nipple.

  • The position should be sustainable for both the mother and the baby.

Support may sometimes be required to assist good positioning. This may be in the form of cushions to support a comfortable position for the mother or to raise the baby to the level of the breast.

The following should be avoided:

  • Holding the back of the baby's head—this will cause the baby to push their head backwards away from the breast

  • Holding the breast away from the baby's nose—this can disturb the attachment and also prevent drainage from some lobes of the breast

  • Holding the baby in a bottle-feeding position—this necessitates the baby to turn their head, which can cause friction to the nipple

  • Taking the breast down to the baby rather than bringing the baby to the breast—this alters the shape of the breast and can cause problems, including ineffective suckling by the baby and backache for the mother.

Biological nurturing

This is a new, non-prescriptive, mother-centred breastfeeding approach that refers to a range of semi-reclined maternal breastfeeding postures and innate feeding behaviours.5 The positions used are similar to those used in skin-to-skin contact. The baby is held instinctively and cuddled in a natural way. This can be done with the baby held long ways, sideways or slanting. The baby always has close contact with the breast and can have unrestricted access to the breast for feeding. This is a useful approach for many mothers and especially those encountering problems with latching on. The Baby Friendly Initiative (BFI) recommends that those working towards BFI accreditation should inform themselves about biological nurturing and to look for ways to incorporate this information within a framework of care that provides women with a range of skills to enable them to adapt their breastfeeding to a variety of situations.6

Attachment of the baby at the breast

Attachment is the term used to describe how the baby's mouth fits around the mother's nipple and areola to suckle at the breast.7

The three main reflexes required for a baby to attach effectively are:

  • Rooting reflex

  • Sucking reflex

  • Swallowing reflex.

If any of these reflexes is absent, the baby will not be able to attach and feed effectively. Premature babies frequently are unable to coordinate the reflexes.

Process of attachment

In order to attach correctly, the baby needs to:

  • Open their mouth in a wide gape with their tongue down and forward (Fig. 24.1)

  • The lower lip, then the tongue, should be the first point of contact

  • The first contact should be well away from the base of the nipple

  • They should then reach up and bring their mouth over the nipple, taking in a large portion of breast tissue to form the teat (Fig. 24.2).

Fig. 24.1 The baby should be encouraged to open their mouth widely.

Fig. 24.1
The baby should be encouraged to open their mouth widely.

Fig. 24.2 Baby correctly attached at the breast.

Fig. 24.2
Baby correctly attached at the breast.

Recognizing correct attachment

  • The baby's mouth is wide open (wider than 100°) and they have a large mouthful of breast.

  • The chin should indent the breast.

  • There should be more areola visible above his top lip than below the baby's bottom lip.

  • The nose should be close to the breast but not squashed.

  • The cheeks are round and full.

  • The whole of the lower jaw moves.

  • The lower lip is curled outwards but this is not always easily visible if the baby is close to the breast.

  • The mother feels a strong, and sometimes uncomfortable, ‘drawing’ sensation as the baby scoops up the nipple and breast tissue, draws it into his or her mouth and commences suckling.

  • Swallowing may be heard but this only indicates that milk is flowing, not that the positioning and attachment are correct.

Exaggerated attachment at the breast

This is useful if:

  • The baby is unable to attach and feed effectively

  • The baby has a ‘tongue tie’ and has difficulty staying attached

  • The baby has a cleft palate

  • The baby is premature

  • The nipples are sore or cracked and feeding is almost unbearable.

How to attain an exaggerated attachment

If the mother is going to feed from her left breast, she needs to cup the breast underneath with her left hand, keeping her fingers well away from the areola. There is always a tendency to want to move the fingers up, but this will affect the success of the attachment. The thumb should tilt the nipple back so it looks like it is pointing away from the baby. This will have the effect of making the breast under the nipple bulge forwards. The baby's bottom lip should make contact with the breast well away from the base of the nipple.

Pattern of sucking

Normally once the baby is attached he or she will take a few quick sucks at the breast which will initiate the oxytocin reflex. As the milk begins to flow and fills the mouth, the baby's sucks will become slower and deeper. The baby will pause occasionally. If a baby continues to take frequent short sucks or there are audible ‘smacking’ noises as the baby sucks, this is a good indication that the attachment is incorrect.

Recognizing incorrect attachment

  • The mouth is not wide open.

  • The bottom lip is not curled outwards, or it is less curled than the upper lip.

  • There is the same amount of areola below the bottom lip as above the top lip.

  • There is a gap between the breast and the chin.

  • The nose is either squashed into the breast or a wide distance from the breast.

  • The cheeks are drawn in as the baby sucks.

  • The breast tissue is puckered.

  • The breast tissue moves in and out of the baby's mouth as he feeds.

  • The baby makes little sucks as if he is sucking a dummy.

  • There is no change in the rhythm of feeding.

  • The baby will show frustration at not having his hunger satisfied, by either becoming sleepy and ceasing to suck or by coming off the breast and crying.

  • The colour of the stools may change back to green/brown from yellow.

Results of ineffective attachment

The mother may:

  • Feel pain when feeding

  • Experience sore nipples, especially cracks across the tip of the nipple or at the base of the nipple

  • Experience engorgement of the breast.

The baby may:

  • Appear unsatisfied

  • Cry a lot and want frequent feeds, or may feed for protracted lengths of time

  • Receive insufficient milk and fail to gain or even lose weight

  • Become frustrated and refuse to feed

  • Receive adequate nourishment for the first few weeks by feeding frequently if the oxytocin reflex works well but then will fail to thrive.

Measures shown to enhance breastfeeding success

A comprehensive systematic review conducted by NICE8 has identified what practices enable a mother to breastfeed for longer, and these should be used in conjunction with the following information.

Baby-led feeding

Baby-led feeding, or demand feeding, simply consists of feeding the baby whenever he or she wishes and for as long as he or she wishes.

There is substantial evidence that the timing and duration of breastfeeds should be responsive to the needs of the baby.9 Babies will feed at the breast for very different lengths of time if left undisturbed, and it is thought that the length of a feed is determined by the rate of milk transfer between mother and baby.10

Limiting the duration of the feed or removing a baby from the breast before they finish spontaneously, may prevent the baby from receiving adequate calorific intake causing failure to gain weight despite frequent feeds and an apparently good milk supply.

Unrestricted frequency of feeds is also advocated. Observation studies have demonstrated that the frequency of feeds in the first few weeks appears to be unpredictable and random, varying between 1h and 8h. Babies who regulate the length and frequency of feeds gain weight more quickly.

Advice to the mother to restrict or limit suckling time or frequency at the breast will not only do no good, but could do harm. However, a baby that has protracted feeds without coming off spontaneously, or a baby that feeds very frequently, may be attached to the breast incorrectly. A baby that is poorly attached can also cause nipple trauma, which may give rise to engorgement and/or mastitis.11

Night feeds

The advantages of night feeds include:

  • Prolactin levels are higher at night, and a breastfeed at night will result in a greater prolactin surge than would occur with a feed given during the day. Night feeds therefore ensure good milk production.12

  • Exclusive breastfeeding that incorporates night feeds raises prolactin levels which, in turn, inhibits luteinizing hormone release, this prevents ovulation.12

  • Frequent feeds, including night feeds, help to prevent/reduce engorgement when the milk first comes in.

