Changes

June 2026 — reviewed. A literature search was conducted in May 2026 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of the topic. No major changes to recommendations have been made.

Update

Goals

To support primary healthcare professionals to:

• Help prevent breastfeeding problems.
• Recognize breastfeeding problems promptly.
• Assess the woman and infant, and refer to a breastfeeding specialist to assess and advise on positioning and attachment if needed.
• Manage breastfeeding problems in primary care, where appropriate.
• Refer to a specialist, when appropriate.

Outcome measures

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

QIPP - Options for local implementation

No QIPP indicators were found during the review of this topic.

NICE quality standards

Postnatal care

• Women receive breastfeeding support from a service that uses an evaluated, structured programme.

[NICE, 2022]

What are breastfeeding problems?

• The World Health Organization (WHO) recommends exclusive breastfeeding until an infant is 6 months of age, with the introduction of solid food around this time and continued breastfeeding up to 2 years of age or longer.
  • Advantages for the infant include nutritional benefits, a reduction in the incidence and severity of infections (including ear, chest and gastrointestinal infections) and asthma. Studies have also shown that children and adolescents who were breastfed as babies are less likely to be overweight or obese.
  • Advantages for the mother include reduced rates of breast and ovarian cancer, diabetes mellitus and hypertensive heart disease.
• Breastfeeding problems which may lead to a mother stopping breastfeeding include:
  • Breast pain.
  • Nipple pain.
  • Low milk supply (true and perceived).
  • Oversupply of milk.
• Effective and efficient breastfeeding requires optimal infant positioning and attachment to the breast. If this is not achieved, there may be:
  • Reduced milk transfer.
  • Reduced stimulation of breast milk production.
  • Insufficient milk to match the infant's needs, leading to possible dehydration and faltering growth.
  • Nipple pain and damage leading to other possible breastfeeding problems.

[Berens, 2016a; Westerfield, 2018; GPIFN, 2019a]  [Pereira, 2021; Page, 2022; Douglas, 2022; ACOG, 2023; WHO, 2023; NICE, 2025a; NICE, 2025b; WHO, 2025]

What are the causes of breast pain?

There are a variety of causes of breast pain in breastfeeding women, and more than one cause may co-exist.

• Engorgement
  • Primary engorgement occurs in the first few days after birth and is usually an indication that mature milk is being secreted. If milk is not removed effectively and frequently, the alveolar ducts distend, and the breasts become swollen and painful. As the body adjusts in response to the baby’s feeding, this congestion and swelling settles.
  • Secondary engorgement can occur at various times throughout the breastfeeding period if there is an imbalance between milk production and removal, for example, if breastfeeding is less frequent or restricted (for example due to illness); infant demands decrease; or weaning off breastfeeding happens too quickly.
  • Engorged breasts are painful, and oedema can prevent the baby from latching on well, increasing the risk of cracked nipples and more pain.
  • Risk factors for severe symptomatic breast engorgement include large amounts of intravenous fluids during labour and past history of premenstrual breast tenderness or breast surgery.
• Compressed or blocked ducts
  • These may be caused by milk stasis, due to ineffective removal of milk from part of the breast. This may be due to suboptimal positioning and attachment, infrequent breastfeeds, or the infant not being fed on demand. Other causes include tight clothing or trauma to the breast, which may obstruct milk flow.
  • Compressed or blocked ducts may lead to the formation of a milk-filled cyst (galactocele) and/or mastitis.
• Ductal infection
  • The phenomenon of 'ductal infection' is controversial in the literature, and definitions vary, with some overlap between bacterial dysbiosis, lactiferous ductal infection, and subacute mastitis.
  • Proposed mechanisms include bacterial overgrowth and biofilm formation (possibly in conjunction with Candida), which may lead to narrowed lactiferous ducts and epithelial inflammation.
  • Some studies have found a correlation between symptoms and the presence of Candida; others have not.
• Mastitis and breast abscess
  • Mastitis may be infectious or non-infectious, and is usually secondary to milk stasis.
  • A breast abscess is a localized collection of pus within the breast which requires urgent referral to secondary care for treatment.
  • See the CKS topic on Mastitis and breast abscess for more information.

[Berens, 2016a; Westerfield, 2018; GPIFN, 2019b; GPIFN, 2019c; Zakarija-Grkovic, 2020]  [Amir, 2021; Mitchell, 2022; ACOG, 2023; NICE, 2025b; WHO, 2025] 

What are the causes of nipple pain?

