OVERCOMING Presented by: CONCERNS Sue Harmon, IBCLC OVERVIEW • Difficulties • Pain • Tongue Tie • Flat/Inverted • Engorgement • • Pacifiers • Low Supply • Supplementation LATCH DIFFICULTIES

Goal is to preserve and protect the milk supply! • Remember, some newborns require additional time to recover from birth effects. • Why is this?*

(LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013; WILSON-CLAY & HOOVER, 2005) LATCH DIFFICULTIES

Interventions if newborn has not/is not latching effectively in the first 24 hours: • Promote frequent, uninterrupted skin to skin. • Attempt to breastfeed during quiet, alert times, whenever the is cueing or at least every 3 hours. • Limit attempts to 10 minutes or stop when infant gives negative cues. •Crying •Pushing away •Demonstrates withdrawal or avoidance behaviors. What are these?* •If occurs, calm the infant and attempt later. (LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013) LATCH DIFFICULTIES

Continued… • Avoid activities immediately prior to a feeding that can disrupt attachment reflexes. What activities might do this?* • Encourage to perform massage and hand express on her and baby’s mouth during attempts. • Encourage patience, practice and persistence.

(MANNEL ET AL., 2013) LATCH DIFFICULTIES

If the baby continues to feed poorly: • Continue to perform breast massage and hand expression with each attempt. • Assist in obtaining a quality, double electric for use until the baby latches and breastfeeds effectively.* • Encourage the mother to express milk: •A minimum of 8 times daily •For 15 minutes until milk flow stops •Manually to completely empty the breast •Consistently, even during the night

(LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013)

PAIN

Pain is the #1 reason why mother’s quit breastfeeding PAIN – WHAT’S NORMAL?

• Nipple tenderness is normal in and early postpartum due to heightened nipple sensitivity. •Peaks on days 3-6 postpartum and is relieved when milk volume increases. • feel discomfort as collagen fibers are stretched with early sucking. •Decreases as nipple flexibility increases. • Increased vascularity of the nipple can occur with a good latch, still resulting in tenderness.

(LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013) PAIN – WHAT’S NORMAL?

Transient Nipple Soreness:

• Many mothers are told breastfeeding should not be painful, but often experience pain early on. • Initial tenderness that resolves within the 1st week postpartum • Occurs with initial latch and resolves after the first few sucks

(LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013) PAIN – WHAT’S NOT NORMAL?

• Any severe nipple pain is NOT normal including: • discomfort that last longer than 1 week • discomfort felt throughout a feeding • There is no association between nipple pain and skin color, hair color, prenatal preparation, or limiting sucking time at the breast. • Pain during a feeding is most commonly a result of incorrect latch.

(LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013) PAIN

To ensure breastfeeding is mutually beneficial what are some things a health provider should assess? • Pain quantity • Pain type • Nipple Appearance • Latch • Infant’s oral anatomy

(LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013) PAIN QUALITY AND TYPE

Pain Quality: Pain Type: • Pain scale • Tugging and pulling? • Sharp? • Biting? • Pinching? • Chewing? NIPPLE APPEARANCE

• Intact? • Pinched? • Creased? • Bruised? • Cracked? • Abraded? • Bleeding? • Scabbed?

(LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013; WILSON-CLAY & HOOVER, 2005) LATCH

• Gape • Lips • Swallows

(WILSON-CLAY & HOOVER, 2005) COMMON SOURCES OF NIPPLE PAIN

•Poor latch •Poor Positioning •Flat or Inverted Nipples •Tongue Tie •Engorgement •Mastitis •Poorly Fit Devices PAIN INTERVENTIONS

• Go back to the basic latch techniques • Skin to skin before latching • Manual expression of milk before latching • Feed on least sore breast first • Apply colostrum to nipples and air dry after feeding • Lanolin or Soothies (gel pads) for comfort • Do not use simultaneously • For cracks/open wounds, a polysporin cream may be needed. • Physician order PAIN INTERVENTIONS

The goal is to continue breastfeeding while making it less painful! Ensuring a correct position and latch promotes healing while stimulating milk production.