  • There is a soporific effect on the mother, which improves the quality of sleep. This results from the release of dopamine, which is believed to be involved in the mechanism of oxytocin release.13


Rooming-in, which allows mother and babies to remain together for 24h a day, has been shown to:

  • Improve breastfeeding outcomes, especially duration; this is partly because rooming-in facilitates demand feeding14

  • Improve mother–baby relationship, regardless of feeding method

  • Be preferable to nursery care for both mother and baby.14

Common reasons to not room in, e.g. it interferes with the mother's sleep, do not appear to be valid.14

Staff training

Healthcare professionals who have not been trained in breastfeeding management cannot be expected to give mothers effective guidance and to provide skilled counselling. It is necessary to increase their skills to enable their knowledge to be used appropriately. Education and training sessions need to incorporate elements that enable health professionals to address bias that will hinder breastfeeding.

In-service training needs to be mandatory to be successful and requires a strong policy supported by senior staff.14

Inconsistent or conflicting information and advice disempowers women, reducing their self-confidence and ability to breastfeed successfully.15

Breastfeeding and growth monitoring

NICE16 recommends that GPs, paediatricians, midwives health visitors, and community nursery nurses should:

  • As a minimum, ensure babies are weighed (naked) at birth and at 5 and 10 days, as part of an overall assessment of feeding. After this healthy babies should be weighed (naked) no more than fortnightly and at 2, 3, 4, and 8–10 months in their first year. Ongoing weekly weighing is unnecessary for healthy babies who give no cause for concern. Unnecessary weighing may lead to an inappropriate intervention and undermine parents’ confidence.

  • Ensure infants are weighed using digital scales which are maintained and calibrated annually, in line with medical devices standards (spring scales are inaccurate and should not be used.

  • It is important that support staff are trained to weigh infants and young children and to record the data accurately in the child health record held by the parents.

Breastfeeding patterns of growth

  • Breastfed babies show a different pattern of growth from formula fed babies.

  • Growth rate is not constant and slowed growth is not always indicative of growth failure.

  • Breastfed infants grow more quickly in the first few weeks and more slowly from about 4–5 months than formula fed infants. The difference is on average ½ to 1 centile channel.17

New UK growth charts, based on breastfed babies, were introduced in May 2009 to plot the weight, height, and head circumference of children from birth to 4 years of age.18 These charts should be used for all new births and new referrals to health professionals. The UK90 Growth charts will continue to be used for children born before this date and for children over 4 years. Fact sheets about the new charts are available at the Royal College of Paediatrics and Child Health website (Breastfeeding

Weight loss of more than 10% from birthweight should be a cause for concern. Check that the baby is having plenty of wet and dirty nappies. Poor urine and stool output indicates the need for the baby to be weighed naked on digital scales even if outside the recommended weighing guidelines. A breastfeeding history should be taken and a breastfeeding assessment form recorded prior to advice being given for strategies to improve feeding. Weight loss of 15% or more requires urgent investigation, paediatric referral, and experienced breastfeeding support.

The 10 steps to successful breastfeeding1

The ‘Ten Steps to Successful Breastfeeding’ are the foundation of the WHO/UNICEF Baby Friendly Hospital Initiative (BFHI). They are a summary of the maternity practices necessary to support breastfeeding. The BFHI was developed to promote the implementation of the second operational target of the Innocenti Declaration.2

Every facility providing maternity services and care for newborn infants should:

  • Have a written breastfeeding policy that is communicated routinely to all health care staff

  • Train all health care staff in skills necessary to implement the policy

  • Inform all pregnant women about the benefits and management of breastfeeding

  • Help mothers initiate breastfeeding within half an hour of birth

  • Show mothers how to breastfeed, and how to maintain lactation even if they are separated from their infants

  • Give newborn infants no food or drink other than breast milk, unless medically indicated

  • Practice rooming-in: allow mothers and infants to remain together 24h a day

  • Encourage breastfeeding on demand

  • Give no artificial teats or pacifiers (also called dummies or soothers) to breastfed infants

  • Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.

Evidence in support of the above steps can be found in the WHO publication Evidence for the Ten Steps to Successful Breastfeeding.2

The seven-point plan for the protection, promotion, and support of breastfeeding in community healthcare settings

All providers of community healthcare should:

  • Have a written breastfeeding policy that is communicated routinely to all healthcare staff

  • Train all staff involved in the care of mothers and babies in the skills necessary to implement the policy

  • Inform all pregnant women about the benefits and management of breastfeeding

  • Support mothers to initiate and maintain breastfeeding

  • Encourage exclusive and continued breastfeeding, with appropriately timed introduction of complementary foods

  • Provide a welcoming atmosphere for breastfeeding families

  • Promote cooperation between healthcare staff, breastfeeding support groups, and the local community.

The UNICEF UK Baby Friendly Initiative University Standards programme

This is an accreditation programme aimed at university departments responsible for midwifery and health visitor/public health nurse education. The purpose of the programme is to ensure that newly qualified midwives and health visitors are equipped with the knowledge and skills needed to support breastfeeding effectively. Accreditation is awarded to an individual course, not to the institution itself. Higher education institutions (HEIs) can apply for accreditation for each of the courses they provide for the training of midwives or health visitors/public health nurses.

Support for breastfeeding

The support the woman receives from her partner, family members, friends, health professionals, and support networks can affect the uptake and continuance of breastfeeding. Emotional support as well as practical support is needed to empower mothers to breastfeed successfully. Various levels of support may be required by breastfeeding mothers, depending upon their social circumstances. Caregivers may find it easier to support breastfeeding mothers effectively if they have had the opportunity to come to terms with their own breastfeeding experiences.1


  • The male partner has a strong influence upon the choice of infant feeding method.2

  • The partner's positive attitude to breastfeeding is important for the mother initiating and continuing to breastfeed.3

  • Women need to talk to their partners antenatally about breastfeeding, as a woman's guesses about her partner's ideas of breastfeeding have often been found to be inaccurate.4

  • Partners need to be informed of the benefits of breastfeeding for both baby and mother.

  • Partners should be involved in antenatal preparation for breastfeeding whenever possible.

  • Partners are invaluable in providing emotional and practical support for breastfeeding mothers.

  • Partners wishing to undertake shared care of the baby should be encouraged to look at alternatives to feeding, e.g. bathing the infant, skin-to-skin contact.

Family and friends

  • Family and friends exert a strong influence on a mother's decision about breastfeeding.

  • About one in four mothers are helped by a relative or friend when they have problems breastfeeding.

  • First-time mothers are more likely to turn to relatives and friends for assistance.

  • Breastfeeding mothers who were breastfed themselves are more likely to be breastfeeding at 4 weeks than those who had been bottle fed.

  • Breastfeeding mothers whose friends mostly bottle fed are more likely to discontinue in the first 2 weeks postnatally.5

Peer support

NICE6 recommends that there should be easily accessible breastfeeding peer support programmes and that appropriately trained breastfeeding peer supporters should be part of a multidisciplinary team. It is also recommends that breastfeeding peer supporters should contact mothers directly within 48h of their transfer to the community and offer them ongoing support according to their individual needs. This could be via telephone, texting, face-to-face, local support groups or the internet.

Breastfeeding peer support projects have been shown to:

  • Demonstrate a positive trend towards increasing continuation of breastfeeding

  • Help mothers at a time when they were strongly considering stopping breastfeeding

  • Empower those living in socially excluded communities.5

Specialist infant feeding advisors

Many maternity units now employ specialist infant feeding advisers. Their role varies depending upon the needs of the local population and the requirements of the maternity units. There is very little research related to the role of the specialist feeding advisors but they can improve the care and support breastfeeding women receive by:

  • Developing and monitoring infant feeding policies and guidelines

  • Providing in service training for health professionals and support workers

  • Auditing infant feeding practices

  • Ensuring up-to-date evidence-based practice related to infant feeding

  • Ensuring that leaflets and information for women are accurate, in line with breastfeeding policies and do not advertise formula milk companies

  • Organizing and running breastfeeding workshops for women in the antenatal period

  • Organizing and running breastfeeding drop-in services

  • Supporting health professionals in their clinical area

  • Supervising health professionals who are undertaking breastfeeding courses e.g. BFI Breastfeeding Management Course

  • Taking the lead role when maternity units and communities are working towards the BFI Award

  • Liaising with local and national organizations to promote, protect, and support breastfeeding

  • Providing a contact person for liaising with formula milk companies.

