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Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care. Geneva: World Health Organization; 2009.

Cover of Baby-Friendly Hospital Initiative

Baby-Friendly Hospital Initiative: Revised, Updated and Expanded for Integrated Care.

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Session Objectives

At the end of this session, participants will be able to:

1. List the points to look for when examining a mother’s breasts and nipples.5 minutes
2. Describe causes, prevention and management of engorgement and mastitis.20 minutes
3. Describe causes, prevention and management of sore nipples.10 minutes
4. Demonstrate through role-play assisting a mother with breast or nipple conditions.25 minutes
Total session time60 minutes


Cloth breast.

Slide 12/1: Breast and nipple size and shape

Slide 12/2: Full breast

Slide 12/3: Engorgement

Slide 12/4: Mastitis

Slides 12/5 and 12/6: Sore nipples

Breastfeed Observation Aid - a copy for each person.

List of Communication Skills from Session 2 - a copy for each person.

Copy of the stories – one story for each group of 4–6 participants.

In Additional Information section

Slides 12/7: Syringe method for an inverted nipple

Slides 12/8 and 12/9: Candida on nipples

Slide 12/10: Tongue-tie

Syringe and a sharp blade to cut it.

Further reading for facilitators

Mastitis: causes and management WHO/FCH/CAH/00.13

1. Examination of the mother’s breasts and nipples

5 minutes

  • The earlier session on promoting breastfeeding during pregnancy mentioned that antenatal nipple preparation was generally not helpful. During antenatal checks, a woman can be reassured that most women’s breasts produce milk well regardless of size or shape.
  • After the baby is born, health workers do not need to physically examine every breastfeeding woman’s breasts and nipples. They only need to do so if the mother has pain or a difficulty.
  • Always observe the condition of the mother’s breasts when you observe a breastfeed. In most cases this is all that you need to do, as you can see most important things when she is putting the baby onto the breast, or as the baby finished a feed.
  • If you physically examine a women’s breasts:

    Explain what you want to do.


    Ensure privacy to help the mother feel comfortable and consider customs of modesty.


    Ask permission before breasts are exposed or touched.


    Talk with the mother and look at the breasts without touching.


    If you need to touch the breasts do so gently.

  • Ask what has she noticed about her breasts – is there anything that worries her? If so ask her to show you.
  • Talk to the mother about what you have found. Highlight the positive signs you see. Do not sound critical about her breasts. Build her confidence in her ability to breastfeed.

Nipple size and shape


Show slide 12/1: Breast and nipple size and shape

  • There are many different shapes and sizes of breast and nipple. Babies can breastfeed from almost all of them.
  • Nipples can change shape during pregnancy and become more protractile or “stretchy”. There is no need to ‘diagnose’ or treat a nipple that looks flat or inverted during pregnancy51.
  • Inverted nipples do not always present a problem. Babies attach to the breast, not to the nipple. If you think her nipples may be inverted, the best way to help is to build her confidence and provide good support from birth52.
  • Long or big nipples may also cause difficulties because the baby does not take the breast far enough back in his or her mouth. Help the mother to position and attach the baby so that there is a large amount of breast tissue in the mouth, not just the nipple.
  • If the baby gags repeatedly because of a large nipple, ask the mother to express the milk and cup feed the baby for some days. Babies grow quickly and their mouths soon become bigger.

2. Engorgement, blocked ducts and mastitis

20 minutes

One of the mothers in our story, Fatima, has heard that breastfeeding mothers can have sore breasts. She is worried this might happen to her, as her breasts seem to be getting swollen.

Ask: What can you explain to a mother about normal breast changes during breastfeeding and changes that may indicate a difficulty?

Wait for a few responses.


What is engorgement?


Slide 12/2:Picture of full breast

  • Normal breast fullness: When the milk is “coming in,” there is more blood supply to the breast as well as more milk. The breasts may feel warm, full, and heavy. This is normal. To relieve fullness, feed the baby frequently and use cool compresses between feeds. In a few days, the breasts will adjust milk production to the baby’s needs.

