Presentation on theme: "Management of Common Breastfeeding Situations"— Presentation transcript:
1Management of Common Breastfeeding Situations Breastfeeding Residency CurriculumPrepared byEmilie Sebesta, MD, FAAPUniversity of New Mexico
2Breastfeeding Assessment Before being able to address common breastfeeding situations, the physician needs to assess breastfeeding by observing the infant feeding at the breastSee Basic Breastfeeding Assessment presentationThe following presentation discusses how to manage common breastfeeding situations and administer treatment to the breastfeeding dyad
3ObjectivesAt the end of this presentation, the learner will be able to discuss:The normal course of establishment of breastfeeding and trouble signsSigns of adequate milk supplyCommon causes and management of reduced milk supplyNormal pattern of weight gain in the breastfed infantCommon causes and management for slow weight gain in the breastfed infantCommon causes and management of sore nipples or poor latch, including inverted nipples
4Prevention, Prevention, Prevention Prevention is the most effective way to deal with the management of low milk supply (real or perceived), sore nipples, and poor weight gainUnderstanding and being able to explain to mothers how normal breastfeeding is established is the key to prevention
5Establishment of Breastfeeding — Hormonal Control Prolactin signals alveolar production of milkOxytocin causes milk to be ejected into the duct system (“let down”)Feedback Inhibitor of Lactation (FIL) – small whey protein whose presence decreases milk productionEffective, frequent emptying of the breasts is essential to milk productionFeedback Inhibitor of LactationBreast is fullBreast is emptierPresence of FIL slows milk synthesisLess FIL present speeds up milk synthesis• Effective stimulation of the nipples causes release of prolactin. Prolactin levels are highest at night and about 45 minutes after a feeding.• Stimulation of the areola causes oxytocin release.• FIL builds up as milk accumulates in the lumen of the mammary gland. If the breast is not drained adequately, volume of milk may be reduced.
6Establishment of Breastfeeding — Infant Role Healthy newborns should breastfeed within the first hour of lifeNewborns should feed 8–12 times per 24 hoursSome normal patterns include:Nursing almost continuously for several hours then sleeping for several hoursBreastfeeding every 30–40 minutes for approximately 10 minutes around the clockFrequent feedings between 9 pm and 3 amEvery infant and mother are different
7Pictured on this slide are the different types of breastfeeding styles Pictured on this slide are the different types of breastfeeding styles. Understanding these styles can help physicians and others to assess and support breastfeeding.Table 7-5 Infant Breastfeeding Styles, p. 86, Breastfeeding Handbook for Physicians
8Establishment of Breastfeeding — Maternal Role Teach mother infant feeding cues:RootingSucking movements or soundsPutting hand to mouthRapid eye movementCooing and sighingRestlessnessNewborns feed 8–12 times every 24 hoursThe infant may need to be woken to feed• Infant cues can include rooting, sucking movements or sounds, putting hand to mouth, rapid eye movements, cooing or sighing, and restlessness.• To wake baby, try undressing baby or removing blankets, changing diaper, placing infant skin-to-skin, or massaging skin.
9Establishment of Breastfeeding — Provider Role Discourage infant-mother separation and encourage breastfeeding within the first hour after birthHelp with proper positioning and attachmentEncourage rooming in and feeding on demandEducate mothers about:Normal volume of colostrumNumber of times the infant should stool and voidWhen milk “comes in”Discourage supplementationProvide follow up 48–72 hours post-dischargeEducate mothers that the small volume of colostrum that is expressed in the first days is normal and adequate nutrition for their baby.Educate mothers that their “milk” may not come in for a few days and that this is normal.
10Establishment of Breastfeeding — Colostrum The first milk, colostrum, is rich in protein and antibodiesNuetrophils in colostrum promote bacterial killing, phagocytosis, and chemotaxisSmall volume is normal:7-123 ml/day first day2-10 ml/feeding day 15-15 ml/feeding day 2
11Establishment of Breastfeeding — Colostrum (cont.) Colostrum stimulates intestinal peristalsis which decreases enterohepatic circulation, encouraging elimination of bilirubin Low volume of colostrum encourages frequent feedings, which encourages milk to “come in”
12Establishment of Breastfeeding — When the Milk “Comes In” Mature milk consists of foremilk (high volume, low fat) and hindmilk (low volume, high fat)Typically “comes in” at hours postpartumRequires effective and frequent milk removal in the first week of life
13How do I know if the infant is breastfeeding effectively? Baby is content after feedingsAudible swallowing during feedingsMother’s nipples are not sore3+ stools/day after day 1No weight loss after day 3Breast feels less full after feeding
14How do I know when the milk has “come in”? 6+ wet diapers/dayYellow, seedy stools by day 4–5Breasts are noticeably larger and feel firmer and heavierMother may begin to feel “let-down” reflexBreasts may leak between or during feedings
15Nutritional Guidelines and Expectations Average milk intake per day at 1 month is ml (range )Average weight loss of 7% at 72 hours (not to exceed 10% in term newborns)15-30 g/day weight gain from day 5 to 2 months
16Nutritional Guidelines and Expectations Normal timing to regain birth weight (by day 10)At least 3 BM’s/day in first 4-6 weeks (after 6 weeks of life, one BM up to every 10 days is normal in an exclusively breastfed baby who is gaining weight normally)
18Perception of Insufficient Milk Supply Very common (50% of breastfeeding mothers)Common cause for weaningOnly about 5% of women will not produce adequate amounts of milk for their baby
19Reasons a Mother May (Falsely) Believe her Milk Supply is Insufficient Lack of education about normal breastfeeding patterns and behaviorSoft breastsGrowth spurts that instigate need for frequent nursingThe ease with which the infant eats from a bottleInability to express large volumes of milkDoes not experience let-downFrequently fussy infantBut gaining weight normally• Lack of education regarding normal establishment of breastfeeding and how little baby needs in first few days of life.• Breasts will be soft initially before milk comes in and after initial breast fullness when milk comes in. Many women mistakenly believe this means they are no longer making sufficient milk, when in fact it just means their bodies have adjusted to their baby’s intake demands.• During growth spurts, babies may increase frequency and/or duration of feedings.• After a feeding, some babies with a strong need to suck may very well want to continue nursing or accept a bottle.• How much milk a woman can express is skill dependent and usually unrelated to her milk supply (especially if she is expecting to express a lot of milk right after her baby has nursed).• Some women do not feel let-down and many will notice their ability to feel let-down decreases with time.
