Common breastfeeding problems

Abstract

The health benefits of breastfeeding are well known; the majority of women in the UK express a desire to breastfeed. However, by 8 weeks of age, only 40% of babies are receiving any breastmilk. Many reasons are given for discontinuing, but GPs, as a primary contact for women concerned about breastfeeding, are often able to identify problems. The aim of this article is to explore what constitutes successful breastfeeding, common concerns expressed by mothers, the pathologies with which they present to GPs and how breastfeeding fits into a holistic picture of postnatal health.

The RCGP curriculum and breastfeeding

The role of the GP in the gynaecology and breast clinical topic guide is to:

Acknowledge that many gynaecological conditions adversely affect physical, psychological and social well-being and they should work with women to manage these impacts

Understand that some women may find it difficult to discuss intimate health issues, for many reasons. Women may prefer to see a female GP to discuss gynaecological and breast problems

Endeavour to adopt a ‘woman-centred life course’ approach, using current contact opportunities occurring over a woman’s life for health promotion and potential interventions

Emerging issues and knowledge and skills relevant to breast health and breastfeeding include consideration of:

Typical and atypical presentations

Recognition of normal variations

Identification of risk factors, alarm or ‘red flag’ features

Providing patient information and education including self-care

Introduction

Breastfeeding is widely acknowledged to be beneficial for both mothers and infants; thus, there has been a concerted effort to increase rates of breastfeeding in the UK over the last few decades. According to Public Health England the breastfeeding rate at 6 to 8 weeks postpartum for England was 46% between 2018 and 2019 (Public Health England, 2019) This includes both exclusively breastfeeding and mixed feeding. However, figures published as part of the NHS maternity data set show that some 75% of babies born in November 2018 had an initial feed of breastmilk. There remains, therefore, a significant cessation rate in breastfeeding, and it is not uncommon for nursing mothers to experience problems in the initial postpartum period. They may ask their GP for advice about these problems, and it is important for GPs to be able advise mothers appropriately at this often difficult time.

Breastfeeding terminology

According to the World Health Organisation (WHO):

Breastfeeding is the normal way of providing young infants with the nutrients they need for healthy growth and development. Virtually all mothers can breastfeed, provided they have accurate information and the support of their family, the health care system and society at large.

They recommend exclusive breastfeeding for 6 months, followed by the introduction of solid food along with breastfeeding until 2 years of age and beyond (WHO, 2019). See Table 1.

Table 1.

Breastfeeding terminology.

Term	Description
Exclusive breastfeeding	The baby is fed only breastmilk, only from the breast with no supplementation with formula milk, water or other food source
Mixed feeding	The baby is fed by both breast and bottle. The contents of the bottle may be expressed breastmilk or formula milk
Responsive feeding	‘Responsive breastfeeding involves a mother responding to her baby’s cues, as well as her own desire to feed her baby. Crucially, feeding responsively (unlike ‘‘demand feeding’’) recognises that feeds are not just for nutrition, but also for love, comfort and reassurance between baby and mother.’ (UNICEF, 2016)
Cluster feeding	Where a baby needs to feed extremely frequently or even continuously for several hours at a stretch, often falling asleep at the breast and not wanting to come off. This is very common during the first few weeks of breastfeeding

Benefits of breastfeeding

In the short term, breastfeeding has benefits that include a reduction in the risk of gastroenteritis, necrotising enterocolitis, ear infections, respiratory infections and dental malocclusion. In the longer term, there is growing evidence for a reduction in type 2 diabetes and obesity (Victora et al., 2016). It protects against breast cancer, helps with child spacing and may protect against maternal type 2 diabetes and ovarian cancer (Victora et al., 2016). There is evidence that breastfeeding reduces the risk of asthma and other atopic conditions (Lodge et al., 2015). As well as reducing morbidity, there is evidence of a generalised reduction in mortality in breastfed children, and this effect is dose dependent, i.e. those that are breastfed the most, have the biggest reduction in mortality (Sankar, et al., 2015).

What is successful breastfeeding?

Successful breastfeeding results in babies that are adequately hydrated and nourished, that latch on effectively to obtain sufficient milk without maternal distress, thus allowing babies to grow according to their potential.

