Your breasts go through a number of changes from pregnancy to birth to postpartum. There can be a number of issues that can occur. Ideally you will be aware of the look and feel of your breasts prior to pregnancy so you are aware of any changes that are not considered within the realm of “normal” for pre & postnatal. If you’re unsure whether a change is normal for you have a chat to your healthcare provider.
CHANGES DURING PREGNANCY
When you are pregnant your body changes your breasts to start preparing them for feeding your baby. Some of these changes include:
- increase in breast size and tenderness
- changes in colour, size and sensation of nipples and areola
- bigger & more noticeable Montgomery glands (raised bumps on areola)
Usually after about the 16th week of pregnancy the breasts are able to start producing milk. This may result in colostrum (the nutrient dense first milk you produce) leaking from the nipples. It may be noticeable through clothing or merely just coat the nipple and areola. Your breasts and nipples will grow in the last few weeks of pregnancy as the milk producing cells enlarge. This can lead to feelings of being overly full and uncomfortable.
As mentioned earlier the first milk you produce is colostrum which is nutrient and energy dense as a new born only has a very small stomach. Some women like to harvest the colostrum, freeze it and save it for after birth. This should be discussed with your gynaecologist first and is generally done after the 37th week.
CHANGES AFTER BIRTH
After giving birth your hormones drop rapidly and severely. Your colostrum gets diluted with your mature milk that comes in generally around 2-4 hours after birth. If you are breastfeeding or pumping there may be several problems that you may encounter on your journey. With all issues the key is to address your individual needs or problems so we always advise seeing a lactation consultant to help along your journey but here are some basic guidelines you can follow for the treatment of some of the more common conditions.
Sore & Cracked Nipples
Nipple main is a common reason for stopping breastfeeding early. Nipple pain or discomfort is very common in the first few days of breastfeeding however if it is persisting beyond that it needs to be reviewed. There are many causes of nipple pain the most common of which is poor attachment of the baby to the nipple; poor positioning; strong baby suckling; not releasing the suction before removing the baby from breast; skin sensitivities as well as climate variabilities. Nipple pain can be accompanied by trauma such as abrasions, fissures or cracks as well as bleeding and scabs.
Management of Sore & Cracked Nipples
As with all breast conditions it is important to determine the root cause of the issue. However there are some key strategies to implement:
- get help early! The earlier the intervention the better the outcome
- the most important thing is to ensure the baby’s attachment is correct, when the attachment is correct the entire areola is in the mouth and your nipple will rest comfortably against the baby’s soft palate at the back of the mouth
- flattened, wedged, lipstick shaped or white nipples can be a sign of poor attachment where the nipple is being pinched & rubbed against the hard palate
- try different feeding positions to reduce pain
- feed with the unaffected side first (unless having any blockage or mastitis issues)
- wash your hands before handling breasts to minimise bacteria and change nipple pads (if you’re using them) with each feed (especially in warm humid countries)
- break the suction on the nipple instead of pulling baby straight off
- keep the baby feeding as long as they want – if you shorten the feeds to “rest” the nipples it does not help & may affect your supply
- wear a cotton bra to let the breast breathe or no bra if possible
If the nipples are already damaged or cracked the evidence is a bit more conflicting but some general advice to follow:
- washing and drying the nipples more frequently
- warm water compresses before feeding
- applying purified lanolin to the nipples (if irritation occurs stop use)
- if pain is persistent and or there is any discharge get checked to ensure there is no infection
- temporarily expressing until pain subsides with gradual reintroduction of breast feeding
Dealing With A Milk Bleb or Blister on The Nipple
A milk blister occurs when your nipple closes over a milk duct opening, becomes inflamed and milk fills up in the area behind it. They look like a small raised bump on your nipple and can be white or yellow. They can look like a tiny line of toothpaste or small crystals.
Management of Milk Blebs
Do not pop as can lead to infection. Try the following to help remove a milk bleb or blister.
- Try applying vinegar to the milk bleb with a cotton wall ball placing it against your nipple inside your bra. The vinegar helps to dissolve calcium so can help relieve the blister
- Try a warm wet compress before feeding for a few mins which will help loosen the skin so when the baby nurses the skin opens and releases the bleb
- Try a saline soak of 2 teaspoons of epson salts with 1 cup of water and dip a flannel in the mix and hold on the area for a few mins
- Try applying olive oil to the milk bleb with a cotton wall ball placing it against your nipple inside your bra between feeds which can help to loosen the skin and release the bleb.
- Encourage breastfeeding as the baby will help apply pressure gently to the bleb helping it to release or have a go at gently manipulating or massaging the area around the bleb after a warm wet compress to help it release
- If it appears inflamed or infected try applying an antibiotic cream to the area in a tiny amount applying after feedings
- If none of the above succeed then you can see your Doctor who may be able to help by releasing it with a sterile instrument (do not try this at home yourself).
Engorgement
Engorgement is usually described as when the breasts become overfull with milk, it feels hard, tight and painful and generally happens when your milk first “comes in”. But if you look at it more in depth, the feeling of engorgement is due to the lymphatic and vascular congestion and swelling of the glandular tissue of the breast. In other words, the swelling is due to the build up of milk but also of blood and lymphatic fluid in the breast. Engorgement can happen at different times during the breastfeeding journey, causes can include a mismatch with feeding requirements and milk production; wearing a bra that is too tight or a baby sling that compresses on the milk ducts. If left untreated it can lead to mastitis; breast abscess and decreased milk supply.
