8) • Wide Mouth Latch… 130 ⁰

Maternal & Infant Conditions

Maternal & Infant Condition Impacting •Be prepared… 70% of all breastfeeding mothers Breastfeeding in the need additional Hospital assistance with breastfeeding at some point while in the hospital Linda Kutner, RN, BSN, IBCLC, FILCA

Common Conditions Seen in the Hospital Sore Nipples

Maternal Conditions Infant Conditions •Frequent causes • Infant has a shallow latch • Sore nipples • Late preterm infant • Letting the infant nurse for long periods of • Fluid engorged nipples • Difficulty latching on • Flat nipples time without switching sides… hanging out • Tongue tie • Large breast and/or nipples • • Fussy infant Not holding the breast when using a gravity • Previous breast surgeries position • Problems with previous • To sleepy to nurse, falls breastfeeding experiences asleep at the breast • Using a gravity position while nursing in the • Maternal fatigue • Infant who nurses all night hospital bed • Sometimes tongue tie or bubble palate

Sore Nipples Myths & Misconceptions • It’s normal to have sore nipples, everyone does • Is it initial latch-on pain? • You just have to tough it out…. • Should only last for a few seconds • It will get better in a week – or two – or three • Is it pain all the way thru the feeding? • Gradually increase the length of time the baby is at the • Does the nipple look misshapen breast to prevent nipple soreness If the baby is latched incorrectly, nipples will be sore after the infant comes off the breast? regardless of length of time • Is there trauma to the nipple? • “Let the baby nurse until she comes off spontaneously” Prolonged non-nutritive sucking can cause small blisters in first couple of days

Suggestions for Sore Nipples Suggestions for Sore Nipples

• Massage each breast for about 60 seconds •Breast compressions during the feeding before putting the infant to the breast to will: reduce the initial latch on discomfort • Encourage the infant to nurse more vigorously • This initiates a quicker letdown and gets the • Will help drain the breast so the infant will infant swallowing sooner get more colostrum/breastmilk • Swallowing reduces the negative pressure in the infant’s mouth and helps prevent the little blisters • Help prevent engorgement when the mother from forming at the end of the mother’s nipple goes home

Suggestions for Sore Nipples Rational

• Watch the infant and when you see his eyes are closing and he •Discourage prolonged “hanging out” first isn’t sucking with much enthusiasm either poke him or shake the few days breast if breast compressions are not working • When you have tried to stimulate him and he still looks like he is Until there is an increase in falling asleep, take him off the breast by breaking suction colostrum/breastmilk the infant can’t stay on correctly and then moving him to the other breast one side indefinitely • Continue to watch him and move him from breast to breast till Once the milk comes in, each swallow he is satisfied releases the negative pressure in the infants • He may nurse as long as he desired, but can’t hangout on one side and give his mother blisters at the ends of her mouth and blisters are no longer a problem nipples

Suggestions for Sore Nipples Suggestions for Treatment

• After massaging the breasts • Lanolin start on the least sore side first • Hydrogel gel pads • Appropriate positioning • Breast shells Of mother’s body • Bactorban Get her out of bed unless using the • Olive oil laid back method • Anti-infective Of baby’s body properties Positional stability for staph aureus • Verallo-Rowell Perhaps pillows for support (2008) • Wide mouth latch… 130 ⁰

• Doesn’t need to be washed off before Lanolin nursing Bactroban/Mupirocin • Mother feels someone listened to her • Antibacterial and antifungal complaint and took action • Suggest for severely traumatized • Mother is Doing Something nipples to prevent then from becoming infected with staph and possibly • Not sure it actually does a whole lot resulting in mastitis after the mother unless the mother’s nipples are really goes home dry • Use a dab on the nipple after all feedings and/or pumpings • Small study indicated a higher nipple • Rinse nipple with warm water before infection rate (bacteria or yeast) nursing or pumping to make the mother when mothers routinely used lanolin feel “safe” after every feed • Discontinue as soon as nipples heal • Sasaki et al, 2014

Hydrogel Dressings Other Causes

• Good for acute nipple trauma • Invaginated nipple • Can become contaminated, especially • Pulled out by baby and with staph friable tissue removed • Good to use in the hospital by nursing • If there has been a break in the integrity of the skin for more than 4 days then staph has moved in • Don’t use on nipples that have broken skin for more than 4 days From Jan Ellen Brown • Use breast shells

