OVERCOMING BREASTFEEDING Presented by: CONCERNS Sue Harmon, IBCLC OVERVIEW • Latch Difficulties • Pain • Tongue Tie • Flat/Inverted Nipples • Engorgement • Mastitis • Pacifiers • Low Milk 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 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. 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 mother to perform breast massage and hand express colostrum on her nipple 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) PAIN Pain is the #1 reason why mother’s quit breastfeeding 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) 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 - ANKYLOGLOSSIA • 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 • Inverted nipple: •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: •Infants 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* • Weaning • Care/Cleaning (LAUWERS & SWISHER, 2016; WILSON-CLAY & HOOVER, 2005) PLUGGED NIPPLE PORE • Aka nipple bleb, 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 breasts 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 edema & 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