(WILSON-CLAY & HOOVER, 2005) TONGUE TIE -

• Early intervention is key! • Should be routinely assessed for on all newborns • Thin membrane that attaches the tongue to the floor of the mouth • Appears as a “heart shape” of the tongue

(ACADEMY OF BREASTFEEDING MEDICINE, N.D.; WILSON-CLAY & HOOVER, 2005) TONGUE TIE

Results in: Decrease in tongue peristalsis Reduced milk transfer Difficult achieving or maintaining latch Nipple pain and/or trauma Long, ineffective feedings

(ACADEMY OF BREASTFEEDING MEDICINE, N.D.; WILSON-CLAY & HOOVER, 2005) TONGUE TIE MANAGEMENT

• Attempt to breastfeed in a semi-reclined position • Compress the breast to assist with a deep latch • Notify physician for treatment referral • Frenotomy*

(ACADEMY OF BREASTFEEDING MEDICINE, N.D.; WILSON-CLAY & HOOVER, 2005) FLAT OR INVERTED NIPPLES

• Perform the “nipple pinch test”* to determine nipple type • Flat or short shanked nipple: • very short to no shank or erectness • : •More rare, retract at rest and with stimulation

(LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013; WILSON-CLAY & HOOVER, 2005) FLAT/INVERTED NIPPLE INTERVENTIONS

• Assess latch and need for intervention, if any. • Manually roll the nipple to stimulate nipples to evert. • Pump breast for 1-2 minutes before latching. • If infant still will not latch or cannot maintain latch, consult an IBCLC for nipple shield application, sizing and use.

(LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013) BREAST SHELLS

• Indications: • Flat or inverted nipples • Sore nipples • How often are they used? • Limited and insufficient data on effectiveness*

(LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013) NIPPLE SHIELD

Nipple shields are not a first line intervention and should not be used to prevent or manage nipple pain. Appropriate uses include: • with decreased muscle strength/tone (preterm, late preterm, SGA) •Short tongue •Tongue tie •High palate •Flat/inverted nipples •Transition to breastfeeding from a bottle •Cleft lip/palate (LAUWERS & SWISHER, 2016) NIPPLE SHIELD CONSIDERATIONS

• Material • Design • Size • Placement* • Application* • • Care/Cleaning

(LAUWERS & SWISHER, 2016; WILSON-CLAY & HOOVER, 2005) PLUGGED NIPPLE PORE

• Aka , milk blister • Small white dot on the face of nipple caused by: •Plugging of nipple opening with milk •Overgrowth of skin over opening • Painful to touch and with feedings • Interventions: •Soak nipple in warm water to soften plug •Place olive oil soaked cotton ball over nipple between feedings •Refer to physician

(LAUWERS & SWISHER, 2016; WILSON-CLAY & HOOVER, 2005) ENGORGEMENT

Normal Physiologic Fullness Engorgement

• Occurs as part of increased tissue • Painful swelling that occurs when the vascularization and the normal become overfull from failure transition from colostrum to full milk to remove milk adequately or production. frequently enough. • Symptoms begin around 3-5 days postpartum & resolve by • Excess fluid causes increased approximately 10 days postpartum pressure on alveoli & milk ducts. with: • Causes: • Unlimited, on-demand, exclusive breastfeeding • Missed or infrequent feedings • 24/7 rooming in • Inadequate milk removal

(LAUWERS & SWISHER, 2016) ENGORGEMENT

Signs & Symptoms: • Firm and hard • Tenderness • Warm or hot to the touch • Shiny, transparent skin • Flattened nipples May result in: • Decreased milk production • Inadequate letdown r/t & pain • Plugged ducts • Mastitis

(LAUWERS & SWISHER, 2016; WILSON-CLAY & HOOVER, 2005) ENGORGEMENT INTERVENTIONS

• Frequent nursing, at least every 2 hours • Moist heat 5 minutes (or less) before feeding* • Breast massage and hand expression • Use of breast pump prior to latching to soften, elongate the nipple and make it easy for baby to grasp • Cold therapy for 10 minutes after feeding

(LAUWERS & SWISHER, 2016) PLUGGED DUCT • Hard, localized area in the breast • Causes: •Incomplete milk removal •Outside pressure on specific areas of the breast which inhibits free flow of milk* • Treatment: •Regular, frequent feedings •Hand massage in the direction of the plug •Positioning infant’s chin over the plugged area during feedings •Beginning feeding on the side with plug •Moist heat and massage (LAUWERS & SWISHER, 2016) MASTITIS

• Breast inflammation • Usually, but not always, cause by bacterial infection • Occurs most often in the first 12 weeks postpartum when the mother is most tired and immunity is lowered from pregnancy.

