21.4: Breasts and Breast-Feeding

Learning Objectives

By the end of this section, you will be able to:

• Explain the difficulties a person learning to breast-feed may experience
• Provide education for a person attempting to breast-feed a preterm neonate

Breast-feeding persons are taught to wear supportive bras, feed newborns on demand, ensure a good latch, and air-dry nipples. Breast-feeding can be complicated because the breast-feeding person and the newborn must work together to ensure a good latch, empty the breast, and stimulate the breasts to make more milk. The nurse provides support and education to help breast-feeding proceed without difficulties. When difficulties do arise, the nurse develops interventions to help overcome them to promote a successful breast-feeding relationship.

Breast-Feeding Difficulties

Breast-feeding difficulties can occur at the initiation of breast-feeding or later in the postpartum period. Ineffective latch can be corrected by the nurse or lactation consultant. Cracked and sore nipples are most often the consequence of an ineffective latch. Breast engorgement usually occurs on postpartum day 3 to 5 (ACOG, 2022). Inadequate supply can occur anytime during the breast-feeding relationship. Once the person and infant are discharged home, community resources are available to assist in breast-feeding, such as lactation consultants, La Leche League, and WIC.

Ineffective Latch

To transfer milk, the infant must have an effective latch. Signs of a good latch include the nipple feeling comfortable and pain free, the infant’s chest being against the breast-feeding person’s chest, the infant’s head being straight and not turned to the side, and the infant’s mouth being wide prior to latching. The areola, not just the nipple, should be in the infant’s mouth. The nurse encourages the person to try to relax and deep breathe. Signs of an inadequate latch include painful, cracked nipples; nipples shaped irregularly after nursing; and lack of emptying of the breast. If the ineffective latch continues, the person will eventually have inadequate milk supply (Griffin et al., 2022).

The LATCH screen (shown in Table 21.1) helps the nurse determine if the infant is getting a good latch to avoid nipple trauma and inadequate supply. The higher the score on the LATCH screen, the better the latch.

Score	0	1	2
Latch	Sleepy, no latch	Holds nipple in mouth, sucks only when stimulated	Holds nipple and areola in mouth, tongue below nipple, lips flanged, sucks rhythmically
Audible swallowing	None	Rarely when sucking	Frequently when sucking
Type of nipple	Inverted	Flat	Everted
Comfort	Severe pain with sucking Cracked, bruised, or bleeding nipples Blisters on nipples	Moderate pain with sucking Nipples reddened, bruised or blisters present	No pain with sucking Nipples intact
Hold	Requires assistance to position and maintain hold of baby	Minimal assistance needed to position or hold baby	Patient able to correctly position and hold baby

Table 21.1 Determining the LATCH Score When Breast-Feeding

Link to Learning

This website from Health for Under 5s provides information, photos, and a video that explain and demonstrate an effective latch for breast-feeding.

Cracked, Sore Nipples

Nipples can become very sore and cracked as the dyad of the breast-feeding person and newborn are learning to breast-feed. The best prevention is ensuring a good latch. Treatment for cracked nipples can be air-drying after nursing, applying nipple ointment, using breast milk on the nipple, and using nipple shells to keep the nipple from brushing against the bra (Coentro et al., 2021).

Clinical Judgment Measurement Model

Take Action: Ensuring a Good Latch

The nurse can educate and provide help to the breast-feeding person to ensure a good latch is achieved. The nurse provides the following education to the patient.

1. Squeeze the breast like a hamburger or sandwich to reduce the size of the breast and make the nipple small enough for your baby’s mouth.
2. Touch the baby’s nose or upper lip with your nipple.
3. Allow the baby to open the mouth wide.
4. Place the nipple inside the mouth, pointing to the roof of the baby’s mouth.
5. Make sure the baby’s head is free to move back and forth.
6. To unlatch the baby, use your pinky finger to break the seal on the baby’s mouth prior to removing the baby from the breast.