There are a variety of causes of nipple pain in women who are breastfeeding, and more than one cause may co-exist.

• Physiological
  • Nipple pain caused by initial milk let-down is common in the first few days post-partum, and usually settles within a few weeks when the infant removes milk effectively and frequently.
• Nipple damage
  • Suboptimal infant positioning and attachment is the most common cause of nipple damage. Abnormal compression of the nipple between the tongue and hard palate may cause suction trauma.
  • Infant anatomical conditions such as ankyloglossia (tongue-tie) may cause restricted tongue movement due to an abnormally short or thickened lingual frenulum, which may affect the infant's ability to suck. Cleft lip and/or palate may also cause nipple damage by affecting infant attachment to the breast.
  • Maternal anatomical variation such as flat, inverted or large nipples (especially if non-protractile) may affect infant attachment. Nipple protractility usually improves in the first few weeks post-partum.
  • Use of a breast pump with an ill-fitting flange or too high pressure may also cause breast or nipple trauma.
• Blocked ducts
  • These may be caused by milk stasis, due to ineffective removal of milk from part of the breast.
  • This may be due to suboptimal positioning and attachment, infrequent breastfeeds, or the infant not being fed on demand. Other causes include tight clothing or trauma to the breast, which may obstruct milk flow.
• Nipple infection
  • Bacterial, fungal, or viral infection of the nipple/areola can occur.
  • The association of Candida infection with nipple pain remains controversial, but if pain persists after effective positioning and attachment, Candida infection should be considered. There may be signs of associated infant oral or nappy area Candida infection, or infection may follow maternal or infant antibiotic treatment. See the CKS topics on Candida - skin and Candida - oral for more information.
  • Bacterial infection may result from damaged skin over the nipple area being rapidly colonized with Staphylococcus aureus, which may be asymptomatic or may cause clinical infection. See the CKS topic on Impetigo for more information.
  • Bacterial and candidal infection may co-exist.
  • Viral infection of the nipple or breast can occur, for example, due to herpes simplex or varicella zoster. Be aware that transmission of some viral infections during breastfeeding can lead to serious illness, especially in neonates or immunocompromised children. For more information, see the CKS topics on Chickenpox and Herpes simplex.
• Skin conditions
  • Atopic eczema on and around the areola may be triggered by skin irritants.
    • See the CKS topic on Eczema - atopic for more information.
  • Irritant contact dermatitis may be caused by breast pads, soaps, detergents, fragrances, and topical creams. Allergic contact dermatitis may be caused by skin care products, cosmetics, nail varnish, fragrances, and topical antibiotics.
    • See the CKS topic on Dermatitis - contact for more information.
  • Psoriasis may flare up post-natally, or as a response to skin injury (Koebnerization) from infant attachment, sucking, or biting.
    • See the CKS topic on Psoriasis for more information.
  • Paget's disease of the nipple (rare) may mimic eczema, but is usually unilateral, persistent, and unresponsive to treatments for eczema.
    • See the CKS topic on Breast cancer - recognition and referral for more information.
  • Be aware that any loss of epidermal integrity due to a skin condition may lead to secondary skin infection.
• Nipple vasospasm or Raynaud's phenomenon of the nipple
  • This is caused by episodic vasospasm and ischaemia of the small blood vessels of the nipples, often triggered by exposure to cold temperatures.
  • It is more common in women with a known personal or family history of Raynaud's phenomenon of the digits, and it may be associated with underlying connective tissue disorders, such as rheumatoid arthritis or scleroderma.
  • See the CKS topic on Raynaud's phenomenon for more information.

[Berens, 2016a; Westerfield, 2018; GPIFN, 2019c; Bourdillon, 2020; Johansson, 2020; Amir, 2021; Pereira, 2021; Douglas, 2022; ACOG, 2023; Evans, 2023; Moreira, 2024; BAD, 2025; WHO, 2025]

What are the causes of low milk supply?

There are a variety of causes of low milk supply in women who are breastfeeding, and more than one cause may co-exist.

