Management of Common Breastfeeding Problems

Management of CommonBreastfeeding ProblemsBreastfeeding Residency CurriculumPrepared by Andrew Hsi MD, MPHandLarry Leeman MD, MPHUniversity of New Mexico School of Medicine11Breastfeeding AssessmentBefore 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 presentationThe following presentation discusses how to further assess for a particular problem and administer treatment to the breastfeeding dyad.ObjectivesAssessment of ineffective breastfeeding due to causes associated with the newborn oral cavity, breast anatomy, disorganized suckle, ankyloglossia, and milk transferAssessment of ineffective breastfeeding due to less common causes including disorganized suckle and ankyloglossiaMonitoring of hyperbilirubinemia and jaundiceAssessment of dehydration in context of poor feeding and/or low milk supply Diagnosis and management of the delay or failure of lactogenesis IIGalactogogue useEvaluation for blocked nipples, engorgement, and milk oversupplyDiagnosis and treatment of mastitis, breast abscess, and candidal breast infections

At the end of this presentation the learner will be able to discuss:33Assessment of Newborn Oral CavityPalpation for hard and soft palate defectsVisual of gingivae, sublingual areas includingAttachment of sublingual frenulumMovement and elasticity of tongueGloved finger in babys mouth assesses function Nail bed placed at lower gum ridge to assess excursionRule out inability to compress milk ducts44The exam of the newborn should include evaluation of the oral cavity. This should include both palpation and visual inspection. The palpation aspect strokes the roof of the mouth to check for defects of the hard and soft palate. The presence of a defect may interfere with feeding and breastfeeding in particular. Identification of a defect should lead to consultation with ENT and close observation of feedings.

Visual inspection combined with functional assessment aids in understanding the babys oral motor coordination. In particular, the appearance of the frenulum and tongue provides information about the extension of the tongue in the nursing process. Using a gloved fifth finger to mimic the alveola and nipple in the babys mouth provides the most important information. This part of the exam provides information about suck, coordination of tongue and suck movements, tongue motion and extension.

The assessment includes: Extension of tongue past lower alveolar ridge Cupping of tongue Seal of lips while sucking (should not hear excessive slurping or smacking during sucking action)

If problems seem apparent, direct observation of the babys latching to the mothers breast should be done to both determine possible problems and to provide anticipatory guidance. The overall reason to assess is to determine that the baby can generate suction around the breast and can extend the tongue out and up to compress the areola and its underlying milk ducts.

Assessment of BreastsBreasts should be assessed during a prenatal visit to prepare the mother for any issues that may arise due to breast anatomyRule out uncommon breast abnormalitiesBreast enlargement/reduction surgeryBreast hypoplasia: tubular breasts, unilateral hypoplasiaGigantomastiaAwareness of potential anatomic mismatchLarge nipple with small babyPerceived problems influence feedingsReference 19, 27 55Marked asymmetry may indicate absence of glandular tissue, a very rare condition.

Perception of problems, not usually a functional problem, related to breast anatomy include: Babys mouth too small to accept areola Babys nose obstructed by breast tissue

Primary Hypoplasia:- insufficient mammary glandular tissue- nulliparous state (adopted infant)- unilateral or bilateral breast anomalies

Secondary Displasia:s/p radiation Rxs/p breast surgerys/p severe mastitis/abscessBreast Assessment Uncommon ConditionsBreast Injury and SurgeryReduction Mammoplasty likely to have difficulty producing enough milk, especially with periareolar incisions Augmentation Mammoplasty compatible with successful breastfeedingLumpectomy may affect breastfeeding if significant nerves or ducts have been removedPrevious Treatment for Breast Cancer radiation after lumpectomy may interfere with lactation. Mother can usually breastfeed on an unaffected breastTrauma and Burns varies, but many people with severe trauma and burns to the breast have been able to breastfeed with successPierced Nipples not associated with breastfeeding difficulties. Nipple devices should be removed before feedingReference 38 See Breastfeeding Handbook for Physicians, page 3839 for further explanation. Disorganized SuckleTerm babies have because:Coordination problemsHypotoniaHypertoniaPreterm babies may have:Neurologic immaturityDisorganized sucking excessive external stimulationWeaker muscles in mouth and tongue

88For term infants, coordination problems may relate to:Choke or gag at breastPull away to breatheRelatively small mandible impeding tongue extensionSuck but not swallow, suck only when triggered by swallow

For preterm infants, disorganization may occur from problems with temperature regulation.

