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Details on'blocked ducts' and mastitis and how to treat them - this is the revised protocol issued in 2022

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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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Handy summary of how to treat mastitis

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For Modern Mothers - Everything for a positive and empowering pregnancy, birth & motherhood

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As you probably already know, I always like to keep you up to date & informed. Making sure you have the latest information and guidance so you can make the right decisions for you and your baby. Because that's super important.

This one is all about breastfeeding, and about a recent update to the Mastitis protocol. It's important as it actually turns-on-it's head a lot of the previous recommendations for Mastitis. Also because the NICE guidelines have not yet been updated, and also many GPs have not been updated either (who are the first port of call for folks with mastitis).

Why the changes?

These changes have been made to the clinical protocol for Mastitis by the ABM as there have been several key changes that significantly shift what we thought we knew about Mastitis. Because science and knowledge moves on doesn't it. Mastitis is now described as a spectrum - not one sole thing. Oversupply (hyperlactation) is the first marker, this can then lead to painful inflammation which causes narrowing of the milk ducts (previously called a 'plugged duct'), which could then progress to inflammatory mastitis.

So what we previously called 'plugged ducts' are now more accurately described as "ductal narrowing," which means that using cold compress and other anti-inflammatory treatments should be used to manage mastitis instead of what was previously advised in guidance - heat (the opposite!). Also that we previously were advised that extra pumping was the way to go that would help to drain/unblock the breast - we know know that may actually exacerbate the problem. Similarly vigorous massaging is now thought to actually just be more uncomfortable and painful - and not actually help solve the problem!

So what is the new guidance then?

As oversupply is now considered to be the first marker on mastitis spectrum we don't want to do lots of extra pumping which could signal the body to continue to produce even more milk and perpetuate the cycle. Instead feed your baby on demand or pump on your normal schedule, and minimize extra pumping.

2. Use ice instead of heat for inflamed ducts & inflammatory mastitis

A hot/warm compress used to be the advice. But because heat doesn't help reduce inflammation the recommendation when you have a painful plugged duct (which is actually a duct narrowing due to inflammation) is now to use COLD to tackle that swelling instead, which will reduce the blood flow and swelling. So you could use ice packs or a cold compress.

3. use ibruprofen

Plugged ducts are actually an inflammation (not a milk blockage as previously thought) so using NSAIDs such as ibuprofen can help.

4.Hand express

If you need to relieve discomfort from your breasts then doing this via hand expression is now advised, so you can be gentle and also not overstimulate.

5. gentle massage only

Be gentle with your massage! Those days of using the intensity of a shower head to massage your boobs, or grabbing an electric toothbrush to try to forcefully massage out your clogged duct are now gone. Infact those things can make the problem worse according to the updated guidelines.

"Attempts to extrude a 'plug' or milk precipitate by squeezing or aggressively massaging the breast are ineffective and result in tissue trauma," note the new guidelines authors.

So instead the guidance now is to try gentle, lymphatic draining massage which involves "a light sweeping of the skin rather than deep tissue massage." Sweep up from the nipple toward the armpit to help drain any extra fluid and calm the inflammation.

6. Sunflower Leicithins and probiotics

It used to be that antibiotic were advised immediately for mastitis, and sometimes as a precautionary measure. But the new protocol says that actually antibiotics may not always be required (only reserved for what's called 'bacterial mastitis' - see more below on this type of Mastitis) and not for inflammatory mastitis nor for mastitis prevention.

It's now said that you should consider taking probiotics for mastitis prevention (and I suggest looking into probiotics to so many mothers in my mum & baby classes already for other reasons too). "A systematic review suggested that probiotics may be effective for both treatment and prevention of mastitis, but a strong recommendation could not be made due to limitations of the studied trials." Specific strains that have clinical research supporting their use with mastitis include: Limosilactobacillus fermentum (formerly classified as Lactobacillus fermentum) or, preferably, Ligilactobacillus salivarius (formerly classified as Lactobacillus salivarius) strains.

Sunflower Lecithin has been recommended to combat recurrent plugged ducts. The usual recommended dosage for recurrent plugged ducts is 3600-4800 mg lecithin per day, or 1 capsule (1200 milligram) 3-4 times per day. After a week or two with no blockage, you can reduce the dosage by one capsule. If there is no blockage within another 2 weeks you can reduce it again by one. You may need to continue taking 1-2 capsules per day if stopping the lecithin leads to additional plugged ducts (info on dosage from KellyMom).

Lecithin is a very common food additive, and is found naturally in many other foods. There are no known contraindications to its use by breastfeeding mothers.

The reason why lecithin may help resolve and prevent plugged ducts is not clear. The well respected Dr. Jack Newman, says "It may do this by decreasing the viscosity (stickiness) of the milk by increasing the percentage of polyunsaturated fatty acids in the milk." Lecithin is an emulsifier (used to keep fats/oils dispersed and in suspension): phospholipid molecules (such as lecithin) contain hydrophobic and hydrophilic elements; the hydrophobic portion has an affinity for fats and oils, and the hydrophilic portion has an affinity for water.

You can read more about Sunflower Lecithin here: https://kellymom.com/nutrition/vitamins/lecithin/

Antibiotics may not always be necessary

According to the new guidance "Use of antibiotics for inflammatory mastitis disrupts the breast microbiome and increases the risk of progression to bacterial mastitis." Antibiotics also shouldn't be used for mastitis prevention. Many antibiotics also boast anti-inflammatory properties, "and this may explain why women experience relief when taking these," state the protocol authors.

THE Signs of bacterial mastitis

You may be experiencing a bacterial mastitis infection if you notice the following symptoms:

Abnormal swelling and/or a wedge of redness on the breast

A painful lump on the breast or general breast tenderness

Pain or burning while breastfeeding

A breast that feels unusually warm or hot to the touch

General malaise or flu-like symptoms

Bacterial mastitis may require antibiotics. So if you have any of these symptoms please contact your GP quickly to check and for treatment recommendations - which may include antibiotics.