• True maternal low milk supply is uncommon.
  • If other causes have been excluded or are unlikely, there may be a subjective maternal perception of insufficient milk supply.
• Reduced milk intake by the infant.
  • If the infant takes only small amounts of milk from the breast, milk production decreases, as effective milk removal is needed to stimulate milk supply. This may occur due to:
    • Insufficient access to the breast (short or infrequent feeds, no night feeds, use of a dummy, nipple shield, giving supplementary feeds other than breast milk, maternal or infant illness, or regular mother-child separation, for example, due to work) — this results in reduced suckling at the breast and subsequently reduced milk production.
    • Suboptimal removal of milk, for example, due to incorrect infant positioning and attachment.
    • Maternal depression, stress, and/or anxiety, which may result in a reduced response to infant feeding cues and a reduced frequency of feeds and reduced stimulation of milk production.
• Maternal prolactin deficiency related to:
  • Drugs, such as oestrogen, combined hormonal contraceptives, dopamine, ergotamine, pyridoxine, nicotine, and alcohol.
  • Anterior pituitary dysfunction, for example, due to severe post-partum haemorrhage and post-partum pituitary necrosis (Sheehan's syndrome, rare).
  • Retained placental fragments.
  • Thyroid disorders, for example, hypothyroidism or post-partum thyroiditis. Consider testing thyroid function to exclude thyroid disorders. See the CKS topics on Hypothyroidism and Hyperthyroidism for more information.
  • Eating disorders such as bulimia.
• Maternal anatomical factors, such as:
  • Hypoplastic breasts (rare, characterized by widely spaced breasts with prominent areolas, due to insufficient glandular tissue).
  • Breast surgery (may interfere with normal nipple sensation which affects milk supply).

[Anderson, 2017; Brodribb, 2018; Grzeskowiak, 2019; GPIFN, 2019d; ACOG, 2023; SPS, 2024; WHO, 2025]

What are the causes of milk oversupply?

There are a variety of causes of milk oversupply in women who are breastfeeding, and more than one cause may co-exist:

• Physiological
  • Milk oversupply is common in the first few weeks post-partum, as the mother adapts to the infant's requirements.
• Suboptimal infant positioning and attachment
  • The infant may not remove milk efficiently and so suckles more, stimulating the breast to produce excessive milk.
• Breastfeeding pattern
  • Moving the infant too early to the second breast before they have finished feeding from the first breast.
  • Excessive expression of breast milk by hand or pump.

[Berens, 2016a; GPIFN, 2019b; Johnson, 2020; ACOG, 2023; WHO, 2025]

How common are breastfeeding problems?

• The UK has one of the lowest rates of breastfeeding in Europe — reasons for this are complex, but experience of problems while breastfeeding is likely to be a contributing factor [RCPCH, 2021].
  • A review of national data from high-income countries found that the prevalence of any breastfeeding at 6 months varied from 4–78%. Rates were highest in Norway (78%), Finland (76%), Iceland (75%), and Sweden (63%). Lowest prevalence levels were reported by Wales (23%) and Northern Ireland (4%) [Vaz, 2021]. 
  • Data on breastfeeding rates at 6 months in the UK is inconsistent, lacks standardization, and is not routinely collected for England or Scotland. 
• The Infant Feeding Survey 2024 (a national survey asking mothers in England about their experiences of feeding their infants) found that [OHID, 2024]:
  • In mothers who stopped breastfeeding when their babies were between 2–5 months (n=1475):
    • 45% stopped because their baby was not latching on or was rejecting the breast.
    • 44% stopped because they did not have enough milk.
    • 25% stopped because they had painful breasts or nipples.
    • 20% stopped because their baby was always hungry.
  • In all mothers who had ever fed their baby breast milk up to 7 months (4527 mothers), nearly 3 in 5 (56%) stated that they had experienced pain, with similar proportions experiencing:
    • Sore nipples with no obvious damage (31%).
    • Sore nipples that were damaged or cracked or bleeding (25%).
    • Painful breasts (25%).
  • Overall, around 7 in 10 mothers who had fed their baby breast milk at any stage up to 7 months had experienced breastfeeding problems:
    • 42% reported breast engorgement; 25% reported difficulty with the baby taking the breast or not sucking effectively; 25% reported insufficient milk; 20% reported blocked milk ducts; 17% reported tongue tie; and 12% reported mastitis.
    • First-time mothers (76%) were more likely to have experienced difficulties compared with mothers who already had children (70%).
    • Mothers living in the least deprived areas (79%) were more likely to have experienced difficulties while breastfeeding than mothers living in the most deprived areas (66%).

How should I assess a woman with breastfeeding problems?

Assessment should include history and examination of both the mother and infant.