Slide 12/3:Picture of engorgement

  • Engorgement: If the milk is not removed, the milk, blood and lymph become congested and stop flowing well, which results in swelling and oedema. The breasts will become hot, hard and painful, and look tight and shiny. The nipple may be stretched tight and flat, which makes it difficult for the baby to attach and which can result in sore nipples.
  • If engorgement continues, the feedback inhibitor of lactation reduces milk production.
  • Causes of breast engorgement include:

    Delay in starting to breastfeed soon after baby’s birth.


    Poor attachment, so that milk is not removed effectively.


    Infrequent feeding, not feeding at night or short duration of feeds.

Do your practices help to avoid engorgement?

  • If much engorgement is seen in a maternity facility, the pattern of care for mothers should be reassessed. Implementation of the Ten Steps to Successful Breastfeeding prevents most painful engorgement. If you can answer “yes” to all of the following questions, there should be very little engorgement in your facility.
  • Ask yourself:

    Is skin-to-skin care practiced at birth? (Step 4).


    Is breastfeeding initiated within one hour after birth? (Step 4).


    Do staff offer help early and make sure that every mother knows how to attach her baby at the breast? (Step 5).


    If the baby is not breastfeeding, is the mother encouraged and shown how to express milk from her breasts frequently? (Step 5).


    Are babies and mothers kept together 24 hours a day? (Step 7).


    Is every mother encouraged to breastfeed whenever and for as long as her baby is interested, day and night (at least eight to twelve feeds in 24 hours)? (Step 8).


    Are babies given no pacifiers, artificial teats, or bottles that would replace suckling at the breast? (Step 9).

Help mothers to relieve engorgement53

  • To treat engorgement, it is necessary to remove the milk from the breast. This will:

    Relieve the mother’s discomfort.


    Prevent further complications such as mastitis and abscess formation.


    Help to ensure continued production of milk.


    Enable the baby to receive breast milk.

  • How to help a mother to relieve engorgement:

    Check attachment: Is baby able to attach well at the breast? If not:


    Help the mother to attach her baby at the breast well enough to remove the milk.


    Suggest that she gently express milk54 from her breasts herself before a feed to soften the areola and make it easier for the baby to attach.


    If breastfeeding alone does not reduce the engorgement, advise the mother to express milk between feeds a few times until she is comfortable.


    Encourage frequent feeds: if feeds have been limited, encourage the mother to breastfeed whenever and for as long as her baby is willing.


    A warm shower or bath may help the milk to flow.


    Massage of the back and neck or other forms of relaxation may also help the milk to flow.


    Help the mother to be comfortable. She may need to support her breasts if they are large.


    Provide a supportive atmosphere; build the mother’s confidence by explaining that soon the engorgement will be resolved.


    Cold compresses may lessen pain between feeds.

Blocked milk ducts and mastitis (breast inflammation)

  • Milk sometimes seems to get stuck in one part of the breast. This is a blocked duct.
  • If milk remains in a part of the breast, it can cause inflammation of the breast tissue or non-infective mastitis. Initially there is no infection, however the breast can become infected with bacteria and is then infective mastitis.
  • Blocked ducts and mastitis can be caused by:

    Infrequent breastfeeding – maybe because the baby wakes infrequently, hunger signs are missed, or the mother is very busy.


    Inadequate removal of milk from one area of the breast.


    Local pressure on one area of the breast, from tight clothing, lying on the breast, pressure of the mother’s fingers on the breast, or trauma to the breast.

  • A woman with a blocked duct may tell you that she can feel a lump, and the skin over it may be red. The lump may be tender. The mother usually has no fever and feels well.
  • A woman with mastitis may report some or all of the following signs and symptoms:

    pain and redness of the area;


    fever, chills;


    tiredness or nausea, headache and general aches and pains.

  • The symptoms of mastitis are the same for non-infective and infective mastitis.

Show slide 12/4:Picture of mastitis. Note that an area is red and there is swelling. This is severe. Participants and mothers need to learn to recognise blocked ducts and mastitis in an earlier stage so that it does not progress to this severity.

Assessment of a mother with a blocked duct or mastitis

  • The important part of treatment is to improve the drainage of milk from the affected part of the breast.

    Observe a breastfeed. Notice where the mother puts her fingers and if she presses inwards, perhaps blocking the milk flow.


