1. Management of Common Breastfeeding Problems
Breastfeeding Residency Curriculum
Prepared by
Andrew Hsi MD, MPH
and
Larry Leeman MD, MPH
University of New Mexico School of Medicine 1

2. Breastfeeding Assessment
Before being able to address breastfeeding problems, the physician needs to assess breastfeeding by observing the infant feeding at the breast.
See the Basic Breastfeeding Assessment presentation
The following presentation discusses how to further assess for a particular problem and administer treatment to the breastfeeding dyad.

3. Objectives
At the end of this presentation the learner will be able to discuss:
Assessment of ineffective breastfeeding due to causes associated with the newborn oral cavity, breast anatomy, disorganized suckle, ankyloglossia, and milk transfer
Assessment of ineffective breastfeeding due to less common causes including disorganized suckle and ankyloglossia
Monitoring of hyperbilirubinemia and jaundice
Assessment of dehydration in context of poor feeding and/or low milk supply
Diagnosis and management of the delay or failure of lactogenesis II
Galactogogue use
Evaluation for blocked nipples, engorgement, and milk oversupply
Diagnosis and treatment of mastitis, breast abscess, and candidal breast infections 3

4. Assessment of Newborn Oral Cavity
Palpation for hard and soft palate defects
Visual of gingivae, sublingual areas including
Attachment of sublingual frenulum
Movement and elasticity of tongue
Gloved finger in baby’s mouth assesses function
Nail bed placed at lower gum ridge to assess excursion
Rule out inability to compress milk ducts
The exam of the newborn should include evaluation of the oral cavity. This should include both palpation and visual inspection. The palpation aspect strokes the roof of the mouth to check for defects of the hard and soft palate. The presence of a defect may interfere with feeding and breastfeeding in particular. Identification of a defect should lead to consultation with ENT and close observation of feedings.
Visual inspection combined with functional assessment aids in understanding the baby’s oral motor coordination. In particular, the appearance of the frenulum and tongue provides information about the extension of the tongue in the nursing process. Using a gloved fifth finger to mimic the alveola and nipple in the baby’s mouth provides the most important information. This part of the exam provides information about suck, coordination of tongue and suck movements, tongue motion and extension.
The assessment includes:
• Extension of tongue past lower alveolar ridge
• Cupping of tongue
• Seal of lips while sucking (should not hear excessive slurping or smacking during sucking action)
If problems seem apparent, direct observation of the baby’s latching to the mother’s breast should be done to both determine possible problems and to provide anticipatory guidance. The overall reason to assess is to determine that the baby can generate suction around the breast and can extend the tongue out and up to compress the areola and its underlying milk ducts. 4

5. Assessment of Breasts
Breasts should be assessed during a prenatal visit to prepare the mother for any issues that may arise due to breast anatomy
Rule out uncommon breast abnormalities
Breast enlargement/reduction surgery
Breast hypoplasia: tubular breasts, unilateral hypoplasia
Gigantomastia
Awareness of potential anatomic mismatch
Large nipple with small baby
Perceived problems influence feedings
Marked asymmetry may indicate absence of glandular tissue, a very rare condition.
Perception of problems, not usually a functional problem, related to breast anatomy include:
• Baby’s mouth too small to accept areola
• Baby’s nose obstructed by breast tissue
Reference 19, 27 5

6. Breast Assessment — Uncommon Conditions
Primary Hypoplasia:
- insufficient mammary glandular tissue
- nulliparous state (adopted infant)
- unilateral or bilateral breast anomalies
Secondary Displasia:
s/p radiation Rx
s/p breast surgery
s/p severe mastitis/abscess

7. Breast Injury and Surgery
Reduction Mammoplasty — likely to have difficulty producing enough milk, especially with periareolar incisions
Augmentation Mammoplasty — compatible with successful breastfeeding
Lumpectomy — may affect breastfeeding if significant nerves or ducts have been removed
Previous Treatment for Breast Cancer — radiation after lumpectomy may interfere with lactation. Mother can usually breastfeed on an unaffected breast
Trauma and Burns — varies, but many people with severe trauma and burns to the breast have been able to breastfeed with success
Pierced Nipples — not associated with breastfeeding difficulties. Nipple devices should be removed before feeding
See Breastfeeding Handbook for Physicians, page 38–39 for further explanation.
Reference 38

8. Disorganized Suckle Term babies have because: Coordination problems
Hypotonia
Hypertonia
Preterm babies may have:
Neurologic immaturity
Disorganized sucking excessive external stimulation
Weaker muscles in mouth and tongue
For term infants, coordination problems may relate to:
Choke or gag at breast
Pull away to breathe
Relatively small mandible impeding tongue extension Suck but not swallow, suck only when triggered by swallow
For preterm infants, disorganization may occur from problems with temperature regulation.
Possible Lactation Specialist referral criteria ordered by appearance in time:
• Latch score < 7 for 2 consecutive feedings (noted in first days of life)
None/few audible swallowing after 24 hrs of age
History of unsuccessful breastfeeding
• Nipple trauma (blisters, cracks, bruising) noted in first days of life
• Pain throughout feeding
• Infant weight loss > 8% birth weight noted by second or third day of life
• Inadequate urine/stool output noted by second or third day of life
• History of unsuccessful breastfeeding
• Mother of CCN/SCN infant
• History of breast surgery
• Abnormal infant oral anatomy
• Multiple births
• Premature infant
Lactation consultant will evaluate patient and consult with medical team as needed. 8

