Common breastfeeding challenges and their solutions

Frequently experienced by breastfeeding women, engorgement occurs due to several concurrent phenomena, such as increased blood flow and interstitial oedema at the time of secretory activation with a major surge in prolactin production. However, it is not linked to an overproduction of milk, as is often believed! This manifests as swelling, tension and pain in the breasts (1). 

Several factors can contribute to breast engorgement. First, infrequent feeds disrupt the breast drainage process. A poor latch by the baby, often due to an incorrect feeding position or difficulties with suckling, can also be a contributing factor. 

Nevertheless, engorgement can occur in a pathological way. A blockage of the milk ducts caused by excess pressure on the breasts — whether from a too-tight bra or a poorly adjusted baby carrier — can lead to breast congestion. Left untreated, it can cause premature weaning, nipple cracks, mastitis, or in the worst case a breast abscess (2).

Relieving engorgement should help ease pain, reduce oedema, address inflammatory processes and restart the milk let-down reflex.

A few solutions to relieve engorgement: 

• Feed frequently to drain the breasts and relieve pressure. 
• Adopt a comfortable and relaxed feeding position to optimise the breast emptying process.
• Use warm compresses to encourage milk flow by softening breast tissue and relieve congestion. 
• Apply cold compresses after feeding to help reduce inflammation and relieve pain. 
• Practise gentle breast massage and manual expression of milk to relieve engorgement and encourage milk let-down. 

By adopting the right habits, you can easily prevent and manage engorgement, helping to maintain comfortable and effective breastfeeding for you and your baby! (3)

Breastfeeding can sometimes lead to the appearance of cracks on the nipples. These small tears can occur and cause significant pain for the breastfeeding mother. 

The breastfeeding nipple cracks can have various causes, each requiring a specific approach to effectively prevent and treat these painful lesions.

• A poor latch causing uneven pressure on the nipples and resulting in skin damage
• A persistent biting reflex in the baby 
• Wearing synthetic clothing creates an environment that encourages skin maceration 
• Breast engorgement issues
• Incorrect use of a breast pump: poorly fitting breast shields, suction that is too strong
• Dry and dehydrated skin

Correcting your baby's position during feeds is essential to prevent and avoid nipple cracks. This means ensuring your back is well supported (properly settled, with no tension in the neck) and that your baby has a good latch. Pain during feeding is a warning sign that may precede the possible appearance of cracks and, ultimately, infections. 

If cracks have already developed, it is important to treat them and support healing. Moisturising the nipples with breast milk, lanolin, or coconut oil can promote healing by creating a protective barrier. Devices such as breastfeeding shells or hydrogel dressings can help protect the nipples and relieve pain during healing. Likewise, the use of warm compresses or gentle massage can reduce pressure on the nipples and help prevent cracks.

The breastfeeding mastitis is a localised inflammation of the breast that can take various forms and degrees of severity, manifesting as flu-like symptoms and significant breast pain. Commonly affecting 3 to 20% of women (5,6,7), two main types of mastitis are typically identified: inflammatory mastitis, resulting from engorgement or blockage of the milk ducts, and infectious mastitis, triggered by pathogens — primarily Staphylococcus aureus (4).

The risk factors for mastitis are numerous and include nipple cracks, infrequent feeds, blocked milk ducts, poor latch, wearing bras that are too tight, maternal fatigue or stress, among others. Studies have also highlighted the impact of certain nutritional deficiencies (selenium, vitamins E and A) (8) or full-time work on the increased risk of mastitis in breastfeeding women, due to long intervals between feeds and a lack of time to express milk. 

That said, mastitis is not inevitable. Simple preventive measures based on good breastfeeding management — ensuring correct positioning and effective latch, as well as adequate breast drainage — can help prevent and limit its occurrence. Staying well hydrated and eating a balanced diet can help reduce the risk of mastitis. The use of breastfeeding compress heat/cold can help with drainage and relieve pain. 

Please note that in the event of mastitis, it is crucial not to stop breastfeeding, as regularly emptying the infected breast is essential to prevent the formation of an abscess. 

If symptoms persist or worsen, medical advice is recommended. Doctors often prescribe analgesics and, in some cases, antibiotics if an infection is present. Education about the early signs of mastitis and preventive measures can play a crucial role in reducing the incidence of this complication in breastfeeding women.

During breastfeeding, certain issues such as cracked nipples and mastitis can occur and cause very severe pain for the new mother. 

Breast shells help to soothe the skin of the breast and nipple while protecting it from friction with clothing. Their shape, adapted to the nipple, allows a few drops of breast milk — with its healing and antiseptic properties — to be applied in the treatment and prevention of cracked nipples. 