Possible Lactation Specialist referral criteria ordered by appearance in time: Latch score < 7 for 2 consecutive feedings (noted in first days of life) None/few audible swallowing after 24 hrs of age History of unsuccessful breastfeeding Nipple trauma (blisters, cracks, bruising) noted in first days of life Pain throughout feeding Infant weight loss > 8% birth weight noted by second or third day of life Inadequate urine/stool output noted by second or third day of life History of unsuccessful breastfeeding Mother of CCN/SCN infant History of breast surgery Abnormal infant oral anatomy Multiple births Premature infant

Lactation consultant will evaluate patient and consult with medical team as needed.

Suckle Problems: AnkyloglossiaPresents as ineffective latch or nipple painLactation specialist consult if possibleAssessment by Hazelbaker Tool Significant ankyloglossia when:Appearance score < 8 and Function score < 11Attention to changing position on breastCare of mothers nipples to prevent injuries

99Hazelbaker tool has Appearance items to assess and Functional items (see next notes page)Appearance itemsAppearance of tongue2: Round or square1: Slight cleft in tip apparent 0: Heart- or V-shaped Elasticity of frenulum2: Very elastic 1: Moderately elastic 0: Little or no elasticity Length of lingual frenulum when tongue lifted2: > 1 cm1: 1 cm 0: 6 d, or mother has a previously affected infant

Supplementation with breast milk substitute Only with consent from mother Preference for SNS or fingerfeeding

Supplemental Nursing System (SNS) consists of feeding tube with end taped to mothers breasts proximal to areola. Feeding tubes connected to reservoir of breast milk substitute. When baby suckles on nipple, sucking pulls fluid down feeding tube increasing fluid volume while increasing stimulation of breast and hormonal reflexes for increased milk production. Finger feeding done with feeding tube attached to fingertip placed in babys mouth with other end connected to syringe containing breast milk substitute. Baby suckles while small amounts of fluid injected down tube into babys mouth.

Baby needs lowered bilirubin rapidly At or above light level, resources limited Close to exchange transfusion level Bilirubin rising with phototherapy Trial intervention for supplementing formula feeding with breast milk feeding as trial intervention if approaching treatment levels. This would apply to avoid exchange transfusion levels.

All clinical scenarios have impact on mother and baby dyad: Breast milk substitute effect may be primary effect of increased fluid volume on hydration and stimulus to pass meconium.

Limited resources may include no hospital space for prolonged stay for baby, no resources for outpatient phototherapy (lack of durable medical equipment providers or lack of payment source for home phototherapy).

Management of Breastmilk JaundiceCause not definedBreastfeeding successfully established yet hyperbilirubinemia persists beyond the fourth week of lifeNo clear reason to intervene if baby thrivingRecommendation 7.3 AAP guidelines for management of jaundiceIf infant requires phototherapy, breastfeeding should be continued if possibleOption to temporarily interrupt breastfeeding and substitute formula to reduce bilirubin levels and enhance efficacy of phototherapyBreastfed infants being treated with phototherapy can be supplemented with expressed breast milk or formula if needed

Reference 3, 17, 27 1515Adjunct considerations:

Rule out other causes such as galactosemia, hypothyroidism, persistent slow hemolysis, urinary tract infection, or pyloric stenosis.

Check conjugated and unconjugated (indirect and direct) bilirubin level of jaundice persists greater than 3 weeksFamily history of prolonged jaundice in 70% of previous children

Outpatient Management of the Jaundiced Breastfed InfantRECOMMENDATION 7.3: In breastfed infants who require phototherapy, the AAP recommends that, if possible, breastfeeding should be continued (evidence quality C: benefits exceed harms). It is also an option to interrupt temporarily breastfeeding and substitute formula. This can reduce bilirubin levels and/or enhance the efficacy of phototherapy 6365 (evidence quality B: benefits exceed harms). In breastfed infants receiving phototherapy, supplementation with expressed breast milk or formula is appropriate if the infants intake seems inadequate, weight loss is excessive, or the infant seems dehydrated. See references to access full policy. Summary for Early Detection of Risk for HyperbilirubinemiaGood gestational age assessmentReview of physiologic risk factorsEarly breastfeeding initiationMonitoring of latching on; feed every 23 hoursUse of LATCH score, similar objective toolDirect observation of latching for near termScreen every baby for jaundice1616Good gestational age assessment: Artificial insemination Highly reliable ultrasound at 8 to 10 weeks gestation to establish dates