• Ask about:
  • Breastfeeding history, including:
    • Concerns the parents have about their baby's feeding.
    • Pattern of breastfeeding (frequency, duration, night feeds, one or both breasts offered).
    • Presence of breast or nipple sensitivity before pregnancy.
    • Milk supply issues (engorgement and low or oversupply).
    • Expressing of milk (frequency, hand or pump used).
    • Other fluids or foods given (when started, quantity, and frequency).
    • Use of nipple shields or breast shells.
    • Maternal beliefs, concerns, and expectations about breastfeeding, including sources of support and barriers to breastfeeding.
    • Previous breastfeeding experiences, problems, and pain.
  • Breast and/or nipple pain history, including:
    • Time of onset post-partum.
    • Presence of nipple trauma (abrasions, fissures, or bleeding).
    • Timing (for example, with attachment, during breastfeeds, between breastfeeds, or with expressing of milk) and whether intermittent or constant.
    • Location (for example, unilateral or bilateral, nipple and/or breast, superficial or deep).
    • Character and severity (for example, burning, itching, sharp, or dull).
    • Presence of associated signs and symptoms (such as fever, breast skin changes, malaise, nipple colour changes, nipple shape, or appearance after feeds).
    • Exacerbating or relieving factors (such as cold, heat, massage, or touch).
    • Previous treatments (such as analgesia and topical or oral drugs, including antibiotics).
  • Maternal history, including:
    • Complications during pregnancy, labour, or post-partum.
    • Known medical conditions, such as thyroid disorders, diabetes, Raynaud's phenomenon, eczema or psoriasis, recent Candida or bacterial infection, chronic pain syndromes, and family history of ankyloglossia (tongue-tie).
    • Previous breast surgery.
    • Medications and allergies.
    • Alcohol and smoking.
    • Associated insomnia, stress, anxiety, or depression. For more information see CKS topics on Depression - antenatal and postnatal and Insomnia.
  • Infant history, including:
    • Birth gestation, birth trauma, and known medical conditions or congenital abnormalities.
    • Birth weight, weight gain, general health, and behaviour (for example, settled or crying).
    • Number of wet and dirty nappies (including stool colour).
    • Behaviour at the breast (for example, rhythmic sucking and audible swallowing, pulling, biting, coughing, breathlessness, or sleepiness).
    • Gastrointestinal symptoms which may suggest oversupply of milk, gastro-oesophageal reflux disease, or cows' milk protein allergy. For more information, see the CKS topics on GORD in children and Cows' milk protein allergy in children.
    • Known ankyloglossia or cleft lip and/or palate and any treatment received.
    • Use of a dummy or pacifier.
• Examine the mother:
  • Carry out a general examination, look for signs of infection or systemic illness.
  • Inspect the nipples and breasts to identify flat or inverted nipples, skin damage, discharge, crusting, fissuring, discolouration, peau d’orange, individual lesions, or rashes.
  • Palpate the breasts to identify any breast lumps, firmness, or tenderness.
• Examine the infant:
  • Carry out a general examination, look for signs of dehydration, jaundice, lethargy, and inconsolability.
  • Check head and neck symmetry, facial features and oral anatomy (ankyloglossia, palate, jaw, and lips), muscle tone, neurological maturity, and behaviour.
  • Look for signs of oral Candida infection.
• Consider use of the UNICEF UK Baby Friendly Initiative Breastfeeding assessment form which may indicate when there is a breastfeeding problem requiring further assessment and observation of a full breastfeed.
• Ensure that a person with appropriate training and expertise (such as a health visitor or breastfeeding specialist) observes the woman:
  • Breastfeeding to check:
    • Maternal and infant positioning.
    • Attachment (mouth wide-open with lips everted).
    • Behaviour at the breast.
    • Pattern of sucking.
    • Shape and colour of nipples after feeding.
  • Expressing milk to check:
    • Hand and/or breast pump expressing technique.
    • Breast shield/breast pump flange fit — nipple or breast trauma may occur due to breast pump use (for example from improper flange fit, excessive high pressure suction, or prolonged duration of use).
• Consider arranging a skin swab of the nipple and/or breast for microscopy and culture, if there is:
  
  • Suspected bacterial, viral,  or candida infection, particularly in the presence of vesicles of the nipple (this may indicate the presence of herpes simplex virus). 
    • Be aware that transmission of infections such as herpes simplex or varicella zoster to an infant can cause serious illness, especially in neonates or those with immunocompromise. If suspected, seek urgent specialist advice.
    • See the section on nipple infection in Management for more information.
  • An uncertain diagnosis — discuss with a specialist if unsure. In some cases, culture of breast milk may be indicated. For information on taking a sample for breast milk culture, see the CKS topic on Mastitis and breast abscess.