9. Suckle Problems: Ankyloglossia
Presents as ineffective latch or nipple pain
Lactation specialist consult if possible
Assessment by Hazelbaker Tool
Significant ankyloglossia when:
Appearance score < 8 and Function score < 11
Attention to changing position on breast
Care of mother’s nipples to prevent injuries
Hazelbaker tool has Appearance items to assess and Functional items (see next notes page)
Appearance items
Appearance of tongue
2: Round or square
1: Slight cleft in tip apparent
0: Heart- or V-shaped
Elasticity of frenulum
2: Very elastic
1: Moderately elastic
0: Little or no elasticity
Length of lingual frenulum when tongue lifted
2: > 1 cm
1: 1 cm
0: <1 cm
Attachment of lingual frenulum to tongue
2: Posterior to tip
1: At tip
0: Notched tip
Attachment of lingual frenulum to inferior alveolar ridge
2: Attached to floor of mouth or well below ridge
1: Attached just below ridge
0: Attached at ridge 9

10. Reliability of Assessment
Hazelbaker Tool in research
Appearance items “moderate” reliability
First 3 function items “substantial” agreement
Lateralization, lift, and extension of tongue
The items for infant sucking; low reliability
Suggest using first 3 function items only
Clinical agreement high for frenulotomy
Function items
Lateralization
2: Complete
1: Body of tongue but not tongue tip
0: None
Lift of tongue
2: Tip to mid-mouth
1: Only edges to mid-mouth
0: Tip stays at lower alveolar ridge or rises to mid-mouth only with jaw closure
Extension of tongue
2: Tip over lower lip
1: Tip over lower gum only
0: Neither of the above, or anterior or mid-tongue humps
Spread of anterior tongue
1: Moderate or partial
0: Little or none
Cupping
2: Entire edge, firm cup
1: Side edges only, moderate cup
0: Poor or no cup
Peristalsis
2: Complete, anterior to posterior
1: Partial, originating posterior to tip
0: None or reverse motion
Snapback
2: None
1: Periodic
0: Frequent or with each suck
*The infant’s tongue is assessed using the 5 appearance items and the 7 function items. Significant ankyloglossia is diagnosed when the appearance score total is 8 or less and/or the function score total is 11 or less. (2;3)
Adapted with permission from Hazelbaker AK: The assessment tool for lingual frenulum function (ATLFF): Use in a lactation consultant private practice Masters thesis, Pacific Oaks College, 1993.
For an alternative way to assess ankyloglossia see the Summer 2004 Section on Breastfeeding Newsletter article, CONGENTIAL TONGUE-TIE AND ITS IMPACT ON BREASTFEEDING by Elizabeth Coryllos, MD, MSs, FAAP, FACS, FRCSc, IBCLC, Catherine Watson Genna, BS, IBCLC, and Alexander C. Salloum, MD, MA,
Reference 5 10

11. Frenulotomy Studies Study using well designed enrollment
Frenulotomy improved feeding
Mothers reported relief from pain
Improved latching
Study of 24 older babies ( days)
Ultrasound studies found
Better position of nipple against palate
More milk transfer, less maternal pain
Research study with 2 independent observers. Assessed degree of ankyloglossia using scales. Analyzed observations.
Study using well designed enrollment
• Poor latch presented at 1.2 days
• Maternal nipple pain presented at 2.0
• Mean function score 7.9 (+ 1.86), appearance score 4.9 (+ 1.81)
• Poor latch shown with LATCH scores
Appearance items, 5 items, moderate agreement between observers.
First 3 function items had good agreement.
4 items related to assessment of sucking activity by the baby (spread, cupping, peristalsis and snapback) had insignificant p values for inter-rater reliability. These did not contribute to distinguishing babies with true ankyloglossia.
Therefore, the researchers suggested confining functional assessment to 3 items instead of 7.
Amir LH, James JP, Donath SM. Reliability of the Hazel baker assessment tool for lingual frenulum function. Int Breastfeed J Mar 9;1(1):3.
8 moms and babies had pre- and post-procedure breast milk production measured
Mean increase after procedure for 6 moms; 194 g
Great improvement on LATCH scores
After ultrasound:
Better placement of end of nipple to hard and soft palate junction
Less deformation of nipple
Associated with more milk transfer, less maternal pain
Jeanne L. Ballard, Christine E. Auer and Jane C. Khoury. Ankyloglossia: Assessment, Incidence, and Effect of Frenuloplasty on the Breastfeeding Dyad. Pediatrics 2002;110;e63
Reference 5,7,23 11

