Cultural Diversity Cultural Diversity and Breastfeedingand Breastfeeding

Sue O’Dell NP-BC, IBCLCSue O’Dell NP-BC, IBCLC

Debbie Pierce NP-BC, IBCLCDebbie Pierce NP-BC, IBCLC

Cultural Basis of Cultural Basis of BreastfeedingBreastfeeding

• Socialization to breastfeed or notSocialization to breastfeed or not• Childhood experiencesChildhood experiences• Reconcile new behaviors (feed on Reconcile new behaviors (feed on

demand) with cultural norms demand) with cultural norms (scheduled feedings)(scheduled feedings)

Common ThemesCommon Themes

• Policy and medical practice contribute to Policy and medical practice contribute to infant feeding behaviors such as infant feeding behaviors such as supplementation and early weaningsupplementation and early weaning

• Early patterns may affect the duration of Early patterns may affect the duration of exclusivity and any breastfeedingexclusivity and any breastfeeding

• Education can only go so far, as Education can only go so far, as postpartum support is vitalpostpartum support is vital

• Mothers may not seek support due to lack Mothers may not seek support due to lack of awareness, availability or knowledge of of awareness, availability or knowledge of an acceptable alternative (formula)an acceptable alternative (formula)

Hispanic CultureHispanic Culture

• 15% of the population15% of the population• 80% ever breastfeed80% ever breastfeed• Little exclusivityLittle exclusivity• Highest incidence of obesityHighest incidence of obesity• Initiation highest when less Initiation highest when less

acculturatedacculturated

Hispanic CultureHispanic Culture

• Influenced by previous experienceInfluenced by previous experience• Tolerance for crying “no llora con hambre”Tolerance for crying “no llora con hambre”• ““Los dos”Los dos”• Return to work or separation from motherReturn to work or separation from mother• Embarrassed to feed in publicEmbarrassed to feed in public• Colostrum may be considered dirty or Colostrum may be considered dirty or

“stale”“stale”• Stress may sour the milkStress may sour the milk

Asian CultureAsian Culture

• ““Doing the month”-addresses the Doing the month”-addresses the imbalance caused by blood and heat imbalance caused by blood and heat loss at birthloss at birth

• Encouraged to stay inEncouraged to stay in• Influenced by husband and mother-Influenced by husband and mother-

in-lawin-law• Belief that supplements are Belief that supplements are

beneficialbeneficial

African American African American CultureCulture

• Lower initiationLower initiation• Shorter durationShorter duration• Fears about painFears about pain• Inadequate timeInadequate time• UncomfortableUncomfortable• Incompatible with personal health Incompatible with personal health

habits (smoking)habits (smoking)

What Can We Do?What Can We Do?

• It is important to provide someone It is important to provide someone who speaks the languagewho speaks the language

• All women have the same fears, All women have the same fears, concerns, frustrations and concerns, frustrations and insecuritiesinsecurities

• Member needs to be heard before Member needs to be heard before we attempt to fix the problemwe attempt to fix the problem

What can we do?What can we do?

• Provider encouragement prenatallyProvider encouragement prenatally• Discuss benefits of breastfeeding for Discuss benefits of breastfeeding for

mom and babymom and baby• Include influential family members Include influential family members

in discussions about breastfeedingin discussions about breastfeeding• Ask about “los dos”Ask about “los dos”• Discuss risks of formulaDiscuss risks of formula

Questions to AskQuestions to Ask

• How are your feeling about your How are your feeling about your baby’s breastfeeding pattern?baby’s breastfeeding pattern?

• How are you feeling about How are you feeling about breastfeeding?breastfeeding?

• How do you feel about the How do you feel about the suggestions I have made today?suggestions I have made today?

ResourcesResources

• Academy of Breastfeeding MedicineAcademy of Breastfeeding Medicine– Protocols in English, Spanish, Japanese, Protocols in English, Spanish, Japanese,

Korean, German and Chinese on various Korean, German and Chinese on various topicstopics

– www.bfmed.orgwww.bfmed.org

ResourcesResources

• La Leche LeagueLa Leche League– www.lalecheleague.org– Click on appropriate language in the Click on appropriate language in the

welcome headingwelcome heading– Go to country heading for more Go to country heading for more

information in a different languageinformation in a different language

• This link is being added to the AVS This link is being added to the AVS under the breastfeeding information.under the breastfeeding information.

ResourcesResources

• Breastfeeding Support Line: 303-Breastfeeding Support Line: 303-636-2929636-2929

• PHHCPHHC

Resources NeededResources Needed

• We are looking for KP staff to We are looking for KP staff to become CLCs!become CLCs!– No medical training neededNo medical training needed– Allow increased postpartum support to Allow increased postpartum support to

members of all culturesmembers of all cultures– Provide expertise at Breastfeeding Provide expertise at Breastfeeding

Support GroupsSupport Groups

Candida and Candida and BreastfeedingBreastfeedingUpdate 2014Update 2014

What’s the Confusion?What’s the Confusion?

Deep, radiating breast pain and Deep, radiating breast pain and burning nipple pain is yeast-right?burning nipple pain is yeast-right?

It’s on the internet!It’s on the internet!

It’s thrush-OR IS IT???It’s thrush-OR IS IT???

Symptoms of ThrushSymptoms of Thrush

• Burning painBurning pain• ItchingItching• Shiny, flaky skin on the Shiny, flaky skin on the

nipples/areolanipples/areola• Deep, shooting pain in the breastDeep, shooting pain in the breast

• BUT. . .BUT. . .