    Notice if her breasts are very heavy. If the blocked duct or mastitis is in the lower area, lifting the breast while feeding the baby may help that part of the breast to drain better.


    Ask about frequency of feeds and if the baby is allowed to feed for as long as the baby wants.


    Ask about pressure from tight clothes, especially a bra worn at night, or trauma to the breast.

Treatment of mastitis

  • Explain to the mother that she MUST:

    Remove the milk frequently (if not removed, an abscess may form).


    The best way to do this is to continue breastfeeding her baby frequently.


    Check that her baby is well attached.


    Offer her baby the affected breast first (if not too painful).


    Help the milk to flow.


    Gently massage the blocked duct or tender area down towards the nipple before and during the feed.


    Check that her clothing, especially her bra, does not have a tight fit.


    Rest with the baby so that the baby can feed often. The mother should drink plenty of fluids. The employed mother should take sick leave if possible.

Rest the mother, not the breast!

  • If the mother or baby is unwilling to feed frequently, it is necessary to express the milk55. Give this milk to the baby. If the milk is not removed, milk production can cease and the breast becomes more painful, possibly resulting in an abscess.

Drug treatment for mastitis

  • Anti-inflammatory treatment is helpful in reducing the symptoms of mastitis. Ibuprofen is appropriate if available. A mild analgesic can be used as an alternative.
  • Antibiotic therapy is indicated if:

    The mother has a fever for twenty four hours or more.


    There is evidence of possible infection, for example an obviously infected cracked nipple.


    The mother’s symptoms do not begin to subside within 24 hours of frequent and effective feeding and/or milk expression.


    The mother’s condition worsens.

  • The prescribed antibiotic56 must be given for an adequate length of time. Ten to fourteen days is now recommended by most authorities to avoid relapse.

Mastitis in the woman who is HIV-positive

  • In a woman who is HIV-positive, mastitis or nipple fissure (especially if bleeding or oozing) may increase the risk of HIV transmission.
  • If an HIV-positive woman develops mastitis, an abscess or a nipple fissure, she should avoid breastfeeding from the affected breast while the condition persists. She must express milk from the affected breast, by hand or pump, to ensure adequate removal of milk. This is essential to prevent the condition becoming worse, to help the breast recover, and to maintain milk production. The health worker should help her to ensure that she is able to express milk effectively.
  • Antibiotic treatment is usually indicated in a woman with HIV. The prescribed antibiotic must be given for an adequate length of time. Ten to fourteen days is now recommended by most authorities to avoid relapse.
  • If only one breast is affected, the infant can feed from the unaffected side, feeding more often and for longer to increase milk production. Most infants get enough milk from one breast. The infant can feed from the affected breast again when the breast has recovered.
  • If both breasts are affected, the mother will not be able to feed from either side. The mother will need to express her milk from both breasts. Breastfeeding can resume when the breasts have recovered.
  • The health worker will need to discuss other interim feeding options (AFASS). The mother may decide to heat-treat her expressed milk57, or to give home prepared or commercial formula. The infant should be fed by cup58.
  • Sometimes a woman may decide to stop breastfeeding at this time, if she is able to give another form of milk safely. She should continue to express enough milk to allow her breasts to recover and to keep them healthy, until milk production ceases.

3. Sore Nipples

10 minutes

  • Breastfeeding should not hurt! Some mothers find their nipples are slightly tender at the beginning of a feed for a few days. This initial tenderness disappears in a few days as the mother and baby become better at breastfeeding. If this tenderness is so painful that the mother dreads putting the baby to the breast, or there is visible damage to the nipples, this soreness is not normal, and needs attention.
  • The most common early causes of nipple soreness are simple and avoidable. If mothers in your facility are getting sore nipples, make sure that all maternity staff know how to help mothers get their babies attached to the breast. If babies are attached well at the breast and breastfeed frequently, most mothers do not get sore nipples.

Observation and history taking for sore nipples

  • Ask the mother to describe what she feels.

    Pain at the start of a feed that fades when the baby lets go, is most likely related to attachment.


    Pain that gets worse during the feed and continues after the feed has finished, often described as burning or stabbing, is more likely to be caused by Candida albicans59.

  • Look at the nipples and breast.

