Overcoming Common Breastfeeding Challenges

Medical Expert Interview

Parent and baby closeup of hands
By Ashley Bell
19 min read

Quick Links 

Getting Off to a Great Start

Parent Issues

Baby Issues

Managing Breastfeeding

Special Circumstances

World Breastfeeding Week

Breastfeeding Tips, Tricks, and Advice

Mother breastfeeding her baby and overcoming common breastfeeding challenges

Breastfeeding may be a natural process, but it’s not always simple or easy. Most parents encounter at least a few unexpected challenges. They have pressing questions and want answers from a trusted source. 

That’s why UCLA Health's The BirthPlace offers compassionate, inclusive, and equitable breastfeeding support to all parents in all circumstances. Their breastfeeding support branch favors a team approach, which enables them to help with a range of challenges as unique and diverse as the parents and babies they serve. By collaborating internally, and also across disciplines and branches of the UCLA Health system, they make sure their patients feel supported pre- and postnatally. 

The BirthPlace team put their heads together to address some of the most common breastfeeding questions and concerns they field from day to day. 

Getting Off to a Great Start

Inverted / Retracted / Flat Nipple

Breast and nipple changes are common during the first trimester of pregnancy. Nipples that are inverted early may evert naturally during the subsequent physical changes involved in pregnancy. No action is needed to prepare them for breastfeeding. 

In fact, the BirthPlace team discourages parents from trying to manually force the nipple to evert before the baby comes, explaining that nipple shape hardly affects a baby’s ability to latch to the breast. 

“Remember: Babies don’t nipple feed. They breastfeed,” says Genevieve Thomas, IBCLC. “It doesn't matter if the nipple is sticking out or not with breastfeeding because we’re not sticking nipples into a baby’s mouth like we might with bottle feeding.” 

She says parents should focus on supporting the breast in a way that moves the nipple tissue forward so the baby can get a deep latch. Different feeding holds or manipulations of the breast can be used to enable a latch, no matter the nipple issue. 

Thomas favors exhausting all natural techniques to achieve a latch before turning to tools such as nipple shields, silicone sheaths designed to help a baby grasp the breast. These tools may help with breastfeeding but they may also make things more challenging. A prenatal lactation counseling session can help those with inverted nipples learn more about how to breastfeed. 

Cracked / Sore Nipples

Cracked and/or sore nipples usually stem from latching issues. Latching issues are common while parents and babies learn how to breastfeed but can be easily resolved to make the process more comfortable for everyone.

Different feeding positions can relieve some nipple discomfort while parents work on latching deeply to the breast. Additionally, hydrogel pads can help with moist wound healing and soothing the pain. 

The BirthPlace team says cracked or sore nipples present no cause for alarm and no reason to stop breastfeeding. 

“It’s very important not to stop breastfeeding because it doesn’t feel good. Nipples can take a beating, they can be bleeding, and they can keep on feeding,” says Genevieve Thomas, explaining that a nipple’s highly vascular nature enables quick healing. 

She urges parents to keep breastfeeding instead of prematurely introducing a bottle and seek help right away. If a baby grows accustomed to a firm, thin bottle nipple, they might have a hard time latching to a soft, ample breast. 

Latching Issues

About 50% of babies struggle to latch on the first day of life. The BirthPlace team recommends resolving latching issues within the first 24 hours by making skin-to-skin contact with the baby. 

"Keeping the baby skin to skin as much as possible in the early days after birth is an important and effective way to get off to a great start with breastfeeding," says Nicole Diaz Del Carpio, RN, BSN, IBCLC. 

They advise maintaining this close contact until the baby latches and through the first breastfeeding. 

“We also recommend skin-to-skin contact at any other time there are latching issues. It’s almost like a reset button for the baby and for the baby’s feeding reflexes, such as rooting, gaping, grasping, and suckling,” Diaz Del Carpio says. 

Positioning and understanding how to support a baby’s head can also help with latching concerns. 

“We get a comfortable latch when a nipple is aligned with the baby’s nose, the baby gapes largely, and we help them get up and over the nipple so the nipple is pressed toward the roof of the mouth,” explains Diaz Del Carpio. 

Having been in the fetal position for so long, newborn babies have a natural inclination to bring their heads down—not up and over the nipple. They also have a complex set of neural circuits and reflexes designed to promote eating. They may move their heads erratically in an attempt to latch. 

“They’re still learning how to move their heads, so supporting them can really improve their ability to grasp the breast.” 

