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Mastitis: Characterized by pain, swelling, warmth and redness of breasts, fever, and malaise, this might be one of the most dreaded words for any lactating parent. Not only is this spectrum of inflammatory breast conditions painful, but it's also notorious for becoming a recurrent problem that can seriously impact a family's breastfeeding journey.

But what if part of the explanation for stubborn, recurrent mastitis is that we've been treating it wrong all this time?

That's the question many lactation consultants are asking themselves after the Academy of Breastfeeding Medicine (ABM) released their new Mastitis Spectrum Protocol earlier this year.

New Research Examining Mastitis Treatment

The ABM's protocols are guidelines for the care of breastfeeding parents and children, and are based on rigorous, peer-reviewed clinical research. Their new findings on mastitis suggest that we had it (at least partially) wrong.

A prime example is the advice commonly given to parents inflicted with mastitis by well-intentioned providers to "nurse, nurse, nurse!" and "pump, pump, pump!" to keep breasts emptied or "massage, massage, massage!" to clear out clogs.
According to the new research referenced by the ABM, following this aspect of the previous mastitis protocol is actually just about the worst thing you can do. VIEW ALL ACCEPTED INSURANCE PLANS
The new research shows that the true cause of mastitis isn't clogged ducts and the lack of frequent and complete milk removal, as once believed. The real culprits? A narrowing of the milk ducts and congestion and inflammation within the breast that are caused by an imbalance of the breast microbiome (dysbiosis) and/or hyperlactation (also known as "oversupply").

Due to the supply and demand basis of milk production, frequent emptying and overstimulation of the breasts (AKA: "pump, pump, pump!") will in fact only exacerbate hyperlactation, increasing congestion within the breasts, and triggering the underlying inflammatory process that leads to mastitis.

With this new information, it's easy to see how previous recommendations could set into motion vicious cycles of recurrent mastitis. That's also why it's vital to get the word out about the new protocol.

New Recommendations for Breastfeeding Patients

With such a significant shift in thinking, some of the recommendations in the new mastitis protocol are almost a complete reversal of the previous prevailing wisdom.

According to the ABM, the priority should be conservative treatment, decreasing inflammation, and correcting dysbiosis. So, how do we do that, and what are the key changes to mastitis treatment in 2022?

First of all, swap out "pump, pump, pump!" for "ice, ice, ice!" The new mastitis treatments are all about decreasing excess stimulation to the breasts and reducing inflammation.

The following table compares treatment recommendations in the new ABM protocol to previous recommendations:

Mastitis Protocol Comparison

Causes

Medications

Is your mind blown right now? If you've ever been up late scrolling through older guidance and articles on how to handle mastitis, it probably is. Let's review: according to new research, you don't need to avoid bras, and you don't need to massage, soak, and endlessly nurse or pump.
Instead, nurse on demand and pump only to comfort, use ice and an anti-inflammatory medication such as ibuprofen to ease discomfort and reduce inflammation, and consider ditching the antibiotics (in consultation with your provider, of course).
Do you have questions about what the new guidelines mean or how you should use it in your own breastfeeding routine? Schedule a convenient online video visit with a Nest Collaborative lactation consultant.

Mastitis is a common problem, and one you shouldn't have to struggle with alone. Our experienced IBCLCs are here to help around the clock. We work with patients to offer the latest evidence-based recommendations tailored to your family's needs. Don't hesitate to .

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Rethinking Mastitis: A Summary Of The New Mastitis Spectrum Protocol From The Academy Of Breastfeeding Medicine | Nest Collaborative

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Mastitis: Characterized by pain, swelling, warmth and redness of breasts, fever, and malaise, this might be one of the most dreaded words for any lactating parent. Not only is this spectrum of inflammatory breast conditions painful, but it's also notorious for becoming a recurrent problem that can seriously impact a family's breastfeeding journey.

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So basically, wash your hands. Place your fingertips around the areola at the base of the nipple. Press inward towards the chest wall for 1-3 mins. This will push milk and fluids back from the areolar area, softening it and allowing your baby to latch.

Blocked Ducts / Mastitis & How To Resolve

If the inflammation from engorgement gets worse we may experience "a blockage". In the past we thought this meant there was a largish clog in one large duct. We thought that we needed to move that one clog out and that resolved the problem. We thought that if we massaged we could move it, or break it up. We now know this isn't accurate as ducts are microscopic and interlacing, and that massage just causes them to collapse and be bruised (causing more inflammation). Vibration using something like a vibrating toothbrush will not be helpful and will likely cause more inflammation.

Symptoms are usually something like:

1. Tenderness in that area of the breast, with some heat and possible redness.

2. If the blockage is close to the skin you may feel a firmness (assess this with the palm of your hand, not your fingertips. It is normal to feel lumpy areas in a lactating breast - often what you are feeling is alveoli full of milk. It's easy to get concerned about normal lumpiness. To avoid this, use the palm of your hand).