Lower reliability with Late ultrasound after 28 weeks Last menstrual period Ballard exam

Additional hospital management requirements: Effective breastfeeding support on unit Follow up plan 1 to 2 days after discharge Screening all newborns with serum bilirubin level for early or extensive jaundice Use of transcutaneous jaundice meter as first screen Clinical assessment by experienced hospital personnel Distinguish ineffective breastfeeding jaundice from prolonged jaundice with breast milk

Assessment of Milk SufficiencyNot enough milk stops breastfeedingVisual cues for feeding interactionBaby eagerly seeks breast, latches on, feedsBaby body tone relaxesMothers body tone relaxesAuditory confirmation of swallowingWeight gain around arrival of mothers milk090 days; median gain 2631 g90180 days; median gain 1718 gReference 15, 27 1717Perception of not enough is most common reason worldwide for cessation of breastfeeding. This perception need to be balanced against possible insufficient milk intake. When perception inaccurate, mother requires support and counseling Real insufficiency requires evaluation

Evaluation of newborn Weight expected to fall first 3-4 days, < 7% from birth 5% to 10% fully breastfed infants lose >10% from birth weight by day 3 Suggesting that adequacy of intake should be evaluated infant monitored if weight loss >10% Passes meconium and urine in first 24 hours 3-5 urines, 3-4 stools per day by day 3 to 5 of life 4-6 urines, 3-4 stools per day by day 5-7 Determination of urine made difficult by diaper materials

Cadwell K, Turner-Maffei C, OConnor B, et al. Maternal and Infant Assessment for Breastfeeding and Human Lactation: A Guide for the Practitioner, 2nd Ed.2006. Jones and Bartlett Publishers, Inc. Mississauga, Canada

Assessment for Slow Weight Gain Versus Failure To ThriveSlow weight gain Generally alert and healthyGood skin turgor and muscle toneFailure to thriveGenerally apathetic, crying, not satisfiedPoor tone, constant rootingWeight loss continued or no weight gainReference 16, 27 1818Normal milk transfer Infant content at end of feeding; feeding time roughly 30 minutes Infrequent pauses and longer periods of active suckling In exclusively breastfed babies, see bright yellow stools by day 5 of life and return to birth weight by day 10 of life

Low milk transfer Infant still rooting, fussy, and needing to suck after 30 minutes Frequent long pauses and short bursts of suckling Lack of bright yellow stools by day 5 of life and return to birth weight by day 10 of life

Additional clinical information related to slow weight gain -

In each 24 hours baby has: > 6 wet diapers, pale dilute urine 4-6 breast stools Feeding 8 to 12 times at breast and mother notes consistent let down reflex

Additional warning signs in clinical information related to failure to thrive

In each 24 hours baby has: Few wet diapers < 6, urine dark with strong odor Infrequent scant stools, darker green to brown color Feedings < 8, duration short ( 10% in first 3 days of life1/3 with hypernatremiaMaternal factorsInfant factorsClose follow up breastfeeding dyads requiredDaily weight evaluationCareful breastfeeding assessmentReference 16 2020Study of exclusive breastfed infants: Inadequate breastfeeding was 4.1%, 169/4136 Hypernatremia (Na > 150 mEq/dl) Excess weight loss mean 15.9% range (5.4-32.7%) Vaginal deliveries 75.7%, First time mothers 74.6%

Major presenting symptoms Neonatal jaundice (47.3%) and Poor infant suck (29.6%)

Maternal factors included: Higher rates of cesarean section Breastfeeding difficulties Use of heater in home Lower maternal education

Infant factors included: less than four stools/24 hours pink diaper mean weight loss in neonates with pink diaper mean uric acid concentration in neonates with pink diaper fever in hypernatremic neonates the correlation of weight loss with both serum sodium and uric acid concentrations

Management of Dehydration Associated with Breastfeeding ProblemsReview maternal history, medicationsAssess infant feeding history, urine and stool outputExamine infant, skin turgor, capillary refillObserve infant on breastStat lab studiesReference 32 21Additional history for infant includes history of poor suck, sleep long intervals, infrequent feedings, and lethargy.