Initially, a baby may only feed 3 to 4 times per day, but after 48 hours this changes dramatically, so most will feed 8 to 12 times a day, for 5–40 minutes each time. Frequent feeding, on-demand is also important for stimulating milk supply to match the needs of the baby. It is, therefore, not possible to overfeed a breastfed baby. Many people may take this frequent feeding pattern as a sign that the baby is not getting enough milk, a view often reinforced by switching to formula milk and the baby going longer between feeds. The neonatal stomach is small and formula milk takes longer to digest than breast milk. Table 2 shows the signs that breastfeeding is meeting the infant’s needs.

Table 2.

Signs that breastfeeding is meeting the demands of the infant.

Sign	Observation
Baby’s mood	Calm whilst feeding Content/sleepy after feeds Alert between feeds
Audible and visual clues	Can see and hear baby sucking and swallowing
Maternal signs	Breasts feel empty at the end of feeding No nipple changes during feeding Feeling sleepy after feeding
Dirty nappies	From day 4, producing at least two dirty nappies a day, often yellow in appearance
Wet nappies	From day 5, producing at least six wet nappies a day
Weight gain	Babies can lose up to 10% of their birthweight initially but most should have reached birthweight again by 3 weeks of age Consistent growth along centile lines

Source: Public Health England/NHS (2018).

Obstacles to successful breastfeeding

The key to successful breastfeeding is correct positioning and attachment. These are learnt skills and up until the 19th century, girls were exposed to women breastfeeding their babies within families and in society more generally. In the 1950s, the introduction of aggressively marketed breastmilk substitutes contributed to a decline in breastfeeding in the UK. This, in turn, contributed to a lack of visible role models and a greater challenge for the promotion of breastfeeding.

Given the many scientifically proven benefits of breastfeeding, it is not surprising that a 2017 survey of over 1000 UK mothers on a well-known parenting website showed that 87% wanted to breastfeed before their baby was born and 92% tried to establish breastfeeding after birth (mumsnet, 2017). It may, therefore, be considered surprising that at 6 to 8 weeks only 42% of babies are receiving any breastmilk. Table 3 shows the reasons that women gave for breastfeeding cessation.

Table 3.

Reasons given for cessation of breastfeeding amongst a group of mothers via an online survey.

	Wanting to breastfeed, stopping within 24 hours (%)	Initiated breastfeeding, stopped by 6 weeks (%)
Concerns about latching on	41	56
Breastfeeding was painful	15	39
‘I felt I didn’t know what I was doing’, needed more help, etc.	62	–
Concerns about milk supply/baby weight gain	–	66
‘I was overwhelmed/exhausted and something had to give’	–	34

Source: mumsnet (2017).

Pain

What is normal?

One of the most common reasons given for discontinuation of breastfeeding is pain or discomfort during feeding. A large American study followed over 500 first-time mothers from birth to 60 days postpartum. Breast pain was reported in 44% at day 3 and became the commonest reported problem until day 60 when 25% of those still breastfeeding, reported ongoing pain (Wagner et al., 2013). Breastfeeding pain is likely to be multifactorial, with both maternal and infant components. In addition to the physical cause of pain, there are psychosocial factors to consider, such as sleep deprivation, mood disturbance and personal/societal pressure, for example from the expectation that breastfeeding should be enjoyable. Breastfeeding pain is most commonly attributed to difficulties with latching on. This may be exacerbated or caused by tongue-tie or palatal variations in the infant. There are important medical conditions to exclude as a cause of pain, but there is some evidence that some babies simply suck harder than others (McClellan et al., 2008). However, there remains a group of women in whom no cause for pain can be found and for whom breastfeeding remains persistently uncomfortable.

Latching problems and tongue-tie (ankyloglossia)

Getting attachment right (see Fig. 1) is vital for successful breastfeeding, as it ensures that the baby obtains milk in a way that is comfortable for the mother. There are many different positions for holding babies, depending on circumstances (e.g. sitting in a chair, lying in bed, etc.). However, the principle of attachment is the same. There may be some initial pain from the let-down reflex, but the rest of the feed is usually pain-free.

Figure 1.

How to breastfeed.

Ankyloglossia is an abnormally short lingual frenulum which can cause problems with the mobility of the tongue interfering with feeds. It affects up to 11% of babies, although not all will have difficulty feeding. It typically causes problems with latching on, resulting in a discontented baby that struggles to feed and a mother with sore or cracked nipples. Treatment, if needed, is division of the frenulum, carried out without an anaesthetic in very young babies by the local specialist service (NHS, 2017).

