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Elaine Webber DNP, PPCNP-BC, IBCLC.  Approached in orderly diagnostic process ◦ Complete history and PE ◦ Details of feeding ◦ Observation of feeding.

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Presentation on theme: "Elaine Webber DNP, PPCNP-BC, IBCLC.  Approached in orderly diagnostic process ◦ Complete history and PE ◦ Details of feeding ◦ Observation of feeding."— Presentation transcript:

1 Elaine Webber DNP, PPCNP-BC, IBCLC

2  Approached in orderly diagnostic process ◦ Complete history and PE ◦ Details of feeding ◦ Observation of feeding ◦ Appropriate labs  Data organization  Will help identify factors that appear under maternal and infant cases separately

3  Weight loss after 10 days  Birth weight not regained by three weeks  Rate of weight gain below 10th% beyond one month of age

4  Weight gain slow but consistent  Weight, length and HC proportional  Developmental milestones normal

5 Infant who is slow to gain weight  Alert  Good muscle tone  At least six wet diapers/day  Pale, dilute urine  Stools frequent, seedy (or if infrequent, large and soft)  Eight or more nursings/day of active feeds  Weight gain consistent by slow Infant with failure to thrive  Apathetic or crying  Poor tone  Poor turgor  Few wet diapers  “Strong” urine odor  Stools infrequent, scanty  Fewer than eight feedings, often brief  No evidence of milk-ejection reflex (no swallowing noted)  Weight erratic, may be losing weight

6  Initial weight loss ◦ Normal 7-10% of birth weight ◦ What might impact excessive weight loss?  Expected weight gain ◦ “Normal” daily weight gain? ◦ Regain birth weight by 2-3 weeks

7  Differences in growth charts ◦ Breastfed infants grow more rapidly first 2 months of life ◦ Less rapidly from 3-12 months  Weight gain only one parameter ◦ Length and HC also important  Familial considerations

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9  Underlying physical problems ◦ Metabolic conditions ◦ Congestive Heart Failure ◦ Cystic fibrosis  Mechanical Abnormalities of the Mouth ◦ Ankyloglossia ◦ Short tongue ◦ Bubble palate ◦ Tight jaw

10  Neurologic ◦ ability to root, suck and coordinate swallows  Acute infections ◦ Septic, GI issues  Chronic fetal infections ◦ CMV, HIV, Toxoplasmosis, etc.  High energy requirements ◦ Some CNS disorders, fetal exposure to stimulants, stimulants transferred in breast milk,

11 Absent or diminished suck  Maternal anesthesia or analgesia  Anoxia or hypoxia  High bilirubin  Prematurity  Trisomy 21  Hypothyroidism  Neuromuscular abnormality ◦ Werdnig-Hoffmann ◦ Muscular dystrophy  Central nervous system infections ◦ Toxoplamosis ◦ CMV ◦ Meningitis Mechanical factors interfering with sucking  Macroglossia  Cleft lip  Fusion of gums  Tumors of mouth or gums  Ankylossia (tongue or labial) Disorders of swallowing  Choanal atresia  Cleft palate  Micrognathia  Post-intubation dysphagia  Pharyngeal tumors  Familial dysautonomia Adapted from Lawrence & Lawrence (2005)

12 Slightly hypotonic infants may demonstrate:  Weak Suck  Poor lip closure  Frequent slipping off the breast Hypotonia Normal Tone Hypertonia Slightly hypertonic infants may demonstrate:  Extended posture  Excessive irritability  Strong bite reflex Note that some infants show “soft signs” or very mild indications of either hypo or hyper tone. These infants are often missed because they appear more “normal” than “abnormal”. Tone should always be assessed with any feeding difficulty.

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14  Causes milk production  Circadian rhythm  Can be increased by emotional and physical stress  Inhibited by dopamine, nicotine and alcohol  Pharmacologic stimulation  Prolactin levels

15  Released from the posterior pituitary  Immediate reaction to nipple stimulation  Causes contraction of smooth muscle epithelial cells surrounding the mammary alveoli  Largely influenced by psychological factors  Pharmacologic stimulation?

16  Modulated by the complex interplay of many hormones  System which requires significant exploration when faced with a an unknown cause of poor milk production

17  Initial milk production governed by prolactin production, activation of prolactin receptors and oxytocin release  Eventually prolactin levels decline and milk production is governed by milk removal  Early stimulation and milk removal are essential in the establishment and continuation of a robust milk supply

18 Maternal Causes Poor production Anatomic Hormonal Pharmacologic StressFatigueIllness Poor Milk-ejection Hormonal Pharmacologic StressPainPsychological Potential maternal causes of FTT

19  Endocrine History ◦ Difficulty conceiving ◦ Thyroid problems ◦ Pituitary problems ◦ PCOS  Previous Breast Surgery  Prenatal History ◦ Breast changes during pregnancy ◦ Leaking colostrum