3. There are no systemic systems (no fever etc)

To resolve this "plug" - which is actually an area of the breast where the ducts are narrowed, follow the same recommendations above as for engorgement - ice, don't overstimulate the breast, and lymphatic drainage and anti-inflammatories.

Inflammatory Mastitis

If the ductal narrowing continues (through overstimulation of the breast, or massage etc) then mastitis can develop. This is an inflammatory mastitis (not bacterial). Symptoms are usually:

1. Fever

2. Tiredness

3. Breast tenderness (usually localised to the area of the congestion / ductal narrowing), with redness and heat

4. Headache and flu like muscle aches

The treatment for mastitis has always been to drain the breast and clear the blockage, and this has often encouraged the advice to "feed feed feed". The new protocol from ABM on mastitis turns this on it's head, because we now understand we need to down regulate the milk production, not increase it. Guidance is now to reassure that inflammatory mastitis resolves best with the measures above (ice, don't overstimulate the breast, and lymphatic drainage and anti-inflammatories). Antibiotics are not required at this stage, and the NICE guidance has said for many years that there should be self care for 24 hours before considering antibiotics. Usually 24 hours of self care above will create improvement. Minimise breast pump usage - unless you are exclusively pumping. If you are exclusively pumping, do not pump more than usual. Lecithin may also be helpful.

It's really important to remember that normal lactating breasts are lumpy. Often once people start to feel unwell they get more hypervigilant to lumps and bumps in the breast, and a bit afraid of them. This can lead them to try to massage them out, and try to clear them and this causes more inflammation and compresses the ducts further. In fact the less we do this, the breast gets the feedback that less milk is required right now. The rate of milk production slows, and that in conjunction with the ice and anti-inflammatories allows the milk to start flowing again.

Bacterial Mastitis

In the past it has been thought that bacteria enter the breast through nipple trauma and this is what causes bacterial mastitis. The new protocol and evidence casts doubt on this. It is now thought to be linked to dysbiosis of the breast microbiome. Most people are now aware that we have many species of bacteria in our gut, and they help us to digest our food and impact our immune function. This is our gut microbiome. We also have a breast microbiome - bacterial species which line the milk ducts. This is normal and healthy, however just like in our gut, we can sometimes get an overgrowth of harmful bacteria. This overgrowth may even occur from hyperlactation (producing more milk than the baby needs through extra pumping/expressing). As the bacteria overgrow they narrow the duct, making it harder for milk to get through causing the same issues described above. ​

Symptoms:

1. Redness and swelling in the breast

2. Fever

Blebs

A bleb is a little white lump on the nipple itself. This is an area of inflammation on the nipple. The guidance is not to unroof the bleb. Opening it with a needle will simply cause further trauma and inflammation, narrowing the duct ending further. To treat a bleb the ABM mastitis protcol recommends taking oral lecithin, and using a topical steroid cream to thin the skin on top of the bleb. The steroid should be wiped off before feeding.

SSRMT Technique

In a previous version of this blog I recommended the SSRMT technique to remove blockages (Seven Step Recanalisation Manual Therapy). In a study of almost 3500 women this technique was found to be highly effective (Zhao et al 2014) in resolving symptoms of mastitis. After just one treatment 91.3% of the women had complete resolution of symptoms. A further 4.9% had marked improvement, 2.4% had some improvement and only 1.5% had no improvement. The 8.8% of the women who had not had a complete resolution had a further treatment 3 days later, and 7.6% had complete resolution, 0.8% had marked improvement and 0.4% had some improvement. NONE had no improvement after the 2nd treatment.

How does this fit with the new guidance? That's a good question. The SSRMT technique is an expression technique, and we now know that we shouldn't overstimulate the breast when we have inflammation. I think there are a few important points with SSRMT - in the study the treatment lasted about 5 mins per breast. This was not a long time compared to what people often do when expressing. I imagine this 5 min session might trigger one letdown and no more - it doesn't drain the breast completely. It removes a little milk but doesn't overstimulate. Number 2, it is not about deep massage - it is simply an effective hand expression technique because it helps to get a letdown stimulated through the nipple stimulation, and many people may not know how to trigger a letdown through hand expression before trying this technique.

Since that it has been shown to improve symptoms, I have maintained it in this blog, even though it is not listed in the new protocol. Given the new evidence however I am including it as a method of hand expression with the idea that this is in preference to using a pump. If your baby is breastfeeding then the new protocol suggest that you should just feed the baby as normal, on cue. If you are expressing anyway however, using this technique may be helpful in triggering a letdown and effectively removing milk. It is certainly preferable to any deep massage in and around an inflamed area with the idea of breaking up or moving a clog.

The technique comprises the following 6 steps:

1. Wash hands and get a clean towel /flannel

2. Stretch out the nipple with one hand. With the other, take the towel and wipe any bits of dried milk, dead skin cells etc from the nipple to clear the duct openings

3. Now the duct endings are clear we move back to clear the nipple of clogs. Hold, stretch, roll and extend the nipple in different directions. You may find that as well as flowing milk, clogs of milk or milky strings may emerge from the duct endings when doing this. What it also does is stimulate the nipple well in order to trigger the milk ejection reflex (the letdown).