Nipple trauma

Nipple trauma is usually the result of difficulties with proper attachment. Without proper attachment the baby takes just the nipple into its mouth with the result that the tongue and hard palate rub on the nipple. If this continues, not only will breastfeeding be extremely painful, but consequent breaks in the skin will predispose to infection.

To treat nipple trauma correctly, the fundamental issue of attachment must be addressed. Referral for expert support can be essential. There is little evidence for specific topical treatments, although many sources recommend simply rubbing expressed milk into the nipple and surrounding area, allowing the affected area to air dry. Alternatives include Vaseline® or Lansinoh® ointment (Dennis et al., 2014).

Mastitis and breast abscess

Mastitis occurs most commonly in the first 6 weeks of breastfeeding; it presents with pain, erythema and swelling of the affected breast. Common organisms include Staphylococcus aureus, Staphylococcus epidermidis and Streptococci. Women should be thoroughly assessed to exclude sepsis warranting hospital admission with signs such as tachycardia, pyrexia or haemodynamic instability. Examination must be performed to exclude an abscess or underlying breast mass. Treatment of mastitis is with analgesia, antibiotics and ensuring the affected breast is regularly emptied of milk. Continuation of breastfeeding is encouraged from the affected breast, as this is the most effective way to achieve milk removal. If not possible, the woman should be encouraged to drain the breast either by pump or by hand. Abrupt cessation of breastfeeding in mastitis may increase the risk of abscess formation (Amir, 2014). Oral analgesia and topical hot compresses may help with pain. Oral antibiotics should be prescribed according to local guidelines, but will usually be for 10–14 days with flucloxacillin or a macrolide equivalent. Failure to improve after 24–48 hours should prompt discussion with a microbiologist, as treatment for MRSA may be needed (National Institute for Health and Care Excellence (NICE), 2018).

A breast abscess can complicate up to 10% of cases of mastitis. It should be suspected if initial treatment fails to produce a response or if an abscess is detected on clinical examination as a discrete, tender, erythematous mass. The diagnosis can be confirmed by ultrasound to detect a collection of pus, and treatment is with either needle aspiration under ultrasound guidance or by surgical incision and drainage. Needle aspiration may need to be repeated every few days with ongoing antibiotic treatment, whereas surgical drainage can be done with local anaesthesia through a very small incision. Prompt treatment of an abscess is vital to avoid permanent damage to the structure of the breast and disfigurement. Breast abscesses are very unlikely to resolve with antibiotics alone (Dixon, 2013).

Dermatoses

There are a wide variety of dermatoses than can affect the breast during lactation. Women with pre-existing psoriasis may have an exacerbation including the nipple area. There is some evidence that they are more likely to experience the Koebner phenomenon around the nipple area due to trauma from latching on. Similarly, women with a history of eczema may experience typical eczematous lesions affecting the nipple area. Irritant contact dermatitis can occur during breastfeeding; with triggers including soaps or washing powders. Similarly, delayed hypersensitivity dermatitis can affect the breast and be caused by various topical agents and other breastfeeding products. If suspected, a detailed history may identify the offending agent. Treatment with low-potency topical steroids is safe, and in the case of psoriasis, topical vitamin-D derivatives are also considered safe (Barrett et al., 2013).

Candidal infection

There is surprisingly little evidence that mammary candidiasis is a cause of breast pain, however, it remains widely diagnosed by both clinicians and breastfeeding advisors. A Spanish study in 2017 looked at milk samples, nipple swabs and nipple biopsies in 529 women with symptoms historically thought to suggest candida infection. Only 2% had positive confirmation of candida species, all of whom had infants with confirmed oral candidiasis, compared with almost 95% identified as having staphylococcal infection. The authors went on to conclude that the symptoms were probably caused by subacute bacterial infection, theorising that Staphylococcus/Streptococcus mastitis forms a ‘synergistic partnership’ causing candida overgrowth in the mouths of infants and candida subsequently an incidental finding on maternal samples (Jimenez et al., 2017).

Notwithstanding this uncertainty regarding causation and pathogenesis, mammary candidiasis is thought to present with pain both during and between feeds and excruciating in severity. It has been described as burning nipple pain or stabbing-type pain behind the breasts, often occurring bilaterally. There may be flaking of the skin or a shiny appearance and often a corresponding infection of the infant’s mouth. This may cause difficulties with feeding for the baby, frequently coming on and off the breast as well as discontent between feeds (La Leche League GB, 2012).