(LAUWERS & SWISHER, 2016; HOOVER-CLAY & WILSON, 2005) CAUSES OF MASTITIS

• Triggered or perpetuated by • Milk stasis and engorgement psychosocial stress • Overproduction of milk • Maternal stress, fatigue, lack of support • Pressure on the breast • Infrequent, scheduled, limited • Nipple damage, bleb, or duration, and/or missed blister feedings • Plugged duct • Inefficient removal of milk* • Maternal or infant illness

(LAUWERS & SWISHER, 2016) MASTITIS

Signs and Symptoms: • Sudden onset • Redness or red streaking of the breast • Tender and hot to the touch • Firm lump in the breast • Fever, chills, flu-like symptoms May result in: • Decreased milk supply • Abscess •Abrupt cessation of breastfeeding* (LAUWERS & SWISHER, 2016; WILSON-CLAY & HOOVER, 2005) MASTITIS INTERVENTIONS

• Refer to OBGYN for antibiotic tx • Heat: warm, moist compresses to inflamed area before and during • Frequent, on demand, unscheduled feeding feedings • Warm shower before feeding • Begin feedings on affected breast • Cold packs to affected area after • Breast compression and massage feeding or pumping to reduce pain • Hand express or pump milk to drain and edema the breast if infant will not nurse and • Increase rest and fluids after feedings to fully drain breast • OTC anti-inflammatory pain reliever • Position baby’s chin pointing toward affected area (LAUWERS & SWISHER, 2016) BREAST PUMPING

Reasons a mother may need to pump: •Exclusively bottle feeding •Maternal infant separation •Nipple trauma •Ineffective removal of milk •Newborn sleepiness or inability to eat • •Preterm/Late Preterm Infants

(BOIES ET AL., 2016; LAUWERS & SWISHER, 2016; MANNEL ET AL., 2013; USBC, 2018) PUMPING PRIORITIES

Preterm & Late Preterm, Maternal Infant Separation, and Exclusively Bottle Feeding Considerations: Pump Early: •NEW! - Ideally within the first hour of delivery and after the first feeding •Regardless of delivery mode Pump Often: •Recommend 8 pumping sessions in a 24 hour period •Not to exceed 4 hours without pumping

(MORTON ET AL., 2012; STEUER & SMITH, 2018) LOW MILK SUPPLY

Actual Perceived • Estimated that 5% of mothers have • Misperception leads mothers to true low milk supply. supplement unnecessarily, resulting in actual insufficient supply • Rates may be higher due to increases in advanced maternal age, • Directly related to maternal self- confidence and self-efficacy* obesity, and comorbidities. • More than 50% of mothers who cite • Most cases are a result of ineffective low milk supply as the reason for breastfeeding. weaning did so within 2 days after birth.

(LAUWERS & SWISHER, 2016) PERCEIVED LOW MILK SUPPLY

Why? • Frequent feedings or cluster feeding • Growth spurts result in temporary increase in feedings • Misinterpret crying as a symptom of low supply • Breasts not feeling full • Pumping lower milk volume (than another mother)

(LAUWERS & SWISHER, 2016; USBC 2018) LOW MILK SUPPLY EDUCATION

Mothers have fewer worries about their milk production when they understand that milk removal triggers more milk production. Encourage mothers on: •Frequent, on demand feedings 8-12x daily •Importance of latch and positioning •Breast compression and massage during feedings •Performing hand expression after feedings to ensure breast emptiness •Utilize IBCLC resources and community support groups

(LAUWERS & SWISHER, 2016) LOW MILK SUPPLY EDUCATION

Remind that: •Actual breastfeeding rates and capacities differ for each mother baby dyad. •3 Factors influence breastfeeding frequency: 1. Breast storage capacity* 2. Infant stomach capacity 3. Infant’s gastric emptying time

(LAUWERS & SWISHER, 2016) SIGNS OF SUFFICIENT MILK PRODUCTION

• Infant has appropriate wets and stools for days of age • Infant routinely feeds 8-12x in 24 hours • Infant regains by 2 weeks of age & continues to gain weight appropriately thereafter • Audible swallows are heard consistently throughout feeding • Baby is alert and active • Baby is content between feedings and wakes on his/her own to feed*

