It is possible to breastfeed with most forms and sizes of nipples although in some cases latching on may be difficult and thus require some help during the first few days.

When nipples are flat but elastic like, the child will need to open his or her mouth wide and make sure most of the areola is inside the mouth. In this way, once suction begins a void is created and the nipple will protrude with suction. There are devices that can help to draw the nipple out.

In the case of “truly inverted” nipples; that is, when the areola is pressed down gently the nipple retracts or disappears, it is more difficult for the child to latch on but it is not impossible. It is important to receive help from and expert right from the beginning.

Cracking or nipple soreness. This is one the most frequent reasons that mothers decide to stop breastfeeding. This usually occurs due to an incorrect technique or due to anatomical abnormalities that the child may have like: lip-tie or tongue–tie and micrognathia. The most important part of breastfeeding is correct latching; a good position and attachment while breastfeeding as well as keeping nipples dry after feeding.

Engorgement: This occurs when more milk is being produced than extracted by the child: When milk “comes in”, if you breastfeed following a strict timetable or if you offer the baby unnecessary supplement feedings. Clinical signs: swollen and painful breasts. Treatment: removing milk from breasts and the use of pain relievers. If the areola is very tight it may be useful to gently press down on the area for a few minutes in order to decrease the swelling (reverse pressure techniques)

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A breast inflammation caused by an obstruction of the milk ducts and by not emptying the breasts. It can sometimes bring about fever when there is an infection which is usually bacterial (Staphylococcus aureus). The symptoms are: intense pain, breast swelling and redness accompanied by fever, chills and body ache.

In recurrent cases of mastitis variations with very little inflammation have been described. It is necessary to analyse the milk in order to identify the infection. The milk produced by an infected breast does not harm the child in any way. Emptying the breast is fundamental as part of the treatment, the child should feed as often as possible followed by manual extraction (http://www.youtube.com/watch?v=JXJpHFIIcA8) or with a breast pump (http://www.youtube.com/watch?v=_ljMAsdKRJQ). Pain killers and anti-inflammatories are required and sometimes treatment with antibiotics.

An incorrect emptying of the breast lobules, usually due to an inadequate feeding technique or the use of bras that compress the breast excessively.

Symptoms: painful swelling and redness of the skin in this area, without fever or any other general symptoms.

Treatment: increase the frequency of feeding, apply warmth, improve the emptying process by making sure the baby´s tongue is in contact with the affected area and massage the area towards the nipple during feeding. If necessary a breast pump may be used afterwards to complete the process. It is very important to use an adequate nursing bra.

When a mother believes that she doesn’t have enough milk, the most common situations are these that follow:

• The child’s position and latching are not correct. It is a good idea for a breastfeeding expert to evaluate and help correct possible errors.
• The baby does not feed frequently enough or the duration of feeding is not long enough.
• The mother has milk but it does not pour out and does not wet the breast-pads and so thinks she there is not enough.
• The baby is going through a speedy growth period and needs to feed more than usual: “a growth spurt or crisis”. The solution is to reduce the time between feeds and thus increase milk production so that there is enough for the child.

Until the child learns how to speak, crying is the baby´s way of communicating and a way of expressing a need but this is not necessarily hunger

Colic and crying bouts more often take place in the evenings or at night but can occur anytime. They quite often last for up to three hours, three times a week and during three weeks in a row in an otherwise healthy child. Colic is usually associated with intestinal immaturity, a cow milk protein intolerance, reflux or even temper. It is advisable to respond quickly, pick the child up and try to soothe the baby. You might try offering your breast. You must never shake the child, this will only make things worse and you can seriously harm the baby.

Worrying about weight gain is fairly common among mothers, but in most cases everything follows a natural course. The things to keep in mind are:

• Many of the growth patterns or charts available have been made out with children who have been fed on formula milk. The charts published by the WHO, based on breastfed babies are the most valid charts when it comes to evaluating a child´s growth. (http://www.who.int/childgrowth/es/)
• It is more important:
  • Weight gain over a period of time and not just at one specific moment.
  • A clinical examination of the child: general aspect, liveliness, wetting nappies 5 times a day.
• The growth of your baby should be controlled by a paediatrtian at the doctor´s consultancy. Weighing a baby at a chemist or pharmacy can be misleading.

– Refusing one breast: First make sure there are no problems regarding the position or latching on, mastitis or discomforts the baby may have; jaw fracture, earache, reaction to vaccines,…)

– Refusing both breasts (breastfeeding or nursing strike): Check that it is not “Nipple confusion syndrome” caused by being used to using dummies and bottle teats. The rejection may be due to some unpleasant experience like aspiration, the use of catheters or even changes in the baby´s routine, the mother´s odour or the taste of the milk… It is necessary to find the cause of the problems in order to find a solution. It can be helpful to increase skin-to- skin contact, try nursing in a quiet place, when the baby is sleepy or just after waking when he or she is not very hungry and use the biological nurturing position.

Slumps or breastfeeding crises are usually temporary. During these periods the baby needs more milk due to growth spurts: (breastfeeding non-stop, restlessness and crying spells…). Mothers notice that their breasts are not as full and so they feel that do not have enough milk.

The slumps coincide with growth spurts. These growth periods usually take place around the third week, sixth week or third month after birth.

If you start to bottle feed, milk production will start to reduce and the situation becomes worse. It is better to breastfeed as often as possible and thus increase milk production. Milk supply will increase with increased nursing.

These symptoms may appear when a child who is breastfeeding is given cow milk based formula or due to the dairy products included in the mother´s diet and the child reacts to the traces of milk protein that are found in breast milk.

As for allergies, after being exposed to cow´s milk protein an immune mediated reaction IgE, causes symptoms such as swelling, itching, wheezing, colic and anaphylaxis. We start to talk about lactose intolerance when it is not an immune response. In both cases (allergy and intolerance) the mother should avoid all types of food that contain dairy products. Most children develop a tolerance to lactose before reaching the age of three.

There are several reasons why babies sometimes bite during breastfeeding: teething trouble, distraction, curiosity or aches and pains. There are many different ways to reduce and stop biting. These methods help the baby understand that it hurts and if he or she continues the feeding will stop:

• Say ¡No! In a firm stern manner (verbal message)
• Make eye contact and look at the baby solemnly (non verbal message)
• Stop feeding gently but keep the baby in your arms.

After this try feeding again and gently say “don´t bite me”. It might be necessary to do this several times but the child will learn and understand.

A white spot on the nipple may also be referred to as a bleb or blister. It is about the size of a pin head, pearly white in colour and can cause pain especially during breastfeeding. It is caused by an overgrowth of skin or a blockage of the ducts at the nipple tip

To resolve this problem we advise applying warmth to the area, soaking the nipple in warm water and suction from the baby helps burst the spot and it usually disappears after a few days. When the above measures are unsuccessful a sterile needle can release the blockage. A medical adviser or nurse should carry out this measure to avoid any sort of infection.