Peppermint might help prevent early breastfeeding nipple problems

peppermintThere are many substances said to prevent or relieve nipple pain and damage during the early days of breastfeeding, including lanolin, expressed breast milk and water compresses. Unfortunately, none as yet have been found to offer any real improvement over leaving nipples untreated1. Given the prevalence of the problem, however, the search for a preparation that can make early breastfeeding more comfortable continues.

Recent research reported in the International Breastfeeding Journal and Medical Science Monitor finally seems to offer a ray of hope. It suggests that peppermint, in the form of a gel or ointment, could play a role in preventing nipple soreness and injury from appearing in the first place. A team at the Alzahra Teaching Hospital in Iran conducted two studies examining whether peppermint could prevent nipple problems caused by breastfeeding, after noticing its use by women in the Azarbaijan Province, North West of Iran. As peppermint has antibacterial properties and can increase tissue flexibility2 it does have the potential to prevent this kind of injury occurring, but it has not before been properly evaluated in a clinical setting.

In the first study, 196 women were randomly allocated to either the experimental group, where they were asked to apply peppermint water after each feed, or the control group, where they applied expressed breast milk3. Mothers who applied the peppermint water reported significantly less pain on breastfeeding, and had significantly fewer nipple cracks (9% in the peppermint group and 28% in the milk group) than the other mothers. Cracks that occurred in the peppermint group were also less severe than those in the milk group.

The second study evaluated the effectiveness of a peppermint gel in a double blind study4. 216 women were randomly allocated to one of three groups: the first used peppermint gel after each feed; the second used lanolin; and the third used a placebo gel. The peppermint gel was shown to be more effective than both lanolin and the placebo gel at preventing nipple cracks. Women in this group were also more likely to be exclusively breastfeeding at 6 weeks, possibly because they had suffered less discomfort.

Both these studies were large and well designed, and as such offer reasonable evidence that peppermint may indeed help to prevent the nipple pain and trauma that can occur when women start to breastfeed. These results alone, however, do not constitute conclusive proof that peppermint is a panacea for nipple problems. The main issue is that both experiments were carried out by the same research group, in a part of the world where peppermint is regularly used as a nipple treatment. In the first study women knew they were applying peppermint water, and this may have affected their perceived levels of pain. These mothers were also found to nurse their babies more frequently and for longer periods than those using milk. The authors suggest this may be due to the lower pain levels in this group, but the possibility that the more frequent feeding somehow reduced pain and trauma cannot be ruled out.

In the second study, both the mothers themselves and the researchers classifying the severity of nipple cracks were unaware which type of gel they were applying, reducing the chance that the results were due to a placebo effect. In this experiment, however, there was no true baseline (where nipples were left untreated) against which to compare the peppermint gel. It was better at preventing cracks than the placebo gel (which was the same preparation, just without the peppermint), but we can’t be sure that the gel didn’t make it worse, and the peppermint simply helped to ease the problems caused by the gel.

Despite these shortcomings, this research does provide a strong indication that peppermint may have the potential to protect mothers against nipple soreness and injury. Peppermint has medicinal qualities that suggest it might be helpful in this context, and it is likely to be a reasonably safe and practical treatment, as it is not harmful to babies when consumed in small quantities. Whether future research can replicate these results is yet unknown, but if it can, then an effective preventative measure for nipple problems may finally be on the horizon.

  1. J Obstet Gynecol Neonatal Nurs. 2005 Jul-Aug;34(4):428-37.
  2. Fitoterapia. 2006 Jun;77(4):279-85.
  3. Int Breastfeed J. 2007 Apr 19;2:7
  4. Med Sci Monit. 2007 Sep;13(9):CR406-411

Can stress affect the let-down reflex?

cartoon of person with numbers flying round their headOne piece of advice you might have heard from midwives (and well-meaning friends and family), is to make sure you breastfeed in quiet and relaxing surroundings. Given the choice, this is probably what you’d opt for (who wants to feed in noisy and distracting surroundings?), but could it actually cause a problem if you’re not able to do this?