(LAUWERS & SWISHER, 2016) ACTUAL LOW MILK SUPPLY

Red Flags: • Previous history of low milk supply • Inadequate breast tissue growth in puberty/pregnancy • History of breast surgery • Radiation to chest • Endocrine disorders (hypothyroid, PCOS) • Obesity • Diabetes • Medications

(LAWRENCE & LAWRENCE, 2016) ACTUAL LOW MILK SUPPLY

• Frequent removal of milk and emptying of the breast • Ensure adequate milk transfer* • Pump after feedings for extra stimulation • * • Remain support and positive regarding mother’s efforts

(LAUWERS & SWISHER, 2016) ACTUAL LOW MILK SUPPLY

Referral Suggestions: • OBGYN for metabolic lab work • Pediatrician to monitor adequate growth and development • IBCLC for additional resources, such as a SNS (supplemental nursing system) BREAST PUMPING GUIDELINES

General concepts: • Avoid overstimulation which can lead to overproduction • Pump for no more than 10-15 minutes • Ensure proper flange size • Utilize appropriate suction • Utilize a quality, reputable, double electric pump to maximize levels • Use “hands on pumping”* • Follow each pumping session with 3-5 minutes of hand expression

(LAUWERS & SWISHER, 2016) BREAST PUMPING GUIDELINES

• If pumping for milk storage bottles: •Once or twice a day right after a feeding is sufficient •Pumping in the morning will provide higher volumes • If pumping to increase supply •Pump after all daytime feedings •Decrease pumping frequency once an increase in supply is attained

(LAUWERS & SWISHER, 2016; USBC, 2018) CLEANING PUMP PARTS

https://www.cdc.gov/healthywater/hygiene/health ychildcare/infantfeeding/breastpump.html

(CENTERS FOR DISEASE CONTROL AND PREVENTION, 2017) REFERENCES

Academy of Breastfeeding Medicine (n.d.). Protocol #11: guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad. Retrieved from https://abm.memberclicks.net/assets/DOCUMENTS/PROTOCOLS/11-neonatal- ankyloglossia-protocol-english.pdf Boies, E. G., Vaucher, Y. E., & the Academy of Breastfeeding Medicine (2016). ABM clinical protocol #10: breastfeeding the late preterm (34-36 6/7 weeks gestation) and early term infants (37-38 6/7 weeks gestation), second revision 2016. Breastfeeding Medicine, 11(10), 494-500. Doi: 10.1089/bfm.2016.29031.egb Centers for Disease Control and Prevention (2017). How to keep your breast pump kit clean: the essentials. Retrieved from https://www.cdc.gov/healthywater/pdf/hygiene/breast-pump-fact- sheet.pdf Lauwers, J. & Swisher, A. (2016). Counseling the nursing mother: A consultant’s guide (6th ed.). Burlington, MA: Jones & Bartlett Learning. Lawrence, R. A. & Lawrence, R. M. (2016). Breastfeeding: A guide for the medical profession (8th ed.). Philadelphia, PA: Elsevier. REFERENCES

Mannel, R., Martens, P. J., & Walker, M. (2013). Core curriculum for practice (3rd ed.). Burlington, MA: Jones & Bartlett Learning. Morton, J., Wong, R.J., Hall, J.Y., Pang, W. W., Lai, C. T., Lui, J., Harmann, P. E., & Rhine, W. D. (2012). Combining hand techniques with electric pumping increases the caloric content of milk in mothers of preterm infants. Journal of Perinatology, 32, 791-796. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/22222549 Steurer, L. M. & Smith, J. R. (2018). Manual expression of : A strategy to aid in breastfeeding success. The Journal of Perinatal & Neonatal Nursing, 102-103. doi: 10.1097/JPN.0000000000000328 Stuebe, A. (2014). Enabling women to achieve their breastfeeding goals. Obstetrics & Gynecology, 123(3. doi: 10.1097/AOG.0000000000000142. Wilson-Clay, B. & Hoover, K. (2005). Breastfeeding atlas (3rd ed.) images. Manchaca, TX: Lactnews Press.