Some positions and holds the BirthPlace team teaches include: 

If skin-to-skin contact and/or positioning does not help the baby latch, the team recommends hand expressing the milk and feeding the baby by spoon instead of using a bottle or a pacifier. Introducing bottles or pacifiers too early can lead to a persistent, long-term refusal to latch. The American Academy of Pediatrics recommends introducing a pacifier once breastfeeding is well established at nap and bedtime to help reduce the risk of SIDS.

Cluster Feeding / Growth Spurts

Cluster feeding is when an infant becomes hungry and feeds frequently, sometimes every half hour for several hours. Expect cluster feeding on the second night of a baby’s life. 

“Cluster feeding is normal behavior; it’s one way a baby ‘calls in an order for more milk later.’ Knowing it’s normal can help new parents be prepared,” says Kristie Kirkley Santoyo, IBCLC, explaining that this behavior is a crucial biological process that calls in the milk. 

Second-night cluster feeding, combined with the release of lactation hormones during placenta delivery, leads to increased milk production on the third, fourth, and fifth days of a baby’s life. Breasts will often feel engorged after cluster feeding. 

Engorgement

Engorgement is a feeling of breast heaviness, fullness, and hardness that usually results from copious milk production combined with fluid retention and swelling. 

“Breasts may feel as hard as a rock,” says Genevieve Thomas. “A baby who had been latching well to the soft breast may understandably struggle to latch to something that now feels like a bowling ball.” 

Engorgement can be resolved with gentle hand expression and alternating heat and ice application on the breast. 

“I always tell parents that days 3-5 are hard. The baby is already crying and then the mom starts crying after she delivers the placenta and gets the ‘baby blues,’” Thomas says, explaining that many parents feel sad due to the hormonal fluctuations that come after placenta delivery. 

“There's often a very deep low. I see a lot of parents who want to give up at that time, but it’s actually the time to push through and ask for support." 

Milk Delayed

About 4 in 10 breastfeeding parents experience a delay in their milk coming in. Milk delays may be caused by pre-existing conditions, such as diabetes or gestational diabetes, but more often than not, it’s just a natural part of the body’s learning process. 

“Often it’s just because of inexperience,” Thomas says. “It’s usually a temporary problem that's resolved by day 6 or 7. Just because there's a delay in the milk coming in doesn't mean a parent won't be able to breastfeed.” 

While waiting for the milk to come in, parents can hand express or pump to feed their baby and supplement the diet if necessary. 

"Every drop counts," says Mina O. Jasovic, MHA (candidate) IBCLC, RLC, BFA, PPD, who works closely with families in the neonatal intensive care unit (NICU). 

She says it’s important for parents experiencing milk delays to get support and guidance for properly feeding the baby and keeping the mother breastfeeding. 

“We like to say the golden rule of lactation is to feed the baby and protect the mother's milk supply,” says Genevieve Thomas. 

Protecting the milk supply often means protecting the mother’s breastfeeding instinct and desire, while keeping the breast stimulated with regular hand expression and pumping.  

Parent Issues

Nipple Thrush / Fungal Infection

Babies can develop thrush, a fungal (yeast) infection, in their mouths. However, the BirthPlace team says nipple thrush is a myth. What many people believe to be thrush may actually be nipple vasospasm.

“Thrush only exists in mucosal surfaces,” says Thomas. “Nipples are highly vascular—not a place where a fungal infection would develop.” 

Thrush and fungal infections typically develop in moist areas: the mouth, the vagina, the armpits, or the area beneath the breasts. People with compromised immune systems or with underlying conditions, such as diabetes, have a higher risk of developing below-the-breast fungal infections. 

Learn more about the nipple thrush myth from Katrina B. Mitchell, MD, IBCLC, PMH-C

Nipple Vasospasm

A nipple vasospasm refers to the spasming of blood vessels inside the nipple, which causes burning and/or radiating pain. The BirthPlace team likens it to a migraine in the nipple.

“Vasospasm often happens after breastfeeding, as a result of nipple compression,” says Thomas. “So we first determine why the nipple is being compressed. If it’s latching issues, we resolve those before we evaluate for vasospasm.” 

Those with Raynaud’s syndrome have a high risk for vasospasm. It can also stem from prolonged latching or latching by a baby with facial asymmetry, which can lead to one-sided nipple compression.

Thomas recommends warmth to reduce the discomfort, advising parents to apply a heating pad or hand warmers to the breasts after each feeding. 

“Warmth makes vasospasm better; cold makes vasospasm worse,” she says. “Sometimes hearing a parent complain about nipple pain when they’re cold after taking a hot shower is how we determine the issue is vasospasm.”