12. Breastfeeding and Hyperbilirubinemia: Guidelines
All infants routinely monitored for jaundice
Accurate gestational age; intensively monitor late preterm
Jaundice while breastfeeding
Kernicterus would be largely preventable
Starting preventive approach would be to institute procedures and policies for mothers to:
• Breastfeed 8 to 12 times in 24 hours
• Promote and support successful breastfeeding
• Increasing the frequency of nursing decreases the likelihood of subsequent significant hyperbilirubinemia in breastfed infants
• Providing appropriate support and advice to breastfeeding mothers increases the likelihood that breastfeeding will be successful
Reference 2,3 12

13. Breastfeeding Preterm or Late Preterm Infants and Hyperbilirubinemia
Jaundice in late preterm infants results from:
Increased bilirubin due to increased bilirubin production
Decreased bilirubin elimination
Insufficient breast milk intake even when mom’s milk established
Inability to ingest larger volumes of breast milk
Hyperbilirubinemia in late preterm infants:
Increased incidence
Increased severity
Longer course
Increased risk of deleterious consequences
Causes of decreased elimination:
May be due to decreased hepatic uptake of bilirubin from the plasma, delayed bilirubin conjugation, or increased entero-hepatic circulation of bilirubin.
Reference 12,13 13

14. Management for Early Jaundice in Breastfeeding Infants
Close clinical observation for jaundice
Largely related to insufficient breast milk intake
Initiate early and frequent breastfeeding
Discourage water, dextrose water, and unnecessary formula supplements
If supplementing with formula, consider using SNS or finger feeding to continue the establishment of lactation
Monitor weight, breastfeeding, urine, and stool
Refer to AAP guidelines for management of jaundice
Additional management considerations:
Monitor for stool output, stimulate stooling if none passed in first 24 hours of life.
When bilirubin level approaches High Risk for age in hours:
Stimulate stooling
Augment feeds; stimulate breast milk production by pumping
Use phototherapy if bilirubin exceeds 20 mg/dl
Trial intervention for withdrawal of breast milk when bilirubin exceeds 20 mg/dl, jaundice lasts > 6 d, or mother has a previously affected infant
Supplementation with breast milk substitute
Only with consent from mother
Preference for SNS or fingerfeeding
Supplemental Nursing System (SNS) consists of feeding tube with end taped to mother’s breasts proximal to areola. Feeding tubes connected to reservoir of breast milk substitute. When baby suckles on nipple, sucking pulls fluid down feeding tube increasing fluid volume while increasing stimulation of breast and hormonal reflexes for increased milk production. Finger feeding done with feeding tube attached to fingertip placed in baby’s mouth with other end connected to syringe containing breast milk substitute. Baby suckles while small amounts of fluid injected down tube into baby’s mouth.
Baby needs lowered bilirubin rapidly
At or above light level, resources limited
Close to exchange transfusion level
Bilirubin rising with phototherapy
Trial intervention for supplementing formula feeding with breast milk feeding as trial intervention if approaching treatment levels. This would apply to avoid exchange transfusion levels.
All clinical scenarios have impact on mother and baby dyad:
Breast milk substitute effect may be primary effect of increased fluid volume on hydration and stimulus to pass meconium.
Limited resources may include no hospital space for prolonged stay for baby, no resources for outpatient phototherapy (lack of durable medical equipment providers or lack of payment source for home phototherapy).
Reference 3,27,21 14

15. Management of Breastmilk Jaundice
Cause not defined
Breastfeeding successfully established yet hyperbilirubinemia persists beyond the fourth week of life
No clear reason to intervene if baby thriving
Recommendation 7.3 – AAP guidelines for management of jaundice
If infant requires phototherapy, breastfeeding should be continued if possible
Option to temporarily interrupt breastfeeding and substitute formula to reduce bilirubin levels and enhance efficacy of phototherapy
Breastfed infants being treated with phototherapy can be supplemented with expressed breast milk or formula if needed
Adjunct considerations:
Rule out other causes such as galactosemia, hypothyroidism, persistent slow hemolysis, urinary tract infection, or pyloric stenosis.
Check conjugated and unconjugated (indirect and direct) bilirubin level of jaundice persists greater than 3 weeks
Family history of prolonged jaundice in 70% of previous children
Outpatient Management of the Jaundiced Breastfed Infant
RECOMMENDATION 7.3: In breastfed infants who require phototherapy, the AAP recommends that, if possible, breastfeeding should be continued (evidence quality C: benefits exceed harms). It is also an option to interrupt temporarily breastfeeding and substitute formula. This can reduce bilirubin levels and/or enhance the efficacy of phototherapy 63–65 (evidence quality B: benefits exceed harms). In breastfed infants receiving phototherapy, supplementation with expressed breast milk or formula is appropriate if the infant’s intake seems inadequate, weight loss is excessive, or the infant seems dehydrated. See references to access full policy.
Reference 3, 17, 27 15

