Collaborative Breastfeeding Care Heggie, Johnson, Licari, Winesett May 25 '17 5/18/17

Disclosure

Collaborave Breaseeding Care: • We have no financial or ethical conflicts to Sore Nipples, Breast Pain & Tongue-Tie declare related to this educaonal acvity

May 25, 2017, Duluth, MN • Pamela Heggie MD, IBCLC, FAAP, FABM • Jane Johnson RN, IBCLC, ANLC • Addie Licari, MD, FAAFP • Heather Winese, MD, FAAP, ABIHM

Topics for this session Objecves ______• Sore nipples • Discuss the collaborave evaluaon and management • Breast pain of sore nipples and breast pain • Tongue-e • Provide an overview of tongue-e and ght frenulums • Case studies in babies and review indicaons for frenotomy • Collaborave team based care • Discuss breaseeding cases-including assessment, management and how a team approach can help

Breaseeding Pain Breast Pain – Causes • Mass • Oen due to “cascade” of events • • concurrent Engorgement • sequenal • Plugged ducts • Nipple damage • Vasospasm • Dermatoses • High milk supply – Eczema, Psoriasis, Contact Dermas, Paget’s dx • Nipple bleb • Infecon – Bacterial, Candida, Viral • Galactocele • Vasospasm/Raynaud’s syndrome • PPD/anxiety • Mechanical • Abscess – High supply, plugged ducts, ght bra, pump • Posture/posioning • High pain sensivity/chronic pain syndromes • Pectoralis cramping • PPD/anxiety • Chronic Pain syndrome

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Sore nipples: causes Academy of Breaseeding Medicine ✓ Poor latch Clinical Protocols ✓ LATCH, LATCH, LATCH ✓ Skin breakdown/cracks-staph colonizaon • Engorgement ✓ Engorgement • Mass ✓ Trauma from pumping • Persistent pain with breaseeding ✓ Nipple Shields • Supplementaon • ✓ Vasospasm Breaseeding the Late pre-term infant • Breaseeding Friendly office ✓ Blocked nipple pore (nipple bleb) • Ankyloglossia ✓ Ankyloglossia (tongue-e) • Hypoglycemia ✓ Eczema or contact dermas • ..... Many more ✓ Thrush, candida (rarer than previously thought) ✓ Oversupply/fast let down bfmed.org ✓ Short inverted nipples-ligament pain

Case 1 – Sore Nipples and “BFW”

• Mother with sore nipples. G1P1 Vaginal delivery, baby is postdates - 41 wks and 8lb 7oz. Day 2 in hospital- mom says her nipples are sore, no cracks or bleeding • Nurse says “latch looks good”. Mom given lanolin and hydrogels. Baby’s weight 5 % below birth weight, Normal output-stools/wets. Nurse reports to MD during rounds - “BFW - “breaseeding well” • Home day 2. Seen in clinic on day 5 for newborn exam - mother sll has sore nipples – she says “a lile bit sore”

Case 1 – 5 day old baby – NB clinic visit

• 11 % weight loss, 1 green-black stool since D/C, no stool in last 24 hrs, 3 wets/day “red spot” in diaper today- brought in diaper • Alert vigorous baby • MMM, jaundice to abdomen • Normal tone, normal NB exam • Bili today 15.1

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Case 1 – 5 day old NB clinic visit -Watch baby breaseed Case 1 – Plans for Mom and Baby -Examine baby and mother • Mom: You observe a feeding and noce that the baby has a • help with comfortable latch very shallow latch, taking just the nipple into her mouth, • ps about engorgement mostly non-nutrive sucking, minimal swallowing heard. • breaseed oen (8-10 x/24 hrs) • express milk (by hand or pump) • increase milk supply ■ Mother exam: Both nipples have mild erythema, no cracks. Breasts are engorged, moderately tender with mild diffuse erythema. • Baby: ■ Baby exam: Mouth- strong suck, normal tongue • needs more milk (EBM, donor milk, formula) • spoon feeding or finger feeding movement- tongue tracks laterally, elevates well and • avoid boles extends past gum line and lower lip, no tethering, • small thin flexible frenulum at base of tongue, upper feed frequently, wake q 2-3 hrs day, 3-4 hrs night lip without tethering and flanges well

LATCH: “Good”(deep) “Bad” (shallow)

Takes areola into

mouth, not just

on nipple = more milk and comfort Nipple only = No milk, Ouch!

