Management of Common Breastfeeding Problems

1
Management of CommonBreastfeeding Problems
Breastfeeding Residency Curriculum Prepared by
Andrew Hsi MD, MPH and Larry Leeman MD,
MPH University of New Mexico School of Medicine
2
Breastfeeding Assessment

• Before being able to address breastfeeding
  problems, the physician needs to assess
  breastfeeding by observing the infant feeding at
  the breast.
• See the Basic Breastfeeding Assessment
  presentation
• The following presentation discusses how to
  further assess for a particular problem and
  administer treatment to the breastfeeding dyad.

3
Objectives
At the end of this presentation the learner will
be able to discuss

• Assessment of ineffective breastfeeding due to
  causes associated with the newborn oral cavity,
  breast anatomy, disorganized suckle,
  ankyloglossia, and milk transfer
• Assessment of ineffective breastfeeding due to
  less common causes including disorganized suckle
  and ankyloglossia
• Monitoring of hyperbilirubinemia and jaundice
• Assessment of dehydration in context of poor
  feeding and/or low milk supply
• Diagnosis and management of the delay or failure
  of lactogenesis II
• Galactogogue use
• Evaluation for blocked nipples, engorgement, and
  milk oversupply
• Diagnosis and treatment of mastitis, breast
  abscess, and candidal breast infections

4
Assessment of Newborn Oral Cavity

• Palpation for hard and soft palate defects
• Visual of gingivae, sublingual areas including
• Attachment of sublingual frenulum
• Movement and elasticity of tongue
• Gloved finger in babys mouth assesses function
• Nail bed placed at lower gum ridge to assess
  excursion
• Rule out inability to compress milk ducts

5
Assessment of Breasts

• Breasts should be assessed during a prenatal
  visit to prepare the mother for any issues that
  may arise due to breast anatomy
• Rule out uncommon breast abnormalities
• Breast enlargement/reduction surgery
• Breast hypoplasia tubular breasts, unilateral
  hypoplasia
• Gigantomastia
• Awareness of potential anatomic mismatch
• Large nipple with small baby
• Perceived problems influence feedings

Reference 19, 27
6
Breast Assessment Uncommon Conditions
Secondary Displasia s/p radiation Rx s/p breast
surgery s/p severe mastitis/abscess
Primary Hypoplasia - insufficient mammary
glandular tissue - nulliparous state (adopted
infant) - unilateral or bilateral breast
anomalies
7
Breast Injury and Surgery

• Reduction Mammoplasty likely to have difficulty
  producing enough milk, especially with
  periareolar incisions
• Augmentation Mammoplasty compatible with
  successful breastfeeding
• Lumpectomy may affect breastfeeding if
  significant nerves or ducts have been removed
• Previous Treatment for Breast Cancer radiation
  after lumpectomy may interfere with lactation.
  Mother can usually breastfeed on an unaffected
  breast
• Trauma and Burns varies, but many people with
  severe trauma and burns to the breast have been
  able to breastfeed with success
• Pierced Nipples not associated with
  breastfeeding difficulties. Nipple devices should
  be removed before feeding

Reference 38
8
Disorganized Suckle

• Term babies have because
• Coordination problems
• Hypotonia
• Hypertonia
• Preterm babies may have
• Neurologic immaturity
• Disorganized sucking excessive external
  stimulation
• Weaker muscles in mouth and tongue

9
Suckle Problems Ankyloglossia

• Presents as ineffective latch or nipple pain
• Lactation specialist consult if possible
• Assessment by Hazelbaker Tool
• Significant ankyloglossia when
• Appearance score lt 8 and Function score lt 11
• Attention to changing position on breast
• Care of mothers nipples to prevent injuries

10
Reliability of Assessment

• Hazelbaker Tool in research
• Appearance items moderate reliability
• First 3 function items substantial agreement
• Lateralization, lift, and extension of tongue
• The items for infant sucking low reliability
• Suggest using first 3 function items only
• Clinical agreement high for frenulotomy

Reference 5
11
Frenulotomy Studies

• Study using well designed enrollment
• Frenulotomy improved feeding
• Mothers reported relief from pain
• Improved latching
• Study of 24 older babies (33 28 days)
• Ultrasound studies found
• Better position of nipple against palate
• More milk transfer, less maternal pain