16. Summary for Early Detection of Risk for Hyperbilirubinemia
Good gestational age assessment
Review of physiologic risk factors
Early breastfeeding initiation
Monitoring of latching on; feed every 2–3 hours
Use of LATCH score, similar objective tool
Direct observation of latching for near term
Screen every baby for jaundice
Good gestational age assessment:
Artificial insemination
Highly reliable ultrasound at 8 to 10 weeks gestation to establish dates
Lower reliability with
Late ultrasound after 28 weeks
Last menstrual period
Ballard exam
Additional hospital management requirements:
Effective breastfeeding support on unit
Follow up plan 1 to 2 days after discharge
Screening all newborns with serum bilirubin level for early or extensive jaundice
Use of transcutaneous jaundice meter as first screen
Clinical assessment by experienced hospital personnel
Distinguish ineffective breastfeeding jaundice from prolonged jaundice with breast milk 16

17. Assessment of Milk Sufficiency
“Not enough milk” stops breastfeeding
Visual cues for feeding interaction
Baby eagerly seeks breast, latches on, feeds
Baby body tone relaxes
Mother’s body tone relaxes
Auditory confirmation of swallowing
Weight gain around arrival of mother’s milk
0–90 days; median gain 26–31 g
90–180 days; median gain 17–18 g
Perception of not enough is most common reason worldwide for cessation of breastfeeding. This perception need to be balanced against possible insufficient milk intake.
When perception inaccurate, mother requires support and counseling
Real insufficiency requires evaluation
Evaluation of newborn
Weight expected to fall first 3-4 days, < 7% from birth
5% to 10% fully breastfed infants lose >10% from birth weight by day 3
Suggesting that adequacy of intake should be evaluated infant monitored if weight loss >10%
Passes meconium and urine in first 24 hours
3-5 urines, 3-4 stools per day by day 3 to 5 of life
4-6 urines, 3-4 stools per day by day 5-7
Determination of urine made difficult by diaper materials
Cadwell K, Turner-Maffei C, O’Connor B, et al. Maternal and Infant Assessment for Breastfeeding and Human
Lactation: A Guide for the Practitioner, 2nd Ed Jones and Bartlett Publishers, Inc. Mississauga, Canada
Reference 15, 27 17

18. Assessment for Slow Weight Gain Versus Failure To Thrive
Generally alert and healthy
Good skin turgor and muscle tone
Failure to thrive
Generally apathetic, crying, not satisfied
Poor tone, constant rooting
Weight loss continued or no weight gain
Normal milk transfer
Infant content at end of feeding; feeding time roughly 30 minutes
Infrequent pauses and longer periods of active suckling
In exclusively breastfed babies, see bright yellow stools by day 5 of life and return to birth weight by day 10 of life
Low milk transfer
Infant still rooting, fussy, and needing to suck after 30 minutes
Frequent long pauses and short bursts of suckling
Lack of bright yellow stools by day 5 of life and return to birth weight by day 10 of life
Additional clinical information related to slow weight gain -
In each 24 hours baby has:
• > 6 wet diapers, pale dilute urine
• 4-6 breast stools
• Feeding 8 to 12 times at breast and mother notes consistent let down reflex
Additional warning signs in clinical information related to failure to thrive –
• Few wet diapers < 6, urine dark with strong odor
• Infrequent scant stools, darker green to brown color
• Feedings < 8, duration short (<10 minutes each side)
• Mother unsure about let down reflex
Reference 16, 27 18

19. Test-weighing To Assess Nutritive Breastfeeds in Failure To Thrive Infant
Weigh naked baby
Before and after breastfeeding episode
May help assess adequacy of breast milk intake
Rationale for diagnostic test
Review of 32 studies found
“Regardless of whether the clinical assessments were performed by nurses, mothers, or lactation educators, the differences between the clinical estimates and the test weight estimates of milk intake were large and random.”
Normal weight loss by type of feeding first 2 to 3 weeks of life:
Type of Feed Median 95th percentile Median time to maximum weight loss
Breast 6.6 ( ) ( ) days
Formula 3.5 ( ) 8.4 ( ) 2.7 days
Mixed 5.9 ( ) ( )
Scanlon KS, Alexander MP, Serdula MK et al. Assessment of Infant Feeding: The Validity of Measuring Milk Intake Nutrition Reviews 2002; 60(8):
P D Macdonald, S R M Ross, L Grant, D Young. Arch Dis Child Fetal Neonatal Ed 2003;88:F472–F476
Reference 29, 37

20. Dehydration and Breastfeeding
Rare, but severe condition
Among exclusively breastfed term infants
Weight loss > 10% in first 3 days of life
1/3 with hypernatremia
Maternal factors
Infant factors
Close follow up breastfeeding dyads required
Daily weight evaluation
Careful breastfeeding assessment
Study of exclusive breastfed infants:
• Inadequate breastfeeding was 4.1%, 169/4136
• Hypernatremia (Na > 150 mEq/dl)
• Excess weight loss mean 15.9% range ( %)
• Vaginal deliveries 75.7%, First time mothers 74.6%
Major presenting symptoms
• Neonatal jaundice (47.3%) and
• Poor infant suck (29.6%)
Maternal factors included:
• Higher rates of cesarean section
• Breastfeeding difficulties
• Use of heater in home
• Lower maternal education
Infant factors included:
• less than four stools/24 hours
• pink diaper
• mean weight loss in neonates with pink diaper
• mean uric acid concentration in neonates with pink diaper
• fever in hypernatremic neonates
• the correlation of weight loss with both serum sodium and uric acid concentrations
Reference 16 20

