Even the name is foreboding and for good reason! (NEC) is a serious gastrointestinal problem that mostly affects the intestines premature babies. This inflammatory condition can happen when infants are not receiving only human milk or have received antibiotics which can cause damage in the digestive tract.
May is Necrotizing Enterocolitis Awareness Month
There is a ton of research which looks at the connection between human milk feeding and significantly reducing the risk of developing NEC.
“Nipple thrush pain is often described as burning, itching, or stinging and may be mild to severe. The pain is usually ongoing and doesn’t go away with improved positioning and attachment of your baby to the breast.”
“When you have nipple thrush, your nipple appearance may change to being shiny in appearance, sometimes chapped, blistered with white patches but may also look completely normal. You may also experience itchy, flaky and red nipples or areola.”
Thrush is an overgrowth of candida or yeast. It mostly commonly causes an infection and overgrowth in people who are immunocompromised. It can overgrow in areas with skin folds which are moist and warm, like armpits, the vagina, etc. It’s very rare to have yeast/candida/thrush in highly vascularized areas like the breasts and nipples.
When providers visually assess for thrush, they may be seeing dermatitis rather than a yeast overgrowth on the nipples. Dermatitis is an allergic reaction or irritation caused by something the parent is sensitive to on their skin. This can include creams, ointments, and medications.
Here are some pictures of parents who thought they had thrush but actually had dermatitis!
Below, is what yeast on the skin actually looks like
So what you should you do if you think you have thrush?
Talk to your Lactation Consultant for a full feeding and breast evaluation. They can make referrals to providers for treatment, if needed, and can help figure out what’s actually going on!
March 22-28 is a time to be grateful for all that doulas provide to us during pregnancy, birth, and beyond!
A doula is a professional labor assistant who provides physical and emotional support to you and your partner during pregnancy, childbirth and the postpartum period.
Did you have a doula? How was your experience supported by your doula?
Doulas can support breastfeeding in lots of ways! By teaching basic hold and latch techniques. By discussing your feeding options and helping you sort out what’s right for you. By helping you to have a healthy and safe birth so you can get started with the Golden Hour right away! By providing education, encouragement, and resources to help you keep breastfeeding if you run into any bumps. By connecting you to other knowledgeable providers who can assist and support you.
March marks Plagiocephaly and Torticollis Awareness Month.
Plagiocephaly is when a baby develops a flat spot on one side or the back of the head. It happens when a baby sleeps in the same position most of the time or because of problems with the neck muscles that result in a head-turning preference.
In babies, torticollis happens when the muscles that connect the breastbone and collarbone to the skull (sternocleidomastoid muscle) are shortened.
There are many reasons that babies can develop these conditions and none of them are your fault! In fact, plagiocephaly and torticollis are becoming increasingly common.
Here are some reasons your baby may have one or both of these conditions:
Being malpositioned in the uterus. A smaller parent may not have as much room for a larger baby which can put baby in the same position for days or even weeks before birth. This can occur with pelvic floor issues or with parents that have differing anatomy
Babies who sleep on their back for long stretches. While sleeping on the back is safest overall, if baby doesn’t move around a lot and sleeps looooong stretches it can increase flattening of the back of the head. These babies need lots of tummy time when awake!
Babies with reflux or torticollis may develop plagiocephaly on the side of the head. When we turn our head, it helps close off the esophagus during refluxing.
A baby who is best soothed in a swing or other baby-holding device. If your baby spends a lot of time in a swing, bouncy chair, or car seat it’s much more likely they will develop plagiocephaly.
The good news is that you can treat both of these conditions! Working with a pediatric PT is very helpful!
At home you can do fun activities with your baby to help them develop and improve.
Encourage baby to turn their head both directions by offering stimulation on the non-preferred side. Talk to them and sing songs to get baby to turn their head. Position baby for sleeping so they will turn to the non-preferred side toward you.
Does your baby gag, choke, and cough during feeding? Are they sputtering and tugging on your breast? Ever notice them clicking or leaking milk? What about gas…do they seem to have an awful of it?
There could be a number of things causing baby to struggle with feeding.
It could be a strong letdown (or as we call it in healthcare Milk Ejection Reflex – MER)
I could be an oversupply
It could be ineffective latch.
Let’s learn about the differences.
Strong MER Inside your breast are milk making cells that form a sphere. These spheres are clustered together so I like to think of them as bunches of grapes with the stems representing the ducts that carry milk to the nipple. Each grape is wrapped with muscle fibers. When your baby is feeding (or sometimes just when you think about your baby!) your oxytocin rises. Oxytocin is a hormone which plays a role in bonding, pleasure, and MER. It’s the same hormone that kicks starts uterine contractions during birth. The muscle fibers respond to oxytocin and squeeze milk down the ducts and out the nipple. To have strong MER you need strong muscle contractions. Over the first 3 months, MER starts to chill out because those little squeezing muscles become less sensitive to it.