4. Now that we have worked on the nipple we move back to the areola. Press and push (gently) the areola from lots of different directions while expressing.

5. Then move back again to the breast area. Knead (gently) and push (gently) the breast towards the nipple - this is what we usually do when we are hand expressing with our hands a bit further back from the nipple.

6. Finally, having worked backwards and expressed using our hands from nipple back through the breast area use the flat of 3 fingers to press over the breast looking for any areas where you can still feel any palpable lumps.

Once again - BE GENTLE. Handling the breast should be done with the pressure you use to apply cream, or to stroke a kitten. Please do not pay attention to some of the suggestions I hear online to massage really hard, or really "get in there and work out the clog". Breast tissue is delicate, and when you have a blockage / mastitis you are dealing with already inflamed tissue. It's very easy to damage it further. The SSRMT study above states that "special attention must be paid to avoid intolerable pain". It also says that a maximum of 2 SSRMTs were given in a single session to avoid injury. Steps 3-6 can be done in the bath with the breasts submerged in water and that has certainly been very helpful for many women I have worked with.

I'd also say - get used to handling your breasts. Often we aren't terribly familiar with our breasts and just what breasts full of milk feel like. You may be able to feel areas full of milk before a feed which aren't clogs - they are just full areas that empty during the feed.

Do I need antibiotics?

If you don't see any improvement after 24 hours of self care then the guidance is to see a GP to be evaluated for antibiotics. The vast majority of cases of mastitis are inflammatory rather than bacterial. Within 2-3 days of taking an antibiotic you should feel much better. You will still need to feed on cue but in general follow the guidance above about ice, not overstimulating the breast and using anti-inflammatories etc.

Breast Abscess

A small number of cases of mastitis may develop into a breast abscess ( at the other end of the spectrum from engorgement). In an abscess the body attempts to isolate an infection or fluid filled area by walling it off from the rest of the ductal system. This leads to a sealed off area of milk and pus which by design cannot drain through the nipple no matter what techniques you use or how much you express or feed. Often in fact it just continues to get bigger and bigger despite all your efforts to clear it. This is a clear sign that the breast needs to be scanned for the presence of an abscess. This would be done by ultrasound at your local breast clinic and if an abscess is confirmed then it will need to be drained by needle, as it is unable to drain through the nipple. 90% of abscesses appear to be caused by bacterial infection (Efrem 1995).

The key to avoiding blockages / mastitis is all about keeping your production in line with your baby's intake and avoiding too much inflammation in the breast. Production -> removal -> production -> removal with no sudden changes in the system like a very long gap between feeds for example can mean that the engorgement process doesn't get fired up to start with, but if you do get a blockage we now know we don't need to work out a clog of milk. We need to treat inflammation in the breast like inflammation in any other organ. Allow the breast to rest and recover with supportive measures like ice and anti-inflammatories, not to overwork the organ through increased removal.

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Mastitis & Blocked Ducts - How Do I Clear a Blockage? | Carol Smyth IBCLC & CBT

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So basically, wash your hands. Place your fingertips around the areola at the base of the nipple. Press inward towards the chest wall for 1-3 mins. This will push milk and fluids back from the areolar area, softening it and allowing your baby to latch.

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Breast massage for mastitis and engorgement

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Breast massage for mastitis and engorgement

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Plus Size Bras, Swimwear & Lingerie from AmpleBosom.com

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What is a tongue-tie (ankyloglossia)?

When a baby has a tongue-tie, the movement of their tongue is restricted by a membrane (the frenulum) that connects the underside of the tongue to the floor of the mouth. Many babies have a visible frenulum without having any problems because it is loose enough to allow the tongue to move freely. It's only when this membrane is tight enough to limit tongue function that it's described as a tongue-tie (Walker, 2006).

Tongue-tie types

You'll often hear people describe tongue-ties as anterior (at the front of the tongue) or posterior (towards the back of the mouth).

You might also hear tongue-ties described using a percentage. This percentage describes how far along the underside of the tongue the frenulum comes. So 100% means the tie comes all the way to the front of the tongue. A tight posterior tongue-tie could cause worse feeding problems than a loose anterior tongue-tie (Oakley, 2017).

Sometimes, tissue on the floor of a baby's mouth (the mucosa) hides the tongue-tie. This kind of tongue-tie is called a sub-mucosal tongue-tie (Genna, 2013).

All of these descriptions are anatomical, so they don't relate to how severely a tongue-tie will affect your baby's feeding (Genna, 2013).

What problems does tongue-tie cause for babies?

Tongue-tie can affect both breastfeeding and bottle-feeding. For some babies, the effects will be quite mild. For others, tongue-tie can make feeding extremely challenging or even impossible.