Well, there’s a possibility it could. For some time, medical evidence has existed that indicates temporary stress or distraction can interfere with the let-down, or milk ejection reflex, meaning your baby has to wait longer for milk to start flowing freely.

Normally, cues that indicate your milk will soon be required (such as your baby crying before a feed, or suckling at the start of one1) trigger the release of the hormone oxytocin, which enters the bloodstream in ‘pulses’ a few minutes apart, forcing milk to flow from the ducts and out of the nipple (see ‘Breastfeeding and Human Lactation’ by Jan Riordan for a full description of this somewhat complicated process.)

In 1948, an experiment conducted with a single breastfeeding woman indicated that distractions can inhibit the release of oxytocin, delaying the start of milk ejection2. This effect was confirmed in a more recent study, which monitored the oxytocin levels in the blood of three groups of breastfeeding mothers who had given birth five days previously3. The first group was asked to perform difficult verbal arithmetic problems whilst nursing their babies (the stress condition), the second was subjected to the noise of a building site through earphones (the noise condition) and the third breastfed without these distractions (the control group).

Oxytocin release occurred significantly later and less frequently in the noise and arithmetic groups than it did in the control group, indicating that these temporary stressors impaired the mothers’ let-down reflexes. The amount of milk the babies consumed (measured by weighing them before and after the feed) did not differ between the groups, however, so although stress affected the frequency of let-down, it did not appear to prevent babies from consuming an adequate amount of milk.

These results demonstrate that mild temporary stress, such as trying to perform difficult arithmetic problems (five days after giving birth!) or being exposed to the noise of construction work can delay the let-down reflex, both at the start of a feed, and throughout its duration. This may explain why in situations where you feel under pressure or distracted (for me, this certainly applies to feeding in public), it feels like your milk takes forever to appear – not great when you’re trying to deal with an angry baby. Fortunately, this problem doesn’t appear to affect the amount of milk your baby consumes overall, so it isn’t necessarily anything to worry about (this would probably only make it worse, after all…) Nevertheless, it is an irritation that both you and your baby would probably prefer to avoid, and therefore the perfect excuse to insist that your surroundings whilst breastfeeding are as chilled out as possible.

  1. Br Med J (Clin Res Ed). 1983 Jan 22;286(6361):257-9.
  2. J Pediatr. 1948 Dec;33(6):698-704.
  3. Obstet Gynecol. 1994 Aug;84(2):259-62

When should mastitis be treated with antibiotics?

pillsMastitis – inflammation of the breast tissue – is a common problem for breastfeeding women. Although it can be associated with bacterial infection, this is rarely its primary cause (see milk stasis – not infection – is the main cause of mastitis). Many doctors nevertheless choose to treat it with antibiotics, ‘just in case’ infection is present. Given the uncertain relationship between bacteria and mastitis, what are the benefits – and drawbacks – of taking antibiotic medication?

There are disappointingly few properly controlled studies looking at the antibiotic treatment of mastitis. A recent Cochrane Review analyzing all the research in this area found only two studies that were sufficiently well designed or reported to provide unbiased evidence1. One study looked at the effects of two different types of antibiotic (Amoxicillin and Cephradine), and found that they were equally good at relieving symptoms. Unfortunately, as the study didn’t have a control group of women who did not take any medication, it is not clear whether the antibiotics actually helped them recover, or whether the mothers would simply have recovered over time anyway.

In the second study, mothers who had ‘infectious mastitis’ (diagnosed when both bacteria and white blood cell counts were higher than normal) were assigned to three groups. In the first group, the women were advised to treat the mastitis by emptying the affected breast every six hours (feeding their baby as normal and then expressing any remaining milk); in the second, mothers were asked to follow the same breast emptying routine, and were also prescribed a course of antibiotics (Penicillin, Ampicillin or Erythromycin); in a third control group no treatment was recommended. The results showed that antibiotics did indeed have a beneficial effect: whilst women in the breast-emptying group recovered more quickly than those who weren’t treated, those taking the medication recovered fastest of all.