Stat lab studies should include: Electrolytes (sodium, potassium, chloride, CO2) BUN, creatinine Hematocrit Bilirubin if jaundiced

Specifically when infant electrolyte abnormalities detected, test of breast milk: Test milk from each breast separately for sodium, chloride, potassium Elevated sodium level related to inadequate lactose in breast milk Increased osmolarity of milk similar to weaning milk

In addition to IV rehydration: Maintain lactation, monitor milk sodium levels Resume breastfeeding as milk sodium levels normalize and IV fluids tapered

Lactogenesis IILactogenesis I : Initiation of milk production which occurs in second trimester of pregnancyLactogenesis II: Postpartum initiation of high volume milk production which occurs as transition from low volume colostrumUsually at 3040 hours postpartumSubjective feeling of breast fullnessDay five term infant receive 500 to 750 cc of milk compared to < 100 cc/day prior to lactogenesis IIIf lactogenesis II has not occurred by postpartum day 5, then delay or failure is presentReference 11, 24, 34, 35 Lactogenesis II initiated by falling progesterone levels in the presence of high prolactin levels.Progesterone levels fall 10 fold in first 4 days postpartum. Breast milk changes in constituents with decreased concentration of secretory IgA and lactoferrin.

22Problems with Lactogenesis IIDelayed: extended time between colostrum and full milk productionFailed: 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 Problems with lactogenesis II are more common in women with minimal or no breast enlargement during pregnancy.

Secondary failure due to breastfeeding difficulties is much more common than primary failure of lactogenesis due to medical problems, breast hypoplasia, or altered maternal breast anatomy secondary to surgery.23Causes of Delayed Lactogenesis IIDelay in first breastfeeding: oral or IBV infant feedingLow breastfeeding frequency-poor stimulationPsychosocial stress/painUnscheduled cesarean or stressful labor/deliveryLess common etiologies secondary to maternal diseaseMaternal obesity Maternal diabetes or hypertension-etiology unknownAny circumstance that leads to delayed, infrequent, or ineffective milk removalReference 24 Causes of Failed Lactogenesis IIBreast surgery or injuryRetained placentaHypothyroidismTheca lutein ovarian cystsMammary hypoplasia (congenital)Polycystic ovarian syndromeSheehans syndrome secondary to postpartum hemorrhageReference 24, 33 True failed lactogenesis II is quite rare and consideration must be given to uncommon etiologies. Failed lactogenesis II can only be diagnosed when effective nursing or manual expression of breast milk is occurring.

Consider assessment of milk volume by using a hospital grade electric automatic pump and/or infant weighing before and after feeding. The use of these tests may help to determine if there is currently insufficient milk in the breasts or if the problem is the infants inability to extract the available milk (Neifert 2001)25GalactagoguesUsed to increase breast milk supplyNeed to attempt to determine the etiology of low milk supply prior to initiationEnsure 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 cystsReference 41 Prolactin levels in postpartum lactating mothers at 10 days or less (Betzold 2004) 200 ng/ml (baseline) 400 ng/mL (after breastfeeding)

Levels in lactating mothers from 1190 days postpartum 60 ng/mL (baseline) 220 ng/ml (after breastfeeding)

Academy of Breastfeeding Medicine Protocol # 9: www.bfmed.org/ace-files/protocol/prot9galactogoguesEnglish.pdf

Watch hands-on pumping for an example of how a mother can use her hands with pumping to maximize milk production http://newborns.stanford.edu/Breastfeeding/MaxProduction.html