    Broken skin is usually caused by poor attachment.


    Skin that is red, shiny, itchy, and flaky, at times with loss of pigmentation, is more often seen with Candida.


    Remember Candida and trauma from poor attachment can exist together.


    Similar to other parts of the body, the nipple and breast can have eczema, dermatitis and other skin conditions.


Show slides of sore nipples:


12/5:This nipple has an open sore in a line across the tip of the nipple. This is likely to be the result of poor attachment


12/6:This nipple is red and sore. Notice the red marks and bruising around the areola. This is likely to be the result of poor attachment

  • Observe a complete breastfeed. Use the Breastfeed Observation Aid.

    Check how the baby goes on the breast, and his or her attachment and suckling.


    Notice if the mother ends the feed or if the baby lets go himself or herself.


    Observe what the nipple looks like at the end of the feed. Does it look misshapen (squashed), red or have a white line?

  • Check the baby’s mouth for tongue-tie and Candida.
  • Ask the mother about previous history of Candida or anything that might contribute to Candida such as recent use of antibiotics.
  • If a mother is using a breast pump, check that it is appropriately positioned and the suction is not too high.
  • Decide the cause of the sore nipple. The most common causes of sore nipples are:

    Poor attachment.


    Secondary to engorgement, or both caused by poor attachment.


    Baby is ‘pulled’ off the breast to end a feed without the mother first breaking the seal between the baby's mouth and the breast.


    A breast pump that may cause excess stretching of the nipple and breast or rub against the breast.


    Candida that can be passed from the baby’s mouth to the nipples.


    The infant’s tongue-tie (short frenulum), which prevents the tongue reaching over the lower gum thus causing friction on the nipple.

  • There are many other less common causes of sore nipples. Arrange for a mother to be seen by someone who has training to investigate these less common causes, if needed60.

Management of sore nipples

  • Reassure the mother that sore nipples can be healed and prevented in future.
  • Treat the cause of the sore nipples:

    Help the mother improve attachment and positioning. This may be all that is needed. If necessary, show the mother how to feed baby in different feeding positions. This helps to ease any pain mother is experiencing because baby will be putting pressure on a different area of the sore nipple and allows her to continue feeding while the nipple heals.


    Treat skin conditions or remove source of irritation. Treat Candida both on the mother's nipples and in the baby's mouth.


    If the baby's frenulum is so short that the tongue cannot extend over the lower gum, and the mother's nipples have been sore for two to three weeks, consider if the baby should be referred and the frenulum clipped.

  • Suggest comfort measures while the nipples are healing:

    Apply expressed breast milk to the nipples after a breastfeed to lubricate and soothe the nipple tissue.


    Apply a warm, wet cloth to the breast before the feed to stimulate letdown.


    Begin each breastfeed on the least sore breast.


    If the baby has fallen asleep at the breast and is no longer actively feeding but remains attached, gently remove the baby from the breast.


    Wash nipples only once a day, as for normal body hygiene, and not for every feed. Avoid using soap on nipples, as it removes the natural oils61.

What does not help sore nipples

  • DO NOT stop breastfeeding to rest the nipple. The mother may become engorged, which makes it harder for the baby to attach to the breast. The milk supply will decrease if milk is not removed from the breast.
  • DO NOT limit the frequency or length of breastfeeds. Limiting feeds will not help if the basic problem is not addressed. One minute of suckling with poor attachment can cause damage to the breast. Twenty minutes of suckling with good attachment will not cause damage to the breast.
  • DO NOT apply any substances to the nipples that would be harmful for the baby to take into his or her mouth, which requires removal before breastfeeding, or which can sensitise the mother’s skin and make the nipple more sore. An ointment is not a substitute for correct attachment.
  • (Include if nipple shields are available in the area) DO NOT use a nipple shield as a routine measure. A nipple shield may cause more problems. Some shields result in less stimulation of the breast and reduce the amount of milk transferred, which may lead to reduced production. It can affect the way the baby sucks resulting in more soreness when it is stopped. It also presents a health risk to the baby from the possibility of contamination.

4. Small group work

25 minutes

Divide participants into groups of 4 people. Give each group one case study and ask them to discuss the questions. Encourage them to role-play so that they actually ask the questions and use communication skills. Remind them that practicing the actual phrases that they will use with the mother is useful even if they find it challenging at first.