Their role is not to deskill the health professional, by taking over the carer role for breastfeeding women, but to develop their skills and increase their knowledge base to ensure that all breastfeeding women are provided with evidence-based, sensitive, and consistent information and support.

Voluntary groups

There are a number of breastfeeding voluntary organizations, or organizations that have expertise in supporting breastfeeding mothers in special circumstances in the UK, including:

  • National Childbirth Trust

  • Breastfeeding Network

  • Twins and Multiple Births Association

  • La Leche League (Great Britain)

  • Baby Milk Action

  • Association of Breastfeeding Mothers.

These organizations supply information and support, by telephone and in leaflets and books. Mothers should be offered leaflets or cards giving details about support organizations prior to leaving the postnatal ward.

Practices shown to be detrimental to successful breastfeeding

Inconsistent information

Despite efforts to ensure that appropriate advice and information are given to breastfeeding mothers, there is still evidence that, for many mothers, difficulty in establishing breastfeeding is compounded by inconsistent advice.1 Conflicting advice does exist and persist, mostly as inaccurate information and practice.

Conflicting advice and information:

  • Reinforce a mother's lack of self-confidence in her ability to breastfeed

  • Disempower women.2

In order to prevent inconsistent advice, midwives need to:

  • Have in-depth knowledge and understanding of the physiology of lactation

  • Be able to communicate effectively

  • Acknowledge their own subjective bias

  • Provide consistent information and support in line with the best available evidence.2

An authoritarian approach to communication is unhelpful and even detrimental.

Use of pacifiers

The use of pacifiers (dummies) has become a widespread cultural practice in the UK. They are used to settle, soothe, or otherwise occupy a fretful or distressed baby.

Reasons given for using pacifiers have included:3

  • Mothers who used them were more sensitive to their baby's crying than mothers who did not use them

  • Mothers used them to space feeds, which they perceived to be too frequent

  • They were used in the past to reduce the number of breastfeeds as part of the weaning process.

The use of pacifiers has been implicated in:

  • Reducing the duration of breastfeeding4

  • Increasing the risk of otitis media5

  • Oral candida infection6

  • Reduced jaw muscle activity7

  • Reduced intellectual attainment8

  • Greater incidence of abnormal jaw development.9

No research to date explores the effect of bottle teats and/or pacifiers on the initiation of breastfeeding. However, there is concern by health professionals that their use may adversely affect initiation and establishment of breastfeeding. Conversely some evidence suggests that the use of pacifiers can reduce the incidence of cot death.10

The use of nipple shields

The use of nipple shields is sometimes advocated as treatment for sore nipples; however, little evidence is currently available to support this practice.

The use of nipple shields:11

  • Has been found to be unacceptable to mothers

  • May lead to a conditioned rejection of the breast by the baby

  • May adversely affect the mother's milk supply.

Clinical experience suggests that judicious use of a thin silicone shield may benefit mothers with severely traumatized nipples, but they should never be used as a substitute for teaching the mother how to correct the problem of sore nipples by improving positioning and attachment. They should never be used in the early postnatal days before the milk has ‘come in’.

Supplementary feeding

Supplementary feeding is the practice of giving extra feeds of formula, glucose, or water. A recent study found that 33% of breastfed babies were given supplementary feeds while in hospital.12 This study also found that breastfeeding mothers whose babies were given bottles were more likely to discontinue breastfeeding in the first 2 weeks postnatally than were other mothers.

Supplementary feeds have been associated with:4 , 12,13

  • Interference with the supply and demand mechanism, therefore reducing milk supply

  • Interference with the development of normal immunological mechanisms

  • Allergic conditions in some babies

  • Reactive hypoglycaemia

  • ‘Nipple confusion’

  • Reduced maternal confidence.

Extra fluids

Giving extra fluids, either in the form of water or dextrose, to babies with jaundice has not been shown to reduce peak serum bilirubin levels, and may, in fact, cause levels to rise by reducing the milk intake and therefore delaying the evacuation of meconium.14

In a breastfed baby, filling the stomach with water will reduce the number of feeds and interfere with the establishment of breastfeeding. Women whose babies are given extra fluids are more likely to discontinue breastfeeding.

Expression of breast milk

Why express?

Expression of breast milk should be taught to all mothers as it helps them to understand how the breasts work. It can aid the mother's understanding of effective attachment and may help her to recognize and overcome many breastfeeding complications.1 Health professionals should be able to teach the skills of both hand expression and mechanical expression to breastfeeding mothers.

Expression of breast milk can be helpful in a variety of situations.1

  • General breast comfort:

    1. To relieve discomfort from overfull breasts if a feed has been missed

    2. To prevent leakage if mother and child are apart

    3. To maintain healthy skin or to assist healing: if damage has occurred to the nipple, a small amount of breast milk may be applied to the nipple and areola.

  • To assist a baby to breastfeed:

    1. Expressing a small amount of breast milk will encourage a reluctant baby to breastfeed by enabling him to smell and taste the milk

    2. By softening an overfull or engorged breast, enabling attachment

    3. Milk may be expressed gently into the baby's mouth if he or she has a weak suck.

  • To prevent or relieve breast conditions:

    1. Overfull breasts due to a feed being missed

    2. Engorgement

    3. Blocked duct

    4. Mastitis.

  • To stimulate milk supply:

    1. When mother and baby are separated or baby unable to suckle

    2. If additional stimulus is required to increase or induce lactation.

  • To maintain milk supply:

    1. When mother and baby are separated, e.g. hospitalization, return to work

    2. When the mother has to suspend breastfeeding temporarily, e.g. due to medication that may be harmful to the baby.

Methods of expression

Hand or manual expression

  • Hand expression is usually gentler than using a pump, it can be undertaken anywhere and no/minimal equipment is needed.

  • Hand expression requires skill, and some mothers find it difficult and prefer to use a pump.

  • The risk of cross-infection is reduced with hand expression as less equipment is required.

  • Hand expression is useful as a self-help method if blocked ducts, engorgement, or mastitis occurs.

  • Inform the mother that when she first starts to express her breasts only small amounts will be expressed, but with practice it will become easier and she will be able to express more.

How to hand express

The mother should:

  • Wash her hands

  • Use a wide-mouthed sterile container to collect the milk

  • Sit comfortably in a warm, peaceful and relaxing environment if possible

  • Lean very slightly forward.

  • Encourage the let-down reflex by:

    1. Relaxing with a warm drink, music, or TV

    2. Being near the baby or a photo of the baby

    3. Warming the breasts

    4. Gently pulling or rolling the nipples

    5. Gently massaging the breasts by stroking with the finger tips, rolling with the knuckles, or using circular movements.

The mother should then:

  • Make a ‘C’ shape with her thumb above and her fingers below the breast near the edge of the areola but away from the nipple (Fig. 24.3)

  • Gently press her thumb and fingers together, release the fingers and repeat in a rhythmic pattern (Fig. 24.4)

  • Sometimes it is helpful to press inwards and back towards the chest wall while squeezing

  • The fingers should be repositioned at intervals to allow drainage from all the lactiferous ducts.

Fig. 24.3 Make a c-shape with finger and thumb.

Fig. 24.3
Make a c-shape with finger and thumb.