21. Management of Dehydration Associated with Breastfeeding Problems
Review maternal history, medications
Assess infant feeding history, urine and stool output
Examine infant, skin turgor, capillary refill
Observe infant on breast
Stat lab studies
Additional history for infant includes history of poor suck, sleep long intervals, infrequent feedings, and lethargy.
Stat lab studies should include:
• Electrolytes (sodium, potassium, chloride, CO2)
• BUN, creatinine
• Hematocrit
• Bilirubin if jaundiced
Specifically when infant electrolyte abnormalities detected, test of breast milk:
• Test milk from each breast separately for sodium, chloride, potassium
• Elevated sodium level related to inadequate lactose in breast milk
• Increased osmolarity of milk similar to “weaning milk”
In addition to IV rehydration:
• Maintain lactation, monitor milk sodium levels
• Resume breastfeeding as milk sodium levels normalize and IV fluids tapered
Reference 32

22. Lactogenesis II
Lactogenesis I : Initiation of milk production which occurs in second trimester of pregnancy
Lactogenesis II: Postpartum initiation of high volume milk production which occurs as transition from low volume colostrum
Usually at 30–40 hours postpartum
Subjective feeling of breast fullness
Day five term infant receive 500 to 750 cc of milk compared to < 100 cc/day prior to lactogenesis II
If lactogenesis II has not occurred by postpartum day 5, then delay or failure is present
Lactogenesis II initiated by falling progesterone levels in the presence of high prolactin levels.
Progesterone levels fall 10 fold in first 4 days postpartum. Breast milk changes in constituents with decreased concentration of secretory IgA and lactoferrin.
Reference 11, 24, 34, 35

23. Problems with Lactogenesis II
Delayed: extended time between colostrum and full milk production
Failed: unable to achieve full lactation due to either primary inability to produce or issues with breastfeeding or infant health
Can lead to hypernatremic dehydration which can rarely progress to neurologic injury, seizures, renal failure, thrombosis, and death
Problems with lactogenesis II are more common in women with minimal or no breast enlargement during pregnancy.
Secondary failure due to breastfeeding difficulties is much more common than primary failure of lactogenesis due to medical problems, breast hypoplasia, or altered maternal breast anatomy secondary to surgery.
Reference 33, 42

24. Causes of Delayed Lactogenesis II
Any circumstance that leads to delayed, infrequent, or ineffective milk removal
Delay in first breastfeeding: oral or IBV infant feeding
Low breastfeeding frequency-poor stimulation
Psychosocial stress/pain
Unscheduled cesarean or stressful labor/delivery
Less common etiologies secondary to maternal disease
Maternal obesity
Maternal diabetes or hypertension-etiology unknown
Reference 24

25. Causes of Failed Lactogenesis II
Breast surgery or injury
Retained placenta
Hypothyroidism
Theca lutein ovarian cysts
Mammary hypoplasia (congenital)
Polycystic ovarian syndrome
Sheehan’s syndrome secondary to postpartum hemorrhage
True failed lactogenesis II is quite rare and consideration must be given to uncommon etiologies. Failed lactogenesis II can only be diagnosed when effective nursing or manual expression of breast milk is occurring.
Consider assessment of milk volume by using a hospital grade electric automatic pump and/or infant weighing before and after feeding. The use of these tests may help to determine if there is currently insufficient milk in the breasts or if the problem is the infant’s inability to extract the available milk (Neifert 2001)
Reference 24, 33

26. Galactagogues Used to increase breast milk supply
Need to attempt to determine the etiology of low milk supply prior to initiation
Ensure proper breastfeeding technique prior to use
Only use galactogogues with adequate milk removal by nursing or electrical pumping or milk stasis will occur
Consider need to evaluate for medical co morbidities e.g., hypothroidism, retained placental fragments, theca lutein ovarian cysts
Prolactin levels in postpartum lactating mothers at 10 days or less (Betzold 2004)
• 200 ng/ml (baseline)
• 400 ng/mL (after breastfeeding)
Levels in lactating mothers from 11–90 days postpartum
• 60 ng/mL (baseline)
• 220 ng/ml (after breastfeeding)
Academy of Breastfeeding Medicine Protocol # 9:
Watch “hands-on pumping” for an example of how a mother can use her hands with pumping to maximize milk production
Reference 41

27. Galactagogues Metoclopramide — most commonly used
Domperidone — not approved in USA. Similar to metoclopramide but less side effects as little crosses blood brain barrier
Fenugreek and other herbal medicines — no scientific data except anecdotal reports
Reference 9, 14, 18, 22