20ReassuranceIf the infant is gaining weight well and stooling and voiding appropriatelyReassure mother her milk supply is adequateDiscourage supplementationReview normal patterns of breastfeeding, elimination, and weight gain
21Causes of Decreased Milk Supply Anything that limits the infant’s ability to extract milk effectively and frequently, such as:Separation of mother and infantScheduled intervals between feedingsPoor latchEarly use of pacifiersPrematurity
22Causes of Decreased Milk Supply Supplementation with formulaDelayed milk ejection secondary toStressPainMaternal medications (e.g., combination oral contraceptive)
23Less Common Causes of Insufficient Milk Supply Maternal hypothyroidismPolycystic Ovarian SyndromePrevious breast surgeryBreast hypoplasiaSheehan’s SyndromeRetained placenta• Previous breast surgery should only interfere with milk supply if nerves or ducts are severed.• Sheehan’s Syndrome is hypopituitaryism caused by infarction of the blood supply to the pituitary secondary to severe postpartum hemorrhage.• Retained placenta results in continued high levels of progesterone, which inhibits milk production.
24Slow Growth as Indicator of Decreased Milk Supply Weight loss > 10% of birth weightFailure to return to birth weight by 2 weeksAverage weight gain < 20 g/day between 2 weeks to 3 months of age
25Other Causes of Slow Growth Ineffective feeding (which in turn, often causes decreased milk supply)Increased caloric demands (e.g., heart disease)Food allergyGastroesophageal Reflux (or more rarely, pyloric stenosis)• Ineffective feeding secondary to e.g., infection, Trisomy 21, congenital anomalies of the face or mouth, congenital heart disease, cystic fibrosis, neurologic conditions, short frenulum, sleepiness, etc.
26Management of Slow Weight Gain Don’t miss it!See the patient at 3-5 days of life or within 48–72 hours of discharge
27Management of Slow Weight Gain (cont.) Obtain a complete medical history including:Maternal historyPresence of breast enlargement during pregnancyBirth historyPsychosocial stressorsSigns and symptoms of maternal or infant illnessCurrent feeding history and problems• Maternal history should include previous breast surgeries, illnesses, previous feeding experiences.• Birth history should include whether infant was premature, suctioning at birth, postpartum hemorrhage, separation of mother and infant.
28Management of Slow Weight Gain (cont.) Complete physical exam including:Mother’s breasts and nipplesInfant oral-motor examEvidence of congenital anomaliesEvaluation of frenulumObservation of a feeding to look at:Infant positioningLatchInfant suckRefer to the Residency Curriculum, Basic Breastfeeding Assessment presentation for guidanceLATCH SCORE: In hospital practice often scores recorded based on mother’s report instead of observationL = Latch0 = Too sleepy or reluctant, No latch achieved,1 = Repeated attempts, Hold nipple in mouth, Stimulate to suck2 = Grasps breast, Tongue down, Lips Flanged, Rhythmic suckingA = Audible swallowing0 = None, 1 = A few with stimulation, 2 = Spontaneous and intermittent <24 hrs. old, Spontaneous and frequent >24 hrs. oldType of nipple0 = Inverted, 1 = Flat, 2 = Everted (after stimulation)Comfort (Breast/Nipple)0 = Engorged, Cracked, bleeding, large blisters or bruises, Severe discomfort , 1 = Filling Reddened/small blisters or bruises, Mild/moderate discomfort, 2 = Soft, Non-tenderH = Hold (Positioning)0 = Full assist (staff hold infant at breast), 1= Minimal assist (i.e. elevate head of bed; place pillows for support), Teach one side, mother does other, Staff holds and then mother takes over, 2 = No assist from staff, Mother able to position & hold infantKumar SP, Mooney R, Wieser LJ, Havstad S . The LATCH scoring system and prediction of breastfeeding duration.J Hum Lact Nov;22(4):391-7.