Point to the list of Communication Skills and remind participants to use them. Facilitators can circulate to ensure that participants understand the exercise.

If there is time, you can ask each group to role-play their case study for the other groups.


Ask if there are any questions. Then summarise the session.

Session 12. Summary

Examination of the mother's breasts and nipples

  • Always observe the condition of the mother’s breasts when you observe a breastfeed. In most cases, this is all that you need to do, as you can see most important things when she is putting the baby onto the breast, or as the baby finished a feed.
  • Examine mothers' breasts only if a difficulty arises. Ensure privacy and ask permission before touching.
  • Look at the shape of breasts and nipples. Look for swelling, skin damage or redness. Look for evidence of past surgery.
  • Talk to the mother about what you have found. Highlight the positive signs you see. Build her confidence in her ability to breastfeed.

Preventing engorgement

  • Fullness is normal in the early days. Over-fullness is not normal.
  • Follow the practices of the Ten Steps:

    Facilitate skin-to-skin contact immediately after birth and initiate exclusive, unlimited breastfeeding within one hour after birth (Step 4).


    Show mothers who need help how to attach their baby at the breast (Step 5).


    Show mothers how to express their milk (Step 5).


    Breastfeeding exclusively with no water or supplements (Step 6).


    Keep mothers and babies together in a caring atmosphere (Step 7).


    Encourage babies to feed at least 8–12 times in 24 hours during the early days (Step 8).


    Give no pacifiers, artificial teats, or bottles (Step 9).

Treating engorgement

  • Remove the breast milk and promote continued lactation.
  • Correct any problems with attachment.
  • Gently express some milk to soften the areola and help the baby's attachment.
  • Breastfeed more frequently.
  • Apply cold compresses to the breasts after a breastfeed for comfort.
  • Build the mother’s confidence and help her to be comfortable.

Blocked milk ducts and mastitis (breast inflammation)

  • May be caused by infrequent breastfeeding, inadequate removal of milk, or pressure on a part of the breast.


  • Improve milk flow:

    Check the baby's attachment and correct/improve if needed.


    Check for tight fitting clothing or pressure from fingers


    Support a large breast to assist milk flow

  • Suggest:

    Breastfeed frequently. If necessary, express milk to avoid fullness.


    Gently massage towards the nipple.


    Apply a moist, warm cloth to the area before a breastfeed to help milk flow.


    Rest the mother not the breast.


    Anti-inflammatory treatment or analgesic if in pain.

  • Antibiotic therapy is indicated if:

    The mother has a fever for longer than 24 hours.


    The mother’s symptoms do not begin to subside after 24 hours of frequent and effective feeding and/or milk expression.


    The mother’s condition worsens.

  • If a woman is HIV-positive and develops mastitis or an abscess she should:

    Avoid breastfeeding from the affected breast while the condition persists.


    Express the milk from that breast, which can be heat-treated and given to the baby.


    Rest, keep warm, take fluids, pain relief and antibiotics.

Sore nipples

  • Decide the cause, including observation of a feed. Examine the nipples and breasts.
  • Reassure the mother.
  • Treat the cause - poor attachment is the most common cause of sore nipples.
  • Avoid limiting the frequency of feeds.
  • Refer skin conditions, tongue-tie and other less common conditions to a suitably trained person.

Session 12 Knowledge Check

What breastfeeding difficulties would suggest to you that you need to examine a mother's breasts and nipples?

Rosalia tells you she became painfully engorged when she breastfed her last baby. She is afraid it will happen with the next baby too. What will you tell her about preventing engorgement?

Bola complains that her nipples are very sore. When you watch her breastfeed, what will you look for? What can you do to help her?

Describe the difference between a blocked duct, non-infective mastitis and infective mastitis. What is the most important treatment for all of these conditions?

Stories for small group practice

Mrs A. tells you her breast is sore. You look at her breast and see that a section of it is red, tender to touch and Mrs A. indicates a lump. She does NOT have a temperature. Her baby is 3 weeks old. Mrs. A probably has ......

What could you say to empathise with Mrs. A?