Other Causes of Nipple Pain Other Causes of Nipple Pain •Mom’s anatomy • Abnormalities in infant oral cavity • • Look at size of nipple in Tongue-tie (anklyoglossia) comparison to baby’s mouth •IMPERATIVE that every baby be evaluated for tongue-tie

Bottom Line Engorged Nipples • Result of general all-over edema of the •Sore nipples – mother’s body • • If her ankles are swollen then there will be Determine the cause additional fluid in her nipples making then bigger • Fix the problem than they normally are • THEN give mom something for her nipples • Almost always seen to have a small baby • If she needs to pump make sure she has a 27- 30 mm flange • Lying flat in bed with bra on may help “elevate” her nipples • Suggest diuresing inducing foods she can eat

Flat and Inverted Nipples

• Try each breast for no more than 5 minutes • Try different positions during that time • Don’t forget to try the laid back position • Cortisol levels start rising in both mother and infant when things don’t go right in a short period of time • No success in the infant latching • Tell the mother… this is the plan when these kind of things happen • Have the mother pump/hand express • Supplement the infant • Usually just a few pumpings/supplementation and infant is able to latch

Large Breasts Large Breasts

•Women with very large breast worry most of all • Essential that you show then how to nurse safely about suffocating their infants while nursing them before they leave the hospital This is one instance where instead of saying “bring • Can place the infant on the bed and then sit beside • the bed and take the breast to the infant your baby to your breast” we say “take your • Can place the infant on the over-bed table and bring breast to your baby” it close to their body • Use the Kola hold

Implants Implants • If they have a periareolar incision they are 5X • Implants are the most common breast surgery you will at risk for a low milk supply see • The collection of saline in the implant can push on the • With all other incisions they are a 3X risk ducts, collapsing them so the the colostrum/breastmilk factor for low supply can’t flow • Getting pumping several times a day (4-6 times) • Ducts and nerves may have been severed during the surgery with lots of gentle massage of the breast • Surgery may have been done because in inadequate breast tissue followed by hand expressing for the first 3 days • These mothers are prone to engorgement

Breast Reduction Problems with Previous Breastfeeding Experiences •Can breastfeed but rare to have a full milk supply • • (Chamblin 2006) Find out why she didn’t meet her goal(s) • Most common reason for stopping in the first week or so are: •Problems with unrelieved engorgement • Sore nipples/breasts •May need to use comfort measures • Infant fussy… seen as being unsatisfied •Decision to have a reduction done before any • I didn’t have enough milk consideration of childbearing or lactation • Did she nurse as long as she desired but didn’t enjoy it •(West, 2001; Souto, 2009) because…. • Mothers with several bouts of mastitis or sore nipples • Chronic low supply • Had to pump/supplement/take herbs or medications

Suggestions for Problems with Previous In-Hospital Fatigue Breastfeeding Experiences • Mastitis • When rooming-in mothers either of vaginal • Show her how to massage her breasts to pervert milk stasis or c/section delivery tend to ensure that • Deal with nipple trauma quickly their babies have optimal care, at the • Discuss with her how she can get additional rest at home expense of their own needs and desire to • Low supply rest ( Kurth 2010, Lai 2014) • Get the mother pumping to max out laying down prolactin receptors • Using the hands on pumping will empty her breasts and prevent a decrease of • In the hospital they awake on an average of her supply 4 times during the night to feed and/care • Usually these mothers are motivated to try and for their infants (Shrago 1990) prevent recurrence of their problem

Late Preterm Infant In-Hospital Fatigue • Must know gestational age • • Gestational age can effect infant’s ability to breastfeed and to initiate and maintain the Prepare women ahead of time for fatigue (Childbirth Class) mother’s milk supply • Women rank fatigue as one of 5 major concerns during the postpartum • Preterm period • Any infant born before 34 weeks regardless of weight • Teach breastfeeding mothers to nurse safely while lying on their sid • Late preterm • Help mothers learn to soothe their infants…infant crying is directly • Infant born between 34 0/7 and 36 6/7 weeks of gestation associated with perceived maternal tiredness and fatigue • Early Term • With 1 minute of infant crying the mother starts to feel tired • Infant born between 37 0/7 – 38 6/7 weeks of gestation • Establish hospital rest periods, limit visitors • Term infant • Delay intrusions by ancillary staff till late morning • Infant born between 39 0/7 and 41 6/7 weeks gestation • Organize nursing activities so mothers can have additional rest times • Post term • (Heinig, 2010; Weersing, 2014) • Infant born at 42 weeks or anytime thereafter