26GalactagoguesMetoclopramide most commonly usedDomperidone not approved in USA. Similar to metoclopramide but less side effects as little crosses blood brain barrierFenugreek and other herbal medicines no scientific data except anecdotal reportsReference 9, 14, 18, 22 Metoclopramide Benefit shown in small placebo controlled crossover study with increase of 50 cc per feed with dose of at least 30 mg per dayEffect is to increase prolactin levelSide effects: gastrointestinal, anxiety, sedation, and rare dystonic reactionsNo documented neonatal reactionsShort term: 13 weeks is common. No evidence supporting long-term use. Usually wean after 1014 daysA common dosing regimen is 10 mg po qd first day, then 10 mg po bid, then 10 mg po TIDReference 9, 25 Patients or lactation consultants may request that physicians prescribe domperidone from compounding pharmacies. FDA issued a caution due to small number of deaths with intravenous formulation and concerns regarding drug importation (American Academy of Breastfeeding Protocol #9). Small RCT (daSilva 2001) of 16 patients showed increase of 49.5 cc with domperidone) compared to 8.0 cc with placebo (p 95% are community not hospital acquired MRSAMost seem to resolve even when given antibiotic that community acquired MRSA is resistant toDraining breast by manual pumping and/or breastfeeding for mastitis or incision and drainage of abscess may be most important part of treatmentReference 26, 31, 36, 40, 46 Cultures are rarely done or are of benefit in mastitis. Culture should be sent from aspiration and drainage of breast abscess. If MRSA positive antibiotic options compatible with breastfeeding may include trimethoprim/sulfamethoxazle or clindamycin. May be resistant to clindamycin despite sensitivities stating susceptible if resistant to erythromycin.

For instruction on hand expression, which may be more comfortable or effective than sucking in getting milk to flow, please see http://newborns.stanford.edu/Breastfeeding/HandExpression.html

36Nipple Candidal InfectionsNot uncommon, but often misdiagnosedNonspecific signs and symptomsNipple 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 patchesThere could be NO external signsReference 38 Neonatal thrush commonly occurs in women with candidal nipple infection. May be difficult to distinguish from cracked nipples due to improper latch-on.

Causes of Nipple CandidaPredisposed factorsDiabetesSteroid useImmune deficiencyAntibiotic useNipple traumaUse of plastic-line breast pads that trap moistureTreatment of Candidal Nipple Infections GeneralDifficult 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 infectionTreat 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 pacifiersMaternal treatment: nystatin suspension/ cream or clotrimazole applied after each nursing. No need to wash off before feedsInfant: nystatin (100,000 u/ml) 1 cc po qid inside mouth to breast after each nursingReference 10 Recommended to routinely treat the infant even if without signs or symptoms of thrush. (Betzold 2007)39Treatment of Candidal Nipple Infections Other OptionsGentian Violet a topical treatment option that uses 0.25%1% gentian violet swabbed on the affected areas for up to 3 daysOral fluconazole may be prescribed if nipples are not significantly better after several days of topical treatment, or in cases of reoccurrenceNote Gentian Violet may cause permanent staining of clothing and temporary violet discoloration of infants mount and the maternal breast. Correlation Between Breast Symptoms and Candida in Breast Milk Cultures> 70% PPV for shiny skin of nipple areola with stabbing breast pain OR flaky skin of nipple/areola with breast pain> 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 The symptoms described here are common. The presence of skin changes with breast pain does appear to correlate with candidal infection or colonization.41Ductal Yeast InfectionLack objective findings on exam as nipple and skin may not be involvedLack reliable microbiologic testsDecision to treat based on deep burning/shooting breast pain without other causesPotential for overdiagnosisReference 10, 45 We have a lack of scientific evidence to determine which women will benefit from treatment.42Treatment of Ductal Yeast InfectionWill not respond to topical medicinesTreatment is usually fluconazole 100200 mg po qd for 1421 days, although not FDA approved for this indicationNeed studies of diagnostic criteria and effectivenessNeed to treat infant with oral nystatin as well for thrush or colonization

Difficult to determine if a woman with deep stabbing or lancinating pain has ductal yeast. There is a need for randomized controlled trials of fluconazole vs. placebo.43Summary: Breastfeeding Problems Problems are common and treatableAssess adequacy of suckle and milk production/transferNeonatal jaundice and dehydration are associated with breastfeeding problemsTreat engorgement and blocked nipples to prevent mastitis and abscessesBacterial and candidal infections can adversely affect breastfeedingReferencesAcademy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #4: mastitis. Revision, May 2008. Breastfeed Med. 2008;3(3):177-180.Alpay F, Sarici SU, Tosuncuk HD, Serdar MA, Inanc N, