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, Breas eeding 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 a ached to p of tongue, with restricted tongue movement- poor lateral tracking, unable to extend tongue past gum line or lower lip, minimal tongue eleva on.
May 25, 2017, Duluth, MN • Breas eeding observa on: Baby has deep latch, mom Pamela Heggie MD, IBCLC, FAAP, FABM Addie Licari, MD, FAAFP with good posi oning, swallows heard and also Lorraine Turner, MD, ABIHM intermi ent 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 coloniza on § 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 ma er how it “looks” … if mom is uncomfortable Nipple Shields it’s a problem and baby not ge ng 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 derma s § Pain is a sign to do something different- change latch, posi on ü Yeast, candida (rare!!) … get help! ü Oversupply § Many women stop breas eeding 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 “Plas c Wrap Treatment”
• MD writes Rx for 2 % mupirocin ointment for mother • Sig: Apply thin layer to nipples a er every feeding or pumping, no need to wash off before next feeding – 2 weeks • Place large square piece of Plas c Wrap (any brand) on the nipple and areola over the ointment • Moist wound healing • Hea ng pad
Ankyloglossia – Tongue- e Ankyloglossia- Tongue- e
Type 3 - frenulum a aches mid- Type 4 - frenulum at base of tongue tongue- shiny and thick
• Type 1- classic heart shaped tongue, frenulum to p
Ref: h p://www.posteriortongue e.com
» Type 2- frenulum a aches 2-4 mm behind tongue p h p://www.posteriortongue e.com
Tongue- e Assessment Indica ons for Frenotomy
• Finger exam of mouth, tongue and sucking- check • Breas eeding problems *** for frenulum and inser on, thickness, elas city – Sore nipples, poor latch, reduced milk transfer, clicking, low suc on, slides off breast, chomps on nipple, low milk supply, weight loss... • Speech ar cula on – o en not affected, frenulum stretches • Look at tongue func on - lateral tracking, • Dental problems- a er teeth erupt...do it later extension, cupping, eleva on • Social – cosme c, “forked tongue”, no ice • Watch breas eeding, is mom comfortable? cream licking – s ll 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 Op ons http://www.youtube.com/watch?v=XN-vVYd1m-o Present op ons to family – benefits, risks, outcome
No Frenotomy
• Observe, support breas eeding, help with Iris scissors and deeper comfortable latch, posi oning tongue elevator Frenotomy
• Scissors – Peds, FP, ENT • Laser – many den sts, ENTs • Benefits: latch, milk transfer, mom less sore • Risks: bleeding, infec on, mild pain (use sucrose) • Outcome: o en helps, not always
Case 4 - Breast & Nipple pain Frenotomy: Before and A er
• 1 mo BF baby, Mother calls clinic with concerns: – “shoo ng pain in my breasts” – “le nipple is sore” • Nipples are turning purple- some mes white a er breas eeding or pumping. Then “shoo ng pains” occur going from nipple into breast- “en re breast is throbbing some mes” • Occurs a er 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 be er during the feeding • No cracked nipples now – but did have sore cracked nipples in first week- started in hospital – then be er with h p://med.stanford.edu/newborns/ coconut oil and now cracks have healed professional-educa on/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 a er BF tender, no erythema of nipple or areola, not shiny, no satellite lesions. • Baby is only nursing- no bo les. Mom wants to start bo les soon, ge ng 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 – Breas eeding Baby Exam: • Excellent growth 54%ile- following WHO curve Breas eeding observa on in clinic exam room: • Normal oral mucosa- no white patches. Skin with • mother latches baby well- with deep latch in sca ered erythematous papules and pustules on cross cradle posi on, 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 le side a ached to the base of tongue, very thin and elas c, tongue not tethered. No heart shape, baby • a er 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 a er feeding, more inser on 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 a er feeding, nipple bleb • High milk supply • History of cracked nipples first week, now resolved • Baby-normal exam, no tongue- e or thrush
h p://www.mother-2-mother.com/nipplepain.htm#MilkBlister
Case 4 – Vasospasm Management Case 4 - Nipple Bleb Management • Adjust posi on to reduce fast flow – laid back posi on, football hold with baby upright and mom reclining • Start with less painful side first • Betamethasone ointment 0.2% on bleb (thin layer) • Hea ng pad on low (or hand warmer, rice sock) placed over • Olive oil on co on ball on nipple and cover with clothing on breasts right a er pumping or nursing plas c wrap • Keep nipples moist and warm and no air drying, protect from fric on, 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 hea ng pad • No needle un-roofing, can make it worse • Mindfulness, medita on, other calming strategies • Lecithin 1200 mg 3x/day – helps prevent recurrent • Ibuprofen/Acetaminophen nipple blebs • Give me course for pain – will resolve...not las ng en re breas eeding 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