These symptoms can also These symptoms can also be:be:

Poor latchPoor latch

Sucking issue in the babySucking issue in the baby

Tongue tieTongue tie

VasospasmVasospasm

Raynaud’s phenomenonRaynaud’s phenomenon

EczemaEczema

Allergic dermatitisAllergic dermatitis

PsoriasisPsoriasis

Bacterial infectionBacterial infection

Damage from pumpingDamage from pumping

American Academy of American Academy of Breastfeeding MedicineBreastfeeding Medicine

• Clinical Protocol #4-MastitisClinical Protocol #4-Mastitis– Information on burning nipple pain is Information on burning nipple pain is

evolvingevolving– May be candidaMay be candida– Diagnosis is difficultDiagnosis is difficult– Exam may be normalExam may be normal– Milk culture not reliableMilk culture not reliable– Staph aureus may be presentStaph aureus may be present

Does Candida Does Candida and/or and/or

Staphylococcus Staphylococcus Play a Role in Play a Role in

Nipple and Breast Nipple and Breast Pain in Lactation?Pain in Lactation?

Amir, L, et al., BMJ, March Amir, L, et al., BMJ, March 20132013

Candida Mastitis: Candida Mastitis: A Case ReportA Case Report

Hanna and Cruz, The Hanna and Cruz, The Permanente Journal, Winter Permanente Journal, Winter

20112011

A Prospective A Prospective Study of Study of

Fluconazole Fluconazole Treatment for Treatment for

Breast and Nipple Breast and Nipple ThrushThrush

Moorhead, Amir, O’Brien and Moorhead, Amir, O’Brien and Wong, Breastfeeding Review, Wong, Breastfeeding Review,

November 2011November 2011

The Absence of The Absence of Candida Albicans Candida Albicans

in Milk Samples of in Milk Samples of Women with Women with

Clinical Symptoms Clinical Symptoms of Ductal of Ductal

CandidiasisCandidiasisHale, Bateman, Finkelman, Hale, Bateman, Finkelman,

BF Medicine, June 2009.BF Medicine, June 2009.

History, Physical and History, Physical and Laboratory Findings and Laboratory Findings and

Clinical Outcomes of Clinical Outcomes of Lactating Women Treated Lactating Women Treated

with Antibiotics for with Antibiotics for Chronic Breast and/or Chronic Breast and/or

Nipple PainNipple Pain

Eglash, et al., Journal of Eglash, et al., Journal of Human Lactation, 2006.Human Lactation, 2006.

Kaiser Permanente Kaiser Permanente Breastfeeding Coalition Breastfeeding Coalition

RecommendationsRecommendations

• Have patient consult with Have patient consult with IBCLC/CLC at clinic, hospital, or IBCLC/CLC at clinic, hospital, or PHHC to evaluate PHHC to evaluate latchlatch, feeding, , feeding, nipples, breasts and infant for signs nipples, breasts and infant for signs of thrushof thrush

Acute MastitisAcute Mastitis

• Dicloxicillin first choiceDicloxicillin first choice• ClindamycinClindamycin• Vancomycin or Septra if MRSA Vancomycin or Septra if MRSA

suspectedsuspected

Cracked NipplesCracked Nipples

• Consider trial of oral antibiotics if Consider trial of oral antibiotics if deep cracks or fissures lasting deep cracks or fissures lasting several weeks or monthsseveral weeks or months

• May trial All Purpose Nipple May trial All Purpose Nipple Ointment available from the Kaiser Ointment available from the Kaiser Permanente Compounding Permanente Compounding PharmacyPharmacy

Continued Pain and/or Continued Pain and/or Signs of ThrushSigns of Thrush

• Treat both mom and baby Treat both mom and baby • Oral Nystatin for infantOral Nystatin for infant• Nystatin ointment for mom’s nipplesNystatin ointment for mom’s nipples• QID after nursing for both mom and QID after nursing for both mom and

babybaby

If All Else Fails. . .If All Else Fails. . .

• Diflucan 150 mg po every other day Diflucan 150 mg po every other day for a total of 6 or more capsulesfor a total of 6 or more capsules

• OROR

• Diflucan 200-400 mg PO STAT Diflucan 200-400 mg PO STAT followed by 100-200mg daily for 2-3 followed by 100-200mg daily for 2-3 weeksweeks

Other TreatmentsOther Treatments

• Gentian Violet ½% aqueous solution Gentian Violet ½% aqueous solution applied to nipples and infant’s mouth applied to nipples and infant’s mouth QD for 3-7 daysQD for 3-7 days

• Good handwashing, boiling of items that Good handwashing, boiling of items that come into contact with baby’s mouth, come into contact with baby’s mouth, breast shields, shells, pump equipmentbreast shields, shells, pump equipment

• Encourage mom to decrease sugars and Encourage mom to decrease sugars and yeast in diet.yeast in diet.

• Encourage yogurts/acidophilus; Kefir-Encourage yogurts/acidophilus; Kefir-like probiotic drinkslike probiotic drinks

Stay Tuned!Stay Tuned!

• Your Kaiser Permanente Breastfeeding Your Kaiser Permanente Breastfeeding Coalition will update you if new Coalition will update you if new evidence comes forward to shed light evidence comes forward to shed light on this very difficult and controversial on this very difficult and controversial issue for lactating women.issue for lactating women.