How should I diagnose the cause of breast pain?

Following a full assessment of the woman and infant, diagnose the underlying cause of breast pain, where possible.

• Engorgement
  • Breast pain typically starts in the first few days after birth, is often bilateral and worse before a feed.
  • Infant attachment may be difficult due to breast fullness and milk flow may be reduced.
  • The whole breast is typically swollen and oedematous and may be shiny, diffusely erythematous and may leak excessively.
  • The nipple may be stretched and look flat in appearance.
  • The infant may cough and pull off the breast on feeding or clamp down on the nipple during feeding to control flow.
• Compressed or blocked ducts
  • May present with a localized, tender cord of tissue in one breast (usually a few centimetres in diameter), which may be relieved by expression of milk — overlying skin may be erythematous.
  • A small white spot (bleb) about 1 mm in diameter may be present at the end of the nipple.
• Galactocele
  • A galactocele develops when milk collects in a cyst-like cavity as a result of obstruction to flow due to a blocked or narrowed duct. It typically presents as a smooth, round, painless breast swelling which causes milky nipple discharge when pressed. 
  • Galactoceles may increase or fluctuate in size over time. They are not associated with erythema or systemic symptoms unless they become infected.
• Mastitis and breast abscess
  • The woman often has a fever and is systemically unwell — mastitis may present with a hard painful swelling in a wedge-shaped distribution in one breast, with erythema of the overlying skin.
  • A breast abscess may present with a worsening painful breast lump, which may be fluctuant, and the overlying skin is often erythematous and warm. There may be a persistent fever and systemic symptoms.
  • See the CKS topic on Mastitis and breast abscess for more information.
• Neuropathic pain
  • For more information please see the CKS topic on Neuropathic pain - drug treatment. 

How should I diagnose the cause of nipple pain?

Following a full assessment of the woman and infant, diagnose the underlying cause of nipple pain, where possible.

• Physiological milk let-down pain
  • There is often pain for the first few minutes of breastfeeding, which resolves with continuation of the feed.
  • Pain often improves during the first few weeks of breastfeeding.
• Nipple damage
  • Suboptimal positioning and attachment typically cause nipple pain at the start of a breastfeed that continues throughout the feed.
  • Pressure from suckling may cause blanching and compression of the nipple, and fissuring across the top of the nipple or around the base. There may be flattening of the nipple from side to side, with a pressure line across the tip.
  • Nipple damage may also occur due to infant ankyloglossia (tongue tie) or breast pump misuse or trauma.
• Compressed or blocked ducts
  • Compressed or blocked ducts may be associated with a small white, yellow, or clear spot (bleb) about 1 mm in diameter (or larger) at the end of the nipple (sometimes called a milk bleb or blister). There may be a localized, tender cord of tissue in one breast, which may be relieved by expression of milk; the overlying skin may be erythematous.
• Nipple infection
  • Bacterial infection may present with purulent nipple discharge, crusting, redness, and fissuring, and is often associated with skin trauma such as persistent cracks and fissures. See the CKS topic on Impetigo for more information.
  • Viral infection (such as herpes simplex, herpes zoster or varicella zoster) may present with vesicular rash affecting the breast.
    • Be aware that transmission of some viral infections during breastfeeding can lead to serious illness (which can be life-threatening), especially in neonates or immunocompromised children.
    • For more information see the section on nipple infection in Management and the CKS topics on Chickenpox, Herpes simplex and Shingles.
  • Candida infection — the association of Candida infection with nipple pain remains controversial, but if pain persists after effective positioning and attachment and other causes have been excluded, Candida infection should be considered.
    • There may be signs of associated infant oral or nappy area Candida infection, or infection may follow maternal or infant antibiotic treatment.
    • See the CKS topics on Candida - skin and Candida - oral for more information.
• Skin conditions
  • Eczema, psoriasis, and contact dermatitis of the areola and nipple may cause itching of the skin.
    • Eczema typically causes a bilateral red, dry, scaly rash which may have lichenified (thickened) areas, which tend to spare the base of the nipple.
    • Psoriasis typically causes red plaques with clearly demarcated borders, which may have a fine overlying scale.
    • Irritant dermatitis may occur due to soaps, nipple creams and other substances in direct contact with the breast.
    • See the CKS topics on Eczema - atopic, Dermatitis - contact, and Psoriasis for more information.
  • Paget's disease of the nipple may mimic eczema, but is usually unilateral, persistent, and unresponsive to treatment for eczema. In addition, there may be skin ulceration or erosions.
    • See the CKS topic on Breast cancer - recognition and referral for more information.
• Nipple vasospasm or Raynaud's phenomenon of the nipple
  • Nipple pain (may be described as shooting, throbbing or burning) is typically intermittent, and present during and immediately after breastfeeds, and in between feeds if exposed to cold temperatures.
  • Blanching of the nipple may be followed by cyanosis and/or erythema.
  • Nipple pain resolves when the nipple returns to its normal colour.
  • There may be a personal or family history of Raynaud's phenomenon of the digits. See the CKS topic on Raynaud's phenomenon for more information.