Breas eeding Pain – Diff Dx Case 5 – breast pain • O en due to “cascade” of events • 34 yo G1P1 - clinic call • concurrent – Right breast hurts, has “red spot” • sequen al • 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 • Infec on – 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 – Mas s Management
• Mas s • Frequent breas eeding, start on affected side • Engorgement • Frequent breast drainage- pump, hand express • Plugged ducts • Warm first then cold compress a er nursing • Vasospasm • Non-infec ous vs infec ous ( **Staph, Strep, E.Coli) • High milk supply • Dicloxicillin- 500 mg QID, cephalexin 500mg TID – 14 d • Nipple bleb • Consider milk culture if not be er in 48 hrs, ?MRSA • Galactocele • PPD/anxiety • Pain control- ibuprofen, maternal self care-rest! • Abscess • Probio cs, fluids • Posture • “Yeast mas s”- 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, ini al trial an bio cs(+/-) • Babies can s ll 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 a er vag delivery- used nipple shield-latched a few mes, mom pumped in the hospital and baby had fingerfeeding for first week, then a er 1 week weaned off shield and breas eeding since then- breas eeds 20 min per side, sleeps “well”- 6 hrs. Feeds q3 hours day me and mom pumps a er feedings since her breasts feel full a lot. • Has 80 oz pumped mik saved in freezer for “going back to work “ at 3 months PP • Stools yellow, every 2-3 days, UOP 6 wets/day
5 Breastfeeding Management in Primary Care Pt 2 Heggie, Licari, Turner May 25 '17 5/15/17
Approach to Underweight Baby Immature Late Preterm Brain
• Mother issue? • Baby issue? • Breas eeding issue?
Case 6 – 37 wks, slow weight gain Case 7 Management 4 mo – less milk for daycare • Give baby all mom pumps each day • 4 mo old baby – mom calls “I don’t have • Breas eed in am- “prac ce” and no pumping x 4-5 hrs– just prac ce breas eeding all enough milk for daycare” morning-clusters • Baby sleeping through the night now -7 hrs • Breast compression and undress baby • Mom back to work, pumps once at lunch • Don’t save any milk in freezer • Using up freezer stash • Pump 4-6 x/day and watch for swallowing • No recent illness, needs 4 mo wcc when breas eeding and gradually reduce as increases in maturity and strength
4 mo WCC Approach to an older baby with slow wt gain slow weight gain
• Medical w/u- exam, thyroid • Distrac on is common • Back to work issues • Needs to pump more at work (3x) • Sleep training effects milk supply • Using freezer stash of milk (supply-demand) • Herbs- fenugreek, moringa, (+/-) • Maternal self care • Needs close f/u and encouragement
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Case 8 – pharmacist said not to Case 9 - Prenatal Care and Meds breas eed • Mother/pa ent calls because she was just told • At 36 weeks a clinic pa ent calls the nurse-line by pharmacist “not to breas eed” while taking with a ques on about medica on and fluconazole for vaginal yeast infec on breas eeding. • 6 week old baby, G1P1, 6 wk postpartum visit • Fluconazole prescribed by MD at 6 wk PP visit • She has MS (mul ple sclerosis). Her doctor said she should not breas eed because she needs high dose prednisolone x1 right a er – What protocols do you have in your clinic for staff to handle med ques ons? delivery to prevent MS flare. – What resources do you use? – Can she breas eed? • Caller in tears, she wants to breas eed!
Maternal Medications: Maternal Medications Is medication compatible with breastfeeding? • Most are safe and compatible with
breastfeeding
q Does medica on pass into • Medication use breastmilk? in pregnancy is not the same as medication use in lactation. q What is the effect on the infant? • Weigh risks/benefits to mom and baby • Make a plan and provide guidance Copyright © 2003, Rev 2005 American Academy of Pediatrics
Maternal Medications: Look it up! Is medication compatible with breastfeeding? Meds & Mom’s Milk LactMed
• Mom’s plasma level • Molecular wt of drug (into milk < 300 daltons) • Lipid solubility • Protein binding • Bioavailability of drug in mom and baby • Half-life in mom/baby plasma • pH/ion trapping References Medica ons and Mother’s Milk, T. Hale & LactMed (NIH)
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Academy of Breas eeding Medicine Clinical Protocols
• Supplementa on • Mas s • Engorgement • Persistent pain with breas eeding • Breas eeding the Late pre-term infant • Breas eeding Friendly office • Ankyloglossia • Hypoglycemia • ..... Many more
bfmed.org
Summary: Helping mothers and families achieve their infant feeding goals
• Clinic lacta on support and guidance affect breas eeding success and family confidence • What we do and say ma ers • Ask about family goals and help them get there • Make sure families have all the info they need to make decisions about infant feeding • Follow up o en...things change fast , give long term perspec ve • If supplemen ng- always hand express or pump too • Create work flows that standardize best prac ce lacta on support– “hardwire” into everyday work • Team based care helps....
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