The length of time for expressing depends on the reason why the mother is expressing. If she wants to express all the milk she can from the breast, she should continue until the flow subsides.

The mother may express from the second breast by repeating the above process. A mother who wishes to express as much milk as possible should continue to switch between breasts for as long as milk is being obtained.1,2

Breast pumps

Mothers who use a mechanical pump may find they are able to express larger volumes, especially if using an electrical pump.1

Numerous pumps are available to hire or buy, but they fall into three types:

  • A hand pump that is mainly for relieving the breasts. These are usually of simple design and work on a simple vacuum principle. They are not suitable for expressing milk which is to be stored and given to a baby because they can not be sterilized effectively.1

  • Battery-operated pumps vary widely in design, all produce a rhythmic vacuum, although some are also designed to give a degree of compression. Some mothers find these pumps useful if they are expressing on a regular basis, as they are less tiring than a hand pump.

  • Electric pumps are usually heavy and bulky and therefore less portable. As they are efficient, they are commonly used within hospitals, but they are usually shared by several mothers and therefore maintenance and cleanliness are essential. Ideally all mothers should be given their own equipment for the machine, which should include a collection beaker, tubing, and sterilizing equipment.1

Using breast pumps

Women may find that their let-down reflex is more difficult to induce with a pump than with hand expressing. Massaging the breast and hand expressing for a short time prior to using the pump may help. A photograph, item of the baby's clothing or toy may also help.

Dual pumping

Dual pumping is when both breasts are expressed at the same time. This can be done either by hand expression or using a pump. It has been shown to shorten the time required for expressing and increases the mother's prolactin levels.1 If using a pump, a Y coupling is required. It is particularly helpful if a large amount of milk is required, e.g. with twins and multiple births, or if there is a need to increase the milk supply rapidly.

Principles of expression

Establishment of lactation:

  • Expression should commence as soon as possible after the birth.

  • Express frequently, 6–8 times in 24h, more if possible.

  • Express at least once during the night.

  • Avoid set patterns of expressing, instead aim to imitate the irregular feeding pattern adopted by most babies.

If lactation is already established, and there is a need to express to maintain lactation because of separation of the mother and baby, the last three of the above principles should be applied. It is important to remember that expressing does not provide the same stimulus to the breast as the baby suckling, and the milk supply may begin to diminish. If this is the case, the mother should be encouraged to increase the number of expressions.

To increase the milk supply, for example if the baby is not feeding sufficiently or if the mother wishes to build up a milk supply before returning to work, the mother should be encouraged to:

  • Express after and/or between feeds or, if the baby is not feeding, to increase the number of expressions

  • Express at least once in the night

  • Avoid set patterns of expressing; rather, expressing whenever she can.

It takes appropriately 24h for the supply to increase.

Recommendations for storage of breast milk

For use in the home3

  • Fresh breast milk can be:

    1. Kept for up to 5h at room temperature

    2. Stored in a refrigerator at a temperature 2–4°C for up to 5 days.

  • If milk is not to be used within 24h, freezing is recommended:

    1. Milk can be kept frozen in an ice-making compartment for 2 weeks

    2. Milk can be kept safely up to 6 months in a domestic freezer.

  • Any plastic container that can be sterilized and made airtight, is suitable for storing breast milk. Many commercial products are available.3

Storing breast milk for use in hospital

  • Some types of plastic are not suitable for storing breast milk for preterm or sick babies.

  • Use up-to-date guidelines, e.g. UK Association for Milk Banking Guidelines,4 for advising mothers which containers to use and how to store the milk.

  • Hospitals often pasteurize milk for use in a milk bank but this is not usually necessary if the milk is for the mother's own baby.

Reheating expressed breast milk at home

  • Frozen milk can be:

    1. Thawed slowly in a refrigerator but must be used within 24h or discarded

    2. Thawed at room temperature and used immediately

  • Frozen milk should never be thawed or heated in a microwave.5

  • Some prefer to warm the milk to body temperature.

  • Never re-freeze breast milk.

Breastfeeding and returning to work

Mothers who are returning to work may find this a stressful time, especially if they are breastfeeding. The longer a mother breastfeeds, the more benefits there are for both mother and baby. Mothers may wish to consider different working options, e.g. part-time work, job sharing, working different hours, working partly at home. Health professionals should give mothers information and assistance to try to make the return to work as easy as possible.

Three practical ways to combine breastfeeding and work are:

  • Expression of breast milk while at work

  • Childcare near the mother's place of work

  • Partial breastfeeding.

There are advantages and disadvantage to all three options and it will depend upon the mother's circumstances which option is most appropriate for her.

If the mother decides to express breast milk at work, she will need to:

  • Practise expressing milk prior to returning to work (if possible she should wait until breastfeeding is fully established, when the baby is about 2 months old). The expressed breast milk (EBM) can be stored in the freezer to give the mother a back-up supply

  • Ensure she has equipment for expressing at work, which will include a pump, storage containers, sterilizing equipment, spare breast-pads, and a cool bag for transportation (many commercial products are being produced now to make this easier for mothers)

  • Consider dual pumping, as this reduces the time required to express

  • Have spare batteries and vacuum seals at work if using a pump

  • Ask at work for the following facilities:

    1. Use of a room that is warm, clean, and has a lockable door

    2. Facilities for hand washing

    3. Somewhere clean to leave equipment for sterilizing

    4. Use of a fridge to store EBM

    5. A low comfortable chair

  • Store milk safely.

The law relating to breastfeeding at work

In the UK, mothers do not have statutory rights to paid breastfeeding breaks, but do have certain legal protection under the health and safety laws. While breastfeeding, she and her baby have special health and safety protection, the same as that for a pregnant woman. However, to use this protection she must inform her employers in writing. Employers are also obliged to provide ‘suitable facilities’ where breastfeeding employees can ‘rest’. If the woman is working with hazardous substances, the employer should take appropriate actions to make the job safe. If this is not possible, an alternative job should be offered or she should be suspended on full pay.1

When to express

This will depend upon the individual and the type of work, but also depends upon the employer's attitude. It is not essential to have regular breaks, as it is better to aim to imitate the irregular feeding pattern that most babies adopt.

Childcare near the mother's workplace

If the baby is in childcare near the mother's place of work, the mother could visit the baby during breaks and breastfeed normally. Although this is the best option, it may prove difficult to demand feed around working hours, and the baby may be upset by the mother coming and going.

Partial breastfeeding

This is when the mother breastfeeds normally when at home but the baby receives formula milk while the mother is at work. This can work very well when the mother is unable to express or visit the baby. However, her milk supply may diminish and she may still have to continue with formula feeds for those feeds that are normally missed when working. Partial breastfeeding is not possible before the milk supply is fully established at around 2 months.

Discontinuation of breastfeeding

The DH recommends exclusive breastfeeding for the first 6 months (26 weeks) of an infant's life, and 6 months is the recommended age for the introduction of solid foods for infants.1 However, the time when mothers discontinue breastfeeding is very variable and depends upon many factors. Sudden cessation should be avoided if possible to maximize the mother's comfort and to avoid mastitis. The mother should be advised to slowly drop one feed at a time, allow several days before dropping a further feed, and to feed on alternate days when down to one feed. This helps the milk supply to adjust and allows the milk to diminish naturally. There are circumstances that need special consideration.

Mother going into hospital

  • If possible, arrange for the baby to accompany the mother and continue feeding.

  • A family carer may need to assist the mother with baby care if the hospital can not provide assistance.

  • If this is known in advance, the mother can express and freeze EBM, especially if she is to undergo a general anaesthetic.

  • The mother needs to ask about equipment and facilities for expressing, sterilizing, and storing breast milk. She may need to take in her own pump.

