Breastfeeding Management in Primary Care Pt 2 Heggie, Licari, Turner May 25 '17 5/15/17 Case 3 – Sore nipples • G3P3 mom with sore nipples, baby 5 days old, full term, Breaseeding Management in yellow stools, output normal per BF log, 5 % wt loss. Primary Care - Part 2 • Mother exam: both nipples with erythema, cracked and scabbed at p, areola mildly swollen, breasts engorged and moderately tender, mild diffuse erythema, no mass. • Baby exam: strong but “chompy” suck, thick ght frenulum aached to p of tongue, with restricted tongue movement- poor lateral tracking, unable to extend tongue past gum line or lower lip, minimal tongue elevaon. May 25, 2017, Duluth, MN • Breaseeding observaon: Baby has deep latch, mom Pamela Heggie MD, IBCLC, FAAP, FABM Addie Licari, MD, FAAFP with good posioning, swallows heard and also Lorraine Turner, MD, ABIHM intermient clicking. Mom reports pain during feeding. Sore cracked nipple Type 1 - Ankyloglossia Sore Nipples § “Normal” nipple soreness is very minimal and ok only if: ü Poor latch § Nipple “tugging” brief (< 30 sec) with latch-on then resolves ü LATCH, LATCH, LATCH § No pain throughout feeding or in between feeds ü Skin breakdown/cracks-staph colonizaon § No skin damage ü Engorgement § Some women are told “the latch looks ok”… but they are in pain and curling their toes ü Trauma from pumping ü § It doesn’t maer how it “looks” … if mom is uncomfortable Nipple Shields it’s a problem and baby not geng much milk…set up for low ü Vasospasm milk supply ü Blocked nipple pore/Nipple bleb § Nipple pain is not normal !! ü Ankyloglossia (tongue-e) (esp if nipple cracks, pain all the me during or between feedings) ü Eczema or contact dermas § Pain is a sign to do something different- change latch, posion ü Yeast, candida (rare!!) … get help! ü Oversupply § Many women stop breaseeding because of nipple soreness ü Fast let down § Help improve sore nipples right away! ü PPD, anxiety, low pain threshold ü Short inverted nipples-ligament pain 1 Breastfeeding Management in Primary Care Pt 2 Heggie, Licari, Turner May 25 '17 5/15/17 Sore cracked nipple “Plasc Wrap Treatment” • MD writes Rx for 2 % mupirocin ointment for mother • Sig: Apply thin layer to nipples aer every feeding or pumping, no need to wash off before next feeding – 2 weeks • Place large square piece of Plasc Wrap (any brand) on the nipple and areola over the ointment • Moist wound healing • Heang pad Ankyloglossia – Tongue-e Ankyloglossia- Tongue-e Type 3 - frenulum aaches mid- Type 4 - frenulum at base of tongue tongue- shiny and thick • Type 1- classic heart shaped tongue, frenulum to p Ref: hp://www.posteriortonguee.com » Type 2- frenulum aaches 2-4 mm behind tongue p hp://www.posteriortonguee.com Tongue-e Assessment Indicaons for Frenotomy • Finger exam of mouth, tongue and sucking- check • Breaseeding problems *** for frenulum and inseron, thickness, elascity – Sore nipples, poor latch, reduced milk transfer, clicking, low sucon, slides off breast, chomps on nipple, low milk supply, weight loss... • Speech arculaon – oen not affected, frenulum stretches • Look at tongue funcon - lateral tracking, • Dental problems- aer teeth erupt...do it later extension, cupping, elevaon • Social – cosmec, “forked tongue”, no ice • Watch breaseeding, is mom comfortable? cream licking – sll consider later • Examine mother’s nipples – sore, cracks, creased? 2 Breastfeeding Management in Primary Care Pt 2 Heggie, Licari, Turner May 25 '17 5/15/17 Video of Frenotomy procedure on YouTube Frenotomy Procedure Opons http://www.youtube.com/watch?v=XN-vVYd1m-o Present opons to family – benefits, risks, outcome No Frenotomy • Observe, support breaseeding, help with Iris scissors and deeper comfortable latch, posioning tongue elevator Frenotomy • Scissors – Peds, FP, ENT • Laser – many densts, ENTs • Benefits: latch, milk transfer, mom less sore • Risks: bleeding, infecon, mild pain (use sucrose) • Outcome: oen helps, not always Case 4 - Breast & Nipple pain Frenotomy: Before and Aer • 1 mo BF baby, Mother calls clinic with concerns: – “shoong pain in my breasts” – “lei nipple is sore” • Nipples are turning purple- somemes white aer breaseeding or pumping. Then “shoong pains” occur going from nipple into breast- “enre breast is throbbing somemes” • Occurs aer nursing, pumping or in between feedings. Mother reports no fever, no breast redness, or lumps in breasts but does have a white spot on the le nipple that is very painful with latch- but gets beer during the feeding • No cracked nipples now – but did have sore cracked nipples in first week- started in hospital – then beer with hp://med.stanford.edu/newborns/ coconut oil and now cracks have healed professional-educaon/frenotomy.html Case 4 – more hx Case 4 – Mother Exam • Mother is pumping 4x/day and is saving all the Mother Exam: milk in the freezer for when she goes back to • Nipples - everted and intact -no cracks or work at 3 mo postpartum. abrasions, le nipple with 1 mm white glistening • Pumping volume – gets more milk from le nodule at lateral edge of nipple at 3 o’clock, mildly side 4-5 oz on le and 1-2 oz on right aer BF tender, no erythema of nipple or areola, not shiny, no satellite lesions. • Baby is only nursing- no boles. Mom wants to start boles soon, geng ready for going • Breasts - full breasts but not engorged, non- back to work. tender, no masses, no erythema 3 Breastfeeding Management in Primary Care Pt 2 Heggie, Licari, Turner May 25 '17 5/15/17 Case 4 – Baby Exam Case 4 – Breaseeding Baby Exam: • Excellent growth 54%ile- following WHO curve Breaseeding observaon in clinic exam room: • Normal oral mucosa- no white patches. Skin with • mother latches baby well- with deep latch in scaered erythematous papules and pustules on cross cradle posion, baby has rhythmic suck cheeks, no diaper rash. and swallowing, mother has pain with latch and • Strong suck, normal tongue tracking, frenulum is during feeding-on lei side aached to the base of tongue, very thin and elasc, tongue not tethered. No heart shape, baby • aer nursing – both nipples blanch white and can elevate tongue to hard palate and extends nipples have linear crease at ps –le more tongue beyond gingival ridge and lower lip. than right. Mother reports nipple pain and • Upper lip not tethered, normal upper lip frenulum breast pain in both breasts aer feeding, more inseron to superior gingiva. Lip flanges well intense on le side. Case 4 – What’s going on? Case 4 - Vasospasm and nipple bleb • Mother with painful breasts, blanching & creased nipples aer feeding, nipple bleb • High milk supply • History of cracked nipples first week, now resolved • Baby-normal exam, no tongue-e or thrush hp://www.mother-2-mother.com/nipplepain.htm#MilkBlister Case 4 – Vasospasm Management Case 4 - Nipple Bleb Management • Adjust posion to reduce fast flow – laid back posion, football hold with baby upright and mom reclining • Start with less painful side first • Betamethasone ointment 0.2% on bleb (thin layer) • Heang pad on low (or hand warmer, rice sock) placed over • Olive oil on coon ball on nipple and cover with clothing on breasts right aer pumping or nursing plasc wrap • Keep nipples moist and warm and no air drying, protect from fricon, light touch • Warm compresses or soak in bowl of warm water • Nifedipine 30 XL QD x 2 weeks, if not improving before nursing or pumping • Consider larger pumping flange- ( if rubbing) • Hand expression/massage • Pump one side at me and cover other breast with heang pad • No needle un-roofing, can make it worse • Mindfulness, meditaon, other calming strategies • Lecithin 1200 mg 3x/day – helps prevent recurrent • Ibuprofen/Acetaminophen nipple blebs • Give me course for pain – will resolve...not lasng enre breaseeding journey • Ibuprofen 6-800 mg 3 mes a day for 1-2 weeks • Close f/u- support for mom 4 Breastfeeding Management in Primary Care Pt 2 Heggie, Licari, Turner May 25 '17 5/15/17 Breaseeding Pain – Diff Dx Case 5 – breast pain • Oen due to “cascade” of events • 34 yo G1P1 - clinic call • concurrent – Right breast hurts, has “red spot” • sequenal • Nipple damage • Fever 101 today and “achy everywhere” • Dermatoses • 4 mo baby, growing well – Eczema, Psoriasis, Contact Derm, Mammary Paget’s • Mom back to work x 1 wk, pumping twice at • Infecon – Bacterial, Candida, Viral work – gets 5 oz each side • Vasospasm/Raynaud’s syndrome • Has large freezer stash of milk • Mechanical • Baby sleeping 7 hours – High supply, plugged ducts, ght bra, pump • Allodynia/chronic pain syndromes – What’s the diagnosis and how would you manage? • PPD/anxiety Breast Pain – Diff Dx Case 5 – Mass Management • Mass • Frequent breaseeding, start on affected side • Engorgement • Frequent breast drainage- pump, hand express • Plugged ducts • Warm first then cold compress aer nursing • Vasospasm • Non-infecous vs infecous ( **Staph, Strep, E.Coli) • High milk supply • Dicloxicillin- 500 mg QID, cephalexin 500mg TID – 14 d • Nipple bleb • Consider milk culture if not beer in 48 hrs, ?MRSA • Galactocele • PPD/anxiety • Pain control- ibuprofen, maternal self care-rest! • Abscess • ProbioScs, fluids • Posture • “Yeast mass”- big controversy- trial of diflucan ONLY if • Pectoralis cramping unresolving breast pain AND – • Chronic pain syndrome mom with candida rash, baby with thrush on exam – first address vasospasm, oversupply, inial trial anbiocs(+/-) • Babies can sll get all the breastmilk • Close f/u- if recurrent, mass- needs U/S, etc Candida rash and Thrush in baby Case 6 – 37 wks & slow weight gain • 1 mo WCC – baby with slow weight gain • Birth weight 5lb 10oz • Now 4 oz above birth weight 5lbs 14oz, gained 4 oz in 14 days since circumcision in clinic at 2 weeks • Baby not latching well in hospital aer vag delivery- used nipple shield-latched a few mes, mom pumped in the hospital and baby had fingerfeeding for first week, then aer 1 week weaned off shield and breaseeding since then- breaseeds 20 min per side, sleeps “well”- 6 hrs.