Medications in the Calcium Channel Blocker and Selective Serotonin Reuptake Inhibitor (SSRI) classes may also help with vasospasm.

Plugged Duct / Transient Engorgement = Breast Congestion

If a parent continues experiencing breast pain after latching and standard engorgement issues have been resolved, the team investigates other potential sources of the pain, including low milk supply (hypolactation), surplus milk supply (hyperlactation), mastitis, and plugged ducts, which they prefer to call breast congestion or transient engorgement.

“Plugged duct is a misnomer,” says Thomas. “The ducts aren’t plugged or clogged. They’re narrowing from interstitial swelling inside the breast. The milk backs up and produces an area of engorgement or fullness in the breast.”

Preventing breast congestion

Refraining from skipping feedings is one way to prevent breast congestion. 

Thomas says parents often complain about breast congestion during milk regulation periods, which happen about every 6 weeks until the baby is 3 months old. The baby begins sleeping for longer stretches during these periods, and parents may be tempted to skip a feeding to get more sleep.

“It hurts to miss a feeding.” 

The team advises people who may need more sleep, including those with insomnia, narcolepsy, and bipolar disorder, to create plans for protected sleep and enlist support as needed to avoid choosing between sleep and breastfeeding. Sometimes this will involve using a breast pump and is best supported by making a plan with a knowledgeable lactation consultant.

Resolving breast congestion

The BirthPlace team says, contrary to some advice available online, that congestion in the milk-making gland cannot be massaged out. They compare that strategy to attempting to massage fluid out of swollen lymph nodes. 

“Those lymph nodes are telling us something is going on, and we need to fix the something else that's going on,” Thomas says. 

The team advises people to manage breast congestion by: 

  • Breastfeeding normally (or pumping normally if exclusively pumping)
  • Resting 
  • Taking Tylenol or Advil per a physician’s guidance 
  • Alternating heat and ice application 

While they don’t recommend attempting to massage the breasts to resolve the congestion, they say lymphatic drainage massage may help relieve some discomfort. Thomas says this can be done by stimulating the lymph nodes in the clavicle and below the armpit and then sweeping up the breast tissue, away from the nipple. 

“The touch should be light,” she advises. “Any time we touch or handle the breast, I always say: jiggle the jello; don't knead the dough.” 

Mastitis

Mastitis refers to breast inflammation. To reduce unnecessary antibiotic use per the Academy of Breastfeeding Medicine’s clinical protocol on mastitis, clinicians choose treatment depending on the severity and causes. 

Mother struggling holding newborn baby depicting the common breastfeeding challenge of mastitis

Mastitis caused by an infection is characterized by a fever of over 100.3 degrees Fahrenheit and severe breast hardening, reddening, and is usually one-sided. Infectious mastitis may require antibiotics and should be treated as soon as possible to prevent the development of an abscess. It may be caused by an oversupply of milk. 

Mastitis caused by inflammation is characterized by breast congestion accompanied by a mild fever, malaise, and erythema, or patchy redness, on both breasts. Techniques for relieving breast congestion may be useful in many cases of inflammatory mastitis. 

Low Milk Supply (Hypolactation)

Some breastfeeding individuals produce below the average 24-32 ounces of milk a day. In some cases, they don’t produce enough milk to fully feed a baby. Little data exists to precisely define all the factors that may lead to low milk supply, though some cases are associated with pre-existing health conditions and histories, including: 

  • Postpartum hemorrhage
  • Insufficient glandular tissue
  • Tubular breast abnormalities 
  • History of breast reduction, augmentation, or any chest-wall surgery  
  • History of complex health issues 

“A great way to troubleshoot the ability to make milk is to learn prenatally about breastfeeding, work with a lactation consultant to assess milk supply, and start off breastfeeding exclusively in the hospital,” says Debora Brechesi-Milioni, IBCLC. “Even if there is a delay in milk coming, our outpatient clinic can be a valuable asset in meeting breastfeeding goals.”

Many cases of low milk supply may not come with satisfying answers and explanations, but the BirthPlace team focuses on helping parents move forward by working around supply issues. 

“Any amount of breast milk is better than no breast milk and has value in a baby’s diet,” Brechesi-Milioni says.

“We always encourage families, and help them find a plan that’s going to be sustainable for their goals, regardless of their capacity to make milk.”  

Let Down / Milk Ejection Reflex Issues

Oxytocin, often called the love hormone, drives a milk let down, also called a milk ejection reflex. 

“It's the same hormone we have flowing when we're kissing our babies, and it's what bonds us together,” says Genevieve Thomas. “In lactation, it's what causes the smooth cellular structures of the lactiferous ducts to move milk down the ductile system and out to the nipple pores and into the baby.” 