  • If a mother has to stop feeding temporarily due to medication, the supply can be maintained by expressing.

  • The mother should ask if safe alternative drugs are available.

Baby going into hospital

  • If possible, the mother should accompany the baby.

  • If not possible, e.g. because of other children at home, the mother should express and send the milk to the hospital.

  • If the baby is unable to suckle and/or receive breast milk, the mother should express to maintain the supply and reduce the risk of mastitis.

  • If stopping breastfeeding, this should be done gradually.

Sudden cessation, due to cot death or illness

  • A small amount should be expressed, just to relieve pressure.

  • Support the breasts well with a firm bra, binding has not been shown to help and may increase the risk of mastitis.

  • Use cold compresses.

  • Mild analgesics, e.g. paracetamol, may help relieve the discomfort.

  • Slightly reduce fluids, but do not drastically reduce fluids as this may temporarily increase the supply.

Breastfeeding problems

A problem-solving approach should be taken when managing common breastfeeding problems. This should include;

  • Listening to the mother

  • Taking a breastfeeding history. Use of the UNICEF BFI Breastfeeding Assessment Form is advised1

  • Observing a breastfeed

  • Offering information on appropriate solutions and alternatives to enable a mother to make her own decision

  • Offering the ongoing support of a breastfeeding peer supporter.

Sleepy/non-feeding baby

There are a number of reasons why a baby will not feed in the first few days following delivery and these include:

  • Drugs given to the mother in labour, e.g. pethidine and epidural

  • Unpleasant experience at the breast, e.g. force applied to the head when fixing

  • Frustration as a result of not obtaining nourishment due to poor fixing at the breast

  • Jaundice

  • If lethargic when awake the baby may not be receiving adequate nutrition

  • Baby is ill.


The first two actions should be addressed with all babies and the following actions acted upon as relevant to the history.

  • A breastfeeding history should be taken to see if the reason can be identified.

  • A breastfeed should be observed and positioning and attachment improved.

  • If necessary wake the baby and give additional feeds (EBM or colostrum if possible) until the situation has improved.

  • If the baby is jaundiced encourage the baby to feed as frequently as possible.

  • Feed the baby when he or she is half asleep.

  • Encourage the baby to stay awake whilst feeding by keeping the baby cooler during feeds.

  • Switch feed—that is change the baby from one breast to the second as the baby becomes sleepy.

  • Change the baby's position while feeding to stimulate the baby to suckle more vigorously.

  • Encourage mother to adopt skin-to-skin as much as possible—do not offer the breast let the baby find it.

  • Change nappy to wake the baby.

  • Bath the baby.

  • Sit in a warm bath to feed the baby.

Sore/cracked nipples

Breastfeeding should be comfortable and pain-free although some mothers may experience some discomfort at the beginning of the feed for the first few days. This usually resolves spontaneously. However, 24% of mothers who discontinue breastfeeding in the first week postnatally do so because of sore or cracked nipples.2 It is very likely that the majority of sore nipples could be prevented and treated by correct positioning and attachment of the baby at the breast.

The causes of sore and cracked nipples include:

  • Poor positioning and attachment of the baby at the breast.

  • Engorgement, which may prevent good attachment.

  • Physiological causes that include a baby with a short tongue or tongue tie, a high palate or a mismatch between the size of the mothers nipple and the baby's mouth.

  • Pulling the baby off the breast without first breaking the seal between the baby's mouth and the mother's breast.

  • The use of substances that may trigger a skin reaction or increase its susceptibility to damage, e.g. soap and scented bath products, antiseptic sprays.

  • Thrush infections (Breastfeeding see Candida (thrush) infection, [link]).

  • Expressing too vigorously with a breast pump.


  • Observe a feed and assist the mother to attain better positioning and attachment.

  • Provide emotional support to the mother.

  • If engorgement is present, express a small amount of milk to soften the area immediately behind the nipple area.

  • If the baby has a short tongue, or tongue-tie an exaggerated fix may help (Breastfeeding see Exaggerated attachment at the breast, [link]). This is where the mother slightly compresses the breast in the same direction as the baby's mouth thus narrowing the width of the breast to enable the baby to attach easier. It may be appropriate to refer the baby for separation of the frenulum.

  • Avoid the use of soap and similar products, which remove the natural oils.

  • Teach the mother how to break the suction by inserting a finger gently in to the baby's mouth before removing the baby from the breast.

  • Alter the position of the baby at different feeds.

  • If the nipple is cracked, correct positioning usually enables the mother to feed without severe pain. In severe cases, short-term topical treatment may assist healing and be soothing for the mother. Moist wound healing promotes granulation and the use of an oil-based preparation may be advocated, e.g. highly purified lanolin.

Inverted nipples

Nipples usually protrude but appropriately 10% of pregnant women who wish to breastfeed have inverted or non-protractile nipples. Currently there is no evidence that any antenatal nipple treatment or preparation contributes to successful breastfeeding. No prediction of success of breastfeeding should be made on antenatal inspection.


  • The mother should be reassured that the baby breast feeds not nipple feeds.

  • Skilled help with attachment is important for these women in the first few days postpartum.

  • If difficulty is encountered attaching the baby, expressing a small amount of milk to soften the area around the areola can sometimes be helpful.

  • Lactation can be initiated and sustained with a breast pump and further attempts made at attaching made when the milk has ‘come in’ and the breasts are softer.

  • Dummies and nipple shields should be avoided as they require a different action and may confuse the baby.

  • Mothers with inverted nipples can be as successful breastfeeding as mothers with protractile nipples.


There are two types of engorgement:

  • Milk arrival engorgement

  • Secondary engorgement.

Milk arrival engorgement

This occurs usually around the 2–4th days postnatal as the milk ‘comes in.’ It can result from poor attachment, restricting feeds in the early days, or not waking the baby enough. It is caused by increased blood supply to the breasts and extra lymph fluid. The mother will have red, painful, and swollen breasts. She may also have a mild pyrexia and flu-like symptoms. If action is not taken it may result in mastitis.

Secondary engorgement

The mother presents with the same symptoms of painful, swollen breasts but this can occur at any time and is due to the ineffective drainage of the breasts. It may result from a variety of causes including:

  • The mother missing a feed

  • Reduced appetite in the baby

  • Over-stimulation of the supply

  • Too rapid weaning

  • Baby sleeping through the night.


The actions taken are the same in both types of engorgement:

  • Warm flannels can be used to aid the milk flow

  • Expressing a small amount of milk will also help to get the milk flowing and make it easier for the baby to attach

  • Improve positioning and attachment

  • Encourage the baby to feed frequently

  • Analgesia may be required (paracetamol is usually the drug of choice).

Reassure the mother that it is a temporary situation.

Blocked duct/s

The woman will generally feel well but she will present with a localized tender lump or a feeling of bruising. It usually occurs in one breast and can occur at any time during the breastfeeding period. The woman's temperature is not usually raised.


  • Ensure effective positioning and attachment.

  • Feed from the affected side first for the next two feeds, then alternate.

  • Ensure the baby feeds frequently.

  • Use warm flannels, the shower or bath to bathe in warm water.

  • Massage the lump gently towards the nipple during a feed, after a feed or while in the bath.

  • Remove any white spot from the nipple.

  • Use alternate positions.

  • Feed the baby with its chin on the same side as the affected duct.

  • Avoid bras that dig into the breast.


Mastitis means inflammation of the breast. The term should not be regarded as synonymous with ‘breast infection’ because although inflammation may be the result of infection, in over 50% of cases of mastitis it is not. Mastitis can be the result of milk leaking into the breast tissue because of a blocked duct or engorgement. The body's defence mechanism reacts in the same way as it would for infection by increasing the blood supply, which in turn is responsible for the redness and inflammation. Therefore antibiotics may not be required if self-help measures are initiated promptly.