If your baby has a tongue-tie and you're breastfeeding, you might notice one or more of the following in your baby:

a small gape so it feels like the baby is biting/grinding

breast refusal - your baby seems unable to latch onto the breast

difficulty in latching

unsettled behaviour during feeds

frequently coming off the breast or slipping back to the nipple

frequent or long feeds

poor weight gain or excessive early weight loss

clicking noises while feeding

colic/wind/hiccoughs

reflux (baby vomits and/or is miserable after feeds)

difficulties with taking solids or speech difficulties in older babies.

(NHS, 2017; ATP, 2019a)

If you're breastfeeding your baby and they have tongue-tie, you might experience one or more of the following:

sore or cracked nipples and pain during feeding

mastitis

breast engorgement

reduced milk supply.

If you're bottle-feeding your baby, you might notice one or more of the following - your baby:

is very slow to take a bottle

needs to be fed very often in order to get enough milk

dribbles a lot during feeds

tends to push the bottle teat out

chokes on feeds even when you slow the feed down

can only manage a teat that has a very slow flow.

(Oakley, 2017)

Can I see if my baby has a tongue-tie?

It might be possible to tell that your baby has a tongue-tie if they:

are unable to extend their tongue fully

have a tongue with a heart-shaped appearance on the tip

have difficulty lifting their tongue or moving it from side to side.

Tongue-tie is not always obvious though. A tongue can look completely normal to an untrained eye yet still cause substantial problems with feeding (Young, 2011).

How is tongue-tie diagnosed?

If you and/or your baby are experiencing feeding difficulties, you might want to get your baby's tongue function and their feeding assessed by a specially trained professional. They'll be able to help you decide what to do next and will look at your baby, watch them feeding and hear from you about how feeding is affected (UNICEF, 2018).

Some health professionals might use a formal assessment of tongue-tie that's based on how things look and function (e.g. the Hazelbaker Assessment Tool for Lingual Frenulum Function).

Tongue-tie treatment

What is tongue-tie division?

Your baby could have a tongue-tie division, which can release your baby's tongue so it can move more freely. This involves cutting the frenulum (NICE, 2005).

Tongue-tie division is a safe procedure that can improve the breastfeeding problems that tongue-tie causes (NICE, 2005).

Does tongue-tie division hurt?

Tongue-tie division procedures are very quick and simple and are thought to be almost painless (NICE, 2005).

Does tongue-tie division resolve feeding problems?

Most parents say their baby's feeding improves after a tongue-tie division and many find it resolves the problem completely (Buryk et al, 2011; Berry et al, 2012). But a few babies do continue to have feeding difficulties even after a tongue-tie division.

Some parents say manual therapy (e.g. osteopathy, craniosacral therapy or chiropractic) aids a tongue-tie division by helping with jaw or neck tightness and associated issues. But there is very limited scientific evidence to tell us whether these therapies are effective or not (ATP, 2019b).

Do I need to get my baby's tongue-tie treated?

The decision on whether to have a tongue-tie divided is a personal one and different parents will make different decisions. Every tongue-tie is different too and the range of issues it causes can vary from very mild to severe. So how much the tongue-tie is affecting feeding and your life with your baby might influence your decision.

Some parents find the thought of cutting anything in their baby's mouth scary. Others feel that the brief distress is worth the long-term improvements. If you are not sure how you feel, you might find it helpful to talk to other parents whose babies have had a tongue-tie division. You should be able to find these parents at a local breastfeeding drop-in or at an NCT Bumps and Babies group.

You might find it helpful to talk things through with an NCT breastfeeding counsellor too. They can help you explore your thoughts and feelings plus find ways of coping if you decide not to have the procedure done.

If you're considering a tongue-tie division, you can ask a health professional or breastfeeding counsellor to talk you through the procedure.

What else might help with feeding difficulties due to tongue-tie?

There are sometimes ways of improving feeding without having a tongue-tie division. Nipple shields used with good breastfeeding support often help.

Sometimes, finding a supportive breastfeeding position like the koala or the rugby hold, can help. A thorough breastfeeding assessment might also offer different ideas - see an NCT Breastfeeding counsellor or other skilled breastfeeding person in your area (Horsfall, 2013)

Babies who are bottle-fed might find feeds easier if paced bottle feeding techniques are used. Occasionally, finger feeding can be a more comfortable option than using a bottle (Genna, 2013).

How can I find tongue-tie division services near me?

Only registered healthcare professionals who have received proper training in tongue-tie division should perform this procedure. In many areas, the NHS provides a tongue-tie division service. But provision varies across the country and parents in some areas have to travel long distances to reach a tongue-tie division service.

It can be even harder to find a tongue-tie division service when a baby is having problems bottle-feeding. Unfortunately, some areas might have no service available (NCT, 2015).

