When do women usually stop breastfeeding?

Painful breastfeeding

Breastfeeding can sometimes be painful (© muro)

Pain while breastfeeding is one of the most common reasons for premature weaning: around a third of women who stopped breastfeeding prematurely stated pain as an important reason for weaning. The following article lists the most important causes of pain while breastfeeding. Typical pain at the beginning of breastfeeding and pain occurring later are discussed separately.

Pain in the beginning of breastfeeding

There is pain that typically occurs at the beginning of breastfeeding and either stops on its own or is soon overcome with competent support.

Breastfeeding is included in the first few days after the birth stomach pain connected: These are caused by contractions of the uterus and promote its regression. Breastfeeding reduces blood loss and lowers the risk of complications. After the uterus has receded, this pain is over: it subsides after a few days and disappears completely within a few weeks.

In the first few days, even with the correct breastfeeding technique, breastfeeding can be temporarily painful because the nipples due to the special hormonal situation after the birth particularly sensitive and still have to get used to the vigorous sucking by the baby. These typical pains in the first few days are bearable and pass by themselves, the skin remains unharmed. They are most uncomfortable when you put them on and wear off during the breastfeeding meal - usually after the first milk ejection reflex has been triggered, i.e. within 10 seconds - because the milk then begins to flow. That is why one speaks here of Suction pain. With the help of a breast massage (according to Marmet or Plata Rueda), the milk donation reflex can be triggered before breastfeeding. Then the milk flows as soon as the baby is put on.

DISPLAY

The pain persists throughout the breastfeeding period and stop as soon as the baby lets go of the breast, then the baby is incorrectly applied or drinking with an unsuitable suction technique. Here it is essential to check the correct application and sucking behavior of the baby, otherwise the nipples can become sore (see The correct application of the baby and the online video course Gut Anlage by midwife Regine Gresens (subject to a fee) new mothers are still learning. In order for the baby to be able to drink effectively from the breast, it has to suck in not only the nipple itself, but also most of the areola. To do this, the baby should open its mouth very large before it begins If the baby's mouth is not opened properly, it cannot grasp the breast correctly. If the baby is laid superficially, the nipple between the roof of the mouth and tongue is incorrectly compressed. This is immediately very painful and can lead to nipple injuries and long-term pain and infection (see also sore nipples).

If the baby is not positioned correctly, the mother can remove it from the breast by inserting her little finger between the mandibular ridges in the corner of her mouth, thereby releasing the suction vacuum. Then she can put the child back on. This process may have to be repeated several times until the child is correctly fitted.

For more causes of donning pain, see the Persistent donning problems section. If the severe pain during breastfeeding is not resolved by correcting the breastfeeding, it may be useful to express the milk temporarily - until the problem has been resolved - and to feed the child with the expressed milk using alternative, breastfeeding-friendly feeding techniques (see also breastfeeding difficulties in Early bed).

Painful milk ejection reflex: Most women can feel the first milk ejection reflex, in which fine muscle contractions drive the milk towards the nipple, the subsequent milk ejection reflexes are usually not noticeable (see more about the milk ejection reflex here). It is often described as pulling, warmth, tingling or light pressure in the chest and is usually a pleasant or neutral feeling. Some women find it temporarily uncomfortable or slightly painful. You can usually feel the milk ejection reflex on the second breast, which is currently pausing, much more strongly than on the breast that is currently breastfeeding. In many cases, this pain also subsides over the course of the weeks and disappears by itself over time. A painful milk ejection reflex can also be a symptom of other problems (e.g. too much milk, blocked milk or breast inflammation, see below).

Later, persistent or recurring pain when breastfeeding

According to research, around 20% of breastfeeding mothers experience pain two months after giving birth. Diagnosis and therapy such persistent, recurring, or newly occurringPain are among the most complex challenges in breastfeeding counseling. They often require interdisciplinary cooperation between midwives, lactation consultants, doctors from various specialties (gynecologists, general practitioners, paediatricians, dermatologists, etc.) and other therapists (such as osteopaths or psychotherapists). Among the midwives and breastfeeding consultants, those with the additional IBCLC qualification are often most likely to help, because they can carry out a detailed diagnosis with a physical examination in personal consultations and also advise on the necessary medication. You will find contact addresses in our directory.

