Common Problems Encountered by Breastfeeding Women

Jaundice; leaking milk; clogged ducts

Breast-Milk Jaundice
Jaundice is a yellowish skin coloration that becomes evident in more than half of all newborns. The yellowish color results from a substance in the blood known as bilirubin, which is released when red blood cells break down. Newborn jaundice can be due to many causes, ranging from benign to serious. The yellow color always should be reported to your baby's doctor.

It is generally agreed that breastfed newborns have a higher incidence of jaundice than formula-fed babies. There are two distinct reasons for increased levels of jaundice in breastfed babies. The most common explanation is known as breastfeeding jaundice. In this case, jaundice becomes exaggerated due to poor breastfeeding and low milk intake. Usually the baby is not nursing often enough or is not breastfeeding effectively. The infant may have lost excessive weight after birth or be failing to gain weight. Jaundice is noticed around the third day of life and continues for several days. The treatment of breastfeeding jaundice should be aimed at improving breastfeeding technique and assuring that the baby gets adequate nutrition. The bilirubin level falls rapidly once the baby is well fed.

The other type of jaundice that is linked with breastfeeding is called breast-milk jaundice. In this case, the bilirubin level becomes elevated as a result of an unknown factor in some mothers' breast milk that increases the absorption of bilirubin from the newborn intestines. This delays the excretion of bilirubin into the stools and causes the baby to remain jaundiced. The problem usually begins toward the end of the first week and can continue for many weeks.

With breast-milk jaundice, the baby nurses well, obtains plenty of breast milk, appears healthy, and gains weight normally. Although low levels of breast-milk jaundice occur quite commonly in breastfed infants, the bilirubin level rarely gets high enough to require specific treatment. If the bilirubin rises to a worrisome level (usually over 20 milligrams percent), or if the baby's doctor is getting anxious about whether some other medical problem could be causing the jaundice, the doctor may recommend that you discontinue breastfeeding for twenty-four to thirty-six hours to see if the bilirubin level drops. A dramatic fall in the bilirubin level within a day or so of interrupting breastfeeding confirms the diagnoses of breast-milk jaundice. During the time that breastfeeding is interrupted, the baby is fed formula. After breastfeeding is resumed, the bilirubin may rise slightly before it gradually declines to a normal level over a couple of weeks.

If your baby's doctor requests that you temporarily stop breastfeeding due to breast-milk jaundice in your baby, it is critical that you use an effective breast pump to empty your breasts at regular feeding times while your baby is formula-fed. This way, you will maintain an abundant milk supply and can resume breastfeeding easily. You don't need to discard your expressed milk while breastfeeding is interrupted. It can be frozen for later use.

Sometimes when a mother must interrupt breastfeeding due to breast-milk jaundice in her infant, she may assume there is something wrong with her milk and wonder whether she should return to breastfeeding. Please know that your milk provides perfect nutrition for your baby and that breastfeeding certainly is worthwhile! Many babies each year are needlessly weaned because of the diagnosis of breast-milk jaundice. Interrupting breastfeeding should be only rarely necessary for this condition. However, both mothers and doctors can become anxious when jaundice persists in a newborn baby, and your doctor may feel compelled to make a diagnosis and resolve the problem. Even when breastfeeding is interrupted, you should be able to resume nursing your baby within about thirty-six hours.

Excessive Leaking of Milk
Most women experience leaking of milk when their milk ejection reflex is triggered, perhaps upon hearing their baby cry or shortly after starting to nurse. Milk usually drips from one breast while a mother is nursing on the other side. For the majority of breastfeeding women, leaking milk represents little more than a minor inconvenience. Some even find it amusing to watch their milk spray during feedings or in the tub or shower.

I consider leaking milk to be an encouraging sign of a well-conditioned milk ejection reflex. Seeing milk flow freely makes me optimistic that a woman will succeed at breastfeeding. Despite my own enthusiasm over leaking milk, for some women, leaking is an irritating and embarrassing problem that represents a definite drawback to breastfeeding. Excessive leakers may complain of drenched clothing, soiled bedding, and constant wetness. To these women, breastfeeding is more messy than convenient. Women not only leak to different degrees but also react to leaking in different ways. For example, you may already have observed that your milk lets-down during lovemaking. Some women find this connection between breastfeeding and sexuality to be fascinating, even erotic, while others find it off-putting.

If leaking milk is a problem for you, let me help you reframe the issue so you might view it in a more positive light. You see, leaking is more than just normal-it's a wonderful marker for breastfeeding success. Leaking usually signals a highly effective milk ejection reflex and an abundant milk supply. When milk flows readily, babies usually nurse easily. Of all the breastfeeding problems I've encountered, I think leaking is the preferred one to have.

