Many breastfeeding issues, such as painful feeding (for you) and worries about whether your baby is gaining enough weight are usually addressed by ensuring your baby is attached properly – that is, attached to the breast in a way that allows him to feed optimally.

Positioning is a term used to describe how you hold your baby to help her attach to your breast. There are lots of ways that you can hold her and you will find one that is good for you both, but there are a few key principles that will help whichever position you try

• Your baby needs to be held close to you so she doesn’t have to stretch to reach your breast. Make sure blankets, your hands or clothing doesn’t get in the way of closeness
• Your baby’s nose, knees and toes should face the same way so she is not having to turn or twist her head to feed
• You can tempt your baby to open her mouth by gently rubbing your nipple between her nose and top lip. Your midwife may use the term ‘nose to nipple’. This is really important because when your baby opens her mouth and tilts her head back your nipple will the slip under her top lip and come to rest way back in her mouth – out of harms way.
• Her head needs to be free to tilt back so make sure not to hold her head or even put your finger on the back of her head. Support her neck and shoulders to allow free movement of her head.

It’s much easier to learn these steps by watching someone else do them, so do click through to our online breastfeeding course to see all these steps clearly being done by experienced mums. It’s useful for you to have an idea of what your baby should be feeling, so with your tongue, feel the roof of your mouth and you’ll find a soft squishy bit at the back. The nipple will end up towards the back of baby’s mouth. If your nipple ends up on your baby’s hard palate at the front it can get sore for you.

Some babies and mums use positions where mums are more reclined. Sitting up straight isn’t always the best way to breastfeed as you can end up taking all baby’s weight on your arms and hands or becoming dependent on using a cushion.

A breastfeeding group can be a good place to learn some different positions. It can also be helpful to learn how to breastfeed when you are both lying down.

If your baby is properly attached, the feed will be relatively pain-free – although some women report that the ‘let down’ reflex (when the milk comes down) feels a little unusual and takes a bit of time to get used to. An effective attachment means your baby looks as though he has nice fat cheeks (that’s because he has a mouthful of your breast) and you’ll be able to hear and see lots of steady sucking and swallowing.

Lots of mums worry about their baby’s nose being pressed against the breast, but if he can’t breathe he’ll simply pull himself back a little bit. That’s one of the main reasons not to hold him to the breast too tightly – let his head have some freedom of movement. You don’t need to press your finger into the breast to help him breathe. This might lead to blocked ducts as the milk can’t flow freely and you have a hand you can’t use for other things like having a drink. Babies will always prioritize breathing over feeding.

If you’re using the cradle hold to breastfeed:

• Hold your baby close, supporting his neck but allowing his head to move
• Your baby needs to start with his nose opposite your nipple
• Your baby’s head should be free to tilt back
• He comes in chin first
• Wait for your baby to open his mouth really wide
• Your baby should take a big mouthful of breast and your nipple just slips under his upper lip
• Let your baby take the breast, rather than you pushing your breast into his mouth
• If your baby isn’t attached properly, insert your little finger gently into the side of his mouth to break the latch, then start again.

The symptoms of thrush – deeper breast pain or nipple sensitivity – are often confused with other things. If you have never had a period of pain-free breastfeeding or the nipple is cracked and visibly damaged, your problems are more likely to be connected to positioning and attachment problems than thrush. It’s important to get a breastfeeding assessment from your local support group or local breastfeeding counsellor. They will watch a feed and look at the nipple as it comes out of the baby’s mouth to check it isn’t coming out squashed or misshapen.

As well as positioning problems, pain could be caused by a bacterial infection, an allergic reaction or another skin condition. Your doctor may do a swab on the nipple to help identify the cause.

Some common signs that your baby might have thrush include:

• Cottage cheesy or milky looking deposits in your baby’s mouth that don’t come off when you rub them gently
• Upset or fussy eating
• Saliva with a white shine or a pearly sheen on the inside of baby’s lips
• Red or spotty face
• Your baby might have a red sore looking bottom, like a nappy rash
• Sore nipples or infected breast for you.

Sometimes the thrush will go away on its own after a day or two.

If it persists, it’s easy to treat. See your doctor or ask your health visitor for advice. You need to be treated as well as your baby since the infection can be passed back and forth between you.

Your doctor may decide to give your baby some antifungal medicine, like Nystatin or miconazole oral gel. It’s a liquid and you use a dropper to put the prescribed amount on the affected area. The medicine doesn’t usually cause any side-effects and most babies have no problem with it.

Mums will usually be given cream (oral gel and nystatin aren’t designed to be used on nipple skin).

Follow advice from your doctor. It’s usually best to give your baby his oral thrush medicine just after he has had a feed or drink.

Once the infection has cleared up, continue to use the medication for another two days. If the thrush hasn’t gone after seven days of continuous treatment, go back to your doctor.

Mastitis is an inflammation in your breast tissue. If not treated quickly, the inflammation may quickly become an infection.

In our videos, we show what a breast with mastitis is likely to look like. Areas of your breasts might be:

• Red
• Hot
• Painful
• Hard
• Swollen.

You may also feel an inflamed lump, which is from the build-up of milk in your breast. This is usually what causes the mastitis. You may also have flu-like symptoms, such as:

• Chills
• Headache
• Exhaustion
• High temperature.