The National Institute for Health and Care Excellence - also known as NICE - recommends tongue-tie division. Yet there is no common agreement among tongue-tie dividers on how to carry out the procedure or how far the membrane should be divided (NICE, 2005). This means the service different health professionals offer varies.

Your midwife or health visitor should be able to signpost you to NHS tongue-tie assessment and division services in your area. Breastfeeding counsellors or lactation consultants can also give you information about tongue-tie division locally.

Online, you can see a directory of both NHS and private tongue-tie practitioners on the Association of Tongue-tie Practitioners (ATP) website.

What can I expect after my baby's tongue-tie division?

Babies are often unsettled in the first day or two after a tongue-tie division and might need more cuddles and nurturing. After the procedure, you'll probably see a white patch under your baby's tongue; this takes 24 to 48 hours to heal but it won't bother your baby (UNICEF, 2018).

Do I need to do anything after the tongue-tie division?

Some tongue-tie dividers will recommend that you massage underneath your baby's tongue or do tongue exercises in the days after the procedure. Many parents find this kind of care is distressing for their baby and are reluctant to continue with it.

As yet, nobody really knows whether massage or exercise techniques are helpful or harmful. But it's helpful to know that the research studies which showed tongue-tie release helps to improve feeding did not involve using exercises or massage afterwards (Oakley, 2017).

Will my baby's feeding improve after their tongue-tie division?

Parents often expect that feeding will improve immediately after a tongue-tie division. But it usually takes a few days before things get better (ATP, 2019c).

Feeding is often more difficult for the first day or two after a tongue-tie division. This could be because it takes time for your baby to adjust to their new, free tongue, or they're just recovering from the procedure (ATP, 2019c).

It helps everyone to be patient, ease your baby into feeding differently and to try to make feeds as easy and stress-free as possible rather than trying to force them to do it properly. Babies will gradually adapt without any special effort (ATP, 2019c).

Many other things can have an effect on feeding in addition to tongue-tie. So some babies might need further support even after a tongue-tie division. If things have not improved after a few days, you might find it helpful to get extra support to improve feeding - see below.
This page was last reviewed in July 2018.
Further information

Our support line offers practical and emotional support with feeding your baby and general enquiries for parents, members and volunteers: 0300 330 0700.

You might find attending one of our Early Days groups helpful as they give you the opportunity to explore different approaches to important parenting issues with a qualified group leader and other new parents in your area.

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby

Attending a Baby Cafe or other breastfeeding support drop-in can be a good way to access support with feeding your baby. You may also find other parents there whose babies have had a tongue-tie.

Make friends with other parents-to-be and new parents in your local area for support and friendship by seeing what NCT activities are happening nearby.

Pictures of babies with tongue-tie can be found on Catherine Genna's website.

The Baby Friendly Initiative, part of UNICEF, has a list of locations where tongue-tie can be divided within the UK, as does the Association of Tongue-Tie Practitioners.

Tongue-tie UK raises awareness about tongue-tie and lip-tie in the UK to help parents get information and support.

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When a baby has a tongue-tie, the movement of their tongue is restricted by a membrane (the frenulum) that connects the underside of the tongue to the floor of the mouth. Many babies have a visible frenulum without having any problems because it is loose enough to allow the tongue to move freely.

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Sore nipples when breastfeeding | Baby & toddler, Feeding articles & support | NCT

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Sore nipples can be a problem in the early days of breastfeeding and beyond. This article discusses causes of sore nipples and how to ease the pain.

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This information can also be viewed as a PDF by clicking here.
The information provided is taken from various reference sources. It is provided as a guideline. No responsibility can be taken by the author or the Breastfeeding Network for the way in which the information is used. Clinical decisions remain the responsibility of medical and breastfeeding practitioners. The data presented here is intended to provide some immediate information but cannot replace input from professionals.
Some gastro-oesophageal reflux (GOR) occurs in most babies. Up to 40-50% of babies younger than 3 months regurgitate their feeds at least once a day (Craig 2004). Incidence peaks around 4 months. GOR is a normal physiological process that usually happens after eating in healthy infants, children, young people and adults. Most of us are familiar with it in the later stages of pregnancy. In reflux there is no retching as associated with a gastric infection, milk simply comes up and out of the baby's mouth.

The predominant symptom is frequent regurgitation of feeds (posseting). Diagnosis is usually made by description of symptoms. Other signs include:

Irritability or excessive crying

Recurrent hiccups

Frequent night waking

Frequent coughing

Studies show that frequency of regurgitation declines over the first 6 months and dramatically after 12 months (NICE 2015). This interestingly corresponds with the time when babies can sit and stand.

Regurgitation of at least 1 episode a day with age (Nelson 1997)

NICE 2015 recommends to healthcare professionals that GOR is a normal physiological process in infancy. Parents should be reassured that it does not need any investigation or treatment unless the child presents with symptoms such as unexplained feeding difficulties, distressed behaviour, or faltering growth. Overfeeding is a common cause in artificially-fed infants who may benefit from smaller, more frequent bottles.