You can take a look at the new mastitis protocol here yourself for more details:
https://www.bfmed.org/assets/ABM%20Protocol%20%2336.pdf
In a nutshell breastfeeding should not be painful. So if you do have pain, or think you may have symptoms of an infection contact a lactation professional or your GP for a consultation. You don't have to do this on your own - help is there for you, please remember that. It's probably the most important thing I tell people on my Empowered Breastfeeding Workshop that's part of my Hypnobirthing & Antenatal Course

Most folks need some help and support at some point in their breastfeeding journey. You can find a lactation consultant here if you need one- https://lcgb.org/

If you need any other sign posting to support, please just let me know.

Susan x

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The NEW Mastitis protocol - For Modern Mothers - Everything for a positive and empowering pregnancy, birth & motherhood

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I like to keep you up to date & informed, so you can make the right decisions for you and your baby. This one is all about breastfeeding, and about a recent update to the Mastitis protocol. It's important as it actually turns-on-it's head a lot of the previous recommendations for Mastitis.

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Strategies for blocked ducts, blebs and mastitis

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Strategies for blocked ducts, blebs and mastitis

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This is the most up to date information on how to manage these issues.

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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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Most of us mothers have a bit of an obsession with our baby's "gassiness". We analyze every little fart and burp. We inspect their poop and how many times they squirmed around and seemed unsettled. We basically blame every little unsettled, "colicky" episode on gas or reflux. We then head out to buy some sort of concoction to help remedy our little fart machine babies.

We need to understand the causes of gas, what is normal, what is abnormal and when we need to worry. I have a few simple things to help you and your gassy, unsettled baby. Almost every new mother I see for a breastfeeding consultation comments on her gassy baby. We just can't seem to stop worrying about this!

So what is normal?

Your baby is going to fart. Your baby is going to spit up and sometimes projectile vomit. Your baby is going to have periods of time where they are unsettled. Your baby will most likely have this unsettled time in the later afternoon/evening hours. This is what my mother calls the "witching" hour. If your baby does not do this then count your lucky stars and do a happy dance. You are in the minority! Most babies have a few weeks or months where they will spit up or vomit quite a bit. Sometimes you will look at that pile of vomit and wonder if they actually digested anything when they breastfed. In conclusion: Your baby is going to fart. Your baby is going to burp. Your baby is going to cry and sometimes they will cry for a few hours for no apparent reason.

What is NOT normal?

*A baby who cries or is unsettled ALOT, or very frequently-24/7.
*A baby who has reflux symptoms which include 1:Your baby is bringing up a large amount of milk after most feeds.She seems to be in pain after breastfeeds. She is fussy and unhappy between feeds. She arches her back after most feeds. She has problems gaining weight. Ongoing breathing (respiratory) problems. Important to note that sometimes a baby will have "silent reflux" where the symptoms are not as obvious. Please seek help from an IBCLC if you suspect this is happening with your baby.
* A baby who is unsettled at every breastfeed and GULPING the milk down like they are drinking out of a fire hose. These babies usually have a "love/hate" relationship with the boob.

What is causing these abnormal symptoms and what can I do?
1. Intolerance to something you are eating that is going through your milk.
THIS IS NOT A LACTOSE INTOLERANCE. An intolerance to dairy is in most cases an intolerance to the protein in the milk, not the lactose. There can be many different symptoms if your baby is experiencing this issues. Cow's milk sensitivity or allergy can cause colic-like symptoms, eczema, wheezing, vomiting, diarrhea (including bloody diarrhea), constipation, hives, and/or a stuffy, itchy nose. 2 While it is estimated that 2-5% of babies have a dairy intolerance to the milk protein, I would argue that this is a commonly under and mis-diagnosed problem with many parent's walking out of their doctor's offices with a colic diagnosis and medication for reflux without any discussion on the breastfeeding mother's diet and how this could be the cause of the issues. Thankfully most babies will outgrow their dairy intolerance by the time they are twelve months old. 3

Three important aspects of figuring out if this is the cause:

-You must cut it out for at least 3 weeks to see if this is it. It takes that long to get out of your system and your baby's system. However if your child has been diagnosed with gastroenteritis, it can take a much longer time for your baby's gut to heal. This means that after you cut out the dairy it could take months for your baby's digestive system to heal. 4

-It must be 100% NO DAIRY. Not even in a cracker! No lactose-free milk. It's not the lactose, for many people it's the protein in the milk.

-Work on your gut health at the same time; take probiotics, eat foods that are fermented and cultured on a daily basis and make homemade bone broths which are good for your digestive system. All of these will go through your milk to your baby and will help both of you!

If after 3 weeks you have not noticed a changed, cut out gluten and soy. These are other foods that commonly cause issues with babies (and adults).
2. Over-supply/over-active let-down/lactose overload 3. Tongue/lip tie. 4. How we care for our babies
Do you have fire-hose boobs like I did with all 3 of my babies?! Does your baby gulp and sputter at the breast or seem to get in lots of milk all at once? Does your baby have a "love/hate" relationship with the breast? You do not have to decrease the amount of time or how frequently you are feeding (you cannot over-feed a breastfed baby) but you can change HOW you are feeding to help with this. Click here to read my article on "pukey" babies and over-supply.

A baby with a tongue or lip tie that is affecting breastfeeding (not every baby with a tie will have a problem latching properly) can often exhibit reflux or colic symptoms. Why is this? Babies with ties can have difficulty latching on to the breast properly. When a baby is unable to latch well, it can cause an increase in air that they are ingesting while breastfeeding which can then lead to more gas and reflux symptoms. If you have any inkling that your child may have a tie (and especially if you also have painful breastfeeding or your baby has weight gain issues) I highly suggest seeking help from an International Board Certified Lactation Consultant who can help diagnose the tie and give you information and form a plan for you. Click here to read my article on tongue ties and how it can affect breastfeeding.