Possible causes of persistent, emerging, and / or recurring pain:

  • unfavorable positioning of the baby: Some mother-child pairs practice awkward investing over a long period of time. The baby is drinking but not effectively and breastfeeding is painful. Correcting the donning and treating any infections will reduce the pain.
  • Breast Pump Injuries: In one study, 15% of pumping mothers said pumping caused nipple injuries. The pump funnel must be selected to match the nipple and correctly positioned. The vacuum should be set below the pain threshold. When the milk flow has decreased, you should no longer pump extensively (possibly 2-5 minutes if you want to increase the amount of milk, but no longer).
  • anatomical peculiarities in the child's mouth area and / or abnormal sucking pattern on the part of the baby: The ability of a baby to properly dock and suckle on the breast depends on numerous factors, including the anatomy of the mouth and jaw, the neurological maturity of the newborn (e.g. in the case of premature births) or the muscle tone. Babies with reflux, breathing problems, low muscle tone, neurological problems, or congenital abnormalities are at high risk of abnormal sucking. The support of lactation consultants and pediatricians is required here; milk production may need to be built up and maintained by pumping / hand emptying so that the child can be fed with breast milk.
  • Tongue ligament too short: A comparatively frequent anatomical peculiarity is the too short ligament of the tongue. This hinders the mobility of the tongue, which means that the baby cannot milk out the breast correctly. Breastfeeding is painful and, on the other hand, the baby cannot suckle properly and drink effectively. More on this in the article shortened tongue.
  • anatomical features of the nipples:special nipple shapes can make effective sucking difficult. Sometimes the nipple is normal in shape, but its size does not fit the child's mouth because it is too big or too small. Different breastfeeding positions can be tried out here. If it is not possible to put it on even with professional support, nipple shields sometimes help. Breastfeeding with a feeding kit or tube can also help relieve pain in such special situations because the milk flows well and the nipples are relieved.
  • Nipple mess: Incorrect suction technology and the resulting pain when breastfeeding can also result from nipple confusion. In these cases, the baby has already received the bottle and learned to suck on the bottle, which is fundamentally different from sucking on the breast. Here, too, it is important that the baby opens its mouth very large before docking so that it can grasp the nipple correctly. This is not necessary for the vial. More on this in the article Getting the baby used to the breast from the bottle.
  • Baby bites its chest or presses its jaws together: This behavior can have various causes, such as a broken collarbone, torticollis, birth trauma to the neck, skull or face, jaw asymmetry, rejection of the chest (e.g. due to forcing), tonic bite reflex, nasal congestion, reaction to a strong milk donor reflex and teething ( more on this in the article Biting While Breastfeeding).
  • Too much milk: Too much milk can lead to uncomfortable tension and pain in the breast and nipple, and increases the risk of blocked breasts and breast infections. Too much milk can also be associated with pain in the milk ejection reflex. If the baby is overwhelmed by the rapid flow of milk, it sometimes squeezes the nipple (with the tongue or jaw), which is very painful. More on this in the article Too Much Milk.
  • Milk congestion: Pain also occurs with a blocked milk because the flow of milk is obstructed. Part of the chest becomes hard and can be extremely painful.
  • Milk vesicles: a skin-covered, white to yellowish blister on the nipple, which is usually associated with a blocked breast and can cause severe, sharp pain. At first, the milk vesicle is only visible immediately after breastfeeding, then permanently.
  • mastitis: Inflammation of the breast (mastitis) is also a common cause of pain during breastfeeding. An abscess can develop as a serious complication.
  • Imbalance of skin germs (dysbiosis / subclinical mastitis / subacute mastitis): Some authors count an imbalance of germs normally found on the skin to cause breast inflammation (mastitis), other authors form a separate category. Because the actual inflammation in mastitis should take place in the surrounding tissue, not in the milk ducts, while the dysbiosis only affects the milk ducts. This is why dysbiosis is also referred to as inflammation of the milk ducts. In the case of dysbiosis, certain bacterial strains - sometimes together with Candida strains - which also normally belong to the skin flora, multiply excessively and form a biofilm. The milk ducts narrow, the epithelium of the milk ducts becomes inflamed. An imbalance of skin germs becomes noticeable in bilateral dull, deep, burning chest pain, pain during and after breastfeeding (sharp, stabbing pain during the milk donation reflex) and pressure pain, especially on the underside of the breast. Otherwise the breast looks inconspicuous. Recurring milk congestion, swelling, too much milk and cracks on the nipples can be associated with this condition. This condition can be treated with antibiotics and probiotics for the lactating breast to restore bacterial balance. Regular consumption of unpasteurized, fermented foods (sour milk products, pickled vegetables with living microorganisms) should also help to restore the bacterial balance.
  • Vasospasm: the nipple turns white / yellow / bluish in color after breastfeeding.