Oversupply We actually just talked about oversupply. If you have an oversupply, when the muscles contract the milk making “grapes” are soo full that milk flows very quickly.
Ineffective Latch Latch, or attachment to the breast, can be ineffective due to positioning, other medical conditions, tongue tie, or due to something else.
Hmmm, I think I know what’s going on. What do I do about it?
Make an appointment with your Lactation Consultant so they can give you personalized instruction and make a plan which will work for you!
All too often, the difficulty is with your baby and not with you. Your IBCLC can direct you to care which can include changing your feeding plan, adjusting your position, suck training exercises, working with a physical/occupational therapist, or SLP.
Many people think a plugged duct is caused by a backup of thickened milk but the plugging comes from outside the duct.
Our milk ducts carry milk from the milk making cells which are grouped together in alveoli. The alveoli are like little clusters of grapes which connect to the ducts. The ducts carry milk to the nipple openings.
A breast “plug” represents an area of swelling in the breast and more accurately reflects lymphatic fluid congestion and dilated capillaries than a “plug of milk.” The plugging is caused by engorgement and congestion of fluid and blood vessels pressing in on the duct from outside which narrows the pathway. Exclusive or excessive pumping, nipple shield use, oversupply, unresolved engorgement, inflammation, or subacute mastitis increases plugging.
To treat plugging, try the following:
Warmth before feeding. A warm shower or warm pack applied to the breast.
Ibuprofen and/or Tylenol as needed along with a cool pack applied after feeding/pumping.
Avoid massage and excessive pumping (remember it’s not milk that’s plugged).
This should resolve in 24hrs. If it does not, contact your provider and lactation consultant for guidance. Therapeutic ultrasound is very effective. Your doctor may prescribe a single dose of 10-30mg of Pseudoephedrine (Sudafed) which acts as a vasoconstricting agent (i.e. decreases blood flow) and may help with any pain.
Any plug or mass persisting for several days and not resolving with conservative interventions requires referral to a medical provider, who may obtain breast imaging to rule out galactocele and/or other mass.
Engorgement is common in the first week after delivery. Rather than a swelling caused by milk, it is an increase of fluid in the breast brought on by the same hormones which transition your colostrum to transitional and mature milk.
Extra fluids from labor (IV fluids) and some medications can increase this fluid retention. You might also notice it in your hands and ankles/feet. It tends to peak on day 5 after birth.
Sometimes, early mastitis is mistaken for engorgement. If you are still engorged after the first week, contact your Lactation Consultant to discuss what’s going on.
To reduce the engorgement very gentle massage can be helpful.
Wearing a soft and supportive garment like a bra without wires or a nursing tank is also helpful.
Frequent feeding will keep your milk flowing and contribute to breast softness. Aim for every 2 hrs, with rest in between. It’s important to let your breasts rest and the rest of you, too! We all need to sleep and rest to recover properly and ensure long-term milk production.
Excessive pumping will increase the engorgement. Instead try hand expression for a few minutes. Diuretic foods (foods that help you urinate frequently) can also help. These can include melons, cucumber, lettuces and dark leafy greens. Avoid caffeine and salty foods. If the feeling persists, the use of Tylenol and cold packs can provide some relief. Avoid excessive heat on the breast.
If not resolved with these measures contact your provider and lactation consultant. Therapeutic ultrasound can be helpful or your doctor may prescribe a single dose of Pseudoephedrine 10-30mg to relieve symptoms.
If your breasts are too full for baby to latch well, reverse pressure softening around the nipple may be helpful.
Hand expressing a little bit of milk may also be helpful.
Avoid: Pumping often (milk is not causing the fullness), firm or excessive massage, heat packs (increases inflammation).
Oversupply or hyperlactation can occur for a variety of reasons but is most common when early and excessive pumping, galactagogue (herbs and foods to promote lactation) use, and exclusive pumping.
You may notice engorgement past the first few weeks, pain, plugging, mastitis, or your baby may sputter or choke on your milk flow or even have a lot of spit up after feeds.
Once baby has reached two weeks of age, they only need 2-5oz per feeding (or about 1oz per hour). If you are finding that you need to pump after feeds or are producing significantly more than 5-6oz with exclusive pumping, you may have an oversupply.
An oversupply puts you at risk of an inflammatory breast condition called mastitis which can develop into an infection which ultimately will reduce your supply.
Work with your Lactation Consultant to address your oversupply. In the meantime, you can try a few things on your own.
Cool packs after nursing
Positioning in a side lying or reclined position while feeding
Reduce your pumping time by half or switch to hand expression. After a few days, reduce the pumping time by half again.
Herbs to gently reduce supply: peppermint tea or sage.
Unfortunately, many parents experience nipple discomfort.