This is something I never hear mentioned when talking about reflux...the simple remedy of holding your baby as a preventative measure. Imagine this...you have just eaten a huge, liquid meal that has filled your tummy. You are then put down on your back, you cannot really move much at all besides pulling your legs up and down. You are full, have some bubbles in your belly and you are immobile. Sounds uncomfortable doesn't it?! Simply cuddling your baby and holding them upright will help prevent many issues with reflux/colic/unsettled symptoms. Often times a baby will burp just from being lifted up over our shoulder or passed to someone else. It gets things moving! It can be really difficult to move gas along (and out) of our bodies if we are lying down, not moving. Babies who are held often and upright will be much less likely to have these issues. You cannot hold your baby too often and it is simply not possible to spoil them.

Do not suffer alone with your baby if you feel as though your baby's symptoms fit into the NOT normal category! Often times a mother will just be prescribed reflux medication for her baby or be recommended to switch to a hyperallergenic formula instead of actually getting to the bottom of WHY her baby has reflux. Switching your baby to formula can do more damage to their gut health in the short and long term, and reflux medications will help fix the symptoms without figuring out the cause. Seek help from an IBCLC if you need some support with this or more information. there are answers for you!

*Rarely, there will be a medical condition that will cause a baby to be unsettled or "colicky". If you have concerns that your baby has issues above and beyond what I have discussed here please seek help from your doctor. This article is not meant to be medical advice or give a diagnosis.

1. https://www.breastfeeding.asn.au/bfinfo/reflux.html

2. http://kellymom.com/health/baby-health/food-sensitivity/#dairy

3. http://pediatrics.aappublications.org/content/118/3/1279.full

4. https://www.breastfeeding.asn.au/bfinfo/lactose.html

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Does my baby have reflux? Is it colic? Why is my baby so gassy and unsettled? | The Milk Meg

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Most of us mothers have a bit of an obsession with our baby's "gassiness". We analyze every little fart and burp. We inspect their poop and how many times they squirmed around and seemed unsettled. We basically blame every little unsettled, "colicky" episode on gas or reflux.

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If it isn’t reflux or colic, could it be. . . ?

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If it isn’t reflux or colic, could it be. . . ?

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Sarah Ockwell-Smith's Blog - The Great Baby Reflux Epidemic (or not....) - October 10, 2014 06:31

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How many people do you know whose baby has, or had, reflux? A lot I'd imagine.Reflux medications such as infant Gaviscon, Losec, Omeprazole, Domperidone...

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Try leaning back - either once baby is latched on, or to enable baby to latch on.

Once baby is on the breast and you are leaning back, try micro-movements - making little adjustments to your and baby’s positions to enable a deeper latch. As you baby suckles he or she will draw the breast in deeper, so tiny adjustments can often help this to happen.

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You will be amazed at how much being able to talk things through can help, so please . . . . .

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You will be amazed at how much being able to talk things through can help, so please . . . . .

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If you are having difficulties do seek help. Phone me (07472 795916), call the nct helpline (0300 330 0700 8am-10pm) come to a Baby Café, or call the local health visitor advice line (01883 340 922 8am-5pm). And please keep seeking help until you get the help you need. . .none of us has all the answers, but we will all help you work things out.

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Breastfeeding Support in Redhill, Reigate and Horley

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This is a list of sources of breastfeeding help and information in our area

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Sometimes feeding issues can arise because parents are misreading their baby’s cues, reading intention where there is none - babies don’t manipulate. This article is a  general one but it has some helpful thoughts

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By L.R.Knost

On a recent trip to the park, I overheard a parent ranting and raving about a little one "being a brat and always pitching fits." It took me less than two seconds of looking at the child to realize his mother had put him down on hot asphalt without shoes on, and his 'fit' was actually cries of pain as he danced around trying to keep his poor little feet off the asphalt while trying to push past his mummy to get back into the car. In a few years this mother will wonder why her ten-year-old is always so sullen and silent.

Later the same day in the supermarket, a three-year-old asked her mummy what plastic wrap was for. The mother rolled her eyes and snapped, "For wrapping food in plastic, duh." A few years from now, this mother will confess to a friend that she has no idea why her nine-year-old is so mouthy and rude.

You may also like: "Quit Crying" and Other Phrases You Should Stop Saying to Your Kids

Minutes later, a two-year-old riding past me in a shopping cart pointed at a toy and babbled in her cute baby language, looking at her daddy with a delighted smile. Her father ignored her first few attempts to get his attention, then finally barked, "Shut up!" without ever looking at her. In a few years this father will complain to his co-workers that his teen aged daughter never talks to him.

Communication in my son's Tae Kwon Do classes is called, "The link between the world and me." In the parent/child relationship, communication is entirely...hear this... entirely the responsibility of the parent. From the moment a child enters the world, they are trying to communicate. Crying, grunting, making eye contact, mirroring expressions, all of these things are the instinctive tools built into infants to reach out into a brand new world and make contact. They can do no more. It is entirely up to the parent to make the connection, to respond, to build those all-important 'lines of communication' that will be so vitally important to parents in later childhood. Communication is not something that just happens. It is not something that begins when a child becomes verbal, and it's not a product of a child's advancing maturity. Communication is a process, a relational building block, a result of intentional and responsive parenting.

Crying is often mischaracterized as manipulation, and adults are certainly capable of using it that way. But to project such motivations on a baby is to grant them a level of skill and control far, far beyond their capabilities, and that is a potentially disastrous mistake. A parent's perception of the motivation behind their child's behaviour is often the single most powerful determinant of the parent's response. And the parental response or lack of response to a nonverbal child's cries either builds or damages their communication and connection. There is no in between, no neutral.

Babies cannot and do not manipulate. They communicate. Listen. Respond. You aren't being manipulated. You are being a parent.

And hear this well, parents, your relationship with your teenager is being established now, while your child is still a toddler. Your discipline issues with your nine-year-old are being minimized or intensified right now, while he is reaching out to you in infancy. Preschooler's tantrums are being moderated or exacerbated at this moment by your response or lack of response to your baby's cries.