    Nipple vasospasm (white nipples): Vasospasm is characterized by the nipples fading to blue or white (depending on the skin tone) and sharp, stabbing, or burning pain that extends deep into the chest. Pain right after breastfeeding, when the nipple comes out of the baby's warm mouth and into the cool air, is typical. Vasospasm rarely occurs immediately after birth, but typically only after weeks to several months. The blood vessels in the nipple narrow (vasospasms), which leads to a reduced blood flow to the nipples. Affected women often also have cold feet and hands. Women diagnosed with rheumatoid arthritis or Raynaud's syndrome are at increased risk of nipple vasospasm. Vasospasm of the nipples has also been described as a side effect of beta-blockers taken against high blood pressure, e.g. during pregnancy. In the case of vasospasm, the non-drug measures include checking the donning (the problem can sometimes be solved by optimizing donning), refraining from (passive) smoking and caffeinated drinks as well as checking any medicines and dietary supplements that may be taken with possible vasoconstricting Effect. As a central therapeutic measure, the nipples should always be kept warm. In the literature, calcium, magnesium, vitamin B6 and omega fatty acids, lecithin or evening primrose oil are recommended as dietary supplements for therapy. It is recommended to take both magnesium (e.g. 1000 mg per day) and calcium (e.g. 2000 mg per day), but not at the same time, but one in the morning and the other in the evening. Some women do best with several smaller doses throughout the day. There are somewhat conflicting recommendations when it comes to vitamin B6. Newman and Kernerman temporarily recommend a short but intense dose of 100 mg twice a day for a week if it helps, another week and longer if necessary. Hale and Rowe, on the other hand, recommend taking no more than 25 mg / day of vitamin B6. Maier, in turn, recommends 125 mg of vitamin B6 for 5 days, then 25 mg daily for 1–2 weeks beyond the symptom-free period. Vasospasm often occurs when women took high doses of magnesium during pregnancy and stopped using it abruptly after giving birth. In such a case, it can be helpful to keep taking magnesium and calcium and slowly tapering it off. Vasospasm can also occur when the milk flows very quickly and the baby squeezes their jaws while breastfeeding to slow the flow. In such cases, women often have a lot of milk. Here, breastfeeding leaning back often helps, as the milk flows more slowly and the baby does not press his jaw together. Vasospasm can also be associated with insufficient milk. If the milk flows too slowly, some babies create too much vacuum to get to the milk. A superficial application, special nipple shapes, sucking difficulties on the part of the baby, e.g. due to the tongue ligament being too short, tension, asymmetries, etc. all cause incorrect strain on the nipples, which in turn can lead to vasospasms. This is why optimizing the application and eliminating any suction problems is so important. With the previously mentioned therapeutic measures, freedom from pain can be achieved in most cases. Often the pain gradually subsides after several weeks. Painkillers (especially ibuprofen, possibly paracetamol, see below) may also be taken. In persistent cases, the prescription drug nifedipine can be used. This has a vasodilating effect and is approved for the treatment of Raynaud's syndrome. Even with nifedipine, it takes several days to weeks before a clear improvement occurs; According to the Goldfarb Nursing Clinic in Canada, nifedipine for nipple vasospasm is usually prescribed for 2 weeks, but can be taken for longer if needed to improve symptoms. The embryotoxicological advice center at the Berlin Charité recommends nifedipine as the drug of choice for babies because it is well tolerated (www.embryotox.de/arzneimittel/details/nifedipin/). Because nifedipine lowers blood pressure, it may not be suitable for women with low blood pressure, and it is advisable to monitor your blood pressure during treatment. Medicines and food supplements should always be taken in consultation with the attending physician.