Silent reflux is described as reflux where the regurgitation is swallowed rather than being spat out. Babies may cry and show signs of distress but not posset. Symptoms may otherwise be identical to GOR.

Most cases of reflux clear up without intervention but simple changes can help reduce symptoms.

Feed more frequently and respond at the baby's first cues that he/she is hungry - crying is a late sign of hunger and will increase the air swallowed making regurgitation of feeds more likely. Scheduling feeds with longer intervals and larger volumes may increase symptoms.

Keep the baby upright after feeds over your shoulder ideally for at least 30 minutes with a muslin to catch milk if necessary.

Using a sling to keep the baby upright may help but ensure there is no pressure on the stomach and do not bend yourself.

Do not put the baby down in a car seat where they become somewhat slumped. Try not to jiggle or move the baby too much as the feed settles.

Take time to burp the baby in a sitting position with his/her head supported with your hand - be prepared with a muslin cloth over your shoulder and a bib on the baby to protect clothing (and reduce washing!)

Put the baby to sleep flat on his or her back.

Ensure that breastfeeding has been optimised to ensure the baby has access to all the milk and that your breasts are well drained after a breastfeed (Woolridge 1988).

Caring for a baby with reflux is difficult, exhausting and confusing. It may be isolating as you may be concerned about the baby vomiting when outside the family home. Do you have enough changes of clothes for yourself and the baby? What will other people say? What if the regurgitated milk goes onto someone or something else?

With GOR, medication is not essential. However you may wish to try remedies to relieve symptoms of excessive crying and posseting in the baby. Medication should not be commenced without support by an expert in breastfeeding to optimise attachment.

If frequent regurgitation associated with marked distress, continues despite a breastfeeding assessment and advice, NICE recommends that alginate therapy can be considered for a trial period of 1-2 weeks. If the alginate therapy (Gaviscon Infant sachets ®) is successful continue with it, but it should be stopped at intervals to see if the infant has recovered as we know that it may resolve with time as described above.

The sachets of alginate should be dissolved in water or expressed breastmilk as described below.

Side effects Alginates, such as Gaviscon®, can cause constipation in the baby as they thicken the gastric contents. This may cause further distress to the baby and anecdotally can lead to prescription of bulk forming laxatives in addition to the alginate. This is inappropriate and symptoms would be better managed with other drugs

Dose: infant body-weight under 4.5 kg, 1 'dose (sachet)' mixed with feeds (or water in breast-fed infants) when required (max. 6 times in 24 hours); body-weight over 4.5 kg, 2 'doses' mixed with feeds (or water or expressed breastmilk in breast-fed infants) when required (max. 6 times in 24 hours);

Manufacturer Gaviscon® directions: Bottle fed infants; Mix each sachet into 115ml (4 fl oz) of feed in the bottle and shake well before feeding as normal. Breast fed infants and other infants up to 2 years mix each sachet with 5ml (1 teaspoon) of cooled boiled water until a smooth paste is formed, add another 10ml (2 teaspoons) of cooled boiled water and mix. For breast fed infants give Gaviscon Infant® part way through each feed or meal using a spoon or feeding bottle.

Symptoms:

The baby is not gaining weight

The baby vomits frequently and forcefully

The baby spits up green or yellow fluid

The baby spits up a liquid which looks like coffee grounds

The baby repeatedly refuses feeds

The baby has blood in the bowel motions

It is reported by Salvatore (2002) that in up to half of the cases of G0RD in infants younger than
1 year, there may be an association with Cow's Milk Protein Allergy. Heine (2006) noted that infants with these conditions often respond to hypoallergenic formula or a maternal elimination diet but that only a few randomized clinical trials have been conducted.

Treatment first line is with alginate but may be replaced with a 4 week trial of the H2 antagonist ranitidine or Proton pump Inhibitor (PPI) Omeprazole. NICE 2015 recommends that metoclopramide, domperidone or erythromycin to treat GOR or GORD are not prescribed without seeking specialist advice and taking into account their potential to cause adverse events.

Ranitidine is licensed to treat Reflux oesophagitis. Studies have suggested that H₂ antagonists are effective in treating children with GORD. Ranitidine is well tolerated and has a low incidence of side effects. Common side effects include fatigue, dizziness and diarrhoea. (Cucchiara 1993). Ranitidine is the H₂ antagonist used most commonly to reduce the acidity of GORD. Cimetidine is rarely used, as concerns surround its effects on cytochrome P450, leading to multiple drug interactions.
Dose (BNFC May 2015):

Neonate 2 mg/kg 3 times daily but absorption unreliable; max. 3 mg/kg 3 times daily

Child 1-6 months 1 mg/kg 3 times daily; max. 3 mg/kg 3 times daily

Child 6 months-3 years 2-4 mg/kg twice daily

An oral solution is available and can be provided as a sugar free formulation. Anecdotally some babies refuse to take the solution with an alcohol content so it is worth asking the dispensing pharmacist to check the excipients.