What are possible reasons this situation has occurred?

What questions might you want to ask?

What relevant information will you give Mrs. A?

What suggestions can you offer Mrs A so that this problem can be overcome and breastfeeding can continue?

What practices could be encouraged to avoid this problem re-occurring?

Mrs B. tells you that she feels as if she has had flu for the last two days. She aches all over and one breast is sore. When you look at the breast a part of it is hot, red, hard and very tender. Mrs B has a temperature and feels too ill to go to work.

Her baby is 5 months old and breastfeeding was going well. The baby feeds frequently at night. Mrs B expresses her milk before she goes to work to leave for the baby and feeds the baby as soon as she comes home from work. She is very busy at work and finds it hard to get time to express during the day.

Mrs B. probably has ......

What could you say to empathise with Mrs. B?

What are possible reasons this situation has occurred?

What questions might you want to ask?

What relevant information will you give Mrs. B?

What suggestions can you offer Mrs B so that this problem can be overcome and breastfeeding can continue?

What practices could be encouraged to avoid this problem re-occurring?

Mrs C's baby was born yesterday. She tried to feed him soon after birth, but he did not suckle well. Mrs C says her nipples are inverted and she cannot breastfeed. You examine her breasts and notice that her nipples look flat when not stimulated. You ask Mrs C to use her fingers to stretch her nipple and areola out a short way. You can see that her nipple stretches easily.

What could you say to accept Mrs C's idea about her nipples?

How could you build her confidence?

What practical suggestions could you give Mrs C to help her feed her baby?

Additional information Session 12

Breast examination

First Ask
  • How did breasts change during pregnancy? If breasts become larger and the areola become darker during pregnancy this usually indicates that there is plenty of milk producing tissue.
  • Has she had breast surgery at any time, which may have cut some milk ducts or nerves, or for a breast abscess?
Next look
  • Are the breasts very large or very small? Reassure the woman that small and large breasts all produce plenty of milk, but sometimes a mother may need help with attachment.
  • Are there any scars which may indicate past problems with breastfeeding such as an abscess or surgery?
  • Is either breast swollen, with tight shiny skin? This suggests engorgement with oedema. Normal fullness, when the milk comes in, makes the breast larger, but not swollen with shiny oedematous skin.
  • Is there redness of any part of the breast skin? If diffuse or generalised, this may be due to engorgement. If localised, this may be a blocked duct (small area) or mastitis (larger clearly defined area). Purple discoloration suggests a possible abscess.
  • What is the size and shape of the nipples? (long or flat, inverted, very big). Could their shape make attachment difficult?
  • Are there any sores or fissures (a linear sore)? This usually means that the baby has been suckling while poorly attached.
  • Is there a rash or redness of the nipple?
Next feel
  • Is the breast hard or soft? Generalised hardness, sometimes with several lumps, may be due to normal fullness or engorgement. The appearance of the skin (shiny with engorgement or normal with fullness) and flexibility of the skin (turgid) should tell you which it is.
  • Talk to the mother about what you have found. Highlight the positive signs you see. Do not sound critical about her breasts. Build her confidence in her ability to breastfeed.

Assisting the mother with inverted nipples

  • If the mother appears to have inverted nipples:

    Ensure uninterrupted skin-to-skin contact immediately after birth and at other times, to encourage the baby to find his/her own way to the breast, in his/her own time.


    Give extra help with positioning and attachment in the first day or two, before the breasts become full. Explain to the mother with an inverted nipple that the baby latches on to the areola not on to the nipple.


    Help the mother to find a position that helps her baby to take the breast. For example, sometimes leaning over the baby on a table so that the breast falls towards his or her mouth can help.


    Suggest that she gently change the shape of the areola into a cone shape or sandwich using C-shaped hold, so that baby can latch onto it.


    Explain that babies may need time to learn and then will latch on spontaneously.


    Suggest that the mother stroke her baby’s mouth with the nipple and wait until the baby opens with a very wide mouth before bringing the baby on to the breast. Teach the mother how to recognise effective attachment.


    Encourage the mother to help her nipples protrude before a feed. She can gently stimulate her nipple; use a breast pump, another mild suction device, or someone else sucking (if acceptable) to draw out the nipple.


