Managing common breastfeeding problems

Engorgement is common during lactogenesis stage II (‘milk coming in’) and following missed feeds. Prevention through frequent and effective milk removal. However, for mothers that are experiencing engorgement, strategies for management may be needed. These include frequent feeding with corrected latch with brief hand expressing to soften areola if baby is struggling to latch (NICE, 2025b). HCP’s should educate breastfeeding mothers that excessive expression of milk can result in oversupply and further engorgement.

Comfort measures include warmth before feeding and cool after feeding. In addition, wearing a well-fitting bra and clothing that does not restrict the breasts, is encouraged (NICE, 2025b). Some simple analgesia such as paracetamol can be taken to help with discomfort.

More than 70% of first-time mothers report nipple and/or breast pain in the first week postpartum (Buck et al., 2014). Cracked nipples and nipple pain during breastfeeding can be incredibly painful for some women. HCP’s can take a family-based approach in assessing mother and baby both separately and together (Cleaugh et al., 2017).

Guidance suggested to assume there is a latch issue until evidence suggests otherwise. Therefore, first steps include observing a full feed and supporting the mother to find correct positioning and attachment. Second, is to consider infant factors (tongue-tie, high palate or oral dysfunction). If any of these factors are indicated, local assessment/ referral pathways should be followed (NICE, 2021).

It is recommended to consider nipple and breast pain separately and to collect detail on the specific location of the pain as patients can use nipple and breast interchangeably (Amir et al., 2021). Understanding the specific details of the pain will help in ruling out, or identification of causes as there are a broad range of reasons for pain including overuse or improper use of a breast pump (NICE, 2025b), conditions such as Raynaud’s disease (Di Como et al., 2020), or dermatological conditions such as nipple dermatitis (Amir et al., 2021).

The UNICEF UK Baby Friendly Initiative Breastfeeding assessment form can be used to identify breastfeeding problems requiring further assessment (NICE, 2025b).

Thrush can be a cause of nipple pain and should be considered only when the symptoms fit. Thrush is caused by an overgrowth of Candida on the nipple or breast. It may start on one nipple and then spread to the other, and it is not related to engorgement or mastitis. A recent course of antibiotics can increase the risk (Amir et al., 2021).

Symptoms of thrush can include burning nipple pain that continues between feeds, and breast pain that may feel sharp or radiating. Some women develop nipple pain after months of pain-free breastfeeding, particularly if they are prone to vaginal thrush (Amir et al., 2021).

Unless the pain clearly starts after antibiotic use in a woman who is prone to vaginal thrush, other causes should be carefully considered first. If thrush is diagnosed, both mother and baby should be treated together to prevent re-infection (Amir et al., 2021).

Many mothers find that breastfeeding is harder than they expected and may have worries or difficulties. Most breastfeeding problems can be resolved with early, kind, and skilled support (Marshall et al., 2021). A common worry is that they are not making enough breast milk, but true low milk supply is uncommon (Marshall et al., 2021). Mothers should be reassured and encouraged to feed their baby whenever the baby shows feeding cues, as this helps build and maintain milk supply (NICE, 2025c).

Crying can be upsetting for parents, and some may think it is caused by conditions such as gastro-oesophageal reflux disease or cows’ milk allergy. However, these conditions are uncommon, affecting fewer than 5% of babies (Marshall et al., 2021). Healthcare professionals should listen carefully to parents’ concerns and carry out a full assessment, following NICE guidance, before suggesting these diagnoses (NICE, 2025c).

Causes of insufficient milk supply can include limited access to the breast (NICE, 2025). This may be suggested by feeds that are short, infrequent, or do not include night feeds. Using a dummy or giving top-ups with milk other than breast milk can also reduce the baby’s time at the breast. Maternal depression, stress, or anxiety may affect a mother’s ability to respond to feeding cues, leading to fewer feeds and reduced stimulation of milk production (NICE, 2025c).

Improper latch can contribute to low milk supply and may be evident from nipple pain or damage (NICE, 2025c) or very short or very long feeds. Babies may appear unsettled, have poor weight gain, or show signs of dehydration (NICE, 2025c). Improving latch and encouraging responsive feeding can support mothers to be confident in their milk supply and transfer of milk.

If the mother does not wish to continue breastfeeding, NICE guidelines (2025a) encourage that breastfeeding should not be stopped abruptly. Breasts should be supported with a comfortable bra, expressing enough milk to keep the breasts comfortable and to take paracetamol or ibuprofen if pain occurs.

This article has shared some of the most common concerns that mothers have when starting breastfeeding but does not reflect a non-exhaustive list of concerns breastfeeding mothers may seek support for. Timely and professional input from health care professionals can equip mothers with the confidence and strategies for self-management, which in turn, can reduce the likelihood of breastfeeding discontinuation (McFaddden et al., 2017; WHO, 2017).