Nipples Not Graspable Flat or inverted nipples
• Use Hoffman technique to break adhesions.
• Wear breast shells to encourage nipples to protrude.
• Grasp nipples and roll gently between the fingers to increase protractility.
• Form the nipple before breastfeeding by hand shaping, ice, or wearing nipple shells a half-hour before feeding.
• Use a breast pump to draw nipples out so that the mother can then put the baby to the breast.
Engorged breasts
• Treat engorgement by feeding the baby more frequently.
• A hand or electric pump or manual emptying of the breast can be done if the baby is unable to grasp the nipple.
Large breasts
• Support breast with opposite hand, or use rolled towel under breast to bring nipple to the level of baby’s mouth.
• Avoid having the nipple pointing downward because this makes latch-on more difficult.
• Use C-hold to make nipple accessible to baby.
Engorgement - Missed or infrequent feedings
• Breastfeed frequently (every 1 1/2 hours).
• Massage and hand express or pump to empty breasts completely when feedings are missed or when a full feeling develops in breasts and baby is not available or willing to feed.
• Avoid excessive stimulation or pumping between feedings because this will increase milk production.
• Place warm compresses on breast just before feeding to soften breast.
• Use cold applications between feedings to slow milk production (frozen bagged vegetables, ice packs, and par-cooked cabbage leaves (Cunningham et al., 2010).
Breasts not emptied at feedings
• Massage breasts and use warm cloths before feedings.
• Breastfeed long enough to empty breasts (10 to 15 minutes on each side at each feeding).
• If baby will not feed long enough to empty breasts, hand express or pump after feeding. Inadequate let-down
• Use relaxation techniques, massage, and warm compresses before breastfeeding.
• Relax in warm shower with water running from back over shoulders and breasts, hand expressing to relieve fullness.
• Use hand or electric pump before placing baby on breast to encourage let-down.
• Listen to soothing music, use visualization or breathing techniques.
• If caused by anxiety, try to eliminate the source of tension.
Baby sleepy or not eager to feed
• Use rousing techniques (e.g., hold baby upright, unwrap blanket, change diaper).
• Pre-express milk onto nipple or baby’s lips to entice baby.
• Avoid use of bottles of water or formula; these will decrease baby’s willingness to suckle.
Inadequate Let-Down/Let-down not well established
• Give the baby ample time at the breast (at least 15 minutes per side) to allow for let-down and complete emptying.
• Breastfeed in a quiet spot away from distractions.
• Massage breasts and apply warm compresses before breastfeeding.
• Drink juice, water, or tea (no caffeine) before and during breastfeeding.
• Condition let-down by setting up a routine for beginning feedings.
• Use relaxation, visualization, and breathing techniques.
• Stimulate the nipple manually before breastfeeding.
• Concentrate thought on the baby and milk flow; turn on a faucet so that the sound of running water helps stimulate let-down.
• Take a warm shower before feedings.
• Use breast pump to stimulate the let-down.
• Avoid waiting to put baby to breast until the baby is famished because this may increase maternal anxiety.
• Assess for maternal pain, cold temperature, or anxiety before feeding. Mother overtired or overextended
• Nap or rest when the baby rests.
• Limit distractions, limit visitors, focus on personal needs.
• Lie down to breastfeed.
• Simplify daily chores; set priorities.
Mother tense, pressured
• Identify the causes of tensions and eliminate or minimize them.
• Decrease fatigue.
• Have others assist with other household duties or tasks.
• Use relaxation, visualization, and breathing exercises to promote relaxation and comfort.
Mother caught in cycle of little milk, worry, less milk
• Try all the actions above.
• Counsel mother that most women do produce enough milk.
• Have infant weighed to ensure adequate weight gain, which is a reflection of milk supply.
• Encourage frequent, uninterrupted feedings.
• Consult a lactation consultant as needed.
Cracked Nipples All causes of sore nipples carried to extreme
• Refer to all actions for sore nipples.
• Ensure infant is properly positioned.
• Feed infant more frequently.
• Avoid soaps, perfumes, or other cleaning products that can dry out nipples and predispose them to cracking.
• Express milk post-feeding and rub into nipple allowing it to air dry.
• Use emollients or lanolin as directed by physician/CNM/lactation consultant.
• Consult doctor about using ibuprofen (Motrin), acetaminophen (Tylenol), or other painkiller.
• Improve nutritional status, increasing protein, vitamin C, zinc. Local infection (baby with staph or other organism may have infected mother’s nipples)
• Refer to physician.
Plugged Ducts Poor positioning
• Try a variety of positions for complete emptying.
• Alternate positions so that different areas of the nipple have different compression pressure.
• Incomplete emptying of breast.
• Breastfeed at least 10 minutes per side after let-down.
• Alternate breastfeeding positions.
• If baby does not empty breasts, pump or express milk after feedings.
External pressure on breast
• Use larger-size bra, insert bra extender, or go braless.
• Wear a sports bra instead of a traditional bra.
• Use nursing bra instead of pulling up conventional bra to breastfeed to avoid pressure on ducts.
• Avoid bunching up sweater or nightgown under arm during breastfeeding. Sore Nipples Poor positioning
• Alternate breastfeeding positions throughout the day.
• Bring the baby close to feed so the baby does not pull on the breast.
• Place the nipple and some of the areola in the baby’s mouth.
• Check to ensure the baby is put on and off the breast properly.
• Check to ensure the nipple is back far enough in the baby’s mouth.
• Hold the baby closely during feeding so the nipple is not constantly being pulled.
• Ensure that shoulder, hip, and knees are all properly aligned and facing the mother.
Baby chewing or nuzzling onto nipple
• Form the nipple for the baby.
• Set up a pattern of getting the baby onto the breast using the rooting reflex.
Baby sucking on end of nipple
• Ensure the nipple is way back in the baby’s mouth by getting the baby properly onto the breast.
• Check for an inverted nipple.
• Check for engorgement.
• If baby is initially placed incorrectly on the end of the nipple, break the suction using a fish hook motion with your index finger and reposition baby on nipple properly.
• Do not allow baby to nurse on end of nipple, reposition immediately.
Baby chewing his or her way off the nipple (nipple being pulled out of baby’s mouth at end of feeding)
• Remove the baby from the breast by placing a finger between the baby’s gums to ensure suction is broken.
• End feeding when the baby’s suckling slows, before he or she has a chance to chew on the nipple.
Baby overly eager to nurse
• Breastfeed more often.
• Pre-express milk to hasten let-down, avoiding vigorous suckling.
Dry colostrum or milk causing nipple to stick to bra or breast pads
• Moisten bra or pads before taking off so as not to remove keratin.
• Ensure that nipples are dry before replacing bra or clothing against nipples. Nipples not allowed to dry
• Remove plastic liners from milk pads.
• Air dry breast completely after nursing.
• Change nursing pads frequently.
• Switch to cotton nursing pads.
Nipple skin not resistant to stress
• Improve diet; in particular, add fresh fruits and vegetables and vitamin supplements.
• Eliminate or decrease use of sugary foods, alcohol, caffeine, cigarettes.
• Check use of cleansing or drying agents.
Natural oils removed or keratin layers broken down by drying agents (soap, alcohol, shampoo, deodorant)
• Eliminate irritants.
• Wash breasts with water only.
Ladewig, Patricia W.; London, Marcia L.; Davidson, Michele C. (2013-05-09). Contemporary Maternal-Newborn Nursing (Maternal Newborn Nursing Care: Nurse, Family, Community) (Page 720-721). Pearson Education.
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