20  Delivery ◦ Length of labor ◦ Drugs during labor ◦ Epidural ◦ Delivery of Placenta  Placental fragments ◦ Excessive bleeding/hemorrhage  Sheehan’s syndrome

21  Postpartum ◦ Stress and exhaustion ◦ Maternal illness ◦ Maternal medications

22 (Pre)- Diabetes PCOS Mammary Hypoplasia

23  Breast inspection  Assessment of nipple and areola  Scars

24  Firm, fibrous breast tissue ◦ nipple and areolar compressibility  Nipple protractility ◦ Flat ◦ Dimpled ◦ Inverted

25  Breast Turgor  Large Nipples  Flat/Fibrous Nipples  Inverted/dimpled Nipples

26  Management of FTT or slow Weight Gain ◦ Complex cause-and-effect relationship ◦ Direct attention to both mother and baby  There is NO substitute for direct observation of the breastfeeding couplet

27  Inadequate Milk Production ◦ Breastfeeding Mismanagement  Positioning  Frequency/duration of feeds  Engorgement  Use of nipple shields  Complimentary/supplemental feeds

28  Measuring Prolactin ◦ Varies based on stage of lactation ◦ Draw baseline (prior to a feed), then 45 minutes after nursing or pumping to measure the surge ◦ In early months; should at least double ◦ If cost an issue – baseline is more important Adapted from Lawrence & Lawrence 2005.

29  PCOS ◦ Metformin – ◦ Informal feedback- variable impact on milk production ◦ Dosages vary (500mg-2500mg daily) ◦ Goat’s Rue  Hypothyroid ◦ Be alert for “low normal” TSH and T3 ◦ Has been correlated with low milk production ◦ Low thyroid during pregnancy should always be rechecked after delivery (2 weeks, 4-5 weeks)

30  Secondary Factors (Physiologic/psycho-emotional) ◦ Maternal Illness/fatigue/diet ◦ Mental illness (PP depression) ◦ Emotional disturbances ◦ Impaired maternal-infant attachment

31  Impaired Milk Ejection reflex ◦ Primary factors (pituitary disease, surgery) ◦ Secondary factors (pain, smoking, alcohol, meds)  Milk Composition ◦ Vegan diet ◦ Extreme maternal malnourishment (can also lead to decreased milk production) ◦ Low fat content of milk

32  Inappropriate Suckling Response ◦ Identify problem  Tongue tie ◦ Identify provider who will clip  NP, ENT, Dentist, etc.

33  Uncoordinated suck swallow  Active feeding

34  Diagnose the problem (methodical) ◦ Remember interplay of various conditions ◦ Various problems can lead to same effect  Don’t make assumptions  Evaluate Mom and baby and OBSERVE THE FEEDING!

35  Support/improve mom’s milk supply  Increase intake for the baby  When to follow up?  When to refer?

36  Accurate Electronic Scale  Supplemental Nursing System or other tube feeding devises  Cup/syringe feeds  Nipple Shields  Piston Action Electric Breastpump

37  Galactagogues: ◦ Metaclopromide ◦ Domperidone ◦ Goat’s rue ◦ Fenugreek ◦ Brewers Yeast ◦ Homeopathics

38  Improve Milk Removal ◦ Correct latch ◦ Correct suck ◦ frequency and/or length of time nursing ◦ Discontinue pacifiers

39  Leads to  milk removal, then  supply  Stategies ◦ Improve latch ◦ Finger feed (suck training) ◦ SNS ◦ Referrals

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41  Improve Milk Removal ◦ Correct suck ◦ length of time nursing ◦ Correct latch

42  Deep latch  Shallow latch

43  Labs ◦ Thyroid ◦ Prolactin  Term pregnancy ng/ml  During lactation:  1st 10 days up to 500  days ranges from

44  Metaclopromide (rx required) ◦ 10mg TID 7-10 days  Fenugreek  Brewers Yeast  Homeopathics ◦ Lactuca Virosa ◦ Alfalfa Tablets

45  Accurate Electronic Scale  Supplemental Nursing System  Nipple Shields  Piston Action Electric Breastpump

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49  Ask what kind of breastpump  After every nursing session  8-10 x daily if not nursing  Night-time pumping very important

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51  Psychological approach  Artificial oxytocin

52  Get rid of the pacifier!!!  Switch nursing ◦ Takes advantage of MER  Bring baby into bed throughout the day

53  Frequent feeds  One sided feeds ◦ fat content of milk  Lengthy active feeds  Pump first to elicit MER  Maternal diet

54  Scale rental for home use  Expectation for weight gain  Weight checks (don’t wait too long) ◦ daily, q other day, weekly  Phone contact and encouragement

55 Making More Milk : Diane West & Lisa Marasco Breastfeeding: A Guide for the Medical Profession : Ruth Lawrence Breastfeeding management for the Clinician: Marcia Walker Medications and Mother’s Milk : Thomas Hale


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