Late Preterm Infant Brain Development

At 35 weeks the brain is only •Chance of death is 7 times higher for a 60% the weight of a full term LPTI than it is for a full term infant infant’s. There is dramatic • (Engle 2007) growth of the brain in the last 4 weeks of gestation •70% of preterm births are of the LPTI (Tonse 2006) category These infants are twice as likely to die of SIDS • (Petrini 2009) Even infants born within 3 days of the 39 th week had a higher morbidity www.medscape.com/viewarticle/569669?sr c=mp

LPTI’s Physical Characteristics LPTI’s Physical Characteristics • Does not behave as a full term infant • Poor state control • Often neurologically disorganized X Sleep quiet alert crying • Suck/swallow/breathe cycle may not be fully developed • Deceptively vigorous • Poor muscle tone, floppiness • Appears to be suckling/swallowing • Inability to maintain sustained periods of at least 10 • Acts satiated sucking bursts puts them at risk for limited milk • Size does not equal maturity! transfer and its consequences • (Wight 2003)

Jaundice and the LPTI Meconium Passage • Peaks at 5-7 days, unlike term infants •Initial meconium passage may occur after 24 • Common dx re-admittance day 5-7 hours post birth and meconium may be • Resurgence of kernicterus passed for 4 to 6 days • (Bhutani, 2007) • This allows the bilirubin in the meconium to be • Transient neurological issues reabsorbed increasing their serum levels • Negative effect on breastfeeding longevity • If this is complicated by poor and inadequate feedings the levels may raise to 20 mg/dl or higher (Bekkali 2008) • Why we need to supplement these infant adequately and early 38

LPTI Who is Large for Gestational Age LPTI Who is Large for Gestational Age • The LPTI who is LGA is at higher risk for significant jaundice •You don’t usually need a chart to • (Bhutani, 2006) • From 1992 to 2002… 24% of infants in the determine who is Large for Gestation Age Kernicterus Registry were late preterm infants •Anytime you, the mother or staff say…. • Risk of high bilirubin levels doubles for each week less than 40 weeks gestation “Just think what he/she would have • Exclusive breastfeeding increases the risk of high bilirubin weighed if he/she was born at 40 levels by a factor of 6 8 lb 2 oz at 34 • (Whyte, 2010) weeks gestation weeks!!”

Hospital Complications Breastfeeding and the LPTI • In the hospital more likely to have trouble with • They may start out nursing fairly well thermoregulation, hypoglycemia, jaundice, feeding problems • But lack stamina and run out of energy and more septic work-ups • Vital signs usually done only once a shift • Unable to continue to initiate and maintain • Cold stress can result in poor feeding, weak suck, decreased tone and mother’s milk supply tachycardia • May be AT the breast, but not transferring milk • Need temperature monitored more frequently • May sleep through feedings • Study showed that most of these problems can be eliminated • With short hospital stays they get in trouble AFTER or decreased with delaying the bath and doing more skin to they go home skin (Cooper, 2012; Loring 2012)

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The LPTI at the Breast Pumping with the LPTI •Study of 26 infants 32 – 37 weeks of gestation • Active sucking at the breast 10% to 60% of the • These mothers need to pump to initiate and feeding maintain supply • Goal is pumping 8X24 hours until a full milk supply is • Mouthing movements, other than active sucking, establish 2% to 35% of the feeding • Then depending on her infant, the mother may do • Pauses ranged from 12% to 67% of the feeding as little as 4X a day or may need to continue doing • (Nyqvist 2001) 8X 24 hr Why we need to have the • They are best served by using a hospital grade mother pump and supplement pump the infant, don’t depend on • Most times can eliminate pumping by due date just feeding from the breast 43 44