  • Fungal infection (thrush) the nipple and / or the milk ducts with Candida: Thrush usually does not appear immediately after birth, but often after a problem-free period of breastfeeding. Very severe pain compared to otherwise inconspicuous nipples is typical. The pain typically occurs when you start breastfeeding and persists until after you have breastfeeding. Vasospasm and thrush occur more often at the same time. Because the reduced blood flow to the nipples due to vasospasm favors the development of thrush. More about this in the article thrush infection.
  • Viral infection of the nipple With herpes simplex or herpes zoster: These infections can also affect the breast, among other things. In such a case, it is advisable not to breastfeed on the affected side, because the child can also be infected, and it can also happen that the infection is passed on from the child to the mother. To be on the safe side, it is recommended that the breast milk obtained on the affected side be spilled temporarily until the infection heals.
  • Psoriasis: Psoriasis can flare up while breastfeeding (typically four to six weeks after giving birth) or in response to nipple injuries from sub-optimal fitting.
  • Rash:
    • atopic eczema can also occur during breastfeeding and affect the breast.
    • Contact dermatitis and allergies: Hypersensitivity to friction on clothing, intolerance to certain breast pads, hypersensitivity reaction to contact with complementary food in older breastfeeding children or certain medications that the baby takes by mouth, allergies to nipple ointments (quite often with lanolin), etc.
  • Injury or Eczema Infections: Injuries caused by improper application / sucking as well as eczema from other causes can be infected by bacteria (Staphylococcus aureus). Non-healing inflammations and fissures, weeping blisters and yellow crusts are typical. Bacterial infections are treated with topical or oral antibiotics.
  • (Postnatal) depression: Breastfeeding pain and depression often go hand in hand. Affected patients benefit not only from the treatment of pain but also from psychotherapy.
  • Tense chest muscles (Mammary Constriction Syndrome): A relatively recent discovery from Edith Kernerman, IBCLC. Here, tension in the shoulders or in the chest leads to tension in the chest muscles. This presses on the blood vessels that supply the breast and nipples. The pain then arises from the reduced blood flow. This tension can have various causes, such as an unfavorable breastfeeding position or fear of pain when breastfeeding. Other orthopedic or musculoskeletal causes can also lead to this tension, which can also occur outside of breastfeeding. Here, too, good chest positioning and relaxation exercises help. In addition, the muscles can be loosened with a targeted massage. More about Mammary Constriction Syndrome and breast massage here.
  • Pregnancy: When a new pregnancy occurs, the nipples in some women become more sensitive, making breastfeeding uncomfortable. This does not have to be noticeable at the beginning of the pregnancy, but sometimes only in the course of the weeks and months. Women do not always know they are pregnant, so vasospasm and thrush are often considered as causes of the pain. In contrast to these causes, the nipple no longer hurts during a new pregnancy once the baby has let go of the breast. When pregnant again, many women experience an unprecedented negative feeling towards breastfeeding.
  • Allodynia / functional pain: Allodynia is a painful response to stimuli that normally do not cause pain, such as mere touch. In affected women, the friction of clothing, nursing pads or drying of the nipples can already cause unbearable pain. Breast allodynia can occur in isolation or with other pain disorders.