28. Metoclopramide
Benefit shown in small placebo controlled crossover study with increase of 50 cc per feed with dose of at least 30 mg per day
Effect is to increase prolactin level
Side effects: gastrointestinal, anxiety, sedation, and rare dystonic reactions
No documented neonatal reactions
Short term: 1–3 weeks is common. No evidence supporting long-term use. Usually wean after 10–14 days
A common dosing regimen is 10 mg po qd first day, then 10 mg po bid, then 10 mg po TID
Patients or lactation consultants may request that physicians prescribe domperidone from compounding pharmacies. FDA issued a caution due to small number of deaths with intravenous formulation and concerns regarding drug importation (American Academy of Breastfeeding Protocol #9). Small RCT (daSilva 2001) of 16 patients showed increase of 49.5 cc with domperidone) compared to 8.0 cc with placebo (p<0.05)
Reference 9, 25

29. Excess Milk Supply Much less common problem than low milk supply
Minimal medical literature
Maternal symptoms; continual engorgement, leaking and increased mastitis risk
Infant: regurgitation and reflux symptoms. Development of poor sucking technique
Uncommon problem.
Breast milk production usually adjusts to match infant consumption.

30. Management of Excess Milk Supply
Attempt to offer just 1 breast at each feeding to decrease stimulation and produce milk stasis in the other breast to decrease production
Practical advice yet lacks research/evidence basis. There is a case report series describing treatment by completely as possible mechanical draining of both breast with a an electronic double pump then offering only one breast during each “block” period and gradually increasing blocks from 3 to 4 to 6 hours to decrease production. (Veldhuizen-Staas 2007)
Reference 43

31. Plugged Ducts Tender lump Predisposing factors
Positions that don’t empty breast
Underwire bras
Predispose to mastitis with possible continuum from engorgement to blocked ducts to inflammatory mastitis to bacterial mastitis
Treatment
Ensure complete drainage
Massage
Warm packs
Position changes
Mastitis, Academy of Breastfeeding medicine Protocol #4. Breastfeeding Medicine 2008;3:
Reference 1

32. Mastitis
Infection of the breast usually caused by Staphylococcus aureus
Risk factors: plugged ducts, untreated engorgement, cracked nipples, missed feedings, excessive fatigue, decreased resistance to infection
Common occurring in 5%–10% of breastfeeding women
Most common in first month
Recurrences occur in 8%–19% of women and commonly (25%) leads to lactation cessation
Infectious and noninfectious etiologies of breast inflammation may mimic each other with engorgement and plugged ducts difficult to distinguish from mild infectious mastitis without fever. In this situation 24 hours of conservative treatment is a reasonable option with frequent breast drainage by breastfeeding and/or pumping during this 24 hours along with compresses to relieve pain and promote drainage
Reference 8, 44

33. Mastitis — History and Physical Exam
Fever, diffuse myalgias, “flu-like” symptoms, breast pain
Wedge-shaped, tender, erythematous, usually unilateral
Upper, outer quadrant most common

34. Mastitis Treatment
DO NOT stop breastfeeding on the affected side, empty the breast
If mild, symptoms occur for less than 24 hours and may attempt to resolve with frequent nursing or pumping and supportive measures including bed rest, fluids, analgesics
Antibiotic options include dicloxicillin 500 mg po qid; cephalexin 500 mg po qid, or clindamycin 300 mg po qid for 10 to 14 days
Observe carefully for signs of abscess formation
No need to obtain breast milk culture unless failure to improve with 48 hours of antibiotics or hospital acquired mastitis. Technique should be a mid-stream “clean catch” of the breast milk by hand expression with the initial expressed milk discarded to minimize skin contamination.
Spencer. American Family Physician 2008; 78:
American Academy of Breastfeeding Medicine Protocol # 4 on Mastitis at
Reference 1, 20, 39

35. Breast Abscess ~3% of mastitis cases develop into an abscess
P.E. — tender, hard breast mass, fluctuant, erythematous
Incision and drainage, antibiotics, analgesia, frequent emptying
Alternative — needle aspiration every other day until pus no longer accumulates. Recommended as first line
Culture fluid from abscess
Serial needle aspiration offers the least trauma to the breast but may be logistically difficult in some health care settings.
Incision will be made at area of fluctuence and as removed as possible from nipple. Incision made with scalpel following lines parallel to areola. Many Ob/Gyn and Family Medicine physicians will be able to incise and drain abscess although some may prefer to refer some or all patients with a breast abscess to a breast or general surgeon.
Amir LH, Forster D, McLachlan H, Lumley J.BJOG. 2004;111:
Reference 4

36. Methicillin Resistant Staph Aureus and Breast Abscess in Lactating Women
Incidence of mastitis and breast abscess from community acquired MRSA appears to be increasing with up to 50% in some studies
> 95% are community not hospital acquired MRSA
Most seem to resolve even when given antibiotic that community acquired MRSA is resistant to
Draining breast by manual pumping and/or breastfeeding for mastitis or incision and drainage of abscess may be most important part of treatment
Cultures are rarely done or are of benefit in mastitis. Culture should be sent from aspiration and drainage of breast abscess. If MRSA positive antibiotic options compatible with breastfeeding may include trimethoprim/sulfamethoxazle or clindamycin. May be resistant to clindamycin despite sensitivities stating susceptible if resistant to erythromycin.
For instruction on hand expression, which may be more comfortable or effective than sucking in getting milk to flow, please see
Reference 26, 31, 36, 40, 46