Treatment is with good hygiene measures such as hand washing, laundering bras at high temperatures and avoidance of breast pads. As candida survives freezing, breastmilk obtained from pumping while treatment is ongoing should not be kept as this can cause reinfection.

Swabs should be sent of both the nipple and the baby’s mouth, but remembering that candida is a common contaminant. First line treatment is with topical antifungals, treating both mother and baby to avoid reinfection. Nystatin, clotrimazole, miconazole or fluconazole are usually effective, and can also be combined with a topical steroid if needed. Treatment should be applied after feeds and continued until symptom-free for 48 hours. If topical treatment fails, then the diagnosis should be reconsidered before treating with oral fluconazole for 2 weeks, remembering that fluconazole is not licensed for use in breastfeeding with babies less than 6 months (NHS, 2018a).

Nipple vasospasm (Raynaud’s disease)

Raynaud’s phenomenon, resulting from distal ischaemia secondary arteriolar vasospasm most commonly affects the digits. However, it can also affect the gastrointestinal tract and coronary vasculature. Similarly, Raynaud’s disease affects the nipple causing intense pain secondary to ischaemia. The classic colour changes of Raynaud’s disease may be seen in the nipple and will often be precipitated by the cold. The patient will commonly have Raynaud’s disease affecting other sites as well (Lawlor-Smith and Lawlor-Smith, 1995) and pain may occur between feeds. Management involves avoidance of precipitating causes (cold), caffeine and smoking. Treatment with analgesics and vasodilators in the form of nifedipine (although this is an off-label use) may be helpful (Anderson et al., 2004).

Herpes simplex infection

Herpes simplex infection is a rare, but potentially serious, infection affecting the nipple and breast. It usually presents with characteristic, virus-containing herpetic vesicles and significant pain. Diagnosis can be confirmed by viral culture of the vesicle fluid and serology. When active herpes is present, breastfeeding should be avoided to prevent neonatal transmission. It is essential to review the infant, as herpes infection can be rapidly fatal in those under 3 months. Treatment is with aciclovir and this is considered safe in breastfeeding (Barrett et al., 2013).

Low milk supply and growth concerns

Concerns about milk supply problems are extremely common, especially in the early days of breastfeeding, and this is often a reason given for stopping breastfeeding. Unlike formula feeding, it is impossible to know exactly how much milk the baby is receiving. However, if the infant is putting on sufficient weight and producing dirty nappies then there is unlikely to be a problem with supply. Concerns commonly arise because of the frequent feeding demands of a new baby, especially when associated with growth spurts and cluster feeding. There is a temptation to top-up the feed with formula; this may settle the baby, reinforcing the perception that the baby is not being fed sufficiently. This will, in the long run lead to genuine milk supply problems. Similarly, it is also quite normal for the time taken for feeds to reduce and the breasts to feel softer between feeds as the baby matures.

Very occasionally there may be a genuine problem with milk supply. Some drugs such as oestrogen and alcohol inhibit milk production, as can nicotine, both in the form of cigarettes and nicotine replacement therapy (Hopkinson et al., 1992). Women who have had any significant breast surgery may have problems with breastfeeding and low supply. This is caused by trauma to the nerves, as well as damage to glandular tissue and the milk ducts themselves. Previous breast surgery is not a contraindication to breastfeeding and the actual effect on milk supply is difficult to predict beforehand

The use of medication to increase milk supply (galactagogues) is controversial with many doctors, understandably, reluctant to prescribe them. Human lactation is influenced by a multitude of hormones with prolactin probably being the most significant for milk production. However, there is no direct correlation between prolactin level and milk supply. Drugs used as galactagogues are all dopamine antagonists and work therefore to increase prolactin levels (The Academy of Breastfeeding Medicine Protocol Committee, 2011). Evidence for efficacy is poor, with a small number of low-quality trials and no evidence for long term benefit. In addition, none of the drugs used are licensed for this indication and serious side effects have been reported. Galactagogues should only be considered after non-drug interventions have been tried. Domperidone is the drug of choice as long as the QT interval is normal, otherwise metoclopramide can be used. The dose of domperidone should not exceed 30 mg daily and treatment should probably not exceed a week (UK Medicines Information, 2014). There is probably more of a role for galactagogues in breastfeeding initiation in preterm babies being fed expressed breast milk (Donovan and Buchanan, 2012). Further advice can be sought from a local lactation consultant or specialist breastfeeding midwife.

Other things to consider

Mood and depression

The postpartum period is a time of great change; physically, psychologically and emotionally. A new mother may present with concerns about feeding, but this may be the ‘tip of the iceberg’ and should prompt an active search for other underlying factors, for example screening for postpartum depression and other mental health issues, as well as domestic abuse. It is important to remember that women may feel guilty about not breastfeeding or wanting to stop and discussion requires a high degree of sensitivity.

Co-sleeping

The issue of co-sleeping (sharing a bed with an infant) is contentious; with the advice for parents and healthcare professionals being both confusing and contradictory. There is concern that co-sleeping may increase the risk of Sudden Infant Death Syndrome (SIDS). The NHS website states: ‘The safest place for your baby to sleep for the first 6 months is in a cot in the same room as you’ (NHS, 2018b). Similarly, the NICE Postnatal care guideline says that new parents should be informed ‘that there is an association between co-sleeping and SIDS’ (NICE, 2015). However, as UNICEF point out, evidence suggests that by 3 months of age, 50% of all babies will have co-slept in a bed with an adult, whether intentional or not. Similarly, co-sleeping supports breastfeeding by helping the baby to settle with less disruption to parental sleep and breastfeeding is in itself, protective against SIDS. By trying to avoid co-sleeping in a bed, nursing mothers may choose to feed in a chair or sofa, where there is a much higher risk of SIDS if she does unintentionally fall asleep. There is, however, good evidence that co-sleeping after the consumption of alcohol or recreational drugs, or if one of the parents is a regular smoker does increase the risk of SIDS and should therefore be avoided (UNICEF, 2018).

A pragmatic approach to co-sleeping needs to be taken, recognising that many babies will co-sleep whether intentionally or unintentionally at some point in the first 3 months and that mothers should not be made to feel guilty if this happens. Co-sleeping is a normal part of early parenting (and breastfeeding) and providing that it does not occur when drugs, alcohol or cigarettes are involved, should be considered a safe practice. It should also be remembered that SIDS is very rare, and in around 50% of cases, the baby was sleeping in a Moses’ basket or cot (UNICEF, 2018).

Contraception

Postnatal contraception for women who are breastfeeding is easily overlooked by both patient and clinician. The lactational amenorrhoea method (LAM) is effective in the first 6 months with a typical failure rate of around 2%, although with perfect use this may be as low as 0.5%. For LAM to be reliable, the mother must be less than 6 months postpartum, completely amenorrhoeic and almost exclusively on-demand breastfeeding. Failure may also be difficult to spot as the woman may remain amenorrhoeic.

If the above conditions are not met or if the woman requests more reliable contraception, this should be provided. Contraception can be started immediately after birth (except for combined hormonal contraception) and, provided it is commenced before 21 days postpartum, no additional precautions are required. Combined hormonal contraception is usually avoided in women who are breastfeeding until at least 6 weeks postnatal due to concerns about the effects of oestrogen on milk supply (Faculty of Sexual and Reproductive Healthcare, 2017).

Smoking, alcohol and medications

Smoking is not a reason to avoid breastfeeding, even though nicotine freely passes into breastmilk and can affect the flavour. To reduce health risks to the baby, cigarettes should ideally only be smoked post-feed to limit the concentration in the next feed and well away from the baby to limit the inhalation of smoke by the baby. Smoking is known to increase the risk of SIDS, colic and childhood asthma in the baby and breastfeeding may help to mitigate some of these risks, although co-sleeping should be avoided. The concentration of nicotine in breastmilk from nicotine replacement therapy (NRT) is lower than that of cigarettes and therefore NRT is preferable to smoking whilst breastfeeding.