It’s not that breastfeeding causes this pain but other things can like a latch which isn’t deep enough, infant conditions like tongue tie, pumping (too much, wrong size flange…), or even some ointments and balms.
There is a prescription ointment called APNO (All Purpose Nipple Ointment) which should be used only as indicated as it’s an anti-bacterial, anti-fungal, and steroidal compound. Nipple pain is very rarely caused by fungus/yeast but anti-fungal medications can actually increase pain.
Care for the nipple like any other skin on your body… Wash once per day with mild, scent free soap. Keep the skin clean and dry.
If there is tissue damage: Lubricate with a moisturizing balm (see above) or try Medi-honey (irradiated, medical grade honey and many nipple wounds respond well to treatment).
Hydrogel pads (changed daily) protect the wound from irritation and keeps the site clean. You can use this with your nipple balm. Expect healing to take at least 1 week.
Nipple shields. Despite the name, these products do not shield your nipple and can cause irritation. They also increase risk of low supply, engorgement, and mastitis.
Gentian violet can cause tissue ulceration. It’s often used to combat yeast which is very unlikely to infect the nipple.
Epsom salt soaks, tea bags, or excessive use of moist compress can break down skin.
Breast shells can cause swelling in the areola and often increase pain.
Using a hair dryer which will dry out the skin.
Nipple bleb. A bleb can look like a little blister which may be white or yellow on the nipple. Blebs show up when there is deeper inflammation and bacterial imbalance. Treat the underlying mastitis (inflammation) and the bleb will resolve. If you have a bleb, let your Lactation Consultant know. Do not try to squeeze or pop the bleb as that will open the skin for infection.
Vasospasm. If your nipples turn colors after feeding (white, purple, or blue) you may be experiencing vasospasm. This is caused by a constriction of blood flow from nipple damage, poor latch, or topical anti-fungals. Fixing the cause stops the vasospasm.
Mastitis is an inflammation in your breasts which may become an infection if not addressed. It affects about 1/3 of lactating parents but can be prevented and treated with quick resolution.
Mastitis is caused by inflammation and can be worsened by massage, excessive heat, overfeeding/overpumping. If you’ve recently had a dose of antibiotics, your risk of developing mastitis is higher because a healthy balance of microbes throughout our body reduces inflammation and bacterial overgrowth. If left untreated, it can develop into an infection which will cause fever, fatigue, and overall body aches.
Mastitis may feel like a burning or hot sensation in your breast. It might start at the nipple and go deep into the breast. It’s more frequently felt in the lower parts of the breast. You may notice plugging or red areas in the breast. Early inflammation is sometimes mistaken for engorgement or plugged ducts.
For some parents, the feeling happens during milk ejection (letdown) and can feel like a burning or stinging sensation starting at the nipple and moving deeper into the breast.
Most commonly mastitis occurs during the first 2-4 weeks. Your risk of developing mastitis is higher if you have diabetes or if you have had antibiotics during or after delivery (ie, Group B Strep). It’s especially important to feed baby often and well in these situations.
Your milk is safe for baby when you have mastitis
Your Lactation Consultant can help you figure out how to prevent mastitis from re-occurring.
Self-care can resolve the inflammation in most cases without the use of medication.
To treat mastitis, try the following:
Warmth before feeding. A warm shower or warm pack applied to the breast.
Ibuprofen and/or Tylenol as needed along with a cool pack applied after feeding/pumping.
Avoid massage and excessive pumping.
5-10 grams daily oral sunflower lecithin supplementation to reduce inflammation.
High-quality probiotics containing L. salivarius, fermentum, and gasseri. are generally refrigerated and contain 10 billion CFUs or higher. Continue taking the probiotics for 2 weeks after symptoms resolve.
Older recommendations included warm compresses, feeding and pumping very often, as well as vigorous massage. We now know this can increase symptoms.
Multiple studies have reported that probiotics (beneficial bacteria) are effective in treating infectious mastitis and also resulted in a lower occurrence of repeat mastitis compared to antibiotic treatment.
Call your doctor if you experience:
Fever over 101F Flu-like aches Nausea and chills Pain and swelling in the breasts Red, hot, tender area which is often wedge shaped Red streaking toward the armpit
You should start to feel better in 8-24 hours. If you are not feeling better with self-care or you develop a fever, flu-like symptoms, or any signs of infection you will need to see your physician. Most people feel much better after 2 days but it’s important to take all 10-14 days of your medication or you may develop an abscess which requires surgical treatment. The most common antibiotics prescribed for mastitis are dicloxacillin or flucoxacillian.
Antibiotics can cause digestive symptoms so follow your doctor’s directions and taken your probiotic dose 2-4hrs after your medication.
Work with your Lactation Consultant to prevent mastitis from happening again.
If you get mastitis frequently or it’s always in the same area, your doctor may order an ultrasound to get more information.