The milk ejection reflex is caused by stimulation of the breast, usually 1-2 minutes of fast suckling or the simulated suckling of a breast pump.  

In some cases, if the breastfeeding individual has hypothyroidism for example, it takes longer than 1-2 minutes for the milk to let down. 

“That may happen if a baby has been bottle fed. They don't know how to trigger the let-down, and the breast doesn't know how to respond to the suckling pattern.” 

Thomas says let-down delays don’t present a problem if breastfeeding has been established. Babies can get plenty of milk; it will simply take longer. 

Some parents may also experience dysphoric milk ejection reflex, where they feel a sense of dread or sadness along with their milk let downs. They should consult their care team to get the right support. 

Breastfeeding Exhaustion

“All new parents, regardless of feeding method, are exhausted, especially in the first 2 weeks. It’s completely normal to feel exhausted,” Thomas says. 

She tells people to adjust their expectations and plan to be exhausted. 

“They might have to sleep and rest at times they’re not used to sleeping and resting.” 

According to the American Academy of Pediatrics safe sleep guidance, tired parents may lay down to breastfeed to reduce the risk of dropping their babies. 

“Learning to lay down and breastfeed is actually one of the safest ways to breastfeed at night. It can take around 6 weeks to learn how to do this well, so I always recommend people practice feeding laying down in the daytime as well,” says Thomas. “There's a high likelihood they'll fall asleep, so they’ll want to have a safety plan in place with partners.” 

Learning and understanding baby behavior can help with parental exhaustion, as well as a range of other issues. 

“Most parents don't know when their baby is fully fed and prematurely put them to sleep only to have them wake up shortly after,” Thomas says. 

That’s why she and her team teach new parents how to observe and interpret a newborn baby’s cues with proper breastfeeding management. 

Breastfeeding Management

Effective breastfeeding management involves understanding baby behavior, specifically a baby’s unique cues for feeding, fullness, fatigue, peeing, pooping, passing gas, and spitting up.

Genevieve Thomas says understanding a newborn baby’s sleep patterns is also important. 

“They alternate from light to deep sleep every 30 minutes,” she says. “All newborn babies struggle to stay asleep because they fall asleep dreaming, and if you lay them down dreaming, they wake right back up. You've got a two-minute window to get them down into the crib in deep sleep.” 

It can be very helpful for the breastfeeding parent to have extra support in soothing and settling the baby back to sleep.

“Any competent adult can settle a baby. It doesn't have to be the person who is breastfeeding.” 

Baby Issues

Baby crying in mother's arms depicting a common breastfeeding challenge

Latching Issues

Jump to the latching issues section.

Baby Spitting Up a Lot

The BirthPlace team tells new parents that spitting up is generally just a laundry problem. 

“We don't see spitting up as a big issue,” Thomas says. “At the beginning of life, babies spit up a lot simply because they don’t know how much milk to take. Their life experience is limited to a few days.” 

Parents concerned about how much their baby is spitting up may troubleshoot by addressing a few different aspects of feeding: 

  • Milk supply. Any oversupply may need to be brought down. 
  • Feeding speed. Fast-flow feeding may be slowed. 
  • Positioning. Trying different feeding positions may mitigate the baby’s issues. 
  • Burping. Parents may need to adjust their burping strategies. 
  • Cue recognition. Better understanding a baby’s cues for hunger, fullness, and gassiness might decrease spit ups.  

Parents should consult their pediatrician if the baby frequently spits up hours after feeding and/or ejects curdled spit up. 

Milk Coming Out of Baby’s Nose

The BirthPlace team reassures parents that milk coming out of a baby’s nose is no cause for concern. 

“Reflux, to some extent, is part of the protective factor of breastfeeding,” Thomas says, explaining that spit up sometimes comes out of a baby’s nose and that the Montgomery gland, which secretes breast milk, may leak milk onto the tip of the nose. 

“It actually coats the mucosal linings, and that’s why we see fewer ear infections in breastfed babies compared to formula fed babies.” 

Choking and aspiration concerns 

Unless a baby has congenital or neurological issues, they generally have efficient neurological reflexes to protect their airways. 

“If we lay them on their back and they spit up, they automatically turn their head to the side,” Thomas says. “In fact, the current literature says the safest position for a baby to be in if they’re going to spit up is on their back, not in a forward prone position.” 

Baby Behavior / Growth Spurts

Parents can prepare themselves for growth spurts by remembering the “rule of three.” 