Nipple Shields and the LPTI Positioning of the LPTI Some of these infants can increase their intake by nursing with a nipple shield • Avoid positions that cause excessive flexion A shield helps them keep the nipple extended in their of the neck and trunk mouth during their long pause phase • Traditional cradle hold is one position to avoid (Meier 2002) • Impedes full rib cage expansion Usually can achieve a full feed without a nipple • Contributes to collapse of airway shield when they reach their due date • Football hold and cross cradle are positions Don’t send them home on a nipple shield without a of choice scheduled return appointment • (Walker 2008)

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Supervision of the LPTI Feeding Schedule for the LPTI • Observe breastfeeding q3h • Some of these infants need to have limited time at • Lactation consult within 24 hours of birth and the breast so they can stay awake to take their seen by lactation every day while in the supplement hospital and after discharge as needed • Best supplement is the breastmilk the mother pumped after the last feeding • Take temp q3h with feeds • Entire feeding… breast + supplement should take no longer than 30- • 40 minutes Supplementation as needed • Make sure infant can take his supplement in about 15 minutes • (Shaw 2008) • If he is too tired to take his supplement, decrease the time at the breast • Teach her paced bottle feeding

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Infant With Tongue Tie Skin to Skin with the LPTI • Evaluate all infants for tongue tie • Talk to the mother about the benefits of skin to • Be suspicious of mother’s complaining of pain during the skin care for as many hours a day as she can. feedings • Better thermoregulation • When nipples are misshapen when the infant comes off the • Better weight gain breast • Normalized respiratory and heart rate patterns • Ask for an evaluation of the mobility of the infant’s • Improved state regulation tongue • Quieter • If clipping is delayed • More restful sleep • More robust wakeful periods • Would a nipple shield help?? • Less time in fussy/drowsy states • Get the mother pumping and supplement appropriately • Creative positioning 49

Clues for Not Latching

• Review the birth history Babies who won’t latch • Review what has happened to the infant since the birth • Separation, stress, hospital routines, prolonged efforts at trying to get him to nurse, waking him to MAKE him nurse • Is he trying to latch? • Check his mouth and frenulum

What Has Been Tried? Rule # 1 • You CANNOT MAKE a baby breastfeed just • Has he ever nursed? because “it’s time” or “he should” or “it’s been • How well did he do? three hours” or “the policy says he has to eat • Has “laid back breastfeeding” been tried? twice on my shift” • How long has he been skin to skin? • Yes, you CAN make a baby bottle feed – even if sound • Are we waiting for baby readiness? asleep • • Has the mother hand-expressed colostrum? Bottle feeding and breastfeeding are NOT the same thing • Buys some time • • Gets some food in the baby A healthy breastfeeding baby can go longer between feeds than the formula fed infant as the nutrients in breastmilk are fully bioavailable

Rule # 2 Rule #3

• Keep mothers and babies together, SKIN TO • ROOTING SKIN • Baby MUST be rooting before he will latch • Want baby to nurse? S2S with mom effectively • Want baby to sleep? S2S with dad • Don’t try to force baby to breast just because his • Usually 30 minutes of S2S will trigger baby’s eyes are open, or has his hands to mouth nursing instincts • Don’t ever try to force baby to breast • Keeping babies in the nursery and expecting them to •He must be ROOTING wake for feeds is not productive

Rules #4, #5, #6 & #7 Important Point

• Rule # 4 – Try laid Back Breastfeeding • Get mom & baby in comfortable laid back position • Because babies are hard-wired to • Rule # 5 – Try the Dominant Hand Position breastfeed, if a baby CAN’T latch • Teach mom how to use her dominant hand to get baby latched on to – there is a problem and you need the breast • Use if “laid back” breastfeeding isn’t working to figure out what it is • Rule #6 – Don’t stress mom & baby • Be alert for signs of shutdown • Rule #7 – Express colostrum, feed with spoon

Outcome Going Home

•Bottle feeding seems easier so • If baby not latching & breastfeeding effectively at discharge moms will quit and either pump or go • Mother has a feeding plan telling her to formula • How much to supplement, when and under what conditions • When to pump and how long •He likes me better when I bottle feed • Mother HAS to have a hospital grade pump him • If WIC mother, must call WIC before discharge to set this •It’s such a relief just to have him eat up • Needs to have an appointment to be seen within two days and not fight with him after discharge by lactation specialist

Sleepy Infant

• Is he a Late Preterm Infant? • Is it the effect of labor & birth? • Medications? Sleepy baby • Long second stage? • Is it because of missed feeding cues which can be subtle • Is it the normal part of first 24 hours? • Is it because the baby is non-compliant with what WE think they should be doing? • Are we more concerned than we need to be?

