Overcoming Breastfeeding Concerns PRESENTED BY KARY JOHNSON, RN, IBCLC Frequent Breastfeeding Issues Nipple pain Engorgement Flat and inverted nipples Mastitis and plugged milk ducts Plugged nipple pores Milk supply concerns Pumping only moms Tongue tie Pain with Breastfeeding The #1 reason mother’s quit breastfeeding Many mother’s are told breastfeeding should not be painful, but often experience pain early on To ensure breastfeeding is mutually beneficial what are some things a health provider should assess? Assess Pain Type (per mother’s report) Tugging and Pulling? (breastfeeding is often a new sensation) Sharp? Biting? Pinching? Chewing? Assess Nipple Intact? Pinched/Creased? Bruising? Cracks? Abraded/Bleeding? Assess Latch Gape Lips Swallows Common Sources of Nipple Pain and Poor Latching Shallow Latch Lips rolled in Poor positioning Flat/inverted nipples Tongue Tie Breast Engorgement/Mastitis Common Treatments for Sore Nipples Go back to basic latch techniques Skin to skin prior to latching Express milk prior to latch using hand expression Rinse with clear water and air dry after feeding Nurse on least sore side first Lanolin or Soothie gel pads for comfort • Do not use them simultaneously Goal is to continue breastfeeding while making it less painful! Ensuring a correct and pain free latch, promotes healing while stimulating milk production! Engorgement Fullness or swelling of breasts due to increased tissue vascularization and transition of colostrum to early milk Symptoms occur between days 3-5 Less common in mother’s who room-in and feed on demand in first 48hours after delivery Assessment of Engorgement Bilateral breast fullness Breast tenderness Hard, firm breasts Areas of redness over breasts Firm lumps in breasts from full milk ducts Flat/short shanked nipples due to breast enlargement Prolonged/Unrelieved Engorgement Can result in: Decreased milk production from insufficient milk removal Plugged milk ducts Mastitis How to help with engorgement Frequent nursing Moist heat before feeding 5 minutes or less • Excessive use of heat can exacerbate engorgement Breast massage and hand expression Pumping before latch to elongate nipple and make it more graspable Cold packs for 10 minutes after feeding Flat/Inverted Nipples Perform a “Nipple Pinch Test” to determine nipple type Flat/short shanked nipple: Very short to no shank or erectness Inverted nipples: More rare, retract at rest and with stimulation Treatment for Flat/Inverted Nipples Assess latch and need for intervention (if any) Manual nipple roll/stimulate nipple to evert Use breast pump to evert nipples Involvement of IBCLC for nipple shield application, sizing and use Nipple Shield Use They are not a first line of defense and should not be used to prevent nipple pain Image by Barbara Wilson Clay and Kay Hoover, www.breastfeedingmaterials.com Use of the nipple shield Why would a mom use this? babies with low tone (preterm and SGA) short tongue tight frenulum high palate flat or inverted nipples transition to breastfeeding from a bottle Considerations Material Design Size Placement Weaning 2 Ways to Apply a Nipple Shield – Video https://www.breastfeedingmaterials.com/products/posters 2 Ways to Apply a Nipple Shield Video Created by Kay Hoover originating with BreastfeedingMaterials.com Breast Shells Indications Flat or inverted nipples Sore nipples How often are they used? Limited and insufficient data on effectiveness Plugged Milk Duct aka. caked breast Hard spot in one breast Tender to touch Usually no systemic symptoms Can lead to mastitis if unresolved Treatment: • Moist heat and massage • Frequent nursing Mastitis Breast inflammation May or may not be caused by a bacterial infection Most often occurs in first 6 weeks postpartum but can occur at any time during lactation Assessment of Mastitis Redness or red streaking of the breast Hot, tender, swelling Firm lump in breast Associated with temps of 101.3 with fever, chills, flu-like symptoms Causes of Mastitis Infrequent/missed feedings Poor or weak suck-leading to ineffective removal of milk Oversupply Weaning Illness in mom or baby Cracks or nipple breakdown Prolonged pressure on breast (from tight bra, seatbelt etc) Plugged duct leading to inflammatory response Maternal Stress, fatigue, lack of support Treatment of Mastitis Referral to MD as antibiotic may be required Frequent on demand feedings, beginning on affected breast Warm showers/compress to assist in milk flow prior to feedings alternated with cool packs to decrease swelling following feeding Ensure feeding with let-down to remove more milk volume Treatment of Mastitis Position infant chin or nose pointing to the blockage to help drain the affected area Massage