  • A red, swollen, usually painful area on the breast, often the outer, upper area.

  • A lumpy breast that feels hot to touch.

  • The whole breast may ache and become red.

  • Flu-like symptoms which arise very quickly and rapidly get worse.

Predisposing factors

There are a number of factors that may make non-infective mastitis more likely; these include:

  • Incorrect positioning and attachment, which may lead to inadequate draining of the breast

  • Restriction of the breast as a result of tight clothing or by pressing the fingers too firmly into the breast when feeding

  • Engorgement

  • Blocked duct/s

  • Stress and tiredness

  • Sudden changes in the baby's feeding pattern.

Prevention of non-infective mastitis

The condition is often a consequence of engorgement and the following simple measures can help to avoid or reduce the risk of mastitis:

  • Ensure correct positioning and attachment

  • Avoid suddenly going longer between feeds—reduce gradually if possible

  • Avoid pressure on the breasts by either clothing or the fingers

  • Commence self-help measures as soon as symptoms occur.

Self-help measures

These measures will help to relieve engorgement and blocked ducts as well as mastitis:

  • Breastfeeding must be continued if possible, it is the most effective way to reduce the symptoms

  • Reassure the mother that her milk will not harm the baby

  • Ensure correct positioning and attachment

  • Increase the frequency of feeds and if the breasts are uncomfortably full express between feeds

  • Ensure adequate drainage of the breasts and express gently following feeds until resolved

  • Feed from the affected breast first

  • Try using different positions for feeding

  • Prior to feeding, apply warmth to the breast and gently express to soften the breast enabling the baby to attach more effectively

  • If necessary, express breast milk by hand or pump until breastfeeding can be resumed

  • Gently massage the breast towards the nipple to help the milk flow while feeding

  • Check positioning of the fingers when feeding and check to see if clothing is restrictive

  • Rest

  • Plenty of fluids

  • An anti-inflammatory agent may help, e.g. ibuprofen. Aspirin should not be taken by breastfeeding mothers. It can result in rashes, platelet abnormalities, bleeding and the potentially fatal Reye's Syndrome is nursing infants. 4–8% of maternal dose can be transferred.

If no improvement has occurred 12–24h after onset of symptoms, or infective mastitis is suspected refer to the doctor.

Infective mastitis

Bacterial infections result from organisms breaching the preventative barrier of the skin and multiplying in spite of the body's defence system. The epithelium of the breast and nipple may be damaged by:

  • Incorrect positioning and attachment

  • Sensitivity to creams, lotions, and sprays.

Treatment of infective mastitis

  • The self-help measures above should be initiated.

  • Systemic antibiotics compatible with breastfeeding should be commenced. This may be needed for 10–14 days.

  • Beneficial bacteria killed by the antibiotics can be restored by taking live yogurt or Acidophilus.

Abrupt discontinuation of feeding increases the chances of a breast abscess, as will unresolved mastitis.

Breast abscess

This is a rare but serious medical condition. The mother will be pyrexial, have severe flu-like symptoms, and the affected area will be very painful and swollen. It presents as a localized breast infection with the presence of pus. The pus is not considered harmful to the baby but if blood is also present, the baby may vomit. It may occur without prior symptoms but often results from unresolved mastitis.


  • Refer immediately to a doctor, who will prescribe antibiotics.

  • Aspiration of the abscess or surgical drainage may be required.

  • The mother should continue to feed on the unaffected breast.

  • It is preferable for the mother to continue breastfeeding on the affected breast but she may prefer to express and discard the milk especially if the baby is vulnerable e.g. on SCBU.

  • The mother may need to boost the milk supply on the affected side once the infection has cleared.

Insufficient milk supply

This is one of the most commonly quoted reasons for women discontinuing breastfeeding. The mother may express concern that she has an insufficient milk supply because the baby is not settling after a feed, is waking frequently for feeds, or the baby is not gaining weight.


  • Reassure the mother that this can usually be dealt with because actual insufficient milk is extremely rare.

  • A breast feed should be observed and the positioning and attachment improved as necessary.

  • There should be no time limit on the frequency or duration of feeding.

  • The baby should drain one breast before being offered the second.

  • Different feeding positions may be suggested, as this will assist drainage of all areas of the breast.

  • Women should be encouraged and supported to continue breast-feeding. Supplementary feeds should not be suggested.

  • If after the above action has been taken, the baby fails to gain weight refer to a breastfeeding adviser or breastfeeding clinic.

Breast refusal

There are two types of breast refusal: the baby who has never had a successful breastfeed and the baby who has breastfed well but then starts to refuse to go to the breast. Forty per cent of mothers who discontinue breastfeeding within the first week postnatally do so because the baby would not suck or rejected the breast,2 therefore it is important for midwives to have the knowledge to help mothers overcome this problem.

Causes when breastfeeding not established

Breast refusal in the initial stages of establishing breastfeeding may be caused a number of factors including:

  • Pain relief the mother received in labour

  • Breast engorgement as the milk ‘comes in’

  • Baby being forced on to the breast

  • Incorrect positioning and attachment

  • Powerful let-down

  • Let-down inhibited

  • Baby prefers bottles.


  • Reassure the mother and try to establish a relaxed environment.

  • Observe a feed and check positioning and attachment.

  • If the breasts are overfull, express a small amount to soften the area around the areola to enable the baby to attach easier.

  • Stimulate the let-down reflex by massaging the breast prior to attaching the baby.

  • Express some breast milk onto the nipple or drip EBM in the baby's mouth to attempt him or her to suckle.

  • Attempt to put the baby to the breast before they are fully awake.

  • Try skin-to-skin stimulation and do not offer the breast, let the baby find it.

  • Co-bathing—where the mother and baby bathe together, this is thought to re-create the birth experience for the baby and has been shown to help. The baby needs to be kept warm by a helper pouring warm water over the baby as it lies on the mother's chest.

  • If supplements of EBM are given to the baby this should be given by either cup or spoon.

Breast refusal once feeding is established

The following are various factors that may cause a baby to refuse the breast but a cause may not be found:

  • Baby ill

  • Hormonal changes in the mother, e.g. menstruation, ovulation, contraceptive pill, pregnancy

  • Mother using different toiletries or mother eating spicy or garlicky food

  • If the mother has undertaken prolonged, vigorous exercise, lactic acid may alter the taste of the milk—but this is usually short lived

  • If the mother has had mastitis the milk may taste saltier for a short time afterwards.


  • Check the baby's health. If he or she appears ill refer to the doctor.

  • If thrush is present, Breastfeeding see Candida (thrush) infection for action.

  • If the baby is teething, offer a cool toy to chew on.

  • Continue to offer the breast.

  • Change the setting in which the baby is fed.

  • Try feeding when the baby is sleepy.

  • Check whether the mother wishes to continue feeding or if she had thought of discontinuing.

  • If the baby is ill and refusing the breast offer EBM. The baby may take it better by spoon or cup.

Candida (thrush) infection

This is an occasional cause of sore nipples although the incidence appears to be increasing. It is caused by a microorganism Candida, which is a yeast. It commonly occurs after the mother has received antibiotic treatment. It often occurs after a period of trouble-free feeding and is commonly bilateral.


  • Hypersensitive or itchy nipples even when wearing loose clothing.

  • Pink and shiny nipples and areola.

  • Shooting pains deep in the breast after feeding which may continue for up to an hour.

  • Cracked nipples that will not heal.

  • Loss of colour in the nipple or areola.

  • Pain in both breasts.

