1. Dr Jenni Goold 2015 Introduction to Supporting Breastfeeding OSC Accreditation Seminar

2. Take home messages All women (almost) are able to breastfeed Provide information about benefits of breastfeeding Provide accurate information & improved supports especially if artificially fed last time Provide Support, or refer these women & babies

3. Common Breast feeding consultation discussion topics: Are these statements true/false? BF provides significant reduction in morbidity and mortality and has implications for adult health Weighing babies pre/post feed is a useful tool to assess supply The quality of breast milk can be assessed by its appearance Supply can be gauged by amount expressed An unsettled baby generally indicates low supply Average weight gain for healthy babies is 150 gm per week If supply is low offering a complimentary feed of formula is helpful Best predictor of successful BF is the women's attitude to BF

4. Common reasons for giving up breastfeeding (And for women to seek help from their GP) Breast and nipple pain Unsettled babies ‘Poor weight gain’ ‘Not enough milk’ Mastitis

5. Rebecca’s Presentation 30 year old female, G3 P1,NVD 3.1kg Baby girl at term, discharged after 24 hrs 4 days postnatal: baby attaching but nipples sore. Thought this was ‘normal' as first baby but now nipples cracked, bleeding & painful. Worried as Breast feel very full since yesterday & baby fussing at attachment. What would you like to know? What are the issues?

6. What would you do? Full history of: - feeding - sleep - development - does the baby have times when settled? Assess the baby’s well being - full examination especially hydration & percentiles Mothers mental health & supports

7. Issues to consider Baby gaining weight appropriately (av 150 gms per week)issues; First baby (3 rd pregnancy) supports? Fatigue Normal process- Milk coming in Early discharge Position/ attachment? Mood? Reassurance - this is a normal healthy baby

8. Attachment, Attachment, Attachment! Painful BF, think attachment until proven other wise! Observe attachment Consider referral to lactation services if beyond individual GP skill level

9. The K sign: Baby’s body contact with mother’s body Head tilt back Wide mouth Significant amount of breast in mouth Nipple is well back in area of soft palate

10. Poor attachment= cracked nipples If attachment not corrected, painful BF will result in cracked nipples

11. Cracked Nipples Causes nipple & shooting pain in the breast during and between feeds Correct attachment: may be able to continue feeding despite cracks Expose to air Topical application: hindmilk, ?balms- beware of contact dermatitis Consider resting nipples: 24 hrs of expressing- beware further trauma ?Nipple shields- beware reducing supply Consider infection Swab & anti-septic measures Antibiotics (eg Cephalexin) or Bactroban (Mupirocin) ointment tds after feeds until healed

12. Rebecca Re-presents Now at 3 weeks post partum ‘I feel awful and my right breast is sore’ What else do you want to know?

13. Further History Rebecca says ‘Two nights ago, my baby slept through the night and my R breast still felt a bit full after I fed her in the morning My breast felt uncomfortable all day This morning, I started to develop shivers, aching muscles and a very sore R breast ’ What are you thinking?

14. Examination Findings What is the diagnosis?

15. Mastitis Causes: Area of milk stasis or a blockage that was not resolved, leading to systemic symptoms Possible contributing Factors: Anything that prolongs time between emptying of breast such as Baby sleeping through the night, or mother going out and not expressing, Spacing feeds (overuse of dummy) Incomplete emptying Tight bra, poor positioning and attachment Infection Infection entering through cracked nipple

16. Mastitis Management Symptomatic treatment: Analgesia Hot & cold compresses Relieve blockage: Good positioning and attachment Offer affected side first Change position to drain affected side better Massage Express Resolve Infection (staph aureus): Dicloxacillin/Flucloxacilllin 500mg qid Cephalexin 500mg qid (if penicillin allergy) Clindamycin 450mg tds for 10 days

17. Untreated If left untreated, what is possible outcome? Breast Abscess

18. Treatment: Antibiotics Alternate daily aspiration Or, if loculated, ultrasound guided aspiration Can continue to breast feed

19. Rebecca returns returns 2 weeks later Presentation: ‘I think that I have mastitis again’ Improved after antibiotics Then sore R nipple Worked hard on correct attachment Pain during and after feeds shooting through the breast No fever What are you thinking?