It is essential to position breast shells correctly in your bra after each feed to avoid any pain or pressure on the breast. It is recommended to remove them at night to prevent breast engorgement, and to clean them with water and soap after each use.

In general, all women, regardless of age, can be affected by breast itching. The sensation of itching in the breast area is medically referred to as mammary pruritus. This condition can affect various parts of the breast, including the nipple, the breast itself, and may even extend to the base of the armpit.

Mammary pruritus can be the first symptom of pregnancy in some women, due to the hormonal changes and physical transformations brought about by gestation. From the very first days of pregnancy, the breasts begin preparing for breastfeeding, becoming more engorged, tense, and prone to itching. 

After childbirth and during breastfeeding, several sources of itching may arise, including dried milk on the nipple, small wounds caused by the baby, cracked nipples, and mastitis (9). Whilst the milk coming in can be accompanied by tingling, an incorrect latch position during feeds can also cause micro-lesions at the tip of the breast and nipple itching.

That said, an itchy chest is sometimes a sign of a skin condition. Several dermatological causes (psoriasis, eczema, parasitic infections, irritation, mastitis) can also be at the root of breast itching. In such cases, the breast may show lesions such as red patches or small spots. 

To soothe this uncomfortable sensation, it is essential to adopt appropriate daily care! This means washing the skin with a gentle, natural soap and favouring lukewarm water when showering to limit irritation and skin dryness. Regular moisturising of the chest is also crucial to maintain its suppleness. To relieve itching, the use of warm or cold compresses can sometimes be beneficial (10). 

Finally, depending on the underlying cause of the itching, medical treatments such as corticosteroid creams or antibiotics may be necessary and must be prescribed by a healthcare professional.

Expressing breast milk is an essential step for many mothers at various stages of breastfeeding. It helps relieve engorgement, maintain milk supply, and simply feed your baby. However, expressing milk is not always straightforward and can sometimes be uncomfortable.

There are several possible reasons. Incorrect use of the breast pump (wrong suction intensity setting, ill-fitting flange) can make expressing milk uncomfortable or even painful. Additionally, sensitive nipples or certain skin conditions (psoriasis, eczema, parasitic infections, irritation, mastitis) can make the expressing process painful. Finally, stress or anxiety can contribute to increased sensitivity during expressing.

To address this, several approaches can be explored. Some mothers adjust their posture by leaning slightly forward, while others use pillows to support their arms and back, in order to reduce discomfort and facilitate milk expression. Certain relaxation techniques, such as deep breathing and meditation, can help reduce any stress and encourage a state of calm that is conducive to milk expression.

Equally, using a breast pump requires the right flange size to avoid excessive friction and irritation. The fit is correct when your nipple moves and glides freely within the flange tunnel. 

Although some discomfort when expressing milk is normal in the first few days after birth, it should not become painful. If the pain persists or worsens, it is important to consult an IBCLC lactation consultant who can provide personalised guidance to make expressing more comfortable and effective. For more information, see our article on how to express breast milk.

Breastfeeding triggers the release of various hormones in the mother's body, including dopamine, prolactin and oxytocin (11). The synthesis and release of these hormones support breastfeeding by promoting milk production and positive interactions between mother and baby (12). 

The Dysphoric Milk Ejection Reflex (D-MER) is a little-known phenomenon experienced by breastfeeding women that can occur before or during milk ejection, or spontaneously between feeds or pumping sessions. Women who experience it face a wave of negative emotions, feelings of depression, profound sadness, and in the rarest cases, suicidal thoughts. Symptoms can last a few minutes or several days, or even throughout the entire breastfeeding journey, but should not be confused with postnatal depression or nipple hypersensitivity.

The exact causes of D-MER are not fully understood, but some researchers believe it may be linked to a dysfunction in the release of oxytocin or dopamine. An abnormal release of oxytocin could trigger a defensive reaction rather than the usual positive response (16). In addition, women who have previously experienced significant stress (13, 14) or who were exposed to synthetic hormones during labour may be more susceptible to developing D-MER (15).

There are several ways to manage D-MER. These include meditation, skin-to-skin contact with the baby, and a balanced diet, which may help to ease symptoms. Certain medications or herbal remedies may also be helpful, though their effectiveness varies from woman to woman (17, 18). Ultimately, it is essential that women affected by D-MER feel supported and understood, and that they find strategies that work best for them.

Ultimately, every challenge encountered during breastfeeding is an opportunity for the mother to learn. Breastfeeding, beyond its nutritional aspect, is a truly emotional and physical journey, contributing to the wellbeing and optimal development of the baby.