Posioning helps with sore nipples Laid back Posion Helps with latching • Football Hold • Cross Cradle Hold

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Nipple “sandwich” U and C Engorgement Tips holds help with deep latching • Reassure that it only lasts 24-48 hrs • “Good” to have increasing milk supply- say “mature milk” NOT “milk coming in” • BF oen-wake baby q 2-3 hrs day, q 3-4 hrs night to nurse • Massage breasts and use warm compress before nursing • Hand massage during breaseeding to help milk to flow well • Cold pack over clothing aer nursing • Cabbage leaf compresses – aer nursing (directly on breasts) • Soen areola with fingers if hard for baby to latch – “reverse pressure soening” technique • Hand express or pump- if needed- only express small • Photos from Lactaon Educaon Resources Free Handouts on line, amount to relieve pressure, not to empty 2009 • www.LERon-line.com

HAND EXPRESSION for spoon feeding

Fingerfeeding Case 2 – Sore nipples • G3P3 mom with sore nipples, baby 5 days old, full term, yellow stools, output normal per BF log, 5 % wt loss.

• 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.

• Breaseeding observaon: Baby has deep latch, mom with good posioning, swallows heard and also intermient clicking. Mom reports pain during feeding.

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Type 1 - Ankyloglossia Sore cracked nipple

Sore Nipples

▪ “Normal” nipple soreness is very minimal and ok only if:

▪ Nipple “tugging” brief (< 30 sec) with latch-on then resolves ▪ No pain throughout feeding or in between feeds ▪ No skin damage ▪ Some women are told “the latch looks ok”… but they are in pain and curling their toes ▪ It doesn’t maer how it “looks” … if mom is uncomfortable it’s a problem and baby not geng much milk…set up for low milk supply ▪ Nipple pain is not normal !! (esp if nipple cracks, pain all the me during or between feedings) ▪ Pain is a sign to do something different- change latch, posion … get help! ▪ Many women stop breaseeding because of nipple soreness ▪ Help improve sore nipples right away!

Sore cracked nipple Ankyloglossia – Tongue-e “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 • Type 1- classic heart shaped tongue, frenulum to p before next feeding – 2 weeks

• Place large square piece of Ref: hp://www.posteriortonguee.com Plasc Wrap (any brand) on the nipple and areola over the ointment • Moist wound healing

• Heang pad » Type 2- frenulum aaches 2-4 mm behind tongue p

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Ankyloglossia- Tongue-e Tongue-e Assessment

Type 3 - frenulum aaches mid- Type 4 - frenulum at base of tongue tongue- shiny and thick • Finger exam of mouth, tongue and sucking- check for frenulum and inseron, thickness, elascity

• Look at tongue funcon - lateral tracking, extension, cupping, elevaon • Watch breaseeding, is mom comfortable? • Examine mother’s nipples – sore, cracks, creased? hp://www.posteriortonguee.com

Indicaons for Frenotomy Frenotomy Procedure Opons Present opons to family – benefits, risks, outcome • Breaseeding problems *** – Sore nipples, poor latch, reduced milk transfer, No Frenotomy

clicking, low sucon, slides off breast, chomps on • Observe, support breaseeding, help with deeper nipple, low milk supply, weight loss... comfortable latch, posioning • Speech arculaon – oen not affected, Frenotomy frenulum stretches • Dental problems- aer teeth erupt...do it later • Scissors – Peds, FP, ENT • Social – cosmec, “forked tongue”, no ice • Laser – many densts, ENTs • cream licking – sll consider later Benefits: latch, milk transfer, mom less sore • Risks: bleeding, infecon, mild pain (use sucrose) • Outcome: oen helps, not always

Video of Frenotomy procedure on YouTube Frenotomy: Before and Aer http://www.youtube.com/watch?v=XN-vVYd1m-o

Iris scissors and tongue elevator

hp://med.stanford.edu/newborns/ professional-educaon/frenotomy.html

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Case 3 - Breast & Nipple pain Case 3 – more hx

• 1 mo BF baby, Mother calls clinic with concerns: – “shoong pain in my breasts” • Mother is pumping 4x/day and is saving all the – “le nipple is sore” • Nipples are turning purple- somemes white aer milk in the freezer for when she goes back to breaseeding or pumping. Then “shoong pains” occur work at 3 mo postpartum. going from nipple into breast- “enre breast is throbbing somemes” • Pumping volume – gets more milk from le • Occurs aer nursing, pumping or in between feedings. side 4-5 oz on le and 1-2 oz on right aer BF Mother reports no fever, no breast redness, or lumps in breasts but does have a white spot on the le nipple that • Baby is only nursing- no boles. Mom wants is very painful with latch- but gets beer during the to start boles soon, geng ready for going feeding back to work. • No cracked nipples now – but did have sore cracked nipples in first week- started in hospital – then beer with coconut oil and now cracks have healed