How should I diagnose the cause of low milk supply?

Following a full assessment of the woman and infant, diagnose the underlying cause of low milk supply, where possible. 

• Note that there may be a subjective maternal perception of insufficient milk supply. However, causes can include the following:
• Insufficient access to the breast
  • Suggested by short or infrequent feeds, and/or no night feeds.
  • Use of a dummy or giving supplementary feeds other than breast milk may also contribute.
  • Maternal depression, stress, and/or anxiety may result in a reduced response to infant feeding cues and a reduced frequency of feeds, which leads to reduced stimulation of milk production.
• Suboptimal infant positioning and attachment
  • Suggested by nipple pain/trauma; frequent feeding more than every 1 to 1.5 hours; no long intervals between feeds; feeding for less than five minutes or longer than 30 to 60 minutes duration.
  • The infant may be generally unsettled, have faltering growth, or show signs of dehydration.
• Maternal prolactin deficiency
  • Maternal conditions that may lead to prolactin deficiency and true low milk supply include thyroid disorders, polycystic ovarian syndrome, retained placenta, postpartum pituitary necrosis, alcohol use, and eating disorders. 
  • Some medications, such as hormonal contraception, can also have a suppressive effect on lactation.  
  • Consider testing thyroid function and serum prolactin levels, depending on the clinical presentation.
  • See the CKS topics on Alcohol - problem drinking, Eating disorders, Hypothyroidism, Hyperthyroidism, and Polycystic ovarian syndrome, for more information.
• Maternal anatomical conditions such as hypoplastic breasts causing a lack of glandular tissue, or a history of breast surgery.

How should I diagnose the cause of milk oversupply?

Following a full assessment of the woman and infant, diagnose the underlying causes of milk oversupply, where possible.

• Suboptimal infant positioning and attachment
  • The infant may not remove milk efficiently so suckles a lot, stimulating the breast to produce excessive milk.
• Breastfeeding pattern
  • Moving the infant too early to the second breast before they have finished feeding from the first breast.
  • Overstimulation due to excessive expression (by hand or pump) between breastfeeds.
• The mother may describe:
  • Breast fullness and possible engorgement or blocked ducts.
  • A painful, forceful milk let-down reflex.
  • Milk leakage and/or milk spraying from the opposite breast when feeding.
• The infant may:
  • Choke and splutter when let-down occurs.
  • Clamp down on the nipple or pull off the breast during feeds.
  • Have colic or frequent explosive loose stools.
  • Faltering growth if unable to feed adequately.

Scenario: Breastfeeding problems - management

From age 14 years onwards (Female).

Paracetamol

• For prescribing information on paracetamol, see the CKS topic on Analgesia - mild-to-moderate pain.

Topical fusidic acid

Topical miconazole

Topical mupirocin

Search strategy

Scope of search

A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of breastfeeding.

Search dates

November 2021 - May 2026

Key search terms

Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.

• Breast Feeding/ breast.tw, breastfeed$.tw, exp Nipples/, nipple$.tw
• exp lactational disorders/ exp galactogogues/
• breast cyst/, galactocele.tw, Raynaud disease/, raynaud.tw, Breast Implants/, Mammaplasty/, cytomegalovirus Infections/, exp Cytomegalovirus/
• Breast feed$ or breast-feed$).ti,ab.
• Breast N3 engorg$.ti,ab.

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.