The 2014 Cochrane review concluded that "Moderate evidence was found to support the use of PPIs, along with some evidence to support the use of H₂ antagonists in older children with GORD, based on improvement in symptom scores, pH indices and endoscopic/histological appearances. However, lack of independent placebo-controlled and head-to-head trials makes conclusions as to relative efficacy difficult to determine. Further RCTs are recommended".

Omeprazole is licensed to treat GORD. It is usually dispensed as Losec MUPS® to be dissolved in water as directed.
Dose (BNFC May 2015):

Neonate 700 micrograms/kg once daily, increased if necessary after 7-14 days to 1.4 mg/kg; some neonates may require up to 2.8 mg/kg once daily

Child 1 month-2 years 700 micrograms/kg once daily, increased if necessary to 3 mg/kg (max. 20 mg) once daily

Child body-weight 10-20 kg 10 mg once daily increased if necessary to 20 mg once daily (in severe ulcerating reflux oesophagitis, max. 12 weeks at higher dose)

Child body-weight over 20 kg 20 mg once daily increased if necessary to 40 mg once daily (in severe ulcerating reflux oesophagitis, max. 12 weeks at higher dose)

Studies of omeprazole and lansoprazole in infants with functional GOR have demonstrated variable benefit, probably because of differences in inclusion criteria (Cochrane 2014)

Cost to NHS (NICE 2015)

British National Formulary

Craig WR1, Hanlon-Dearman A, Sinclair C, Taback S, Moffatt M.Metoclopramide, thickened feedings, and positioning for gastro-oesophageal reflux in children under two years. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD003502

Cucchiara S, Minella R, Iervolino C, Franco MT, Campanozzi A, Franceschi M, et al. Omeprazole and high dose ranitidine in the treatment of refractory reflux oesophagitis. Archives of Disease in Childhood 1993;69:655-9.

Heine RG. Gastroesophageal reflux disease, colic and constipation in infants with food allergy. Curr Opin Allergy Clin Immunol. 2006 Jun;6(3):220-5.

Jones W Breastfeeding and Medication Routledge 2013

Nelson SP, Chen EH, Syniar GM; Christoffel KK Prevalence of Symptoms of Gastroesophageal Reflux During Infancy. A Pediatric Practice-Based Survey , Arch Pediatr Adolesc Med. 1997;151(6):569-572.

NICE 2015 Gastro-oesophageal reflux disease: recognition, diagnosis and management in children and young people www.nice.org.uk/guidance/ng1/ifp/chapter/reflux-in-babies

Salvatore S, Vandenplas Y Gastroesophageal reflux and cow milk allergy: is there a link? Pediatrics. 2002 Nov;110(5):972-84)

Woolridge MW andFisher C. Colic, "overfeeding", and symptoms of lactose malabsorption in the breast-fed baby: a possible artifact of feed management. The Lancet, 1988; ii:3

©Dr Wendy Jones MBE, MRPharmS and the Breastfeeding Network August 2021

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Reflux and Breastfeeding - The Breastfeeding Network

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This information can also be viewed as a PDF by clicking here. The information provided is taken from various reference sources. It is provided as a guideline. No responsibility can be taken by the author or the Breastfeeding Network for the way in which the information is used. Clinical decision…

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Thrush (of the breast/nipple) and Breastfeeding - The Breastfeeding Network

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This information can also be viewed as a PDF by clicking here. The information provided is taken from various reference sources. It is provided as a guideline. No responsibility can be taken by the author or the Breastfeeding Network for the way in which the information is used. Clinical decision…

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your baby is under 4 months and has signs of oral thrush you do not see any improvement after 1 week of treatment with a mouth gel you have difficulty or pain swallowing It's still important to get help from a GP if you need it.

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Concerns that they are struggling with low milk supply are often cited by UK mothers as a reason for cessation of breastfeeding and certainly cessation of exclusive breastfeeding ¹.

However not all mothers who worry about low milk supply have an actual issue. Perception of low milk supply is a common problem when parents misinterpret normal newborn behaviour (such as cluster feeding, growth spurts and frequent feeding in a newborn) or misunderstand how breastfeeding works (not appreciating that breasts may come to feel softer as weeks go by, a baby's swallowing pattern may change as the fat content of breastmilk milk rises or that response to a breast pump is not a measurement of milk supply).

When a mother fears low milk supply and begins supplementation, this may then lead to an actual decrease in her milk production.

In some cases there is an insufficient milk intake, as indicated by inadequate weight gain and insufficient stooling under 5 weeks. In the majority of cases this will be initially due to the quality of milk transfer (though over time, poor quality milk transfer will impact on milk production.)

Fears about low milk supply, whether due to perception or reality, can erode a mother's confidence and cause on-going distress. Effective support may enable a mother to accept normal breastfeeding patterns and move forward with greater confidence or correct issues with milk transfer and adjust her milk production.

