Management of Breastfeeding

Associated Pain

Holly Montgomery, PGY2

03/22/17

Disclosures

No financial disclosures

Currently breastfeeding

Outline

Why is breastfeeding important?

Why do women quit?

Focused H&P

Breastfeeding-associated pain differential

Treatment options

Infant Benefits

↓ Otitis media

↓ Asthma

↓ Atopic dermatitis

↓ Gastrointestinal tract infections

↓ Obesity

↓ Diabetes

↓ High blood pressure

↓ SIDS

Maternal Benefits

↓ Breast cancer

↓ Ovarian cancer

↓ Type II diabetes

↓ Hypertension

↓ Heart Disease

Recommendations

Exclusive breastfeeding for up to around 6 months, followed by continued breastfeeding

for at least 1 year

American Academy of Pediatrics, American College of Obstetricians and Gynecologists,

WHO/UNICEF

Healthy People 2020

Increasing worksite lactation programs

Reducing formula supplementation of BF infants in the first 2 days of life

Increasing the proportion of births that occur in facilities that provide recommended care for

lactating women and their infants

Contraindications – galactosemia, HIV, HTLV, active TB or varicella, active HSV on nipple

The Ten Steps to Successful Breastfeeding

1. Have a written breastfeeding policy that is routinely communicated to all health care

staff

2. Train all health care staff in the skills necessary to implement this policy

3. Inform all pregnant women about the benefits and management of breastfeeding

4. Help mothers initiate breastfeeding within one hour of birth

5. Show mothers how to breastfeed and how to maintain lactation, even if they are

separated from their infants

The Ten Steps to Successful Breastfeeding

6. Give infants no food or drink other than breast-milk, unless medically indicated

7. Practice rooming in – allow mothers and infants to remain together 24 hours a day

8. Encourage breastfeeding on demand

9. Give no pacifiers or artificial nipples to breastfeeding infants

10.Foster the establishment of breastfeeding support groups and refer mothers to them on

discharge from the hospital or birth center

Why do women quit?

Rates

80% for initiation

51.4% at 6 months

29.2% at 12 months

Exclusive BF

43.3% at 3 months

21.9% at 6 months

Why do women quit?

Low milk volume

Work

Lack of support

PAIN

Differential

Nipple trauma

Mastitis

Areolar Dermatitis

Vasospasm

Oversupply

Engorgement

Blocked Duct

Candida

History

Onset – early (latch) vs. late (infectious)

Clinical setting (fullness vs. during pumping)

Feeding history (when milk came in, latch)

Previous breastfeeding experience

History of yeast infections

Maternal breast surgeries, implants, inverted nipples

Nipple pain during pregnancy

Hx of Raynaud’s or autoimmune disease

Physical Exam

Infant – focus on head and neck

Torticollis > unilateral sore nipple

Tight lingual frenulum > sore, traumatized nipples

Cleft lip/palate, retrognathia, large adenoids, oral defensiveness

Mucocutaneous candidiasis

Breast exam

Swelling, rash, vasospasm, impetiginized nipples pores, blocked pores, abrasions, ulcers, open cracks

Overfullness, masses, abscesses, tenderness, erythema

Feeding

Assessment of the latch and feeding technique

Nipple Soreness - timeline

Normal – subsides approx. 30 s to 1 m

after suckling begins; improves aver

PPD#4 and resolves after PPD#7

Not normal – persists at the same or at an

increasing level throughout nursing

episode; extends beyond the first

postpartum week

Nipple injury

Poor latch

Biting

Prevention

Proper positioning and latch

Avoidance of excessive moisture of the nipples and irritating cleansers

Lactation consultant

Evaluation of infant oral cavity

Anticipatory guidance regarding engorgement prior to hospital discharge

Care

Moist wound-healing principles

If cracked or abraded – antibiotic ointment (bacitracin or mupirocin)