The use of alcohol in breastfeeding is also controversial. Alcohol passes freely into the breastmilk peaking at around 60 minutes after oral consumption. As the blood alcohol level falls, the alcohol returns from the stored breastmilk into the maternal blood and is metabolised, and hence, the breastmilk level also falls. Therefore, consuming a small amount of alcohol immediately after a feed means that by the time of the next feed, very little is likely to remain in the milk. Drinking large amounts of alcohol can result in a more significant amount of alcohol remaining in the milk, and hence, affecting the baby. It is reported that a maternal blood alcohol level of around 300 mg/dl is required before infant effects (in terms of drowsiness etc.) are seen. To put this in context, this equates to four times the current drink– drive limit. Alcohol can also affect the baby’s feeding. In the first few hours after alcohol consumption, babies take less milk, compensating with an increased milk demand 8–16 hours later. Women can be safely advised that the occasional drink of alcohol while breastfeeding is safe, although co-sleeping should be avoided. Women who consume large amounts of alcohol regularly should be advised to limit their alcohol consumption to safe levels, but if this is not possible then breastfeeding should be stopped. If a woman wishes to consume a more significant amount of alcohol as a one-off (a social event for example) she could feed the infant some stored expressed milk, pump and throwaway the milk produced immediately after alcohol consumption and resume normal feeding once she feels normal.

Prescribing in breastfeeding is outside the scope of this article, but it should be remembered that very few drugs are licensed for the use in breastfeeding and there is often very little clinical data with which to make decisions. Most drugs pass into breastmilk, but usually at very low levels and few drugs should be considered completely contraindicated in breast feeding. Drugs that should always be avoided, or breastfeeding discontinued include lithium (a very large amount passes into the milk), cytotoxic drugs and retinoids.

Resources for support

There are many organisations and sources of information on breastfeeding both for the general public and healthcare professionals. For parents, La Leche League and the National Childbirth Trust provide up-to-date information and support on breastfeeding issues, whereas The GP Infant Feeding Network UK (GP Infant Feeding Network, 2016) is targeted specifically at GPs. Similarly, UNICEF and WHO both provide copious resources for medical professionals.

KEY POINTS

Breastfeeding has numerous health benefits to both mother and child and most women want to breastfeed

Women stop breastfeeding for many reasons, but pain, difficulties with latching on and concerns about growth are commonly cited

Most problems can be managed by checking the latching on technique and reassurance

Co-sleeping is common and a normal, safe part of breastfeeding providing simple measures are taken to reduce the risk of SIDS

Smoking and alcohol consumption are contraindications for co-sleeping, but not for breastfeeding

Women presenting with breastfeeding concerns or difficulties should be screened for postnatal depression and domestic abuse

Footnotes

ORCID iD

Alexander Field

References

Amir

(2014) Academy of Breastfeeding Medicine: Clinical protocol #4: Mastitis. Breastfeeding Medicine 9(5): 239–243. DOI: 10.1089/bfm.2014.9984.

Anderson

Held

Wright

(2004) Raynaud’s phenomenon of the nipple: A treatable cause of painful breastfeeding. Pediatrics 113(4): e360–e364. DOI: 10.1542/peds. 113.4.e360.

Barrett

Heller

Stone

, et al.(2013) Dermatoses of the breast in lactation. Dermatologic Therapy 26(4): 331–336. DOI: 10.1111/dth.12071.

Dennis

Jackson

Watson

(2014) Interventions for treating painful nipples among breastfeeding women. Cochrane Database of Systematic Reviews 12. art. no.: CD007366. DOI: 10.1002/14651858.CD007366.pub2.

Dixon

(2013) Breast infection. BMJ 347. DOI: 10.1136/bmj.f3291.

Donovan TJ and Buchanan K (2012) Medications for increasing milk supply in mothers expressing breastmilk for their hospitalised infants. Cochrane Database of Systemic Reviews. Issue 3. Art. No.CD005544. DOI: 10.1002/14651858.CD005544.pub2.

Faculty of Sexual and Reproductive Healthcare (2017) CEU clinical guidance: Contraception after pregnancy - January 2017. Available at: www.fsrh.org/standards-and-guidance/documents/contraception-after-pregnancy-guideline-january-2017/ (accessed 08 May 2019).

GP Infant Feeding Network (n.d) GP infant feeding network. Available at: https://gpifn.org.uk/(accessed 20 May 2019).

Hopkinson

Schanler

Fraley

, et al.(1992) Milk production by mothers of premature infants: Influence of cigarette smoking. Pediatrics 90(6): 934–938.

10.

Jimenez

Arroyo

Cardenas

, et al.(2017) Mammary candidiasis: A medical condition without scientific evidence? PLoS One 12(7): ) DOI: 10.1371/journal.pone.0181071.

11.