37. Nipple Candidal Infections
Not uncommon, but often misdiagnosed
Nonspecific signs and symptoms
Nipple pain, itching, or burning sensation or shooting breast pains that radiate back towards the chest wall (possibly ductal candidal infection; may persist or worsen after feeding is complete and breast is drained)
Nipple and areola may appear erythematous or shiny or have white patches
There could be NO external signs
Neonatal thrush commonly occurs in women with candidal nipple infection. May be difficult to distinguish from cracked nipples due to improper latch-on.
Reference 38

38. Causes of Nipple Candida
Predisposed factors
Diabetes
Steroid use
Immune deficiency
Antibiotic use
Nipple trauma
Use of plastic-line breast pads that trap moisture

39. Treatment of Candidal Nipple Infections — General
Difficult to prove that Candida is the causative organism in all situations (milk or skin cultures are not helpful and should not be performed routinely)
Infant usually has thrush when mother has candidal infection
Treat mother and infant simultaneously (the mother’s partner may also need to be treated in some instances)
Sterilize objects that contact breast or infants mouth: pumping supplies, bottles, and pacifiers
Maternal treatment: nystatin suspension/ cream or clotrimazole applied after each nursing. No need to wash off before feeds
Infant: nystatin (100,000 u/ml) 1 cc po qid inside mouth to breast after each nursing
Recommended to routinely treat the infant even if without signs or symptoms of thrush. (Betzold 2007)
Reference 10

40. Treatment of Candidal Nipple Infections — Other Options
Gentian Violet — a topical treatment option that uses 0.25%–1% gentian violet swabbed on the affected areas for up to 3 days
Oral fluconazole — may be prescribed if nipples are not significantly better after several days of topical treatment, or in cases of reoccurrence
Note – Gentian Violet may cause permanent staining of clothing and temporary violet discoloration of infant’s mount and the maternal breast.

41. Correlation Between Breast Symptoms and Candida in Breast Milk Cultures
> 70% PPV for shiny skin of nipple areola with stabbing breast pain OR flaky skin of nipple/areola with breast pain
> 50% PPV with 2 of the 6 symptoms (sore nipples, burning nipple/areola, breast painful [nonstabbing], breasts painful [stabbing], shiny skin, flaky skin)
The symptoms described here are common. The presence of skin changes with breast pain does appear to correlate with candidal infection or colonization.
Reference 16, 21

42. Ductal Yeast Infection
Lack objective findings on exam as nipple and skin may not be involved
Lack reliable microbiologic tests
Decision to treat based on deep burning/shooting breast pain without other causes
Potential for overdiagnosis
We have a lack of scientific evidence to determine which women will benefit from treatment.
Reference 10, 45

43. Treatment of Ductal Yeast Infection
Will not respond to topical medicines
Treatment is usually fluconazole 100–200 mg po qd for 14–21 days, although not FDA approved for this indication
Need studies of diagnostic criteria and effectiveness
Need to treat infant with oral nystatin as well for thrush or colonization
Difficult to determine if a woman with deep stabbing or lancinating pain has ductal yeast. There is a need for randomized controlled trials of fluconazole vs. placebo.

44. Summary: Breastfeeding Problems
Problems are common and treatable
Assess adequacy of suckle and milk production/transfer
Neonatal jaundice and dehydration are associated with breastfeeding problems
Treat engorgement and blocked nipples to prevent mastitis and abscesses
Bacterial and candidal infections can adversely affect breastfeeding

45. References
Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #4: mastitis. Revision, May Breastfeed Med. 2008;3(3):
Alpay F, Sarici SU, Tosuncuk HD, Serdar MA, Inanc N, Gokcay E. The value of first-day bilirubin measurement in predicting the development of significant hyperbilirubinemia in healthy term newborns. Pediatrics. 2000;106(2): e16.
American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114(1):
Amir LH, Forster DA, Lumley J, McLachlan H. A descriptive study of mastitis in Australian breastfeeding women: incidence and determinants. BMC Public Health. 2007;7:62.
Amir LH, James JP, Donath SM. Reliability of the hazelbaker assessment tool for lingual frenulum function. Int Breastfeed J. 2006;1(1):3.
Andrews JI, Fleener DK, Messer SA, Hansen WF, Pfaller MA, Diekema DJ. The yeast connection: is Candida linked to breastfeeding associated pain? Am J Obstet Gynecol. 2007;197(4):424.e1-e4.
Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110(5):e63.
Barbosa-Cesnik C, Schwartz K, Foxman B. Lactation mastitis. JAMA. 2003;289(13):
Betzold CM. Galactagogues. J Midwifery Womens Health. 2004;49(2):
Betzold CM. An update on the recognition and management of lactational breast inflammation. J Midwifery Womens Health. 2007;52(6):
Betzold CM, Hoover KL, Snyder CL. Delayed lactogenesis II: a comparison of four cases. J Midwifery Womens Health. 2004;49(2):
Bhutani VK, Johnson L. Kernicterus in late preterm infants cared for as term healthy infants. Semin Perinatol. 2006;30(2):89-97.
Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999;103(1):6-14.
Bishop J. Is domperidone safe for breastfeeding mothers? J Midwifery Womens Health. 2004;49(5):461.
Cadwell K. Maternal and Infant Assessment for Breastfeeding and Human Lactation: A Guide for the Practitioner, 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2006.