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Babies Don't Manipulate-They Communicate - The Natural Parent Magazine

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By L.R.Knost On a recent trip to the park, I overheard a parent ranting and raving about a little one "being a brat and...

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This video shows the difference between effective feeding and ineffective, with tips on how to improve things

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A common concern of a new mother is whether her baby is getting enough milk. This video shows signs to tell whether the baby is feeding well. About the Breastfeeding Series " DOWNLOAD

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Nappies are a parent friendly way of checking how much milk your baby is taking, especially during the first few weeks.

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On days 5-6

Wees: Five or more heavy nappies per day.

Poos: At least two soft, yellow poos per day. They're yellow, because there is no more 'mec' in the bowel.

False menstruation or pseudo menstruation is harmless. It is a very light bleed from the vagina in some baby girls. It comes from the effects of your own hormones on her system, and it soon stops.

After the first week: babies continue to wee and poo several times each day for the first few weeks.

After about six weeks, some (not all) babies poo much less often. Breastfed babies may go many days without producing any poo at all after this time - that's normal, too. As long as your baby is growing well, and the poo he produces is soft, you don't need to be worried. Ask your health visitor about this, if you need to.

What's a 'heavy nappy'?

Try this test - pour three tablespoons of water (45ml) into a dry nappy, and pick it up. That's how heavy your baby's nappy will be, after the first five to six days.

How do I know if my baby is weeing often enough when disposable nappies just absorb the wee?

All babies should produce several heavy nappies every day. If you use disposable nappies, do the 'heavy nappy' test with water so you know what you are looking for. You can also place a cloth inside the nappy, which will stay wet when your baby wees. Any questions about your baby's health or feeding, just ask your midwife.

Urates, sometimes known as brick dust because that's what it looks like: tiny orange or pinkish crystals. They are harmless: they are salts in the urine, and tend to show up in the very early days. Most babies will pass them once only. They can be a sign your baby needs a little help to feed more often or more effectively. Ask you midwife.

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 NCT's 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.

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Newborn baby poo in nappies: what to expect | Baby & toddler articles & support | NCT

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Wees: Five or more heavy nappies per day. Poos: At least two soft, yellow poos per day. They're yellow, because there is no more 'mec' in the bowel. False menstruation or pseudo menstruation is harmless. It is a very light bleed from the vagina in some baby girls.

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Worried about constipation?

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The contents of your babies nappy will change from day to day, newborn babies will pass dark sticky stools for a few days (called meconium). It is black, tar like and contains bile and other substances your baby swallowed while still in the womb.

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a good starting point

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As the mother of a child who cried constantly for the first few months of their lives I know how difficult that can be. As the mother of a child who had to either be feeding or asleep to be happy, I know how awful that can become. As the mother of a child who was sick so often we would leave puddles where ever we went, we would both get through multiple outfit changes throughout the day and we never ever owned enough muslins, I know how draining that is. As the mother of a child who didn't gain weight at the rate he should've, I know how scary that feels. I am the mother of a child with Cow's Milk Protein Allergy and I know firsthand how incredibly daunting that diagnosis is. But a diagnosis is an answer, it's a chance to make changes and see improvements, and honestly, that diagnosis changed our lives. If any of this is sounding familiar to you, or your baby is presenting other symptoms that you can't seem to explain or get under control it's very possible that a CMPA diagnosis could change your lives too.

I've shared more about our diagnosis and personal experience with CMPA and soya allergy in a guest post over at Mamanatal. This post is mainly about facts and common misconceptions as well as frequently asked questions. Scroll down to the bottom for a video going through some frequently asked questions. It's important to point out this is information I have picked up through my experience with allergies and shouldn't be used in place of appropriate medical guidance. It should be useful to everyone dealing with CMPA but is written from the perspective of a breastfeeding mother so is more focused around that.

If you're looking for dairy free cake (aren't we all?) head straight to my Breastfeeding with CMPA Dairy Free Treats List (also soya free)

Cow's Milk Protein Allergy (CMPA) is an immune system response to one or both of the two proteins found in cow's milk. It is the most common infant food allergy in the world, presenting in between 3-7% of infants. It shouldn't be confused with lactose intolerance (the inability to digest the sugar found in all milks, including human breast milk) which is incredibly rare in infants. What makes the diagnosis of CMPA difficult is that often these symptoms vary dramatically; they can be seen as "normal" to a degree, or are often linked to other problems or health issues. For example colic symptoms, such as difficulty settling or excessive crying, vomiting or reflux, mucous filled nappies, eczema or rashes on the skin are all common symptoms. Symptoms can also include constipation or diarrhoea, a runny nose, conjunctivitis or slow weight gain. Your baby may suffer from one or many of these symptoms in varying degrees and that can often make it very difficult to pinpoint a cause. The allergy is divided into two categories- IgE mediated and non-IgE mediated response, based on how the body reacts to the allergen. Generally IgE responses are immediate, such as hives or swelling, and non-IgE are delayed reactions, like eczema, diarrhoea or constipation. It is also possible to also develop anaphylaxis to cow's milk protein.

What Should we do if we Suspect Our Child Has CMPA?

If your baby is showing symptoms of CMPA I would recommend visiting your GP or Health Visitor and asking for a referral to a dietician. It may be useful if you can show them a food diary and any pictures of reactions/symptoms you have. Your health care providers should help you confirm diagnosis, usually by excluding the allergen and then reintroducing, and subsequently create a personalised care plan. The Milk Allergy in Primary care (MAP) algorithm shows what should take place and in what order.

Can we Have a Test Done to Confirm?

