PHYSICIAN’S TOOLKIT B R E AS TF E E DING Q U I C K R E F E R E N C E G U I D E P H Y S I C I A N ’S B R E A S T F E E D I N G T O O L K I T The Physician’s Breastfeeding Toolkit: Evidence-informed Practice for Newfoundland & Labrador 2014 (Revised 2016). Revised with permission by Renfrew County and District Health Unit, January 2020. This toolkit is designed to assist health care providers in providing optimal care and consistent information to breastfeeding families. The toolkit is based on current evidence and reflects best practice in the care of breastfeeding families. Topics include initiating and sustaining breastfeeding, management of common concerns, medication safety, establishing a breastfeeding-friendly practice environment and local support resources. Acknowledgements The development of this resource was initiated by the Baby-Friendly Council of Newfoundland & Labrador in an effort to promote evidence-informed practices for breastfeeding. The Baby-Friendly Council of Newfoundland and Labrador acknowledges the contribution of the two consultants for this project, Dr. Amanda Pendergast, BSc (Hons), MD, CCFP, FCFP and Janet Fox-Beer BN, RN, IBCLC. Their professional knowledge, clinical expertise and commitment to this project are exemplary. Thank you also to members of the advisory committee for their guidance in the development and review of the resources for the toolkit. Members of the advisory committee include: Dr. Rebecca Rudofsky MD, CCFP Janet Murphy Goodridge RN, MN, IBCLC Clare Bessell RN, BVoc Ed Dr. Anne Drover MD, FRCPC Designed and Produced by Fonda Bushell Inc. Renfrew County and District Health Unit “Optimal Health for All in Renfrew County and District” www.rcdhu.com Exclusive breastfeeding for the first six months and continue up to two years and beyond. PHAC, 2012 HEALTH OUTCOMES ASSOCIATED WITH BREASTFEEDING MOTHER BABY Breast and Otitis media/LRTI ovarian cancer Obesity Diabetes Diabetes Osteoporosis Childhood cancer CVD Gastro Rate of return to pre-pregnancy state SIDS NEC Asthma, atopy IQ P H Y S I C I A N ’ S B R E A S T F E E D I N G T O O L K I T TABLE OF CONTENTS What are the Signs of a Good Latch? ........................................................... 1 Influence of Latch & Milk Production on Breastfeeding Outcomes ............. 3 Signs of Effective Breastfeeding .................................................................. 5 Factors that May Impact Lactation ............................................................... 6 Questions to Consider when Assessing Breast & Nipple Pain ...................... 9 Diagnosis & Treatment of Common Breastfeeding Concerns ...................... 10 Management of Poor Infant Weight Gain .................................................... 16 Medical Indications for Supplementation ................................................... 19 Guidelines for Supplementation .................................................................. 20 Breastfeeding Medication Safety ................................................................. 23 Lactation Consultants & Public Health Nurses ............................................ 29 Bibliography and Photo Credits .................................................................... 33 WHAT ARE THE SIGNS OF A GOOD LATCH? L LIPS FLANGED OUT Wide, gaping mouth to accommodate areola and nipple A ASYMMETRIC LATCH More areola visible above the baby’s top lip T TUMMY TO MUMMY Baby’s ears, shoulders and hips in alignment C CHIN TOUCHING BREAST Nose free in the sniffing position H HAVE A LISTEN & WATCH Active suckling and swallowing indicates milk transfer 1 BREASTFEEDING SUCCESS • EARLY & OFTEN • EFFECTIVE (OPTIMAL LATCH) • EXCLUSIVE (NO SUPPLEMENTS) P H Y S I C I A N ’ S B R E A S T F E E D I N G T O O L K I T INFLUENCE OF LATCH & MILK PRODUCTION ON Note: If the latch is optimal, even a reduced milk production can lead to a healthy infant weight gain. LATCH Milk Outcomes for Mother & Baby Production • Excellent weight gain • Pain free feeding Optimal Optimal • Efficient feeding • Satisfied baby • Good weight gain Adequate Optimal • Pain free feeding • Longer & more frequent feedings • Good weight gain Optimal Adequate • Pain free feeding • Efficient feeding • Satisfied baby • Slower weight gain • Lower milk production Poor Optimal • Longer feeds • Possible weight loss • Sore nipples • Slow weight gain • Longer feeds Poor Adequate • Growth concerns • Fatigue (mom & baby) • Sore nipples 3 PHYSICIAN SUPPORT IS KEY TO SUCCESSFUL BREASTFEEDING UNNECESSARY SUPPLEMENTATION UNDERMINES BREASTFEEDING P H Y S I C I A N ’S B R E A S T F E E D I N G T O O L K I T SIGNS OF First 6 weeks • Exhibits readiness to feed at least 8 or more times in 24 hours • Suckles and swallows effectively to transfer milk and stimulate production • Has alert periods • Settles after a feeding • Yellow, seedy bowel movements and clear urine (see stool & urine output chart) • Back to birth weight by day 14 • Appropriate weight gain (see page 16)* • No pain with breastfeeding *It may be acceptable for a healthy baby to have a slower weight gain pattern. INFANT STOOL & URINE OUTPUT CHART INFANT AGE WET DIAPERS / DAY STOOLS / DAY Days 1 to 2 1 - 2 clear or pale yellow 1+ meconium (colostrum) Days 3 to 4 3+ clear or pale yellow 3+ green, brown or yellow (milk coming in) After 1st week 6+ clear or pale yellow 3+ soft, yellow, loose, seedy (milk is in) After 4 weeks 6+ clear or pale yellow Varies. 