    Avoid artificial teats and pacifiers as these devices may make it more difficult for a baby to attach and take a large mouthful of breast.


    Prevent breast engorgement as this makes attachment difficult for the baby. If necessary, express and feed by cup while the baby learns to breastfeed.

Syringe method for treatment of inverted nipples

This method can help an inverted nipple to stand out and assist a baby to attach to the breast. The mother must use the syringe herself, so that she can control the amount of suction and avoid hurting her nipple.

  • Take a syringe at least 10 ml in size and if possible 20 ml so that it is large enough to accommodate the mother’s nipple.
  • Cut off the adaptor end of the barrel (where the needle is usually fixed). You will need a sharp blade or scissors.
  • Reverse the plunger so that it enters the cut (now rough) end of the barrel.
  • Before she puts the baby to her breast, the mother:

    Pulls the plunger about one-third of the way out of the barrel.


    Puts the smooth end of the syringe over her nipple.


    Gently pulls the plunger to maintain steady but gentle pressure for about 30 seconds.


    Pushes the plunger back slightly to reduce suction as she removes the syringe from her breast.

  • Tell the mother to push the plunger back to decrease the suction, if she feels pain. This prevents damaging the skin of the nipple and areola.

Slide 10/7: Syringe method for an inverted nipple

Adapted from: N. Kesaree, et al, (1993) Treatment of Inverted Nipples Using Disposable Syringe, Journal of Human Lactation; 9(1): 27–29

Class discussion: Engorgement (optional)

Maria gave birth three days ago to a healthy baby. Her baby is in the nursery and is only brought to her for feeding at scheduled times. As the midwife makes rounds in the postpartum ward, she finds that Maria’s breasts are much engorged and Maria says they are painful.

What can the midwife do to help this mother?

How could her engorgement have been prevented?

How can Maria avoid becoming engorged again?


Support the breasts well to make her more comfortable (however, do not bind the breasts tightly, as this may increase her discomfort).

Apply compresses. Warmth is comfortable for some mothers, while others prefer cold compresses to reduce swelling and pain.

Express enough milk to relieve discomfort. Expression can be done a few times a day when the breasts are overfull. It does not need to be done if the mother is comfortable. Remove less milk than the baby would take, so as not to stimulate milk production.

Relieve pain. An analgesic, such as ibuprofen or paracetamol, may be used62.

Some women use plant products such as teas made from herbs or plants, or raw cabbage leaves, placed directly on the breast to reduce pain and swelling.

The following are not recommended:

Pharmacological treatments to reduce milk supply63. The above methods are considered more effective in the long term.


Aspirin is not the first choice for breastfeeding women as it has been linked with Reye’s condition in the infant.


Pharmacological treatments which have been tried include:

–Stilboestrol (diethylstilbestrol) - side effects include withdrawal bleeding, and thromboembolism.

–Oestrogen - breast engorgement and pain decreases but may recur when the drug is discontinued.

–Bromocriptine - inhibits prolactin secretion. Side effects including maternal deaths, seizures and strokes. Withdrawn from use for postpartum women in many countries.

–Cabergoline - inhibits prolactin secretion. Considered safer than bromocriptine. Possible side effects include headache, dizziness, hypotension, nose bleed.

Treatment of a breast abscess

  • If mastitis is not treated early, it may develop into an abscess. An abscess is a collection of pus within the breast. It produces a painful swelling, sometimes with bruising discoloration.
  • An abscess needs to be aspirated by syringe or surgical drainage by a health worker.
  • The mother64 may continue breastfeeding if the drainage tube or incision is far enough from the areola not to interfere with attachment.
  • If the mother is unable or unwilling to breastfeed on that breast because of the location of the abscess, she needs to express her milk. Her baby can start to feed again from that breast as soon as it starts to heal (usually 2–3 days).
  • The mother can continue to feed from the unaffected breast as normal.
  • Good management of mastitis should prevent formation of an abscess.

Nipple shields

  • Sometimes a nipple shield is offered as a solution for a baby who does not suck well or if the mother has sore nipples. Nipple shields may cause difficulties. They can:

    Reduce stimulation of the breast and nipple and thus can reduce milk production and the oxytocin reflex.