Unfortunately testing for Cow's Milk Protein Allergy is not straightforward. You may be offered 'skin prick' or blood tests but these can only determine an IgE mediated response. If your child has non-IgE mediated CMPA this will give a negative result. There are also many other causes of false negatives or false positives, especially in young children. These tests can be useful when guiding reintroduction but there aren't incredibly helpful for confirming a diagnosis. The gold standard for confirming CMPA is to eliminate dairy for a period of time and keep track of symptoms. If it is CMPA you should see some improvements. You can then confirm diagnosis by reintroducing milk into your/their diet to see if symptoms come back. Read more about how to confirm CMPA in a breastfed baby.

Can I Still Breastfeed?

A common misconception of CMPA is that you can't continue to breastfeed and instead must move your child on to a suitable formula. This is totally incorrect. What you will need to do if you want to continue feeding is to remove the allergen from your diet immediately. This seems impossible in the beginning because milk seems to be hidden in so many things, like wine, ham, pineapple juice and even pickled onions! Eventually though you do get the hang of reading labels and there are so many delicious alternatives out there you'll be fine. It can take up to 3 weeks for your system to be completely dairy free and another 3 for your little one's system to also be clear, but you should start seeing improvements before then. If you aren't breastfeeding or want to move on from it there are a number of suitable formulas out there which your GP should be able to prescribe.

Does This Mean my Child May Have Other Food Allergies?

Multiple food allergies are possible but rare, and the chances of your child having more than one aren't increased by having CMPA, with one exception. The proteins in soya are very similar to the proteins in cow's milk and sometimes the body attacks them both in the same way. Around 30-50% of those with CMPA will also react to soya protein so it may be necessary to cut this out also. If symptoms still persist after 6 weeks of a dairy free diet you might want to explore the possibility of further allergies with support from your health care providers. Keeping a food and symptom dairy may help you establish a pattern.

What Milk Alternatives Can I Use?

There are many alternative milks available and these can be used in food/cooking once your little one is 6 months old. Make sure to choose a fortified version to help with your child's daily calcium intake. These alternative milks shouldn't be used as a main drink for young babies as they don't contain enough nutrients and calories. NICE guidelines advise that CMPA children stay on breastmilk or formula until 2 years old. Rice milk shouldn't be a main drink for children under 5. For a great chart comparing the main alternative milks available check out this great post.

What About Goat's Milk or Buffalo Mozzarella?

It's predicted that up to 90% of CMPA children will react to all animal milks as the proteins are so similar, so I would recommend avoiding goat's milk, cheese, etc.

How Can I Make Sure My Child Gets Enough Calcium?

Your GP may be able to prescribe calcium supplements for you if you're breastfeeding. If your child is breastfeeding they will be getting everything they need from you. There are also lots of vegan sources of calcium out there like green leafy vegetables, almonds and apricots so try to offer these often.

What About Foods Labelled "May Contain Milk"?

It's really important to note that a 'may contain' label (or any type of similar wording - wording is NOT an indication of severity) isn't legally required. Brands cannot use the warning if there is no risk of cross contamination, but they are not obliged to include it on packaging if there is a risk. Due to how most pre packaged food is produced - on mass in large warehouses which produce all kinds of other foods, it's likely that ALL packaged food items will be at a small risk of containing traces of allergens. However this risk is very small. Avoiding may contains (which would need to include all packaged foods, all foods from bakeries and any food produced in a restaurant which also handles dairy products) would put a huge limit on your diet and would most likely be unnecessary. It comes down to chance. It's very possible to eat a 'may contain' 99 times and have no reaction, then react on the 100th. It's equally possible to react to something once and then eat it 99 more times with no issue. Overall I think avoiding 'may contains' is not something you need to do, and avoiding only the ones labelled as such is basically pointless.

The one exception here is chocolate. As chocolate is a viscous product the machines for making it cannot be cleaned and therefore it is at more risk of containing milk traces. This doesn't mean you have to avoid may contain chocolates, but it's important to be aware there is a slightly elevated risk. There are several companies who produce chocolate in a dairy free factory, like Plamil and Moo Free.

Will My Child Out Grow It?

Hopefully! Around 50% of children will outgrow CMPA by 12 months, 60-75% by 2 years and 85-90% by 3. Depending on the severity of your child's allergy you may be asked to "challenge" their allergy periodically using something called a milk ladder. You typically start at the bottom of the ladder with baked milk as this is when the protein is most broken down and work your way up to raw milk. Some children are able to tolerate up to a certain step on the ladder before reacting, and recent research shows that regularly exposing them to even a very small amount of the allergen can speed up the rate they outgrow the allergy.

USEFUL LINKS
For a full list of symptoms and some excellent links to helpful information you can visit the CMPA Support webpage.

For more support to continue breastfeeding a baby with CMPA check out the Breastfeeding with CMPA and Other Food Allergies - Support Group UK - please note this is a private group for breastfeeding mums only. Look out for a message from our admin team after you request to join.

For a treats list of dairy and soya free foods as well as recipes and more resources take a look at our Dairy Free page

To read NICE guidelines for CMPA click here and you can find the MAP algorithm for suspected CMPA mentioned earlier here

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CMPA Frequently Asked Questions - Dilan and Me

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As the mother of a child who cried constantly for the first few months of their lives I know how difficult that can be. As the mother of a child who had to either be feeding or asleep to be happy, I know how awful that can become.

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A handy get-me-out-of-here tip for a baby who quickly stops suckling. It's a short term fix to get more milk into your baby while you work out what the problem is.

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What Is Switch Nursing?

Switch nursing is a breastfeeding technique that involves alternating breasts multiple times during a feeding. When you use this breastfeeding method, your baby breastfeeds for a few minutes on one breast, switches over to the other breast for a few minutes, then switches back to the first breast again and so on.

When Would You Use the Switch Nursing Technique?

If your baby is latching on and breastfeeding well, you shouldn't stop him to switch breasts.

Let your child finish breastfeeding on one side, then offer the other breast. However, if your breast milk supply is low, your baby is sleepy at the breast, or your little one is gaining weight slowly, the switch nursing technique may be helpful.

