9/21/2018

OVERCOMING Presented by: CONCERNS- PART 1 Kary Johnson, IBCLC

OVERVIEW

• Difficulties • Pain • Tongue Tie • Flat/Inverted • Engorgement •

1 9/21/2018

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 infant 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 - hiccupping, coughing, gagging, sneezing • If occurs, calm the infant and attempt later.

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

2 9/21/2018

LATCH DIFFICULTIES

• Avoid activities immediately prior to a feeding that can disrupt attachment reflexes. What activities might do this? • Encourage mother to perform massage and hand express colostrum 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 breast pump 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)

3 9/21/2018

PAIN

Pain is the #1 reason why mother’s quit breastfeeding

4 9/21/2018

PAIN – WHAT’S NORMAL?

• Nipple tenderness is normal in pregnancy and early postpartum due to heightened nipple sensitivity. •Peaks on days 3-6 postpartum and is relieved when milk volume increases. • Mothers 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)

5 9/21/2018

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

Assess: • Pain quantity • Pain type • Nipple Appearance • Latch & Positioning • Infant’s oral anatomy

Picture source: https://www.momjunction.com/articles/breastfeeding-memes-to-get-you-through-that-nursing-session_00441453/

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

6 9/21/2018

NIPPLE APPEARANCE

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

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

GENERAL PAIN MANAGEMENT • Go back to the basic latch techniques • Skin to skin before latching The goal is to • Manual expression of milk before latching continue • Feed on least sore breast first breastfeeding • Apply colostrum to nipples and air dry after while making it feeding less painful! • Lanolin or Soothies (gel pads) for comfort • Do not use simultaneously • For cracks/open wounds, a polysporin cream may be needed – MD order

7 9/21/2018

TONGUE TIE - ANKYLOGLOSSIA

• 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 Results in: Management: • Decrease in tongue peristalsis • Use a semi-reclined position • Reduced milk transfer • Difficult achieving or maintaining latch • Compress the breast when latching • Nipple pain and/or trauma • Notify MD for treatment & referral • Long, ineffective feedings • 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)

8 9/21/2018

FLAT/INVERTED NIPPLE MANAGEMENT

• 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)

9 9/21/2018

NIPPLE SHIELD

Nipple shields are not a first line intervention and should not be used to prevent or manage nipple pain.

(WILSON-CLAY & HOOVER, 2005)

NIPPLE SHIELD Appropriate uses include: • Infants with decreased muscle strength/tone (late preterm, SGA) • Short tongue • Tongue tie • High palate • Flat/inverted nipples • Transition to breastfeeding from a bottle • Cleft lip/palate • NICU: small oral cavity, ineffective suck

(LAUWERS & SWISHER, 2016)

10 9/21/2018

NIPPLE SHIELD CONSIDERATIONS

• Material • Design • Size • Placement • Application • Weaning

• Care/Cleaning http://www.breastfeedingmaterials.com/vid eo/J8DB74-nipple-shield/ (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)

11 9/21/2018

ENGORGEMENT

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

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

ENGORGEMENT MANAGEMENT

• 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)

12 9/21/2018

PLUGGED NIPPLE PORE

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

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

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)

13 9/21/2018

MASTITIS

Inflammation of the breast • Usually caused by a bacterial infection • Occurs most often in the first 12 weeks postpartum •Fatigue is highest •Immunity is lowest

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

MASTITIS

Causes: • Maternal stress, fatigue, illness, lack of support • Infant illness • Infrequent, scheduled, limited duration, and/or missed feedings • Milk stasis and engorgement • Overproduction of milk • Pressure on the breast • Nipple damage, bleb, or blister • Plugged duct (LAUWERS & SWISHER, 2016)

14 9/21/2018

MASTITIS

Signs and Symptoms: May result in: • Sudden onset • Decreased milk supply • Redness or red streaking of the • Abscess breast •Abrupt cessation of breastfeeding* • Tender and hot to the touch • Firm lump in the breast • Fever, chills, flu-like symptoms

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

MASTITIS MANAGEMENT

• 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)

15 9/21/2018

REFERENCES

American Academy of Pediatrics (2012). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 129(3), 827-841. Doi 10.1542/peds.2011- 3552 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. 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

Evans, A., Marinelli, K. A., Taylor, J. S., & The Academy of Breastfeeding Medicine. (2014). ABM clinical protocol #2: Guidelines for hospital discharge of the breastfeeding term newborn and mother: “The going home protocol,” revised 2014. Breastfeeding Medicine, 9(1), 3-8. Doi 10.1089/bfm.2014.9996 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 lactation consultant 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 Noble, L. M., Okogbule-Wonodi, A. C., Young, M. A., & the Academy of Breastfeeding Medicine (2018). ABM clinical protocol #12: Transitioning the breastfeeding preterm infant from the neonatal intensive care unit to home, revised 2018. Breastfeeding Medicine, 13(4), 230-236. Doi: 10.1089/bfm.2018.29090.ljn 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. United States Breastfeeding Committee (2013). Implementing the joint commission perinatal core measure on exclusive breastfeeding (2nd ed). Retrieved from file:///C:/Users/adenke1/Downloads/TJC-Measure-EBMF-2013-rev-USBC.pdf Wilson-Clay, B. & Hoover, K. (2005). Breastfeeding atlas (3rd ed.) images. Manchaca, TX: Lactnews Press. Wood, R. B. (2018). Effective communication strategies for nurses to discuss infant feeding with new mothers during postpartum hospitalization. The American Journal of Maternal Child Nursing, 43(4), 218-224. doi: 10.1097/NMC.0000000000000436

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