The baby may also exhibit signs of a thrush infection, such as:

  • Creamy white spots in the mouth which do not rub off

  • Baby keeps pulling away from the breast, which may be a result of a sore mouth

  • A windy unsettled baby

  • Nappy rash.


  • Ensure correct positioning and attachment.

  • Continue breastfeeding.

  • Refer to the GP for treatment. Effective treatment enables the mother to continue pain-free breastfeeding. When left untreated, many mothers find the severity of pain difficult to deal with and will discontinue feeding earlier than they wish.

  • Both the mother and baby need to be treated simultaneously to prevent reinfection even if only one shows signs of infection.

  • Surface infection on the nipple is treated by application of an antifungal cream (usually miconazole) is prescribed.

  • Oral treatment is required for infected milk ducts (usually nystatin or fluconazole is prescribed). Poor absorption of nystatin in the gut can delay resolution of symptoms. Fluconazole is not licensed for lactating mothers although the WHO recognizes it as compatible with breastfeeding.3

  • Babies are usually prescribed nystatin drops, or miconazole oral gel. However, due to change in the manufacture's licence, use of miconazole oral gel is no longer considered suitable for use in babies <4 months old due to being a potential choking risk. Responsibility for use in a baby <4 months remains the responsibility of the person who prescribes or recommends its use.

  • Any teats, dummies, or nipple shields used should be sterilized.

  • Strict hygiene should be observed—washing of hands and use of separate towels for each member of the family.

  • Any EBM collected during the infected period is best discarded to prevent reinfection.

  • Acidophilus capsules may help restore the normal, healthy bacterial flora which helps prevent thrush infections.

  • Painkillers may help the mother to cope with the pain.

Breastfeeding in special situations

Twins and higher multiples

The production of breast milk is based on a demand and supply system; therefore, provided the infants are suckling effectively, nature will supply the milk. In the early days postnatally, the mother will require a lot of reassurance and assistance to get breastfeeding established.

There are no rights and wrongs for whether the babies should be fed separately or together. The RCM1 advocates that in the early days the babies should be fed separately, so that common early problems can be resolved, whereas the Twins and Multiple Births Association2 believes that feeding the babies together in the early days will help to stimulate the milk supply, and feeding them together at night will ensure that the mother gets more sleep. Ultimately, the decision is up to the mother and the babies, as the infants’ feeding patterns may not synchronize. One option is to mix and match so that at some feeds the babies are fed together and at others separately. The mother may decide that each baby has its own breast, or she may wish to swap breasts at each feed.

Positions for breastfeeding twins

When breastfeeding both babies at the same time, positioning of the babies at the breast may take some time and practice to get it right. The mother should:

  • Ensure she has adequate cushions to provide support for both herself and the babies

  • Use a footstool under her feet if necessary, to create a lap

  • Find a position in which she feels comfortable to feed the babies. This may be the ‘double football position’, where the babies are tucked under the mother's arms and their heads are opposite each other at the front. This enables the mother to support each baby's head. Alternatively, one baby could be held conventionally in the cradle hold and the other held in the football position, so that the babies are parallel to each other. Another position is the criss-cross, where both babies could be held conventionally, one lying across the other.

A mother who is breastfeeding twins must remember her own needs, she should eat well, and try to obtain some rest each day to prevent exhaustion.

Cleft lip and palate

Cleft lip and palate are congenital malformations that result in the incomplete fusion of the upper lip and jaw.

Cleft lip should not present any problems for breastfeeding. Following surgery, some surgeons encourage breastfeeding soon afterwards, while others prefer an initial period of spoon-feeding.

A cleft palate, however, may present major difficulties. The baby is unable to form an effective seal between mouth and the breast, so that the breast and nipple cannot be formed into a teat. There are feeding plates/palate seals (palatal obturator), which can assist in ‘closing’ the defect. A baby with a cleft palate will not usually stimulate the breast effectively, which will result in a diminished milk supply. A mother with large, elastic breasts and a ready milk ejection reflex may succeed in breastfeeding, but normally mothers will need to supplement with a nursing supplementer (Breastfeeding see Alternative methods of giving EBM/formula, [link]). Alternatively, mothers may wish to express breast milk and feed it to the baby with a special bottle, teat, or spoon. Breastfeeding is both possible and beneficial following surgical repair, but the mother will need practical and accurate support from appropriately skilled professionals.

Breastfeeding and HIV

Mother-to-child transmission of HIV can occur through breastfeeding. WHO3 advises that HIV-infected, pregnant mothers should consider their infant feeding options. It stipulates that ‘when replacement feeding (formula milk) is acceptable, feasible, affordable, sustainable, and safe, HIV infected mothers should avoid breastfeeding completely’. This view is endorsed by the DH,4 which recommends that HIV-infected women should avoid breastfeeding. Advice and counselling should be given to mothers during the antenatal period. If a mother decides to breastfeed once she has received advice, there may be a child protection issue, especially if she has a high viral load, which will place the baby at severe risk.

Breastfeeding and diabetes

Diabetes is not a contraindication to breastfeeding. It can be advantageous to the mother's and baby's health.

  • For the mother it can: facilitate better management of diabetes and improve the mother's long-term health; this is because breastfeeding is a natural response to childbirth and the hormones responsible for lactation allow the physiological changes that follow childbirth to occur more gradually.

  • For the baby it may: reduce the risk of developing diabetes.5

Considerations for diabetic mothers when breastfeeding

  • Mothers may require extra carbohydrate to facilitate breastfeeding. An extra 50g of carbohydrate per day has been suggested.6 These extra carbohydrates are best spread equally over the day, remembering especially to increase the supper snack to cover the night-time feeds.

  • Warnings should be given to all diabetic mothers about the possibility of hypoglycaemia especially when breastfeeding. They should be advised to eat before breastfeeding the baby or have a snack handy while feeding.

  • Mothers who are breastfeeding are at an increased risk of mastitis and candida (thrush), especially if their blood sugar levels are poorly controlled. Therefore they should be informed of the symptoms of mastitis and thrush, how they can help themselves and where help is available e.g. midwife, health visitor, breastfeeding peer supporter, National Childbirth Trust, etc.

  • Diabetic mothers may find a delay in their milk production (lactogenesis II) and the milk may not ‘come in’ until the fourth or fifth postnatal day. Expressing (if mother and baby are separated) or breastfeeding every 2–3h during the first few days following delivery can help reduce the delay.

Care of the new born infant of a diabetic mother

  • Babies of diabetic mothers are more prone to hypoglycaemia this is because in intrauterine life the hypertrophic islets of Langerhans produce more insulin in response to the maternal blood sugar levels. After birth the pancreas initially continues to produce excess insulin thus causing hypoglycaemia.

  • Preparation for prevention of neonatal hypoglycaemia can commence in pregnancy with the expressing and storage of colostrum for use in the immediate postnatal period. Expression and storage of colostrum should be discussed with the hospital during the antenatal period.

  • The baby should be given its first feed as soon as possible (within 30min of birth) and then 2–3h until pre-feeding blood glucose levels are maintained at 2 mmol/L or more.7

  • The baby's blood glucose levels should be monitored until stabilized. The frequency and timing of testing neonatal blood glucose levels may vary according to hospital policies but NICE7 recommends routine testing 2–4h after birth and prior to feeds until the blood sugar levels are stabilized.

  • The mother and baby should not be transferred to community care until the baby's blood sugar levels have stabilized and feeding is established.

  • The mother should be given the opportunity for peer support with breastfeeding.8


There are many reasons why a baby may be separated from its mother. The usual cause of separation of mother and baby immediately following delivery is that the baby requires specialist care in a special care baby unit, neonatal surgical unit, or paediatric ward. Alternatively, the mother may be seriously ill, requiring care in either an intensive care or high-dependency unit. Whenever possible, mothers and babies should be cared for together.