In rare cases, where mothers have a primary issue with lactation, more specialist help may be required to investigate the underlying issues.
An Issue with Milk Transfer

Is the mother breastfeeding regularly enough?

Is she feeding in response to baby's cues ie. not trying to impose a 'routine'?

or alternatively is the baby sleepy and jaundiced and she is waiting for cues which could cause insufficient feeds?

Is she staying on one breast for extended periods beyond the point the baby is effectively transferring milk and milk volume needs to be increased with some 'switch nursing' (using other side)?

Or is she removing the baby from the breast prematurely and reducing the amount of higher fat content milk the baby receives?

How is the POSITIONING and ATTACHMENT (latching)

Is the mother comfortable? (not just nipples but mother's back/ arms)

Is the nipple misshaping after a feeds? (suggesting it's being pressed incorrectly against the hard palate or against the rear of the tongue)

Does the nipple come out looking blanched because of compression?

Is there visible nipple damage?

Does the mother experience blocked ducts and mastitis (suggesting ineffective milk transfer)?

Could there be an issue with the baby's anatomy?

? (which may not be immediately visible and doesn't have to mean a frenulum at the tip of baby's tongue)

Asymmetry

High palate

Low tone

An Issue with Lactation

In rarer cases, there may be issues with the mother's primary ability to lactate. Figures vary but based on breastfeeding figures in comparable countries, we can suppose approximately 2-5% of women have underlying issues that may affect milk production and milk transfer2, 3. Multiple factors may account for this, for example:

This could be due to a history of breast surgery or breast injury,

PCOS (a 1/3 of mums with PCOS will experience supply problems)

Other hormonal issues (e.g. retained placenta, theca lutein cysts, thyroid conditions)

Insufficient glandular tissue/hypoplasia (breasts may be tubular, widely-spaced, not developing in puberty, not changing in pregnancy, mother not experiencing breast changes after birth)

or significant blood loss in delivery (without sufficient transfusion causing pituitary compromise).

Is the mother taking hormonal contraceptives? Both Combined Hormonal Contraception and Progesterone Only Contraception (POP/LARC) may affect supply in some women.
Remember: A baby may also have underlying health issues which affect weight gain. How Would we Help a Mother who Describes Low Milk Supply?

Has anyone observed her feeds? Who observed and when? Where could she go to have her feeds properly observed?

Has she had information about what is normal in the first few weeks of breastfeeding and newborn care?

Could she use expressing/pumping to stimulate supply? Double hospital grade pumping is ideal (eg. renting from a local NCT pump agent or national pump hire company). Pumping after applying warm compresses and breast massage, using hand expression at the end of a feed or to help stimulate the milk ejection reflex.

We need to monitor weight but bear in mind overweighing may not be helpful and could affect maternal confidence.

The mother can gain reassurance from monitoring nappies, but stooling rate over 5 weeks is not a reliable indicator of milk transfer and as a baby receives more breastmilk, their stooling rate may actually decrease.

Look at bottlefeeding technique if top-ups are being used. Does the bottle shape and position encourage a wide latch that mimics a breastfeeding gape? In some cases, 'paced bottlefeeding' may be encouraged (though caution advised if baby's weight gain is a serious concern and higher flow feeds may be needed).

Help her to understand that supplementation may make a baby healthier/ stronger/more effective at the breast and can support breastfeeding (rather than being 'failure'). That supplementation isn't simply 'getting a baby to put on weight so it looks better on a chart' but helping to make a baby a better breastfeeder. However she also needs to understand the relationship between the quantity of supplementation and her own supply.

Encourage her to reflect on her support network. Have her family and friends faded away now they perceive the newborn phase to be over? The next two weeks may be particularly crucial if a mum is going to focus on developing her supply.

Consider testing thyroid function in mothers with low milk supply
With thanks to Emma for her contribution to this website. Her own website Emma Pickett Breastfeeding Support can be found here. Further Information Global Health Media Project: Breastfeeding Series Not Enough Milk Video Breastfeeding After Breast and Nipple Surgeries (BFAR) NHS Website: Tongue Tie
NICE CKS Breastfeeding Problems Last Revised May 2017
References

1. UK Infant Feeding Survey (2010)

2. Australian Government Department of Health: Norway -The WHO Code and Breastfeeding: An International Comparative Overview Updated May 2012 - Includes data on breastfeeding rates in Norway which can be compared to those in the UK.

3. OECD Family database: OECD- Social Policy Division- Directorate of Employment, Labour and Social Affairs, CO1.5: Breastfeeding Rates Updated October 2009 - Includes breastfeeding rates in Hungary and other OECD countries which can be compared to those in the UK.

Published April 2017, Updated August 8th 2019

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by Emma Pickett IBCLC Concerns that they are struggling with low milk supply are often cited by UK mothers as a reason for cessation of breastfeeding and certainly cessation of exclusive breastfeeding1. However not all mothers who worry about low milk supply have an actual issue.