breast from blockage area towards the nipple during feeding Express milk (hand expression or pump) following feeding to ensure removal of any additional milk and to relieve pressure and drain breast fully Increase rest and fluids Medical Treatment of Mastitis Ibuprofen Antibiotics (Dicloxacillin or Clindamycin) if symptoms do not improve within 12-24 hours. Complications of Untreated or Persistent Mastitis Decreased milk supply Abscess • Which may require surgical drainage Mother may choose to stop breastfeeding • Abrupt cessation of BF may make symptoms worse and increase risk for abscess. Plugged Nipple Pore aka. nipple bleb, milk blister Small white dot on face of nipple Painful to touch and with feeding Caused by: • plugging of nipple opening with milk • overgrowth of skin over nipple opening Treatment: • soak nipple in warm water • place cotton ball soaked in olive oil over nipple between feedings to soften • referral to MD to open Priorities for Pumping Only Moms For any mother that chooses to pump for bottles, separated from her infant, or in instances of nipple trauma or infrequent feedings due to newborn sleepiness: Pump Early: Pump within 2hrs for vaginal delivery and 4 hrs after a c/s Pump Often: Recommend 8 pumping sessions/day (not to exceed 4 hours without pumping) Utilize a hospital grade double electric pump and double pump to maximize prolactin levels Low Milk Supply: Perceived vs. Actual Perceived Low Milk Supply: Frequent/cluster feedings During growth spurts Breasts not feeling full Pumping lower milk volume Lower milk volume than that of a relative or friend Perceived Low Supply Solutions: Back to breastfeeding basics • Feed 8-10x/day • Ensure breast emptying with feeding • Assess for correct latching techniques and positioning Breast compression and massage Contact IBCLC or community breastfeeding support groups Average Newborn Intake If pumping after breastfeeding… Avoid overstimulation which can lead to overproduction Only need to pump for 10-15 minutes on each side If pumping for milk storage or bottles • Once or twice a day right after feeding is sufficient • Pumping in the morning will give higher volume If pumping to increase supply • Pump after all daytime feedings • Decrease pumping frequency once increased supply is attained Actual Low Milk Supply Red Flags: Inadequate breast growth in puberty/pregnancy • Tubular or widely spaced breasts History of breast surgery • Augmentation or reduction • Breast biopsy Radiation to chest Endocrine disorders • Hypothyroid • PCOS Obesity Actual Low Milk Supply Solutions: Frequent nursing Ascertain adequate milk transfer Pump after breastfeeding for extra stimulation Galactogogues Remain supportive and positive in mother’s efforts Referral to maternal MD for lab work to check for metabolic issues Referral to baby MD to help monitor adequate infant growth IBCLC can initiate a SNS feeding system to directly supplement infant at breast Tongue Tie “Ankyloglossia” refers to a thin membrane that attaches the tongue to the floor of the mouth (sublingual frenulum). Depending on length and location of frenulum under the tongue and it’s elasticity, the tongue appearance may change. A short, tight or more anterior frenulum can cause a decrease in tongue peristalsis, ineffective milk transfer, latch difficulty or sustaining a latch, nipple pain/trauma, long feedings. Tongue-Tie Management ©B.Wilson-Clay,K.Hoover. From, The Breastfeeding Atlas, 2017. Used with permission Attempt to feed in a semi-reclined position Compress breast to assist with a deep latch May require referral to MD for evaluation Frenotomy If conservative care is ineffective, a Frenotomy or “snipping” of the tongue-tie may be considered. This procedure releases the membrane allowing for more tongue movement and easier, ideally pain free latching. Put to breast right after procedure if possible. We reviewed Frequent Breastfeeding Issues References American Academy of Pediatrics, (2012). Policy Statement: Breastfeeding and the Use of Human Milk, Pediatrics 129 (3) DOI: 10.1542/peds.2011-3552 Amir, L., & the Academy of Breastfeeding Medicine Protocol Committee. (2014). The Academy of Breastfeeding Medicine Clinical Protocol #4: Mastitis. Breastfeeding Medicine, 9 (5). DOI: 10.1089/bfrm.2014.9984.Obtained from http://www.bfmed.org/Media/Files/Protocols/2014_Updated_Mastitis6.3 0.14.pdf Ballard, J., Chantry, C., & Howard, C. (2004). The Academy of Breastfeeding Medicine Clinical Protocol #11: Guidelines for the evaluation and management of neonatal ankyloglossia and its complications in the breastfeeding dyad, obtained from http://www.bfmed.org/Media/Files/Protocols/ankyloglossia.pdf Breastfeeding.org “Breastfeeding facts, Did you