46. References
Caglar MK, Ozer I, Altugan FS. Risk factors for excess weight loss and hypernatremia in exclusively breast-fed infants. Braz J Med Biol Res. 2006;39(4):
Chou SC, Palmer RH, Ezhuthachan S, et al. Management of hyperbilirubinemia in newborns: measuring performance by using a benchmarking model. Pediatrics. 2003;112(6 Pt 1):
da Silva OP, Knoppert DC, Angelini MM, Forret PA. Effect of domperidone on milk production in mothers of premature newborns: a randomized, double-blind, placebo-controlled trial. CMAJ. 2001;164(1):17-21.
Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. J Plast Reconstr Aesthet Surg. 2008;61(5):
Foxman B, D'Arcy H, Gillespie B, Bobo JK, Schwartz K. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002;155(2):
Francis-Morrill J, Heinig MJ, Pappagianis D, Dewey KG. Diagnostic value of signs and symptoms of mammary candidosis among lactating women. J Hum Lact. Aug 2004;20(3):
Gabay MP. Galactogogues: medications that induce lactation. J Hum Lact. 2002;18(3):
Geddes DT, Langton DB, Gollow I, Jacobs LA, Hartmann PE, Simmer K. Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008;122(1):e188-e194.
Hurst NM. Recognizing and treating delayed or failed lactogenesis II. J Midwifery Womens Health. 2007;52(6):
Kauppila A, Arvela P, Koivisto M, Kiniven S, Ylikorkala O, Pelkonen O. Metoclopramide and breast feeding: transfer into milk and the newborn. Eur J Clin Pharmacol 1983;25(6):
Kriebs JM. Methicillin-resistant Staphylococcus aureus infection in the obstetric setting. J Midwifery Womens Health. 2008;53(3):
Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia, PA: Mosby, Inc.; 2005:46, , , 607.
Lawrence RA. Mastitis while breastfeeding: old theories and new evidence. Am J Epidemiol. 2002;155(2):
Macdonald, PD, Ross, SR, Grant, L, Young, D. Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonatal Ed 2003;88(6):F472–F476
Moazzez A, Kelso RL, Towfigh S, Sohn H, Berne TV, Mason RJ. Breast abscess bacteriologic features in the era of community-acquired methicillin-resistant Staphylococcus aureus epidemics. Arch Surg. 2007;142(9):

47. References
Mohrbacher N, Stock J. The Breastfeeding Answer Book. Rev. ed. Schaumburg, IL: La Leche League International; 1997.
Morton J. Salty milk-- when to worry. West J Med. 1995;163(5):164:
Neifert MR. Prevention of breastfeeding tragedies. Pediatr Clin North Am. 2001;48(2):
Neville MC, Morton J. Physiology and endocrine changes underlying human lactogenesis II. J Nutr. 2001;131(11):3005S-3008S.
Neville MC, Morton J, Umemura S. Lactogenesis. The transition from pregnancy to lactation. Pediatr Clin North Am. Feb 2001;48(1):35-52.
Reddy P, Qi C, Zembower T, Noskin GA, Bolon M. Postpartum mastitis and community-acquired methicillin-resistant Staphylococcus aureus. Emerg Infect Dis. 2007;13(2):
Scanlon KS, Alexander MP, Serdula MK, Davis MK, Bowman BA. Assessment of infant feeding: the validity of measuring milk intake. Nutr Rev. 2002; 60(8):
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.
Spencer JP. Management of mastitis in breastfeeding women. Am Fam Physician. 2008;78(6):
Stafford I, Hernandez J, Laibl V, Sheffield J, Roberts S, Wendel G, Jr. Community-acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization. Obstet Gynecol. 2008;112(3):
The Academy of Breastfeeding Medicine. Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Supply Accessed October 13, 2008.
Unal S, Arhan E, Kara N, Uncu N, Aliefendioglu D. Breast-feeding-associated hypernatremia: retrospective analysis of 169 term newborns. Pediatr Int. 2008;50(1):29-34.
van Veldhuizen-Staas CG. Overabundant milk supply: an alternative way to intervene by full drainage and block feeding. Int Breastfeed J. 2007;2:11.
Vogel, A, Hutchinson, B, Mitchell, E, Mastitis in the first year postpartum. Birth. 1999;26(4)
Wiener S. Diagnosis and management of Candida of the nipple and breast. J Midwifery Womens Health. 2006;51(2):
Wilson-Clay B. Case report of methicillin-resistant Staphylococcus aureus (MRSA) mastitis with abscess formation in a breastfeeding woman. J Hum Lact. 2008;24(3):