Having mastitis is painful and can make you feel really miserable. Luckily, with the right approach, it can be cleared up quickly. It’s usually only in one breast, but it’s possible to have it in both breasts at the same time. Unfortunately, you can get mastitis more than once.

It’s most common in first-time mums and during the first few weeks when you’re getting the hang of breastfeeding.

Common causes of mastitis:

• Build up of milk in your breast
• Usually caused by ineffective poor attachment
• Cracked nipples becoming infected.

Ineffective attachment

The number one cause of sore nipples and mastitis is ineffective attachment – the milk isn’t being drained from the breast efficiently, so instead builds up in the milk ducts and milk storage areas. And your nipple will soon get sore if your baby has an incorrect latch. Nipple creams don’t solve this problem – they just soothe the symptoms, so it’s really important that you get help immediately from your midwife, doctor or a breastfeeding counsellor at your local breastfeeding drop-in clinic.

The good news is that once your baby attaches properly, things will start to clear up very quickly.

Treating mastitis

Follow these steps to help manage the symptoms of mastitis:

• It is crucial that you continue to breastfeed as stopping will make mastitis a lot worse. Feeding with mastitis will not harm your baby in any way.
• Feed on affected breast first as early vigorous suckling will clear the blockage. If it hurts too much start on other side and move to affected side after a few minutes.
• Massage the swollen lumpy area during feeding to help clear the blockage. A wide toothed comb can help as a massage aid if area very sensitive.
• After feeding, express your breast to empty it as much as possible. Warm flannels or running a warm shower over your breast will encourage a good flow of milk.
• Continue to feed/express frequently until symptoms improve.
• Take care of yourself. You need to rest and drink lots of fluids. Over counter painkillers can help with pain and anti-inflammatory tablets will reduce inflammation but seek advice from your health visitor or doctor before taking the latter.
• If your symptoms do not improve within 12-24 hours you may need antibiotics and contact your GP immediately if you see pus on your nipples or if you feel very unwell.
• If you have a crack on your nipple, you can use a medical grade lanolin cream (if you are not allergic to lanolin) or white petroleum jelly to prevent scabbing and promote moist wound healing of cracked nipples.
• Wash the areas daily with plain soap and water, no perfumed products.
• Try the rugby breastfeeding position on that side, changing positions can often help clear things up. Some mums use a ‘dangle feed’ where they lie baby on a flat surface and lean over them on all fours. The breast dangles over the baby.

You need to do two separate things if you get sore or cracked nipples or mastitis:

1. Get expert help to solve the cause of your sore nipples – You need to get help from the most skilled person available to you. This could be your midwife, a peer supporter, breastfeeding counsellor or lactation consultant. The most important thing is not to suffer in silence – it’s an issue that affects many, many breastfeeding mums and there’s nothing to be ashamed of. Breastfeeding may be ‘natural’ but that doesn’t mean we don’t need a little help sometimes!
2. Treating your sore nipples – If you have sore nipples there are a number of things you can do which may help to relieve the pain and promote healing. Remember that your nipples will only heal if you also remove the cause of the pain – once your baby starts to feed effectively, with a good latch, your nipple should start to heal. If the cause of the pain is thrush you’ll need to get the right thrush treatment – nipple creams won’t help.

• Try to feed on the uninjured nipple first and then move to the sore nipple second as your baby may not feed as vigorously at the second breast being offered
• Let the fresh air get to your nipples – don’t let them get too wet against damp breast pads as this can cause further tissue damage
• If you have a crack on your nipple, you can use a medical-grade lanolin cream (if you’re not allergic to lanolin), soft white paraffin or a dressing designed for nipples to prevent scabbing and promote moist wound healing of cracked nipples
• If you feel like you are unable to feed on the injured nipple for a time, speak to your breastfeeding counsellor about expressing from that side or hand express from that side if using a breast pump is too painful. If you are resting an injured nipple, though, you’ll need to use a method that means you can take the milk out regularly and effectively or you may be at greater risk of developing mastitis.
• Nipple shields are a last resort and will not solve the cause of your cracked nipples. It’s vital to get expert help with positioning and correct your baby’s latch, which will enable you to heal and feed comfortably and quickly
• Wash the affected areas daily with plain soap and water – no perfumed products. Dry gently.
• If an infection has developed, see your doctor, who may prescribe antibiotics. Your doctor can help you find antibiotics that are safe to combine with breastfeeding. Always finish a course of antibiotics, even if you think you are getting better. If we don’t finish a course, the strain of bacteria may become resistant to antibiotics or your symptoms can reoccur.

• Try some new breastfeeding position on that side, as changing positions can often help clear things up. Some mums use a ‘dangle feed’ where they place their baby on a flat surface and lean over him on all fours letting the breast dangle over the baby.
• Feed little and often – don’t wait between feeds
• Wear loose, non-irritating clothes
• Drink lots of water
• Gentle massage and warm compresses can help encourage ‘stuck’ milk to move
• Ibuprofen or paracetamol can help with pain and inflammation
• Don’t stop breastfeeding or expressing. This just leads to more milk build-up and will make the situation worse. In severe cases, if milk isn’t moved, a mother with mastitis may go onto to develop an abscess that requires more complicated treatment.
• Remember, feeding from a breast with mastitis won’t affect your baby and will help you to get better more quickly.