20. Examination reveals: What is the diagnosis?

21. Poor attachment results in trauma & cracks, then allows infection, such as thrush or other bacterial infection such as staph

22. Thrush in the breast Possible presenting history & examination findings: Shooting pain in breast during and after feeds Sore nipples with good positioning and attachment Recent mastitis/antibiotic use/thrush in baby No fever Nothing to see on examination of nipple Examine babies mouth

23. Thrush Management Baby: Miconazole gel ¼ tsp qid after feeds or Nystatin oral drops 1ml qid for 7 to 10 days Avoid dummy use. If used, sterilize daily and change weekly Mother: Miconazole gel qid after feeds to nipples or Nystatin ointment for 7 to 10 days and change breast pads after every feed ? place of systemic treatment However: Beware over diagnosed and overuse of anti-fungals Long term use of Miconazole can cause contact dermatitis Always consider an alternative cause of nipple pain

24. Other Causes of nipple/breast pain? Attachment, trauma & infection commonly cause painful BF Consider other pathology: Eczema/Contact Dermatitis Vasospasm

25. Dermatitis/Eczema May be a past history of skin problems Woman may have been using a cream on the nipples (Miconazole, Paw Paw, Lanolin based) May occur after the introduction of solids Responds very well to the removal of the offending agent and topical steroid eg Advantan (methylprednisolone aceponate) ointment daily for few days

26. Vasospasm of nipple Pain caused by blood vessels tighten and go into spasm, so that blood does not flow to the nipple. Can be accompanied by sudden whitening of the nipple Two main contributors: Response to trauma Associated with Raynaud’s phenomenon

27. Vasospasm of nipple Treatment: Correct any contributors to trauma- positioning & attachment Apply warmth after feeding- cover up ; warm pack; breast-warmers; massage with olive oil under clothing Vit B6 and magnesium- nil evidence base Nifedipine- 30 mg SR 1 tab daily for 2 weeks and cease 10% recurrence rate- recommence another 2 weeks Can use increased dose if 30 mg inadequate Side effects: postural hypotension, headache, flushing Nitroglycerine paste no longer recommended 50 % efficacy & high incidence of severe headache

28. Resources for Breastfeeding Problems (Section 19 Protocols) National BF helpline 1800686268 www.breastfeeding.asn.auwww.breastfeeding.asn.au Domiciliary Midwives Breastfeeding Clinics LMHS, Gawler, FMC, Mt Barker, Giles plains, Parks CYWHS: 24 hr parent helpline 1300364100 Drop in service- no appointment required day clinics: self referral- 1300 733 606 Residential (Torrens House): referral through CaFHS staff Australian Breastfeeding Association Counsellor Find a GP/LC: http://www.lcanz.org/find-a-consultant.htmhttp://www.lcanz.org/find-a-consultant.htm Online resources Want further skills- IBCLC qualification

29. Online Resources Royal Children’s Hospital: Clinical Practice Guidelines (links to Royal Women’s breastfeeding management site) http://www.rch.org.au/rchcpg/index.cfm?doc_id=9790 http://www.rch.org.au/rchcpg/index.cfm?doc_id=9790 Australian Breastfeeding Association Fact Sheet http://www.breastfeeding.asn.au/bfinfo/index.html SA College of LCs, list of local breastfeeding support services http://www.lactation.org.au/sa/index.html NHMRC: Infant feeding guidelines for health workers. (Publication is still under review) http://www.nhmrc.gov.au/publications/synopses/n20syn.htm Mothers direct shop: all kinds of parenting books and breastfeeding resources & aids http://www.mothersdirect.com.au Sensible parenting advice from Melbourne midwife/LC http://www.pinky-mychild.com Very good pregnancy, breastfeeding and parenting books http://www.capersbookstore.com.au