1 or more soft, large or may go several days without a BM** 5 P H Y S I C I A N ’ S B R E A S T F E E D I N G T O O L K I T FACTORS THAT MAY IMPACT LACTATION OBSERVATION AND EVALUATION INFANT OF BOTH MOTHER & BABY WHILE BREASTFEEDING IS ESSENTIAL. NEWBORN HISTORY • Preterm or late preterm • SGA • IUGR • Multiple gestation • Congenital anomalies • Ankyloglossia • Traumatic delivery FIRST DAYS OF LIFE • Signs of illness: jaundice, fever, lethargy, hypoglycemia • Separation from mother • Resuscitation FEEDING HISTORY • Ineffective latch • Early introduction of artificial nipples/pacifiers • Non-medical supplementation • State around feedings (e.g., fussy, sleepy, unsettled) s necessary when assessing 6 P H Y S I C I A N ’ S B R E A S T F E E D I N G T O O L K I T FACTORS THAT MAY IMPACT LACTATION PREGNANCY HISTORY MOTHER • Infertility • Hypertension SOCIAL HISTORY • Gestational diabetes • Primiparous • Depression/anxiety • Inadequate social supports • Anemia • Uninvolved partner • Early return to work or school LABOUR & DELIVERY • Uncertain feeding goals • Gestation • Adolescent or older mother • Induction of labor • Physical or sexual abuse • Prolonged labor • Unrealistic postpartum expectations • Assisted delivery or C/S • Hx of previous breastfeeding challenges POSTPARTUM MEDICAL HISTORY • Infection • Breast surgery • Hemorrhage • PCOS • Retained placenta • Thyroid dysfunction • Delayed lactogenesis • Some medications • Breast or nipple pain • Flat or inverted nipples • Inadequate milk production • Obesity • Hormonal contraception before • Endocrine disorders breastfeeding well established • Anemia • Thyroid dysfunction Ankyloglossia Premature baby Inverted nipple 7 BREASTFEEDING PRIORITIES 1. FEED THE BABY 2. PROTECT THE MILK PRODUCTION 3. FIX THE PROBLEM Frequent removal of milk from the breasts is the trigger for ongoing milk production. USE IT OR LOSE IT! P H Y S I C I A N ’S B R E A S T F E E D I N G T O O L K I T QUESTIONS TO CONSIDER WHEN ASSESSING BREAST & NIPPLE PAIN NOTE: IT IS IMPORTANT TO ASSESS IF THE BREAST / NIPPLE PAIN IS UNILATERAL OR BILATERAL. QUES TION POSSIBLE DIAGNOSIS BREAST PAIN • Palpable, tender mass or lump? Blocked duct or Mastitis • Fever, malaise and erythema? YES: Mastitis NO: Blocked duct • Palpable, tender, red lump not responding Breast abscess to mastitis or blocked duct RX? • Persistent breast fullness and pain? Engorgement • Shiny, taut skin and nipple effaced? (more common if < 1 week PP) • Baby choking on feeds? • Strong letdown, hypersensitive nipples, very full breasts? Overproduction NIPPLE PAIN • Soreness or pain with no skin breakdown? Sore nipples • Nipple pain with skin breakdown? (nipple compressed, crease or blanching across the tip, Abrasion/cracked nipple ecchymosis, shallow or deep fissure) • Erythema and crusting? Infected abrasion/cracked nipple • Shooting or burning pain worse with feeding, itchy nipples? Candida • Nipple blanching, blue/red colour changes? Vasospasm/Raynaud’s • Dry, flaking skin, pruritus and erythema? Dermatitis/Eczema • Painful, white lesion? Bleb or sebaceous cyst P H Y S I C I A N ’ S B R E A S T F E E D I N G T O O L K I T DIAGNOSIS & TREATMENT OF COMMON BREASTFEEDING CONCERNS DIAGNOSIS SYMPTOM SIGN TREATMENT • Engorgement • Breasts over • Hard, tight, • BEFORE feeding: facilitate full with milk, shiny breasts milk let-down with: causing • Usually bilateral • warm compresses to tightness and breast or warm shower pain • Nipple effaced • gentle hand massage • Areola firm and expression • Difficulty latching • reverse pressure (Peaks days 3- softening (see below) 5 postpartum, • Poor let-down • DURING feeding: and anytime milk is not • optimize latch removed • frequent feedings with breast compression (see below) effectively) • AFTER feeding: • hand expression • cool compresses to breast • NSAIDs prn REVERSE PRESSURE SOFTENING (RPS) 1. Apply gentle, but firm, positive pressure inwards towards the chest wall, on the areola at the base of the nipple for 40-60 seconds prior to latching the baby. 2. Apply pressure with the fingertips moving around the circumference of the areola. This