Switch Nursing for a Sleepy Baby

Switching breasts frequently during a feeding may help to keep a sleepy baby sucking longer. Each time your baby slows down, stops sucking, or starts to fall asleep, changing side can wake him up and encourage him to start sucking again.

Switch Nursing for Slow Weight Gain

If you baby isn't gaining the expected amount of weight, switch nursing may help to increase the amount of breast milk that he gets at each feeding. By switching back and forth between breasts, it could encourage your baby to suck for a longer period while stimulating the let-down of breast milk from your breasts to occur multiple times.

Switch Nursing to Increase Your Breast Milk Supply

If you have a low breast milk supply, you can use switch nursing to try to boost it up.

The extra stimulation to both breasts from changing sides a few times throughout a feeding can lead to an increase in the supply of breast milk.

Monitor Your Baby While You're Switch Nursing

If you have a low breast milk supply, a sleepy newborn, or a baby who's gaining weight slowly, be sure to keep in close contact with your child's health care provider.

While you're working on getting breastfeeding established and going well, the pediatrician can make sure your baby is healthy and that he's getting enough breast milk.

You can also monitor your child at home by keeping track of his wet and dirty diapers and watching for signs of dehydration.

When to Stop Switch Nursing

Switch nursing may work well during the first few days of breastfeeding or when your child is going through a growth spurt, but it's not meant to be used over an extended period of time. Once your breast milk supply goes up, your baby is more alert, and breastfeeding is going well, you do not need to change sides more than once a feeding. You should be able to breastfeed your child on one side until that breast is emptied before switching to the other side for the remainder of the feeding. Some newborns will even be happy and satisfied with just a single breast at each feeding. Just remember to alternate the breast you begin each feeding on so that you can keep both breasts stimulated and making breast milk.

The Downside to Switch Nursing

One of the issues with switch nursing is that a baby may not breastfeed long enough on either breast to get to the hindmilk. Hindmilk is the high fat, high-calorie milk that mixes into the breast milk a few minutes into a feeding.

A baby who's only breastfeeding for a few minutes on one side may only get foremilk on that side. Then, when he switches over to the other breast, he gets foremilk again. So, while a child may get more breast milk from switch nursing, he may not be getting the fat and calories that he would be getting if he were to breastfeeding longer on the same breast.

Where to Find More Information or Assistance

If, at any time, you're worried that your little one isn't getting enough breast milk or that she's too sleepy for most feedings, notify your baby's doctor. The doctor will check your child's weight and health.

You can also talk to your doctor, a lactation consultant, or a local La Leche group to learn about other techniques or get answers to any questions you may have about building and maintaining a healthy supply of breast milk for your baby.
American Academy of Pediatrics. New Mother's Guide To Breastfeeding. Bantam Books. New York. 2011. Lawrence, Ruth A., MD, Lawrence, Robert M., MD. Breastfeeding A Guide For The Medical Profession Seventh Edition. Mosby. 2011. Riordan, J., and Wambach, K. Breastfeeding and Human Lactation Fourth Edition. Jones and Bartlett Learning. 2014.

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Breastfeeding and Switch Nursing: What Is It and When Is It Helpful?

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Switch nursing is a breastfeeding technique that involves alternating breasts multiple times during a feeding. When you use this breastfeeding method, your baby breastfeeds for a few minutes on one breast, switches over to the other breast for a few minutes, then switches back to the first breast again and so on.

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the WHY and the HOW

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The purpose of breast compression is to continue the flow of milk to the baby when the baby is only sucking without drinking. It is possible to know when a baby is getting milk from the breast - the pause in the chin means baby got a mouthful of milk. The longer the pause, the more milk the baby got. If baby is no longer drinking on his own or drinking is slowing down, compressions can be used to "turn sucks or nibbling into drinks", and keep baby receiving milk. Breast compressions simulate a milk ejection reflex (let-down reflex) and stimulate a milk ejection reflex. See also our blog on breast compression.

The technique may be useful for:

Poor weight gain in the baby

Fussy babies

Frequent feedings and/or long feedings

Sore nipples in the breastfeeding parent

Recurrent blocked ducts and/or mastitis

Encouraging the baby who falls asleep quickly to continue drinking not just sucking

A "lazy" baby, or baby who seems to want to just "pacify". Incidentally babies are not lazy, they respond to milk flow, so that if flow slows, babies may start to fall asleep, or if they are older, may pull away from the breast.

Breast compression is not necessary if everything is going well. When all is going well, allow the baby to "finish" feeding on the first side and offer the other side. How do you know the baby is finished the first side? When he is just sucking (rapid sucks without pause) and no longer drinking at the breast ("open mouth wide - pause - then close mouth" type of suck). Breast compressions help baby to get the milk.

Breast compression works particularly well in the first few days to help the baby get more colostrum. Babies do not need much colostrum, but they need some. A good latch and breast compression help them get it.

It may be useful to know that:

1. A baby who is well latched on gets milk more easily than one who is not. A baby who is poorly latched on can get milk only when the flow of milk is rapid. Thus, many breastfeeding parents and babies do well with breastfeeding in spite of a poor latch, because most breastfeeding parents produce an abundance of milk. However, the breastfeeding parent may pay a price for baby's poor latching-for example: sore nipples, a baby who is "colicky", and/or a baby who is constantly on the breast (but drinking only a small part of the time).

2. In the first 3-6 weeks of life, many babies tend to fall asleep at the breast when the flow of milk is slow, not necessarily when they have had enough to eat and not because they are lazy or want to pacify. After this age, they may start to pull away at the breast when the flow of milk slows down. However, some pull at the breast even when they are much younger, sometimes even in the first days and some babies fall asleep even at 3 or 4 months when the milk flow is slow.

Breast compression-How to do it
(Use with the other information provided in the "Latching and Feeding Management" information sheet)

1. Hold the baby with one arm.

2. Support your breast with the other hand, encircling it by placing your thumb on one side of the breast (thumb on the upper side of the breast is easiest), your other fingers on the other, close to the chest wall.

3. Watch for the baby's drinking, (see videos) though there is no need to be obsessive about catching every suck. The baby gets substantial amounts of milk when he is drinking with an "open mouth wide-pause-then close mouth" type of suck.

4. When the baby is nibbling at the breast and no longer drinking with the "open mouth wide-pause-then close mouth" type of suck, compress the breast to increase the external pressure of the whole breast. Do not roll your fingers along the breast toward the baby, just squeeze and hold. Not so hard that it hurts and try not to change the shape of the areola (the darker part of the breast near the baby's mouth). With the compression, the baby should start drinking again with the "open mouth wide-pause-then close mouth" type of suck. Begin breast compression when the baby is not drinking much and before the baby gets too sleepy.

5. Keep the pressure up until the baby is just sucking without drinking even with the compression, and then release the pressure. Release the pressure if baby stops sucking or if the baby goes back to sucking without drinking. Often the baby will stop sucking altogether when the pressure is released, but will start again shortly as milk starts to flow again. If the baby does not stop sucking with the release of pressure, wait a short time before compressing again.

6. The reason for releasing the pressure is to allow your hand to rest, and to allow milk to start flowing to the baby again. The baby, if he stops sucking when you release the pressure, will start sucking again when he starts to taste milk.

7. When the baby starts sucking again, he may drink ("open mouth wide-pause-then close mouth" type of suck). If not, compress again as above.

8. Continue on the first side until the baby does not drink even with the compression. You should allow the baby to stay on the side for a short time longer, as you may occasionally get another letdown reflex (milk ejection reflex) and the baby will start drinking again, on his own. If the baby no longer drinks, however, allow him to come off or take him off the breast.

9. If the baby wants more, offer the other side and repeat the process.

10. You may wish, unless you have sore nipples, to switch sides back and forth in this way several times.

11. Work on improving the baby's latch.

12. Remember, compress as the baby sucks but does not drink. Wait for baby to initiate the sucking; it is best not to compress while baby has stopped sucking altogether. Watch our videos to see how compressions are used.

In our experience, the above works best, but if you find a way which works better at keeping the baby drinking with an "open mouth wide-pause-then close mouth" type of suck, use whatever works best for you and your baby. As long as it does not hurt your breast to compress, and as long as the baby is "drinking" ("open mouth wide-pause-then close mouth type" of suck), breast compression is working.

You will not always need to do this. As breastfeeding improves, you will be able to let things happen naturally.
The information presented here is general and not a substitute for personalized treatment from an International Board Certified Lactation Consultant (IBCLC) or other qualified medical professionals.
This information sheet may be copied and distributed without further permission on the condition that you credit International Breastfeeding Centre it is not used in any context that violates the WHO International Code on the Marketing of Breastmilk Substitutes (1981) and subsequent World Health Assembly resolutions. If you don't know what this means, please email us to ask!

©IBC, updated July 2009, June 2017

Questions or concerns? Email Dr. Jack Newman (read the page carefully, and answer the listed questions).
Make an appointment at the Newman Breastfeeding Clinic.

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International BreastFeeding Centre | Breast compressions to increase milk flow to the baby

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The purpose of breast compression is to continue the flow of milk to the baby when the baby is only sucking without drinking. It is possible to know when a baby is getting milk from the breast - the pause in the chin means baby got a mouthful of milk.

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Here's Jack Newman showing how breast compression results in more swallowing by baby

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Breastfeeding Breast Compression to Help get the Milk with Dr. Jack Newman

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If you think there might not be enough, or you're worried there is too much, click here

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In the first few days, sometimes the breasts can get very hard and full. this makes it difficult for the baby to latch on. Here is a useful way of softening the area around the nipple, making attachment easier.

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How To Relieve Engorgement - RPS By Mother

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Breastfeeding should not hurt, nor should it cause damage. More information here.

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Is nipple pain normal in the early weeks?

Some mothers never experience any nipple pain at all, but studies show that the majority of women in the US and other western countries do have some nipple pain in the beginning. How do we tell the difference between this typical nipple pain and a problem that would benefit from the help of an experienced breastfeeding counselor and/or IBCLC (International Board Certified Lactation Consultant)?

Typical nipple pain ("transient soreness") that does not usually indicate a problem:

Latch-on pain that lasts no more than 30 seconds into the feeding. This is often described as mild pain or discomfort, but since the pain sensation is very subjective every mother experiences pain differently-some mothers feel more severe pain. The pain should not continue through the entire feeding, and there should not be pain between feedings.

Pain usually peaks around the third day after birth, and is gone within two weeks.

There is no skin damage - no cracks, blisters, or bleeding.

Your nipple should look the same before and immediately after the feeding - not flattened, creased or pinched.

Get help from an experienced breastfeeding counselor and/or IBCLC if you experience the following:

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Intense, excruciating pain

Pain that continues through the entire feeding

Pain between feedings

Pain that continues past the first couple of weeks

Skin damage-cracks, blisters, or bleeding

If you're experiencing any of the above issues, then don't let someone tell you that "everything looks fine" - it is either a sign that damage is being done or of some underlying condition (infection, etc.). If you're experiencing pain that makes you dread feeding your baby or that you describe as excruciating or if you have cracked or bleeding nipples, then this is NOT typical and there is almost always something that can be done to address the issue and to alleviate the pain. Please do not assume this is simply "what breastfeeding is supposed to be like" and just suffer through it - ask for help! It doesn't mean you're doing something wrong - there can be many causes, from anatomical issues to infection. Cracking, bleeding or any other nipple damage is not typical- something is causing the damage and pain, and a good IBCLC can help you to find the cause. Seeing a knowledgeable breastfeeding professional could make all the difference.

Some things to investigate if you have nipple pain:

Did breastfeeding get painful when your milk came in? Engorgement can make it difficult for baby to latch deeply. Reverse pressure softening or expressing a little milk can help baby get a deeper latch that does not hurt.

