Breasts and Breast-Feeding
Key Points
- Breastfeeding success depends on effective latch, adequate breast emptying, and frequent infant-led feeding.
- Common early difficulties are ineffective latch, cracked nipples, engorgement (often day 3 to 5), and perceived low supply.
- LATCH scoring helps standardize assessment and guide targeted coaching.
- For preterm newborns, frequent expression and donor milk pathways support nutrition until coordinated suck-swallow develops.
Pathophysiology
Lactation depends on milk production, transfer, and removal. If latch is shallow or feeding is infrequent, milk stasis and nipple trauma increase. Ongoing poor transfer can reduce stimulation of milk synthesis, worsening supply concerns.
Engorgement develops when milk volume rises faster than removal. Tissue edema and fullness can flatten the nipple, making latch more difficult and creating a feedback loop of painful feeding and incomplete drainage.
Classification
- Latch transfer problems: Poor areolar latch, nipple pain, ineffective emptying.
- Nipple integrity problems: Cracking, soreness, and trauma from poor mechanics.
- Milk-volume discomfort: Engorgement with swollen, hard, painful breasts.
- Supply concerns: Actual or perceived inadequate milk transfer or production.
- Preterm feeding challenges: Delayed oral coordination requiring expression, gavage, or donor milk support.
Nursing Assessment
NCLEX Focus
Priority assessment is whether infant transfer is effective and safe, not just whether feeding was attempted.
- Use latch-score criteria to evaluate latch quality, audible swallowing, nipple type, comfort, and hold.
- Assess nipple pain pattern, post-feed nipple shape, and visible trauma.
- Assess engorgement findings: breast firmness, swelling, warmth, and nipple flattening.
- Review feed frequency and newborn output cues (wet/dirty diapers) with weight trends.
- For preterm infants, assess expression schedule and readiness for transition to direct breast-feeding.
Nursing Interventions
- Provide hands-on latch coaching and relatch strategies when pain or shallow attachment occurs.
- Support nipple-healing measures: air drying, ointment, and trauma-minimizing techniques.
- Manage engorgement with warm measures before feeds, brief cool compress between feeds, and comfort analgesia.
- Encourage feeding every 2 to 3 hours (about 8 to 12 times/day), skin-to-skin, hydration, rest, and ongoing lactation follow-up.
- For preterm pathways, teach frequent expression and coordinate use of donor milk/gavage plans when indicated.
Ineffective Latch Cascade
Persistent shallow latch can lead to nipple trauma, poor milk transfer, reduced supply, and early breastfeeding discontinuation.
Pharmacology
| Drug Class | Examples | Key Nursing Considerations |
|---|---|---|
| nsaids | Ibuprofen context | Helps pain/inflammation in engorgement and supports continued feeding participation. |
| acetaminophen | Acetaminophen context | Adjunct analgesia when breast discomfort disrupts rest or feeding. |
| topical-emollients | Nipple-ointment context | Supports nipple comfort and healing when trauma is present. |
Clinical Judgment Application
Clinical Scenario
On postpartum day 4, a patient reports painful feeds, cracked nipples, and increasingly firm breasts; infant feeds briefly and remains unsatisfied.
Recognize Cues: Nipple trauma, engorgement signs, short ineffective feeds, and likely poor transfer. Analyze Cues: Shallow latch is sustaining both pain and inadequate breast emptying. Prioritize Hypotheses: Immediate goals are improve latch, reduce engorgement, and preserve milk transfer. Generate Solutions: Relatch coaching, pre-feed softening, post-feed comfort measures, and close output/weight monitoring. Take Action: Implement bedside feeding support and schedule lactation follow-up. Evaluate Outcomes: Pain decreases, latch depth improves, and infant output/weight trends normalize.
Related Concepts
- postpartum-infections - Nipple trauma raises risk for mastitis and fungal complications.
- mastitis - Milk stasis and nipple breaks can progress to breast infection.
- nursing-care-during-the-postpartum-period - Discharge teaching includes feeding plans and warning signs.
- physiologic-changes-during-the-postpartum-period - Lactation changes overlap with broader postpartum adaptation.
- care-of-the-typical-newborn - Infant feeding cues and output trends guide breastfeeding adequacy checks.
Self-Check
- Which findings best indicate an effective latch and milk transfer?
- Why can aggressive pumping to full emptying worsen engorgement in some situations?
- Which interventions are most important when breastfeeding a preterm newborn who cannot latch effectively?