29Management of Slow Weight Gain (cont.) Optimize positioning and latchTreat sore nipplesIncrease frequency of feedsExpress/pump milk after feedings to ensure complete emptying of breastsTreat maternal or infant illness if present• Refer to a lactation consultant if possible.
30Management of Slow Weight Gain — Supplementation If clinically indicated, supplementation may be necessarySupplement with expressed breast milk if possibleBegin with only 1-2 oz after each feeding until milk production increases• Clinical indications for supplementation include dehydration, malnourishment, and failure to increase milk supply with increased frequency, complete emptying of breasts, and correct positioning and latch.
31Management of Slow Weight Gain Evaluate weight gain and breastfeeding every 2–4 daysOnce infant is gaining at least 20 g/day, can change to weekly visits until infant is above birth weight and following a consistent growth curveOther considerations include:Supplemental feeding systemSupplementing with hind milkUse of a galactagogue to enhance milk production• Galactagogues are discussed in the Management of Common Breastfeeding Problems presentation.
32Sore NipplesBrief pain at the beginning of a feeding can be normal in the first weekSevere pain, pain that continues throughout a feeding, or pain that persists beyond the first week is NOT normal
33Sore NipplesPoor positioning and improper latch are the most common causes of sore nipplesPain may also be caused by yeast infection or mastitis• Improper latch may be secondary to “tongue-tie” (ankyloglossia), which along with mastitis and yeast infections are discussed in the Management of Common Breastfeeding Problems presentation.
34Sore Nipples and Low Milk Supply If caused by improper latch, baby may not be effectively emptying breast, leading to accumulation of Feedback Inhibitor of Lactation (FIL) and decreased milk supplyNipple pain can inhibit let-down reflex
35Inverted NipplesTrue inverted nipples retract toward the breast when you press the areola between 2 fingers• Breast shells apply gentle pressure equally around the nipple to help diminish adhesions and improve nipple protraction. If considering this, strongly advise lactation consultant assistance.• Most experts do not recommend prenatal attempts to fix inverted nipples as this may lead to premature labor through nipple stimulation, can send a message to mother that there is something wrong with her, and often baby will be able to effectively nurse without any intervention.
36Inverted Nipples10% of women have congenital inversion of one or both nipplesMay be intermittent and may become erect with infant suckling aloneMay pump prior to feeding to draw nipple outBreast shells worn between feedings controversial
37Treatment of Sore Nipples Ensure infant is well-positioned and latching on correctly — this may be all that is neededApply breast milk to nipple and areola after feeding, allow to air dry, then apply medical-grade lanolinUse only water to clean breastsMay use acetaminophen or ibuprofen for pain management
38Treatment of Sore Nipples (cont.) If nipples are still sore, cracked, or bleeding, have mother begin breastfeeding on less affected side then switch to more affected side after let-downMay use a nipple shield during feedings and/or a breast cup or shell between feedingsAssess for ankyloglossia (tongue-tie)
39Summary — Common Breastfeeding Situations Most common breastfeeding situations are preventable with proper breastfeeding assessment and care pre- and postnatallyThose that are not preventable are often treatable and should not induce weaningMothers should be educated pre- and postnatally about breastfeeding expectations and common preventable situationsPhysicians should be able to identify common breastfeeding situations and treatMore complicated breastfeeding problems can be referred to a lactation specialist
40ReferencesBonuck, K.A. Metoclopramide did not increase milk volume or duration of breastfeeding for preterm infants. Evidence-based Obstetrics & Gynecology. 2006; 8, Issue 1.Eglash, A., Montgomery, A., Wood, J. Breastfeeding. Disease-A-Month. 2008; 54, Issue 6.International Lactation Consultant Association, Clinical Guidelines for the Establishment of Exclusive Breastfeeding, 2nd ed. June 2005.Kumar SP, Mooney R, Wieser LJ, Havstad S . The LATCH scoring system and prediction of breastfeeding duration. J Hum Lact Nov;22(4):391-7.Miltenburg, D.M., Speights, Jr., V.O. Benign Breast Disease. Obstetrics & Gynecology Clinics. 2008; 35, Issue 2.Mohrbacher N, Stock J. The Breastfeeding Answer Book. Rev. ed. Schaumburg, IL: La Leche League International; 2003.Powers, N.G. How to Assess Slow Growth in the Breastfed Infant Birth to 3 months. Pediatric Clinics of North America. 2001; 48, Issue 2.Prachniak, G.K., Common Breastfeeding Problems. Obstetrics &Gynecology Clinics. 2002; 29, Issue 1.Saint, L., Smith, M., Hartmann, P.E. The yield and nutrient content of colostrum and milk of women from giving birth to 1 month post-partum. Br. J. Nutri. 1984; 52:Schanler RJ, Dooley S. Breastfeeding Handbook for Physicians. Elk Grove Village, IL: American Academy of Pediatrics, Washington, DC: American College of Obstetricians and Gynecologists; 2006.