Does your nipple look flattened, creased, or pinched when baby unlatches? Can you see a white line across the nipple when baby unlatches? This is usually the sign of a shallow latch. A shallow latch can usually be remedied by adjusting latching technique, but it can also be caused by anatomical variations in mom or baby.

Do you have skin damage (bruising, cracks, blisters/blebs, bleeding)? While you investigate and address the cause of the damage, use these tips-Healing damaged skin in the nipple area.
Some potential causes of nipple pain and damage include:

shallow latch, baby's lips tucked inward instead of flanged outward when breastfeeding, removing baby from the breast without first breaking the suction;

unusual infant anatomy such as tongue-tie or lip-tie, unusual palate shape, receding chin, short tongue;

strong/unusual suckling; jaw clamping/clenching;

unusual nipple anatomy such as inverted or flat nipples, very long, or large nipples.

Do you have a rash on the nipple or areola? Contact dermatitis (from breast pads, nipple creams, soaps/detergents, etc.), eczema, psoriasis, poison ivy/oak can all be present on the nipple or breast and cause sore nipples.

Are you using a breast pump? Incorrectly sized pump flanges, too-high suction settings, or too-slow cycling settings can cause nipple pain or damage.

Are you experiencing pain between feedings (in addition to or instead of during feedings)? Investigate thrush (yeast infection) and nipple blanching (turning white) and vasospasm.

Do you have a forceful milk ejection/let-down reflex? Some babies will clamp down on the nipple to slow the milk flow, causing pain.

Has the pain started after weeks or months with no issues? See Why are my nipples sore after months of pain-free nursing?

Are you breastfeeding while pregnant with a new baby? See nipple soreness during pregnancy.

More resources on sore nipples:

When Baby Bites @ KellyMom

Sore nipples by Dr. Jack Newman

Sore/cracked nipples from the Australian Breastfeeding Association

Ouch! What If Pumping Hurts? by Nancy Mohrbacher, IBCLC, FILCA

Berens P, et al. ABM Clinical Protocol #26: Persistent Pain with Breastfeeding. Breastfeed Med. 2016 Mar;11(2):46-53. doi: 10.1089/bfm.2016.29002.pjb. Epub 2016 Feb 16.

Cadwell K, et al. Pain reduction and treatment of sore nipples in nursing mothers. J Perinat Educ. 2004 Winter;13(1):29-35.

Nipple Pain: Causes, Treatments, and Remedies by Jahaan Martin, from LEAVEN, Vol. 36 No. 1, February-March 2000, pp. 10-11.

Eczema of the Areola and Nipple in the Breastfeeding Woman by Penny Lane DNP, CNM, IBCLC

Barankin B, Gross MS. Nipple and Areolar Eczema in the Breastfeeding Woman. J Cutan Med Surg. 2004 May 3.

Is breast pain common the early days?

It is normal for your breasts to become larger and feel heavy, warmer and uncomfortable when your milk increases in quantity (" comes in") 2-5 days after birth. Engorgement typically begins on the 3rd to 5th day after birth, and subsides within 12-48 hours if properly treated (7-10 days without proper treatment). Read more about minimizing and treating engorgement here: Engorgement. See also Engorgement when tandem breastfeeding.

Breast pain

Following are some things to investigate if you are experiencing breast pain.

Engorgement (in addition to appearing during the first week, you may also experience engorgement if you skip a breastfeeding session or wait too long between breastfeeding sessions)

Plugged Ducts and Mastitis are the most common causes of breast pain in breastfeeding mothers (other than engorgement).

Breast pain is sometimes associated with a forceful milk ejection/let-down reflex and oversupply. This pain will appear when the milk lets down, soon after the feeding begins; it usually decreases over time and is gone within the first month after birth.

Raynaud's phenomenon/vasospasm can cause deep breast pain.

Some breast pain might also be caused by a tightening of the chest muscles leading to a reduced blood flow to the breast and nipples. Edith Kernerman, IBCLC has hypothesized and described this set of symptoms, called mammary constriction syndrome (read more about it here), which is treated with pectoral muscle massage.

Sometimes breast pain may be referred pain from nipple trauma or a muscle strain or injury.

A badly fitting bra or tight straps on a baby carrier can cause shooting breast pains.

Breastfeeding mothers may also experience premenstrual breast pain or fibrocystic breast pain.

Have you had breast surgery or a breast injury in the past? Internal scarring can sometimes cause pain, as can a ruptured breast implant.

Mothers with very large breasts sometimes experience muscle strain due to the weight of their breasts, which may be relieved with a well-fitting bra.

Thrush (yeast infection) may cause breast pain along with other symptoms (shiny or flaky skin on the nipple/areola, nipple pain) but breast pain is unlikely to be the only symptom of thrush.

More resources:

Additional references:

Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession, 7th ed. Maryland Heights, Missouri: Mosby; 2011: 253-257, 267-270, 599-600, 956-962.

Mohrbacher N. Breastfeeding Answers Made Simple. Amarillo, TX: Hale Publishing; 2010: 629-724.

Riordan J, Wambach K. Breastfeeding and Human Lactation, 4th ed. Sudbury, MA: Jones and Bartlett; 2010: 291-306.

Wilson-Clay B, Hoover K. The Breastfeeding Atlas, 5th ed. Manchaca, TX: LactNews Press, 2013: 51-65, 84-101.

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Sore nipples or breasts? Here's help... * KellyMom.com

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Some mothers never experience any nipple pain at all, but studies show that the majority of women in the US and other western countries do have some nipple pain in the beginning. How do we tell the difference between this typical nipple pain and a problem that would benefit from the help of an experienced breastfeeding counselor and/or IBCLC (International Board Certified Lactation Consultant)?

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This video combines the nipple flip technique with the koala bear hold and might be helpful for babies who struggle to get enough in, for example if they have a tongue tie

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The "flipple" breastfeeding technique in the koala hold