Reference 5,7,23
12
Breastfeeding and Hyperbilirubinemia Guidelines

• All infants routinely monitored for jaundice
• Accurate gestational age intensively monitor
  late preterm
• Jaundice while breastfeeding
• Kernicterus would be largely preventable

Reference 2,3
13
Breastfeeding Preterm or Late Preterm Infants and
Hyperbilirubinemia

• Jaundice in late preterm infants results from
• Increased bilirubin due to increased bilirubin
  production
• Decreased bilirubin elimination
• Insufficient breast milk intake even when moms
  milk established
• Inability to ingest larger volumes of breast milk
• Hyperbilirubinemia in late preterm infants
• Increased incidence
• Increased severity
• Longer course
• Increased risk of deleterious consequences

Reference 12,13
14
Management for Early Jaundice in Breastfeeding
Infants

• Close clinical observation for jaundice
• Largely related to insufficient breast milk
  intake
• Initiate early and frequent breastfeeding
• Discourage water, dextrose water, and unnecessary
  formula supplements
• If supplementing with formula, consider using SNS
  or finger feeding to continue the establishment
  of lactation
• Monitor weight, breastfeeding, urine, and stool
• Refer to AAP guidelines for management of jaundice

Reference 3,27,21
15
Management of Breastmilk Jaundice

• Cause not defined
• Breastfeeding successfully established yet
  hyperbilirubinemia persists beyond the fourth
  week of life
• No clear reason to intervene if baby thriving
• Recommendation 7.3 AAP guidelines for
  management of jaundice
• If infant requires phototherapy, breastfeeding
  should be continued if possible
• Option to temporarily interrupt breastfeeding and
  substitute formula to reduce bilirubin levels and
  enhance efficacy of phototherapy
• Breastfed infants being treated with phototherapy
  can be supplemented with expressed breast milk or
  formula if needed

Reference 3, 17, 27
16
Summary for Early Detection of Risk for
Hyperbilirubinemia

• Good gestational age assessment
• Review of physiologic risk factors
• Early breastfeeding initiation
• Monitoring of latching on feed every 23 hours
• Use of LATCH score, similar objective tool
• Direct observation of latching for near term
• Screen every baby for jaundice

17
Assessment of Milk Sufficiency

• Not enough milk stops breastfeeding
• Visual cues for feeding interaction
• Baby eagerly seeks breast, latches on, feeds
• Baby body tone relaxes
• Mothers body tone relaxes
• Auditory confirmation of swallowing
• Weight gain around arrival of mothers milk
• 090 days median gain 2631 g
• 90180 days median gain 1718 g

Reference 15, 27
18
Assessment for Slow Weight Gain Versus Failure To
Thrive

• Slow weight gain
• Generally alert and healthy
• Good skin turgor and muscle tone
• Failure to thrive
• Generally apathetic, crying, not satisfied
• Poor tone, constant rooting
• Weight loss continued or no weight gain

Reference 16, 27
19
Test-weighing To Assess Nutritive Breastfeeds in
Failure To Thrive Infant

• Weigh naked baby
• Before and after breastfeeding episode
• May help assess adequacy of breast milk intake
• Rationale for diagnostic test

• Review of 32 studies found
• Regardless of whether the clinical assessments
  were performed by nurses, mothers, or lactation
  educators, the differences between the clinical
  estimates and the test weight estimates of milk
  intake were large and random.

Reference 29, 37
20
Dehydration and Breastfeeding

• Rare, but severe condition
• Among exclusively breastfed term infants
• Weight loss gt 10 in first 3 days of life
• 1/3 with hypernatremia
• Maternal factors
• Infant factors
• Close follow up breastfeeding dyads required
• Daily weight evaluation
• Careful breastfeeding assessment

Reference 16
21
Management of Dehydration Associated with
Breastfeeding Problems

• Review maternal history, medications
• Assess infant feeding history, urine and stool
  output
• Examine infant, skin turgor, capillary refill
• Observe infant on breast
• Stat lab studies