“Beginning around week 3, and for every 3 weeks after that until they are 3 months old, the baby goes through little growth spurts as they’re doubling their birth weight,” Thomas says, explaining that it’s crucial to support them in this growth through proper feeding. 

The growth spurts are characterized by daily periods of fussiness that last about 3 hours and happen after 3 PM. After the first 3 months, growth spurts slow down to about every 3 months until the baby is about a year old, and then every 6 months after that. 

Thomas says every time a baby gains a couple of pounds, they’ll probably sleep an hour longer at night, which makes things feel significantly easier for the parents.

Managing Breastfeeding

Returning to Work / Pumping

Thinking about returning to work, the theme of this year’s National Breastfeeding Month in August, is crucial for sustaining long-term breastfeeding. The BirthPlace team says families should begin thinking about return-to-work plans for breastfeeding after the 3-week growth spurt. 

“Somewhere between 4 and 6 weeks, we recommend they begin by pumping to build a little stash of milk, about 15 ounces, and also to make sure they’re used to pumping,” Thomas says. 

The team also advises parents to introduce a bottle around 6 weeks. This ensures the baby remembers how to take a bottle and makes them less likely to refuse it later on. 

“We think it’s important to offer a bottle for feeding once a week, or even daily at the parents’ discretion.” 

Nursing Strike

The team says babies may refuse to breastfeed at any time from birth until the first year of life. They follow one primary rule in this situation: Feed the baby and protect the milk supply.

“If a baby is having a nursing strike, start pumping to protect the milk supply about as often as the baby is breastfeeding and then feed them the milk through a bottle,” Thomas advises. 

She says they’ve seen babies refuse to breastfeed for a range of reasons, so parents should get in touch with a lactation consultant to work through their unique issue. 

“Most of the time, babies will come back to breastfeeding. The longest nursing strike of a well-feeding baby I ever saw was 9 days.” 

Breastfeeding Exhaustion

Jump to the breastfeeding exhaustion section.

Other Notes on Breastfeeding Management

The team advises parents to offer both breasts. 

When the baby is breastfeeding from the first breast, milk is being generated in the other one. The team says breastfeeding is not the same as bottle feeding, and that it’s fine to move the baby and even wake them up to switch breasts. 

Parents should watch for signs of ineffective feeding at the first breast and be prepared to switch. 

“Babies often need to switch back and forth multiple times until they're fully fed,” Thomas says. “That's largely because they're learning, and the breast is learning. Practice is important, and recognizing the baby’s cues is important, and that’s when a lactation consultant can really help.” 

If for whatever reason, the baby can’t latch to one breast, it is possible to fully feed a baby from one breast. 

Special Circumstances

The BirthPlace team at UCLA Health has an unwavering commitment to helping lesbian, gay, trans, and gender-diverse patients achieve their breastfeeding, chestfeeding, and infant feeding goals. They’re proud to support all families, including: 

  • Non-birthing parents who want to induce lactation 
  • Trans patients who want to induce lactation 
  • Same sex couples who want to share breastfeeding 
  • Same sex couples who need access to breast milk and support with chestfeeding where no breast is involved 
  • Parents with medical conditions that make breastfeeding a challenge 
  • Parents of babies with medical conditions that make breastfeeding a challenge, including cleft lip and/or cleft palate 

World Breastfeeding Week

For World Breastfeeding Week, the BirthPlace team wants to emphasize a few essential tips to help parents with successful breastfeeding management.  

Feed the baby; protect the milk supply.

One simple way parents can adhere to both tenants of this golden rule is to avoid quitting. 

Keep breastfeeding 

The team says it’s important for parents to keep going, even if and when they encounter any of the numerous issues and concerns that arise with breastfeeding. 

“Breastfeeding is a skill—and as with any new skill it can take a bit of practice until it feels comfortable,” says Emily Magid, IBCLC, MPH, MSW. “Lactation consultants can support parents along their journey, whether that means working on a latch, returning to work, or weaning the baby. We are here to help parents reach their breastfeeding goals.”  

Access support and resources. 

Breastfeeding feels hard because change is hard. The body does a lot of work and goes through many changes to enable breastfeeding. The team encourages people to work through the first difficult weeks and establish breastfeeding. Getting support early and often can help make breastfeeding easier. 

“Find a support circle, whether it’s a UCLA Health weekly group or a community meet up nearby,” says Caroline Armstrong, MSN, RN, IBCLC. “Groups can help new parents navigate their breastfeeding journey alongside other parents who truly understand what they are going through.”

Prenatal Breastfeeding Education 

The 10 Steps to Successful Breastfeeding 

Academy of Breastfeeding Medicine