I don't mean to trivialize your concerns if you are one of those women who leak excessively and are bothered by it. The following pointers will help you better understand and deal with leak-ing milk:

• Leaking is usually worst from two to six weeks. It takes a week or two for the milk ejection reflex to start working well. Within several more weeks, the capacity of the milk ducts increases, so less milk leaks from the nipple openings when milk is letting-down.
• The sensations of the milk ejection reflex will alert you that your let-down is being triggered. You can stop milk from leaking by applying pressure against the nipple openings. To do this discreetly in public, cross your arms in front of your chest and press your thumbs against your nipples. No one needs to know what you are doing.
• To protect your clothing, wear washable or disposable breast pads inside your nursing bra to absorb any leaking milk. Change wet pads frequently, however, to keep your nipples free of excess surface moisture. Don't try to reuse disposable pads after they have dried, as they get very stiff and rough. Wash reusable pads and your nursing bra daily. If you don't want to purchase nursing pads, you can stitch together reusable ones from 100 percent cotton cloth. Even an all-cotton handkerchief works fine.
• You can wear plastic breast shells to prevent leaking milk from soiling your outer clothing. Breast shells, also known as milk cups, can be worn over your nipples and held in place by your nursing bra (see the photograph on page 59). Among their many purposes, breast shells are used by some women to collect leak-ing milk. (Don't try to save the milk that drips into breast shells.) Some employed breastfeeding mothers wear breast shells to protect their clothing since leaking at the workplace can prove especially embarrassing.

Clogged Ducts (Caked Breast)
Sometimes one or more of the lobes of the breast don't drain very well, causing a temporary backup of milk, known as a clogged duct or caked breast. Unlike generalized breast engorgement, a clogged duct is a localized blockage of milk. A tender, hard knot can form in the affected duct system, and the surrounding area of the breast usually feels full and tender. Most often, the outer lobes near the armpits are involved, since more milk glands are concentrated in those areas. The problem usually results from incomplete emptying of milk from the breast or by going too long between nursings. A clogged duct also can be caused by breast trauma and chronic inflammation from a low-grade, unrecognized breast infection. Women who have an overabundant milk supply are more prone to getting clogged ducts. A few women are plagued by the problem.

A clogged duct can be quite uncomfortable, and if it doesn't get relieved promptly, it can progress to a full-blown breast infection. Don't ignore a clogged duct. It's an important warning sign and calls for your immediate attention to prevent a breast infection from occurring. The following simple measures usually provide relief for a clogged duct within eight hours:

• Nurse more often. A clogged duct is the result of incomplete or irregular removal of milk from the breast. The best way to counter it is to nurse more often. This is easier if you can be more available to your baby. Cut back on other activities as much as possible so you can concentrate on relieving the problem.
• Gently massage the clogged area. Gentle pressure applied to any tender knots or caked portions of the breast will help milk to flow from the obstructed area. Keep your massage gentle, as overly rough manipulation of the breast increases the risk of mastitis. Massage and pressure work best when applied prior to and while nursing your baby.
• Start several feedings in a row on the clogged side. A baby's most vigorous nursing occurs at the first breast suckled. To help drain the clogged side, you can start several consecutive nursings on the affected breast. Be careful, however, not to let the second breast remain overly full or you could develop a blocked duct on that side or a decline in your milk supply.
• Vary your nursing position to empty all lobes well. Different nursing positions result in better drainage of different lobes of the breast. In addition to the traditional cradle hold, try the cross-cradle hold, the football hold, and lying down to nurse to find which position works best to empty your clogged area. Try pointing his chin toward the plugged duct.
• Take a warm shower or apply warm compresses to the caked area. Heat usually helps trigger the let-down reflex and facilitates milk flow. Many women spontaneously drip milk in the shower or bathtub. Try applying warm compresses to the clogged area, especially just before nursing and in conjunction with breast massage.
• Use a breast pump to empty the engorged area well. If your baby doesn't nurse well or you are separated from your baby during part of the day, you may need to use an effective breast pump to relieve a clogged duct. Women who have an overabundant supply may need to periodically express some surplus milk to soften their overfull breasts.
• Try to identify and eliminate any risk factors you may have, especially if you have a recurring problem with clogged ducts. As mentioned earlier, women with superabundant milk supplies are at increased risk for clogged ducts whenever their breasts don't get well drained. Other risk factors include an erratic feeding or pumping schedule-typical of employed mothers-or wearing a constrictive bra. In addition, breast trauma, such as being bitten or kicked by the baby or massaging the breast too vigorously, can produce inflammation in a duct system and interfere with milk drainage. If you suffer frequent clogged ducts, I suggest you review your breastfeeding practices with a lactation consultant.

A Word of Caution
I have encountered more than one woman in my career who had a cancerous breast lump which was mistaken by her physician for a clogged duct. Although the mass persisted for months, proper diagnosis of the malignancy was inappropriately delayed, while treatments were prescribed for the presumed "clogged duct." Please never label a persistent breast lump as a clogged duct. Clogged ducts come on abruptly, are painful, and resolve within a day or so. Only a few things can happen with a true clogged duct. It will clear quickly, and the tender lump will disappear; it will progress to mastitis, which will become painfully obvious; it won't empty well, so the lobe will partially dry up, in which case the lump will disappear; or, it will temporarily resolve, but return at a later date. Any lump that persists for days or weeks must be accurately diagnosed. It is not a clogged duct.