Engorgement

When the breast becomes very full of milk, it is called engorgement. It usually occurs when the colostrum transitions into mature milk. However, engorgement can occur at any time during the breast-feeding relationship, especially if feedings are skipped. Symptoms of engorgement include firm, swollen, hard, painful breasts. The breast might feel warm and look shiny from swelling. The nipple can become flat from the engorgement. To relieve pressure and pain, the breast-feeding person can apply a warm compress or get into a warm shower and hand express enough milk to allow the nipple to protrude and the breast to soften. The nurse explains that the newborn will have difficulty latching if the nipple is flat and the breasts are full. The patient can also apply a cool compress for 5 to 10 minutes between feedings to decrease inflammation, and can take NSAIDS for pain relief. The nurse also explains that the person should not pump or express to empty the breast, as that will increase milk production and engorgement (Mitoulas & Riccardo, 2022).

Inadequate Supply

Many breast-feeding persons are concerned with inadequate milk supply. Signs of adequate milk supply include breasts feeling softer as the baby nurses, appropriate numbers of wet and dirty diapers, and appropriate infant weight gain (see Chapter 24 Care of the Typical Newborn). If the health-care provider is concerned about inadequate milk supply, the nurse can encourage the breast-feeding person to nurse every time the baby is hungry, being sure to nurse every 2 to 3 hours (or 8 to 12 times per day) (CDC, 2023a). The nurse will evaluate the latch to ensure the newborn is deep enough on the areola to drain the breast. Recommend avoiding bottles and pacifiers. The nurse encourages the person to get plenty of rest, eat a good diet, drink plenty of liquids, and keep the newborn skin-to-skin as much as possible. The breast-feeding person can also pump between feedings to stimulate the breast to make more milk.

Breast-Feeding a Preterm Neonate

Breast milk is essential for the health of the premature infant. Breast milk helps prevent infections, is easy to digest, and protects against necrotizing enterocolitis. However, premature infants may not be able to breast-feed after birth. Normal suck and swallow coordination does not mature until 34 to 36 weeks’ gestation. To stimulate and maintain the milk supply until the infant can breast-feed, the breast-feeding person should attempt to empty the breasts every 2 to 3 hours. The nurse can help the postpartum person hand express into a cup. The nurse reassures the person that the colostrum, while not large in amount, is the perfect amount for the newborn. If the newborn needs more milk, donor milk might be provided. Donor milk is milk that is provided to milk banks and then pasteurized. Donor milk protects preterm infants by decreasing the risk for necrotizing enterocolitis (inflammation of the intestine leading to necrosis) (Tran et al., 2020). Once the mature milk is present, the breast-feeding person can pump and provide milk to the newborn. As the premature infant grows, the nurse will assist the breast-feeding person to latch and nurse the baby.

Link to Learning

The Human Milk Bank offers information and resources about milk banks, which provide donor milk that is used by preterm or low birth weight infants when breast-feeding is not available.

While the infant is in the neonatal intensive care unit (NICU), the pumped milk can be given to the newborn in different ways. Milk can be given through a feeding tube until the newborn is strong enough to suck. Once the newborn is able to suck, the newborn can attempt to nurse. Sometimes, the newborn will start to feed on the breast, and then the nurse will gavage-feed the newborn if they become too tired while sucking. The newborn can remain skin-to-skin with a parent during tube-feeding and bottle-feeding to allow for bonding and to stimulate the breasts to increase milk supply. The NICU nurse works with the family to balance quiet time with feeding time.

Real RN Stories

Nurse: Patricia, BSN, RN
Years in Practice: 4
Clinical Setting: Mother/baby unit
Geographic Location: Georgia

In my facility, the lactation consultant was not available to assist with breast-feeding twenty-four hours a day. The night nurses on the mother/baby unit were expected to provide lactation assistance. I remember this one newborn who was latching on one breast but was refusing to latch on the other. The birthing person was becoming frustrated. She would be going back to the mission in remote Guatemala to be with the rest of her family within the next four to six weeks, and it was important for breast-feeding and the milk supply to be established. I noticed when I was doing the shift assessment on the newborn that he had a very prominent tonic neck reflex with his head facing the left. The newborn latched on well to the right breast using the traditional cradle hold. I suggested the birthing person use the clutch hold when switching the baby to the left breast at the next feeding. When I performed my next rounds and walked into the room, she was smiling because the newborn was latched on and nursing well on the left breast using the clutch hold.