La Leche League GB (2012) La Leche League GB. Available at: www.laleche.org.uk/thrush/#research (accessed 21 March 2019).

12.

Lawlor-Smith

(1995) Vasospasm of the nipple—a manifestation of Raynaud's phenomenon: Case reports. The British Medical Journal 314: 644–645. DOI: 10.1136/bmj.314.7081.644.

13.

Lodge

Tan

Lau

MXZ

, et al.(2015) Breastfeeding and asthma and allergies: A systematic review and meta-analysis. Acta Paediatrica 104: 38–53. DOI: 10.1111/apa.13132.

14.

McClellan

Geddes

Kent

, et al.(2008) Infants of mothers with persistent nipple pain exert strong sucking vacuums. Acta Paediatrica 97(9): 1205–1209. DOI: 10.1111/j.1651-2227.2008.00882.x.

15.

mumsnet (2017) Why women stop breastfeeding. Available at: www.mumsnet.com/babies/why-women-stop-breastfeeding (accessed 19 March 2019).

16.

NHS (2017) Tongue-tie. Available at: www.nhs.uk/conditions/tongue-tie/ (Accessed 10 May 2019).

17.

NHS (2018a). Breastfeeding and thrush. Available at: www.nhs.uk/conditions/pregnancy-and-baby/breastfeeding-and-thrush (accessed 21 March 2019).

18.

NHS (2018b). Reducing the risk of sudden infant death syndrome (SIDS). Available at: www.nhs.uk/conditions/pregnancy-and-baby/reducing-risk-cot-death/ (Accessed 08 May 2019).

19.

NICE (2015) Postnatal care up to 8 weeks after birth. Available at: www.nice.org.uk/guidance/CG37. (accessed 20 March 2019).

20.

NICE (2018) Clinical knowledge summaries: Mastitis and breast abscess. Available at: https://cks.nice.org.uk/mastitis-and-breast-abscess (accessed 20 March 2019).

21.

Public Health England (2019) Breastfeeding at 6 to 8 weeks after birth: annual data. Available at: www.gov.uk/government/statistics/breastfeeding-at-6-to-8-weeks-after-birth-annual-data (accessed 13 January 2020).

22.

Public Health England/NHS (2018) Breastfeeding. Available at: www.nhs.uk/start4life/baby/breastfeeding (accessed 20 May 2019).

23.

RCGP. Clinical topic guide: Gynaecology and breast. Available at: www.rcgp.org.uk/training-exams/training/gp-curriculum-overview.aspx (accessed 5 February 2020).

24.

Sankar

Bireshwar

Chowdhury

, et al.(2015) Optimal breastfeeding practices and infant and child mortality: A systematic review and meta-analysis. Acta Paediatrica 104(S467): 3–13. DOI: 10.1111/apa.13147.

25.

The Academy of Breastfeeding Medicine Protocol Committee (2011) ABM clinical protocol #9: Use of galactogogues in initiating or augmenting the rate of maternal milk secretion (first revision January 2011). Breastfeeding Medicine 6(1): 41–49. DOI: 10.1089/bfm.2011.9998.

26.

UK Medicines Information (2014). Drug treatment of inadequate lactation. Available at: www.sps.nhs.uk/articles/drug-treatment-of-inadequate-lactation/ (accessed 23 April 2019).

27.

UNICEF (2018) Co-sleeping and SIDS: A guide for healthcare professionals. Available at: www.unicef.org.uk/babyfriendly/wp-content/uploads/sites/2/2016/07/Co-sleeping-and-SIDS-A-Guide-for-Health-Professionals.pdf (accessed 08 May 2019).

28.

UNICEF (2016). Responsive feeding infosheet: Supporting close and loving relationships. Available at: https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/relationship-building-resources/responsive-feeding-infosheet/ (accessed 15 March 2019).

29.

Victora

Bahl

Barros

AJD

, et al.(2016) Breastfeeding in the 21st century: Epidemiology, mechanisms. The Lancet 387(10017): 475–490. DOI: 10.1016/S0140-6736(15)01024-7.

30.

Wagner

Chantry

Dewey

, et al.(2013) Breastfeeding concerns at 3 and 7 days postpartum and feeding status at 2 months. Pediatrics 132(4): e865–875. DOI: 10.1542/peds.2013-0724.

31.

WHO (2019) Breastfeeding. Available at: www.who.int/topics/breastfeeding/en (accessed 20 May 2019).