If the mother intends to breastfeed, expression of breast milk should commence as soon as her condition allows (if the mother is ill) or as soon as possible following delivery (if the baby is on a special care baby unit). The mother should be encouraged to express breast milk and will need extra reassurance and support in these circumstances, especially if the baby is in a unit where there are no midwives to assist and support her. For detailed guidance on expression and storage of breast milk Breastfeeding see Expression of breast milk, [link].

Breast surgery

  • Advice should be sought from the surgeon prior to surgery if the woman is of an age where she may wish to breastfeed.

  • There are two types of breast reduction, pedicle and free-nipple. With the former, the mother may be able to breastfeed but with the latter, it is not possible.

  • Augmentation is not a contraindication to breastfeeding but if a peri-areolar surgical technique has been used then the mother may find she has an insufficient milk supply.

  • Women can breastfeed successfully following unilateral mastectomy.

Alternative methods of giving EBM/formula

Breastfeeding is the natural way to feed infants, but occasionally some infants may not be able to breastfeed immediately or the mother may require assistance to help improve her milk supply. The method of choice will depend upon the individual situations, and the aim of any alternative method of feeding should be to attain full breastfeeding as soon as possible. The alternative methods of feeding include cup, syringe, dropper, spoon, pipette, Lact-Aid®, and nasogastric feeding. The means used will depend upon the age of the baby and the reason for not breastfeeding. The main methods discussed in this text are nasogastric feeding, cup feeding, and supplementing with a Lact-Aid® device.

Nasogastric feeding

  • Sometimes, if a baby is so premature, ill, or weak that oral feeding is not possible, the option is to tube feed the baby.

  • A baby requiring nasogastric feeds would usually be cared for in a special care baby unit.

  • Staff require training in the technique.

  • Encourage the mother to express breast milk so that the baby can receive it via the nasogastric tube.

  • A baby that has been fed via a nasogastric tube may present with sensory defensiveness and aversive behaviour once oral feeding commences, thought to be a result of a sore throat or irritated nasal passages.5

Cup feeding

  • Cup feeding prevents exposure of the baby to artificial teats.

  • In some countries, where teats are difficult to obtain and to clean, cup feeding is widely practised.

  • Once the skill of cup feeding is mastered, then it is no more stressful than bottle feeding.

  • Cup feeding is very useful to promote the early acquisition of oral skills.

  • Cup feeding also accelerates the transition from nasogastric feeding to established functional breastfeeding by providing a positive way to learn suck/swallow/breathing coordination.

  • Caution needs to be taken with premature or compromised babies if their cough reflex is immature. This could lead to an increased risk of aspiration.

  • There is also a higher level of spillage when cup feeding, and this needs to be taken into account if trying to calculate the amount taken.

  • It is important that mothers be taught the correct technique.

Technique for cup feeding

  • Stabilize the baby's head and body.

  • Place the baby in an upright position on your lap.

  • Have the cup at least half full (if possible).

  • Place the rim of the cup at the corners of the baby's mouth. Rest the side of the cup lightly on the lower lip. Do not apply pressure to the lower lip.

  • Tilt the cup so that the milk just touches the upper lip.

  • The baby can then control the intake, pausing as necessary.

  • In effect, the baby laps from the cup, rather than milk being poured into the baby's mouth.

  • It is important that the milk is offered but never poured.

The Lact-Aid ®

  • This is a feeding tube device that allows the infant to be supplemented at the breast with either EBM or formula.9

  • The aim of these devices is to deliver a faster flow of milk to the baby while he or she is still suckling at the breast.

  • Feeding tube devices are helpful for mothers who have a very poor milk supply, are trying to re-establish lactation, or if attempting to induce lactation for an adopted baby.

  • Mothers need supervision when first using these devices.

  • They are more effective if the baby is able to latch onto the breast, although an augmented flow may assist a baby to suck better because he or she is being rewarded for their efforts.


  • The tube is usually positioned on the nipple so that it enters the baby's mouth centred along the palate. However, the positioning of the tube may need to be adapted to enable the baby to obtain the flow of milk more effectively.

  • The flow of milk from the receptacle is determined by a combination of the baby's suck and its position/height.

  • Adjustments will be required to establish the correct flow for the baby.

Lactation and nutrition

All new mothers need to eat a healthy diet for their own well-being and to help them to replenish stores of certain nutrients that become depleted during pregnancy. They also need a healthy diet to assist them to cope with the demands of a new baby and possibly older siblings. Even if eating a suboptimal diet, either in calories or content, they will still produce high-quality milk which will satisfy their infant's nutrition requirements.

A healthy diet should be based on the five food groups and a breastfeeding mother should include:

  • Group 1—Carbohydrates—a portion of bread, rice, potatoes, pasta or other starchy food should be eaten with each meal. Wholegrain should be eaten whenever possible.

  • Group 2—Fruit and vegetables should be included in each meal aiming for five portions a day.

  • Group 3—Dairy products—two to three portions of milk, cheese and yogurt should be eaten a day and they can be of low-fat varieties if desired.

  • Group 4—Protein—meat, fish, nuts, and pulses should be included in two meals per day. Non-meat eaters should ensure they include eggs, nuts, and pulses in their diet on a regular basis.

  • Groups 5—High fat and sugar foods and drinks—these should be kept to a minimum and the diet basically based on the other four food groups.

Fluids and breastfeeding

Breastfeeding mothers do not need to drink excessive amounts of fluid but should drink to their thirst. A minimum of eight drinks a day is recommended and can include a range of sources including water, fruit juice, milk, tea, coffee, and soups. Milk is not necessary to produce breast milk. In hot weather more fluid may be required to quench the mother's thirst.

Food to avoid whilst breastfeeding

Generally women who are breastfeeding do not need to avoid certain foods, however, there are several recommendations;

  • Oily fish—can be included in the diet but no more than two servings a week.

  • Large fish—shark, swordfish, and marlin should be avoided all together as they contain large amounts of mercury.

  • Alcohol—passes into the blood stream and levels peak at 30–90min after consumption. The recommendation is that daily consumption should not exceed 1 unit per day.

  • Peanuts—mothers are advised to avoid eating peanuts if they, the infant's father or siblings suffer from allergic conditions such as hay-fever, asthma, or eczema.

  • Caffeine—in tea, coffee, cola, energy drinks, and chocolate should be limited as it can make some babies restless and may cause breast pain in some women.

Mothers who are overweight or obese should not embark on very low-calorie diets while breastfeeding but should eat a balanced diet and limit high fat and high sugar foods. Once breastfeeding is established some regular physical activity of at least 30min on all or most days of the week will help weight loss and women can still breastfeed successfully and lose about 450g (1lb) in weight each week.

Even with a healthy diet it is difficult to get an adequate intake of vitamin D in the UK. Breastfeeding mothers are therefore advised to take 10micrograms of vitamin D each day to prevent vitamin D deficiency in both them and their baby. Vitamin D is needed for bone health and the immune system. Babies of mothers who did not take vitamin D supplements during pregnancy may be born with low levels of vitamin D. There is a very small chance that these babies may have fits due to low levels of calcium. Older babies and toddlers with very low levels of vitamin D can develop rickets.

The NHS Healthy Start vitamins for women contain 10micrograms vitamin D along with 400micrograms folic acid and some vitamin C and are ideal for breastfeeding mothers. The vitamins are free for mothers included within the Healthy Start Scheme (see Breastfeeding Vegan mothers may need a supplement containing vitamin B12 and calcium in addition to vitamin D.


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