Management of Engorgement
Depending on the reason for the engorgement will determine the treatment. If you are struggling with recurrent engorgement & oversupply we strongly recommend seeing a lactation consultant to assess your individual needs. However there are some general guidelines you can follow:
- self massage of the boobs – see post video for some massage techniques to try
- frequent and effective feeding or pumping/expression at regular intervals (roughly 8-12 times/day)
- warming the breasts with hot flannels or hot packs before feeding to help getting the milk flowing
- cooling the breasts with frozen cabbage leaves or cool packs
- wear a good fitting nursing bra
- expressing a little milk to relieve discomfort
- there are certain over the counter pain medications that are safe to be taken during breastfeeding discuss with your doctor
- other treatments such as ultrasound & lymphatic massage for pain relief
- if symptoms do not improve or if you develop any fever or flu like symptoms then consult a doctor
See the PDF attached for more tips.
Blocked Ducts
The milk making glands in your breasts are segmented and bunched together somewhat like an orange. Then narrow tubes carry the milk from the glands to the nipple, these are called ducts. When a blockage in the ducts occurs it can lead to a build up of milk behind the blockage. This usually leads to a small and tender lump and sometimes a small milk blister on the nipple. The overall health of the mother is unaffected but if the blockage is not treated quickly it can lead to mastitis.
Management of Blocked Ducts
While it is not always known what causes a milk duct to get blocked it is usually due to insufficient drainage of a duct. This can be due to tight clothing around the breast (eg a tight poorly fitted nursing bra); long periods between breast feeding or the baby not attaching well. In the case of the difficult attachment seeking the help of a lactation consultant is really going to help. The key thing is to remove the blockage so here are some general guidelines you can follow:
- try getting your baby to feed more frequently on the affected side
- try different positions, if possible pointing the baby’s chin towards the lump
- avoid wearing tight clothes or bras
- certain over the counter pain medications can be taken even if breastfeeding discuss with your doctor or pharmacist
- try warm flannels or hot packs to get the milk flowing
- massage the affected area before and during feeding or pumping gently but firmly trying to work the lump towards the nipple
- temporarily expressing after feeding
- ultrasound therapy to the blocked duct combined with lymphatic drainage my help break down the blockage and clear it out
MASTITIS
Mastitis is where your breast becomes swollen, hot and painful and may be accompanied by infection. It occurs most frequently in the first 6 weeks postpartum but can occur at any point during lactation and sometimes in women who are not breastfeeding or men. Mastitis generally affects one breast at a time, you may have a swollen wedge-shaped lump or hard area in your breast usually accompanied by a fever (>38.5C/101.3F). You may also present with flu like symptoms of aches, chills & fatigue.
Management of Mastitis
Mastitis may result from blocked ducts and or engorgement. If left untreated it can lead to a breast abscess. Mastitis can worsen rapidly and needs careful & immediate treatment. If the mastitis is a result of blocked ducts or engorgement and is an ongoing issue we strongly encourage seeing a lactation consultant to determine what specific issues need to be addressed.
Other causes for mastitis include: damaged nipples; infrequent or missed feedings; poor attachment; rapid weaning; oversupply of milk; pressure on the breast (eg from a poor fitting bra as well as maternal stress, fatigue or illness. While the cause needs to be determined and addressed on an individual basis here are some evidence based guidelines to follow:
- Effective milk removal – either via increased frequency of feeding on the affected side or ensuring the latch is correct or using a pump
- pain can interfere with the let down reflex, if this is the case start feeding on the other side until the let down occurs and then switch
- Certain over the counter pain medications such as ibuprofen are deemed safe to take during breastfeeding but should be discussed with your doctor or pharmacist before commencing
- Position the baby with either the nose or chin pointing towards the blockage to try and help drain it
- Massaging during the feed to help get the milk flowing ensure to massage from the blocked area towards the nipple
- If feeding, once completed, try expressing or pumping any remaining milk out of the breast
- Lymphatic drainage towards the ducts can also help along with appropriate application of ultrasound therapy
- Resting as much as able
- If the symptoms are not improving in 12-24 hours or if you’re unwell then a course of antibiotics is advised
If symptoms are not improving then further tests may need to be done to determine what the cause is or to rule out other issues.
Pain In Upper Back, Neck & Shoulders
This is usually down to the position you are breastfeeding. Your shoulders should not be protruding forwards and your head bending down. Try to support yourself with cushions and pillows and position yourself as shown below.
BREAST ABSCESS
A breast abscess is a painful build up of pus in the breast caused by an infection. They are more common than previously believed, especially among lactating women. Breast abscesses are benign however if one occurs in a non-lactating person then more serious problems need to be ruled out. If you think you have a breast abscess you need to see a healthcare professional as it is not something you can manage yourself as the abscess will need to be surgically drained and you will then likely be put on a course of antibiotics.
WHAT IF I AM UNABLE TO OR I CHOOSE NOT TO BREASTFEED?
If you are unable to or you choose not to breastfeed & you do not express any milk then your mild production will stop. However for several days your breasts may feel uncomfortable & sore. Keep an eye out for any signs of mastitis & wear a supportive bra.
WHAT SHOULD I DO IF I WANT TO STOP BREASTFEEDING/PUMPING?
Once you have decided you wish to cease breastfeeding and your supply and routine are well established it is advised to slowly reduce the number of feeds/pumping sessions as stopping too quickly can lead to engorgement and or mastitis. Your body will continue to produce milk as long as there is demand. So reducing length of feeds/pumping and dropping a session will help you wean. After you have stopped you may still leak for a while after if something triggers your let-down reflex. If you are struggling have a chat to your doctor as there are some medications which may help to cease breast milk production.