This single study does appear to show that antibiotics can help treat mastitis associated with bacterial infection. Does this provide adequate evidence for treating all cases of mastitis in this way? Well, not really, for a number of reasons.

Firstly, the antibiotics were shown to be effective when infection was present. In many cases of mastitis, infection is not present, so antibiotics wouldn’t be any use. A risk of prescribing antibiotics without diagnosing infection is that it may not treat the root of the problem. As mastitis is more commonly caused by milk stasis than infection, it is vital to tackle this issue to ensure proper recovery and avoid reoccurrence.

Inappropriate antibiotic treatment is also problematic as it increases the chance that the bacteria may become resistant to the drug. Staphylococcus aureus is the bacteria most commonly associated with mastitis, and a well-known strain of this – MRSA – is already resistant to antibiotics, so this is potentially a serious problem2.

There is also the possibility that antibiotics taken by breastfeeding mothers may have adverse effects on their babies. Exposure to antibiotics through breast milk has been linked with problems such as minor infant breathing difficulties3 and diarrhoea4. Although such complications are not regarded as serious enough stop women from taking medication when they need it (particularly if it enables them to continue breastfeeding), it seems sensible to avoid putting babies at any unnecessary risk, particularly given that this area is currently under-researched1.

So, what does all this mean for mothers who have mastitis, and health professionals who are trying to treat it? There is some evidence that antibiotics help treat mastitis when infection, diagnosed using both bacteria and white blood cell counts, is known to exist. Ideally, antibiotics would be prescribed only in this situation, as using them unnecessarily increases the chance bacteria will develop resistance to them – leading to strains such as MRSA – and may expose babies to unnecessary health problems. Diagnosing infection is notoriously difficult, however, as the bacteria which potentially cause infection can be present even when infection itself isn’t5, and measuring both white blood cell and bacteria counts is rarely going to be practical in a normal health care setting, such as a GP surgery. In a paper published last year discussing this difficult issue, Linda Kvist and colleagues recommend a daily follow-up of mothers with mastitis, and the prescription of antibiotics when symptoms are persistent. In the meantime (and indeed, in the first instance) treating milk stasis, the primary cause of mastitis, remains the top priority.

  1. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD005458
  2. Int Breastfeed J. 2008 Apr 7;3:6.
  3. Pediatrics. 2007 Jan;119(1):e225-31
  4. Am J Obstet Gynecol. 1993 May;168(5):1393-9.
  5. Mastitis: causes and management. World Health Organization; 2000.

Could a laid-back approach to breastfeeding help your baby latch on?

baby_cryingAlthough it’s perfectly feasible to feed your baby any way that feels comfortable, four positions are commonly recommended. These are the cradle hold, the football hold, lying on your side, and the cross-cradle hold. This last position requires you to sit up with a straight back, hold your baby sideways on, and carefully position him with his nose opposite your nipple so he has a large mouthful of breast when he latches on. It can seem like quite a complicated process for a beginner, particularly when a crying baby is added to the equation. Nevertheless, it is particularly recommended to new mothers, as it is apparently the best position in which to ensure your baby is latching on correctly – something that many women (and babies) can find quite difficult.

Despite the strong recommendation of these feeding positions, there appears to be virtually no scientific evidence to justify their use. In practical terms, it is easy to see why being able to discreetly breastfeed whilst sitting up is a useful skill to master, but for a new mother, simply being able to comfortably nourish her baby may be a more immediate priority.