Case 3 – Mother Exam Case 3 – Baby Exam Baby Exam: Mother Exam: • Excellent growth 54%ile- following WHO curve • Nipples - everted and intact -no cracks or • Normal oral mucosa- no white patches. Skin with abrasions, le nipple with 1 mm white glistening scaered erythematous papules and pustules on nodule at lateral edge of nipple at 3 o’clock, mildly cheeks, no diaper rash. • Strong suck, normal tongue tracking, frenulum is tender, no erythema of nipple or areola, not aached to the base of tongue, very thin and elasc, shiny, no satellite lesions. tongue not tethered. No heart shape, baby can elevate tongue to hard palate and extends tongue • Breasts - full breasts but not engorged, non- beyond gingival ridge and lower lip. tender, no masses, no erythema • Upper lip not tethered, normal upper lip frenulum inseron to superior gingiva. Lip flanges well

Case 3 – Breaseeding Case 3 – What’s going on?

Breaseeding observaon in clinic exam room: • Mother with painful breasts, blanching & • mother latches baby well- with deep latch in creased nipples aer feeding, nipple bleb cross cradle posion, baby has rhythmic suck • and swallowing, mother has pain with latch and High milk supply during feeding-on le side • History of cracked nipples first week, now • aer nursing – both nipples blanch white and resolved nipples have linear crease at ps –le more • Baby-normal exam, no tongue-e or thrush than right. Mother reports nipple pain and breast pain in both breasts aer feeding, more intense on le side.

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Case 3 – Vasospasm Management Case 3 - Vasospasm and nipple bleb • Adjust posion to reduce fast flow – laid back posion, football hold with baby upright and mom reclining • Start with less painful side first • Heang pad on low (or hand warmer, rice sock) placed over clothing on breasts right aer pumping or nursing • Keep nipples moist and warm and no air drying, protect from fricon, light touch • Nifedipine 30mg QD x 2 weeks, if not improving • Consider larger pumping flange- ( if rubbing) • Pump one side at me and cover other breast with heang pad • Mindfulness, meditaon, other calming strategies • Ibuprofen/Acetaminophen • Give me course for pain – will resolve...not lasng enre breaseeding journey • Close f/u- support for mom hp://www.mother-2-mother.com/nipplepain.htm#MilkBlister

Case 3 - Nipple Bleb Management Case 4 – Breast pain

• Betamethasone ointment 0.2% on bleb (thin layer) • 34 yo G1P1 calls clinic- right breast hurts, has “red spot” • Olive oil on coon ball on nipple and cover with • fever (101) today and “achy everywhere” plasc wrap • 4 mo baby, growing well • Warm compresses or soak in bowl of warm water • Mom back to work x 1 wk, pumping twice at work – gets 5 before nursing or pumping oz each side • Hand expression/massage • Has large freezer stash of milk • No needle un-roofing, can make it worse • Baby sleeping 7 hours • Lecithin 1200 mg 3x/day – helps prevent recurrent nipple blebs – What is going on? • Ibuprofen 6-800 mg 3 mes a day for 1-2 weeks – How to manage? Collaborave care...

Case 4 – Mass Management Candida rash and Thrush in baby

• Frequent breaseeding, start on affected side • Frequent breast drainage- pump, hand express • Warm first then cold compress aer nursing • Non-infecous vs infecous ( **Staph, Strep, E.Coli) • Dicloxicillin- 500 mg QID, cephalexin 500mg TID – 14 d • Consider milk culture if not beer in 48 hrs, ?MRSA • Pain control- ibuprofen, maternal self care-rest! • Probiocs, fluids • “Yeast mass”- big controversy- trial of diflucan ONLY if unresolving breast pain AND – mom with candida rash, baby with thrush on exam – first address vasospasm, oversupply, inial trial anbiocs(+/-) • Babies can sll drink the breastmilk • Close f/u- if recurrent, mass- needs U/S, etc

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Lactaon Consultant Referral • Slow weight gain • Low maternal milk supply – perceived or actual • Breast concerns – nipple damage, mass, thrush, plugs, vasospasm, pain with breaseeding (incl. neck, shoulder, breast) • Complex breaseeding issues- mother or baby with medical issues • Latch problems, inverted nipples, nipple shield concerns • Ankyloglossia, breaseeding evaluaon • Breast reducon, hypoplasia, abnormal breast appearance • Maternal medicaon queson & lactaon management • Baby with special needs including premature and early term infants • Pumping issues – back to work, pain with pumping • Twin, triplets, or more

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