    Increase the risk of low weight gain and dehydration.


    Interfere with the baby suckling at the breast without a shield.


    Harbour bacteria or thrush and infect the baby.


    Cause irritation and rub the mother’s nipple.

  • The mother, baby and health worker may become dependent on the shield and find it difficult to do without it.
  • Stop and think before recommending a nipple shield. If used as a temporary measure for a clinical need, ensure that the mother has follow-up assistance to enable her to discontinue using the shield.

Candida (Thrush) infection

  • Thrush is an infection caused by the yeast Candida albicans. Candida infections often follow the use of antibiotics to treat mastitis, or other infections, or if used following a caesarean section. It is important to treat both the mother and the baby so that they will not continue to pass the infection back and forth.
  • Soreness from poor positioning can occur at the same time as Candida; before starting treatment for Candida, check for other causes of nipple pain such as poor attachment.

12/8: Candida on a dark-skinned nipple


12/9: Candida on a light-skinned nipple

  • Signs of a thrush infection are:

    The mother’s nipples may look normal or red and irritated. There may be deep, penetrating pain and the mother may state that her nipples “burn and sting” after a feed.


    The nipples remain sore between feeds for a prolonged time despite correct attachment. This may be the only sign of the infection.


    The baby may have white patches on the skin in his or her mouth.


    The baby may have a fungal diaper rash.


    The mother may have a vaginal yeast infection.

Treatment for thrush
  • Use a medication for the nipples and for the baby’s mouth according to local protocols. Continue to use for 7 days after soreness has gone. Use medication that does not need to be washed off the nipples before a breastfeed.

Name some commonly used treatments for Candida.

  • Some women find it helpful to air dry and expose the nipples to sunlight after each breastfeed. Change bra daily and wash it in hot soapy water. If breasts pads are worn, replace them when they become moist.
  • If a vaginal Candida infection is present, treat it. The woman’s partner may need to be treated also.
  • Wash hands well after changing the baby’s diapers and after using the toilet.
  • Stop the use of any dummies, pacifiers, teats, or nipple shields; if they are used, they must be boiled for 20 minutes daily and replaced weekly.


  • An infant may have “tongue-tie” because of a short frenulum, which restricts tongue movement to the extent that the tongue cannot extend over the lower gum. The tongue then rubs against the base of the nipple causing soreness (slide 12/10).



Wearing of breast shells or special exercises during pregnancy to help the nipples protrude are no longer recommended as they may be painful and can give a woman the impression that her breasts are not right for breastfeeding. Build her confidence and provide good support from birth.


Supportive practices such as skin to skin contact, encouraging the baby to find his/her own way to the breast, help with positioning and attachment and avoiding artificial teats and pacifiers, assist breastfeeding to be established. These practices were discussed in earlier sessions.


Relieving engorgement when a mother is not breastfeeding is discussed in the Additional Information section for this session.


See Session 11 for details of how to express milk.


See Session 11 for details on expressing milk.


Generally oral antibiotics are used - erythromycin, flucloxacillin, dicloxacillin, amoxacillin, cephalexin. See Mastitis: causes and management WHO/FCH/CAH/00.13 for further information.


This milk can be heat treated and used for the baby. Small lumps may form in the milk after heating, but these lumps can be removed and the milk used.


Session 11 describes milk expression and cup feeding.


Oral candida is also called thrush.


This course does not train participants to deal with complex or rare breastfeeding situations. Establish to whom participants could refer a mother if her breastfeeding difficulty is complex.


This is normal washing procedure, not just for when nipples are sore.


If the mother is HIV-positive, it is not recommended that she continue to breastfed from a breast with an abscess.

Copyright © 2009, World Health Organization and UNICEF.

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 3264; fax: +41 22 791 4857; email: tni.ohw@sredrokoob).

The World Health Organization and UNICEF welcome requests for permission to reproduce or translate their publications — whether for sale or for noncommercial distribution. Applications and enquiries should be addressed to WHO, Office of Publications, at the above address (fax: +41 22 791 4806; email: tni.ohw@snoissimrep or to UNICEF email: gro.fecinu@samidp with the subject: attn. nutrition section.

Bookshelf ID: NBK153481


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