A recent study conducted at hospitals in the UK and France calls into question the idea that the traditionally recommended feeding positions are automatically the best ones1. During the study, 40 women whose babies were less than a month old were videotaped breastfeeding in a series of recording sessions. As long as feeding was going well, mothers were not advised or guided in any way: they were simply left to get on with it in whichever was most comfortable for them. In the ‘best’ recorded feeding session 21 of the mothers sat upright to feed their babies, one lay flat on her back, and one lay on her side; the remaining 17 were semi-reclined with their babies lying on their tummies (a behaviour termed ‘Biological Nurturing’).

There were some striking differences in the feeding process when mothers adopted a reclining position, as opposed to sitting upright. When babies lay on their mothers’ tummies, their mothers’ hands were free to gently guide them. Stroking their babies’ feet seemed to be particularly helpful, as it released mouth and tongue reflexes that helped them to latch on. By contrast, when babies were held in their mothers’ arms, their legs and feet were left in thin air, and the foot-to-mouth connection was lost.

The reclinining group did not need to line up the nose and nipple, and make sure the baby’s mouth was open wide enough before initiating the latch: as the baby was on top, gravity pulled his tongue and chin forward, allowing him to attach himself, even when he was sleepy. Gravity also automatically ensured a close fit between the baby’s chin and the mother’s breast, facilitating deep suckling and producing the ear and jaw movements that indicate successful feeding.

Perhaps the most interesting result, however, was that babies exhibited reflexes that helped feeding when their mothers were reclined, but hindered it when their mothers were upright. When they were lying on their mothers’ tummies, head-righting and -lifting reflexes allowed the baby to orientate himself for successful latching on. When mothers were upright however, these irregular, jerky head movements had the opposite effect: the head bobbing that resembled ‘nodding’ when a mother was reclined was perceived as ‘head butting’ when a baby was held sideways against an upright mother. The gravitational forces that had helped attachment in reclining postures dragged babies away from their mothers when they sat up. It was harder to keep the baby latched on, and mothers reacted by tightening their grip, resulting in back arching and arm and leg cycling that appeared like thrashing or flailing.

It is important to view these results in context: this was an observational, rather than a controlled study, so the data cannot ‘prove’ that one feeding method is better than another. Many of the mothers who participated fed quite happily whilst sitting upright – as do many women every day – so it’s clear that a reclining posture is not required for successful feeding.

Nevertheless, this research does call into question the idea that a position like the cross-cradle hold is the best one to recommend to new mothers. Innate early breastfeeding behaviours were observed to help attachment when a mother lay back with her baby lying on her tummy, but not when she sat up;  reflexes and gravitational forces which aided latching on when a mother reclined, hindered it when she was upright. If, as this study suggests, women can just lie back and let nature take its course, the often fraught early days of breastfeeding could potentially be a much more relaxed affair.

  1. Early Hum Dev. 2008 Jul;84(7):441-9.

Not enough milk? The “symptoms” you don’t need to worry about.

glass of milkA huge proportion of women worry that they aren’t satisfying their babies through breastfeeding alone, and many give up as a result. Much of the time, however, they are worrying about nothing. Although the precise relationship between perceived and actual milk supply isn’t well researched (see insufficient milk: all in the mind?), it is certainly the case that many of the “symptoms” that women think indicate they aren’t producing enough milk are actually completely normal, and can in fact be indicators that breastfeeding is going well.

In an article for Australian Family Physician journal, Dr Lisa Amir summarizes the common misconceptions of low supply. They include your breasts feeling softer, your baby taking less time to feed or feeding more frequently, your baby seeming unsettled or settling better on formula, and your baby’s growth appearing to slow down after three months1. In the absence of any genuine indicators of ill health, none of the above are a cause for concern, yet they perturb many mothers to the extent that they stop breastfeeding. Why do mothers interpret these commonplace occurrences as signs that their milk production is diminishing, and what actually causes them? The sections below address each ‘symptom’ in turn, outlining why they can be misconstrued as a problem with milk supply, and explaining what actually causes them.