Sleepy Infant

• Skin to skin! • Do Not Try to wake the sleepy baby by rocking him, cool water on his skin, tickling his back • Strip down & put him skin to skin by the breast Fussy baby in the hospital • Some sleepy babies will latch on their own even without being woken up if you leave them alone • Allow him to wake on his own • Gentle stimulation for a few minutes if at all • If he doesn’t wake have mother hand express, feed him the colostrum and let him sleep

Something is Wrong Physiology of Crying

• I’m hungry or thirsty • I’m too hot or too cold • Immediate and long-term sequela of crying • Increased heart rate, blood pressure, reduced oxygen • I’m tired • I’m not comfortable levels, elevated cerebral blood pressure. • I’m lonely or I’m bored • I don’t know where my • Initiation of stress response, depleted energy reserves and • I have been over mother is oxygen. stimulated • It’s too quiet, I’m scared • Interrupted mother-infant interaction • • I’m in pain Caregivers are encouraged to answer infant cries swiftly, consistently and comprehensively • I’m sick • (Luddington-Hoe 2002)

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Things We Can Do What We See In The Hospital • Do NOT • Baby who is not happy unless he is on the breast • Offer to take baby back to the nursery… • Take him way from the breast and he fusses • Or insist the baby is hungry and give her formula… • Will not sleep for any period of time • Suggest • Help her put the baby skin to skin, show her laid back breastfeeding and observe • Seems to startle easily which wakes him again a feed to make sure all is going well • Mother reports that he always wants to nurse, especially all • Encourage her to breastfeed the baby – yes, again – even if she “just finished” night • Have her hand express after nursing, which brings her milk in sooner and provide the infant with a bit more colostrum • He may be difficult to calm him enough to get him on the • Remember about 1 minute of infant crying and the mother breast starts to feel exhausted

Other Things We Can Do Infant Who Nurses All Night

• Dim the lights •Big red flan when mother says the infant • Decrease the stimulation nursed all night • Calm the environment • First of all, she will have sore nipples come • Discourage folks from playing “pass the baby” morning • Secondly, no mother has enough colostrum in • nd Teach her about 2 Night, even if it is the her breasts to provide for all night nursing first day

Infant Who Nurses All Night Infant Who Nurses All Night

• Establish first of all by what the mother means by • Have the mother massage her breasts then have her he nursed all night hand express • Don’t ask how often he nursed… ASK how long he • Was she able to express a half a teaspoon or more could rest between nursings • Tells you there is something in the breast and best guess is that the infant was not transferring the colostrum • This gives you a much better picture of what went on during the night • Despite breast massage and multiple attempts of hand • expression in several areas around the areola nothing Essential that the infant’s latch is assessed comes out review the mother’s history for reasons for • Look for shallow latch the colostrum to be scant or for her milk to be delayed in • Look for the compressed, flattened nipple coming-in

Who is at Risk for Delay in Their Milk Normal Onset Coming-in •Normal onset of milk production is by 72 • First time mother is at higher risk • Mothers with diabetes hours (noticeable fullness/heaviness in • Faulty insulin uptake in the cells breasts) • Mothers with edema, swollen ankles and hands • If pitting edema – 65% will have a delay in their milk coming-in • Generally 48 for a multip • Even with mild edema – 49% will have a delay • Around 72 for a primip • Use of SSRIs during pregnancy • Zoloft and Paxil both implicated •Beyond 72 hours is delayed onset of milk • Hale, 2013 • Obesity (BMI >27 = 2.5x more likely to have delayed onset coming-in • Dewey, 2003 • Nommsen-Rivers, 2011

How Can We Help •Make sure mothers at risk are seen by lactation specialist •Remind moms there is a light at the end of the tunnel: less than 2% of all mothers never experience their milk coming in • It may be slow to come-in but with good, frequent stimulation it will come-in • Nommsen-Rivers, 2011