Reference 32
22
Lactogenesis II

• Lactogenesis I Initiation of milk production
  which occurs in second trimester of pregnancy
• Lactogenesis II Postpartum initiation of high
  volume milk production which occurs as transition
  from low volume colostrum
• Usually at 3040 hours postpartum
• Subjective feeling of breast fullness
• Day five term infant receive 500 to 750 cc of
  milk compared to lt 100 cc/day prior to
  lactogenesis II
• If lactogenesis II has not occurred by postpartum
  day 5, then delay or failure is present

Reference 11, 24, 34, 35
23
Problems with Lactogenesis II

• Delayed extended time between colostrum and full
  milk production
• Failed unable to achieve full lactation due to
  either primary inability to produce or issues
  with breastfeeding or infant health
• Can lead to hypernatremic dehydration which can
  rarely progress to neurologic injury, seizures,
  renal failure, thrombosis, and death

Reference 33, 42
24
Causes of Delayed Lactogenesis II
Any circumstance that leads to delayed,
infrequent, or ineffective milk removal

• Delay in first breastfeeding oral or IBV infant
  feeding
• Low breastfeeding frequency-poor stimulation
• Psychosocial stress/pain
• Unscheduled cesarean or stressful labor/delivery
• Less common etiologies secondary to maternal
  disease
• Maternal obesity
• Maternal diabetes or hypertension-etiology unknown

Reference 24
25
Causes of Failed Lactogenesis II

• Breast surgery or injury
• Retained placenta
• Hypothyroidism
• Theca lutein ovarian cysts
• Mammary hypoplasia (congenital)
• Polycystic ovarian syndrome
• Sheehans syndrome secondary to postpartum
  hemorrhage

Reference 24, 33
26
Galactagogues

• Used to increase breast milk supply
• Need to attempt to determine the etiology of low
  milk supply prior to initiation
• Ensure proper breastfeeding technique prior to
  use
• Only use galactogogues with adequate milk removal
  by nursing or electrical pumping or milk stasis
  will occur
• Consider need to evaluate for medical co
  morbidities e.g., hypothroidism, retained
  placental fragments, theca lutein ovarian cysts

Reference 41
27
Galactagogues

• Metoclopramide most commonly used
• Domperidone not approved in USA. Similar to
  metoclopramide but less side effects as little
  crosses blood brain barrier
• Fenugreek and other herbal medicines no
  scientific data except anecdotal reports

Reference 9, 14, 18, 22
28
Metoclopramide

• Benefit shown in small placebo controlled
  crossover study with increase of 50 cc per feed
  with dose of at least 30 mg per day
• Effect is to increase prolactin level
• Side effects gastrointestinal, anxiety,
  sedation, and rare dystonic reactions
• No documented neonatal reactions
• Short term 13 weeks is common. No evidence
  supporting long-term use. Usually wean after
  1014 days
• A common dosing regimen is 10 mg po qd first day,
  then 10 mg po bid, then 10 mg po TID

Reference 9, 25
29
Excess Milk Supply

• Much less common problem than low milk supply
• Minimal medical literature
• Maternal symptoms continual engorgement, leaking
  and increased mastitis risk
• Infant regurgitation and reflux symptoms.
  Development of poor sucking technique

30
Management of Excess Milk Supply

• Attempt to offer just 1 breast at each feeding
  to decrease stimulation and produce milk stasis
  in the other breast to decrease production

Reference 43
31
Plugged Ducts

• Tender lump
• Predisposing factors
• Positions that dont empty breast
• Underwire bras
• Predispose to mastitis with possible continuum
  from engorgement to blocked ducts to inflammatory
  mastitis to bacterial mastitis
• Treatment
• Ensure complete drainage
• Massage
• Warm packs
• Position changes

Reference 1
32
Mastitis

• Infection of the breast usually caused by
  Staphylococcus aureus
• Risk factors plugged ducts, untreated
  engorgement, cracked nipples, missed feedings,
  excessive fatigue, decreased resistance to
  infection
• Common occurring in 510 of breastfeeding women
• Most common in first month
• Recurrences occur in 819 of women and commonly
  (25) leads to lactation cessation

Reference 8, 44
33
Mastitis History and Physical Exam

• Fever, diffuse myalgias, flu-like symptoms,
  breast pain
• Wedge-shaped, tender, erythematous, usually
  unilateral
• Upper, outer quadrant most common