•    Your breasts feel softer

After the problems with engorgement that can occur in the post-birth period, it should come as a relief when breasts go back to a softer, more normal consistency. In reality, it can be somewhat unnerving. If you’re used to rapidly filling up with milk, any decline in this can give the impression of a dwindling supply. In fact, your breasts are simply adjusting to maximize their efficiency, by producing as much milk as your baby needs, but not going overboard – an important process, given how energy intensive it is to produce milk. Initially, production is controlled by hormones that are released after giving birth, causing a significant amount of milk to appear regardless of whether a woman intends to breastfeed. Within a few days, however, the amount produced starts to be determined by the amount of milk that your baby takes at a feed2. The quantity of milk required by your baby increases rapidly to start with, but by the end of the first month it has stabilized, and your production becomes fine-tuned too, so you can supply your baby with exactly what she requires, without wasting energy by producing too much3. This isn’t to say you can’t make more if necessary, but simply that you won’t do it unless the demand is there.

•    Your baby takes less time to feed

Whilst the amount of milk a baby has at each feed remains relatively consistent as he gets older, the speed at which he takes it on board increases. A five month old baby sucks more frequently and ingests more milk with each suck than a two-month old, meaning that he can get through a meal much faster4. Although this gives the impression that he isn’t getting as much milk, you can be reassured he is – he’s simply getting it in a shorter time.

•    Your baby is unsettled, or seems to settle better on formula

The research into colic, crying and the type of food a baby receives presents a confusing picture. Some studies show babies sleep longer if they are breastfed5, while others say formula fed infants are more settled6. One problem that frequently arises with the research in this area is that feeding method is confounded with style of care-giving, and cross cultural studies indicate that the the latter might have a much greater impact on how irritable babies are than the former5. The main thing to remember is that there are many factors affecting how much your baby cries: if you are feeding on demand, a problem with your milk supply is unlikely to be one of them.

•    Your baby feeds more often

A long term study in Sweden has shown that the number of feeds a baby takes in a day can vary by a huge amount, both from baby to baby, and for the same baby over time7. A change in feeding frequency is not unusual, and is not associated with a problem with your milk supply.

•    Your baby’s growth slows after three months

What if your baby has been gaining weight steadily, and then suddenly starts to falter?  The amount of weight babies put on may vary over time for many reasons, but an apparent slow-down from around three months should pretty much be expected. Although the new WHO growth charts were published in 2006, many health care providers (including my own) still aren’t using them, so your baby’s growth is being compared with that of formula fed infants. The really important thing to remember in this situation is that it is actually the breastfed babies’ pattern of weight gain that is considered desirable, so formula fed infants whose growth curve continues to climb are actually gaining too much weight. Or at least this is what the WHO states – presumably the rest of the medical profession will catch up in the next few years.

The issues discussed above frequently cause mothers to worry that they aren’t producing enough milk when in reality their supply is absolutely fine. A baby may cry, fuss or feed more frequently because she is hungry, but this does not mean that her mother is unable to provide her with sufficient milk. The efficient nature of milk production means that if a baby indicates that he needs more milk by taking more at a feed, then the breasts will increase production as required.

The only time to worry is if your baby appears physically ill. If her growth has genuinely stalled, or she is continually tired, weak and listless, there may be a problem: if you’re in any doubt, consult a professional. Just keep in mind that any other ‘symptoms’ of low supply are probably nothing of the sort: as long as your baby is healthy, you almost certainly have nothing to worry about.

  1. Aust Fam Physician. 2006 Sep;35(9):686-9.
  2. Exp Physiol. 1993 Mar;78(2):209-20
  3. J Midwifery Womens Health. 2007 Nov-Dec;52(6):564-70.
  4. J Reprod Fertil. 1999 Mar;115(2):193-200.
  5. Early Hum Dev. 2000 May;58(2):133-40.
  6. Early Hum Dev. 1998 Nov;53(1):9-18.
  7. Acta Paediatr. 1999 Feb;88(2):203-11.