Suitable painkillers and other medication during breastfeeding

If necessary, pain relievers may also be taken for chest pain. Ibuprofen and paracetamol are suitable painkillers during breastfeeding, but not acetylsalicylic acid (e.g. aspirin or ace), which should not be taken during breastfeeding (however, a single tablet does not require a breastfeeding break). Side effects in infants when taking ibuprofen or paracetamol by the nursing mother have not been observed. These two active ingredients are also the drugs of choice for babies if they have pain or a fever. When administered therapeutically up to 1600 mg / day, ibuprofen is not even detectable in breast milk. In many cases, taking these pain relievers makes it possible to continue breastfeeding.

The same applies to other drugs such as antibiotics. Breastfeeding can be maintained by taking appropriate medication that effectively treats the underlying diseases. When choosing the medication suitable for breastfeeding, the usual drug information (package insert, red list, etc.) is not very suitable, as it generally advises against use during breastfeeding. With this general warning, pharmaceutical manufacturers protect themselves against possible lawsuits against a small target group that is insignificant for them and that at the same time requires a great deal of attention. You can find more about medication for breastfeeding and suitable reference works in the article “Medicines and breastfeeding”

Swell:

  • Basim P, Özdenkaya Y: Can Traditional Fermented Food Products Protect Mothers Against Lactational Mastitis? Breastfeed Med 2020, https://doi.org/10.1089/bfm.2019.0261
  • Berens P, Eglash A, Malloy M, Steube A, Academy of Breastfeedinf Medicine: ABM Clinical Protocol # 26: Persistent Pain with Breastfeeding. Breastfeeding Medicine 2016; 11 (2).
  • Buck ML, Amir LH, Cullinane M, et al. Nipple pain, damage, and vasospasm in the first 8 weeks postpartum. Breastfeed Med 2014; 9: 56-62.
  • Glass A: Pain while breastfeeding - a challenge in breastfeeding counseling. Lactation & Breastfeeding 2016/04.
  • Hale T, Rowe H: Medications and Mother's milk, 2014. 16th ed. Amarillo, TX: Hale Publishing; quoted in Lauwers J, Swisher A: Counseling the Nursing Mother. 6th edition 2016, p. 610.
  • Herzl Family Practice Center, Goldfarb Breastfeeding Clinic: Nipple Vasospasm: Patient Handout. https://cdn.ciussscentreouest.ca/documents/hgj/pfrc/Breastfeeding_clinic/Vasospasm_px_handout_2019.pdf?1561062105
  • Johnson HM, Eglash A, Mitchell KB, Leeper K, Smillie CM, Moore-Ostby L, Manson N, Simon L, the Academy of Breastfeeding Medicine: ABM Clinical Protocol # 32: Management of Hyperlactation. Breastfeed Med 2020; 15 (3).
  • Monastery I: breastfeeding management in various breastfeeding situations. Seminar of the Lactation & Breastfeeding Training Center, August 2019.
  • Li R, Fein SB, Chen J, et al. Why mothers stop breast-feeding: Mothers ’self-reported reasons for stopping during the first year. Pediatrics 2008; 122 (Suppl 2): ​​S69-S76
  • Maier C: Extreme vasospasm. Lactation & Breastfeeding 2018; 1: 35-36.
  • Newman J, Kernelman E: Vasospam and Raynaud's phenomenon. Rev 2009. http://www.nbci.ca; quoted in Lauwers J, Swisher A: Counseling the Nursing Mother. 6th edition 2016, p. 610.
  • Qi Y, Zhang Y, Fein S, et al. Maternal and breast pump factors associated with breast pump problems and injuries. J Hum Lact 2014; 30: 62-72.
  • Schaefer C, Spielmann H, Vetter K: Medicinal prescription in pregnancy and breastfeeding. Urban and Fischer. 7th edition (2006)
  • Wilson-Clay B, Hoover K: The Breastfeeding Atlas, 2013
  • Wiessinger D, West D, Pitman T: The womanly art of breastfeeding. La Leche League International. 8th edition 2010. p. 418.
  • Walker M: Breastfeeding Management for the Clinician. Using the Evidence. Jones and Bartlett Pubishers, 2014. and 2016 (p. 591).

© Dr. Z. Bauer - Publications in Breastfeeding Promotion. 2003-2021. Last additions: April 2021.