34
Mastitis Treatment

• DO NOT stop breastfeeding on the affected side,
  empty the breast
• If mild, symptoms occur for less than 24 hours
  and may attempt to resolve with frequent nursing
  or pumping and supportive measures including bed
  rest, fluids, analgesics
• Antibiotic options include dicloxicillin 500 mg
  po qid cephalexin 500 mg po qid, or clindamycin
  300 mg po qid for 10 to 14 days
• Observe carefully for signs of abscess formation

Reference 1, 20, 39
35
Breast Abscess

• 3 of mastitis cases develop into an abscess
• P.E. tender, hard breast mass, fluctuant,
  erythematous
• Incision and drainage, antibiotics, analgesia,
  frequent emptying
• Alternative needle aspiration every other day
  until pus no longer accumulates. Recommended as
  first line
• Culture fluid from abscess

Reference 4
36
Methicillin Resistant Staph Aureus and Breast
Abscess in Lactating Women

• Incidence of mastitis and breast abscess from
  community acquired MRSA appears to be increasing
  with up to 50 in some studies
• gt 95 are community not hospital acquired MRSA
• Most seem to resolve even when given antibiotic
  that community acquired MRSA is resistant to
• Draining breast by manual pumping and/or
  breastfeeding for mastitis or incision and
  drainage of abscess may be most important part of
  treatment

Reference 26, 31, 36, 40, 46
37
Nipple Candidal Infections

• Not uncommon, but often misdiagnosed
• Nonspecific signs and symptoms
• Nipple pain, itching, or burning sensation or
  shooting breast pains that radiate back towards
  the chest wall (possibly ductal candidal
  infection may persist or worsen after feeding is
  complete and breast is drained)
• Nipple and areola may appear erythematous or
  shiny or have white patches
• There could be NO external signs

Reference 38
38
Causes of Nipple Candida

• Predisposed factors
• Diabetes
• Steroid use
• Immune deficiency
• Antibiotic use
• Nipple trauma
• Use of plastic-line breast pads that trap moisture

39
Treatment of Candidal Nipple Infections General

• Difficult to prove that Candida is the causative
  organism in all situations (milk or skin cultures
  are not helpful and should not be performed
  routinely)
• Infant usually has thrush when mother has
  candidal infection
• Treat mother and infant simultaneously (the
  mothers partner may also need to be treated in
  some instances)
• Sterilize objects that contact breast or infants
  mouth pumping supplies, bottles, and pacifiers
• Maternal treatment nystatin suspension/ cream or
  clotrimazole applied after each nursing. No need
  to wash off before feeds
• Infant nystatin (100,000 u/ml) 1 cc po qid
  inside mouth to breast after each nursing

Reference 10
40
Treatment of Candidal Nipple Infections Other
Options

• Gentian Violet a topical treatment option that
  uses 0.251 gentian violet swabbed on the
  affected areas for up to 3 days
• Oral fluconazole may be prescribed if nipples
  are not significantly better after several days
  of topical treatment, or in cases of reoccurrence

41
Correlation Between Breast Symptoms and Candida
in Breast Milk Cultures

• gt 70 PPV for shiny skin of nipple areola with
  stabbing breast pain OR flaky skin of
  nipple/areola with breast pain
• gt 50 PPV with 2 of the 6 symptoms (sore nipples,
  burning nipple/areola, breast painful
  nonstabbing, breasts painful stabbing, shiny
  skin, flaky skin)

Reference 16, 21
42
Ductal Yeast Infection

• Lack objective findings on exam as nipple and
  skin may not be involved
• Lack reliable microbiologic tests
• Decision to treat based on deep burning/shooting
  breast pain without other causes
• Potential for overdiagnosis

Reference 10, 45
43
Treatment of Ductal Yeast Infection

• Will not respond to topical medicines
• Treatment is usually fluconazole 100200 mg po qd
  for 1421 days, although not FDA approved for
  this indication
• Need studies of diagnostic criteria and
  effectiveness
• Need to treat infant with oral nystatin as well
  for thrush or colonization

44
Summary Breastfeeding Problems

• Problems are common and treatable
• Assess adequacy of suckle and milk
  production/transfer
• Neonatal jaundice and dehydration are associated
  with breastfeeding problems
• Treat engorgement and blocked nipples to prevent
  mastitis and abscesses
• Bacterial and candidal infections can adversely
  affect breastfeeding

45
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