If infected – culture

If thrush is suspected – KOH prep

Cool or warm compresses

Mild analgesics

APNO – mupirocin, miconazole, hydrocortisone

If persistent – consider exclusive pumping

Frenotomy with ankyloglossia

Mastitis

Firm, red, tender area of the breast

Fever higher than 101

Muscle aches, chills, malaise

Mastitis

2-10% of breastfeeding women

Week 1-6 – most common

Staph aureus – most common but don’t forget about MRSA

Damaged nipples or engorgement

Etiology

Partial blockage of milk duct

Pressure on the breast

Oversupply

Infrequent feedings

Nipple excoriation or craking

Rapid weaning

Illness in the mother or baby

Maternal stress or excesive fatigue

Maternal malnutrition

Mastitis

Symptomatic treatment

NSAIDs

Cold compresses

Complete emptying of the breast

Antibiotics (10-14 day course)

Dicloxacillin 500 mg PO QID or cephalexin 500 mg PO QID or clindamycin 300 mg PO TID

Clindamycin 300 mg PO TID or TMP-SMX 1 tab PO BID (not in newborns or compromised infants)

Vancomycin 15-20 mg/kg/dose Q8-12 hrs (do not exceed 2 g per dose)

No improvement within 24 hours > US imaging to look for abscess

Areolar Dermatitis

Tender, burning, red, fissures without

exudate

Itching, oozing with well-defined plaques

Areolar Dermatitis

Hx of eczema or psoriasis

Soaps, fragrances

Topical agents: lanolin, antifungals,

antibiotics

Management

Avoidance

Medium potency topical steroids (apply

after feeding and remove prior to next

feeding)

Vasospasm

Shooting pain

Burning pain

Parasthesias with cold exposure, nursing

or nipple trauma

Blanching > cyanosis > erythema

Vasospasm

Prior nipple trauma with persistent pain

despite intact skin

Past hx of Raynauds, migraines or cold

sensitivity

Management

Warmth

Avoidance of vasoconstricting meds

(nicotine and caffeine)

Nifedipine

Oversupply

Infant pulls off breast in distress

Pain with latch

Infant coughs with let down

Explosive stools

Excellent weight gain or poor weight gain

Oversupply

Typically resolves over the first few weeks

Evaluate for drugs that increase milk

production

Thyroid disorder

Management

Nurse with infant in more upright position

Manual reduction of flow

Frequent burping

Block feedings

Avoid pumping

Cold compresses!

Low dose OCPs or pseudoephedrine

Engorgement

Breast fullness and firmness

Pain and tenderness

Engorgement

Primary

Onset of copious milk production

Day 3-5

Interstitial edema due to decreased

progesterone levels after placenta delivers

Secondary

Mismatch between production and

extraction

Management

Proper latch

Optimal positioning

Manual expression prior to nursing if areola

is involved

Pumping if needed

Warm compress/warm shower

Cold compresses between feedings

Analgesics

Cold green cabbage leaves

Blocked Duct

Palpable lump in breast

Decreases in size with milk removal

Develops gradually

Localized pain

Blocked Duct

Poor feeding technique

Tight clothing or ill-fitting brassiere

Abrupt decrease in feeding

Engorgement

Bacterial intraductal infections

Management

Optimize feeding (chin near area of

concern)

Pumping/hand expressing after feeding

DO NOT STOP BREASTFEEDING

Warm compresses or showers

Analgesics

Candida

Pain out of proportion to exam

Infant with oral thrush/diaper

rash/systemic candida

Inflamammary rash, itching, shiny, flaky

skin

No response to topical mupirocin/barrier

ointments for dermatitis

Candida

Management - Maternal

Topical miconazole or clotrimazole

Gentian violet

Fluconazole 400 mg PO on day 1 and 200

mg PO x 13 days

Management – Infant

Nystatin 100,000 units/mL oral suspension

0.5 mL to each side of the mouth QID

Summary

Breastfeeding is best

Breastfeeding is hard

Breastfeeding hurts

Thank you!

Resources

USPSTF Breastfeeding: Primary Care Interventions

WHO/UNICEF’s Ten Steps to Successful Breastfeeding

ACOG Committee Opinion #658, #570

UNC Center for Maternal and Infant Health OB Algorithms

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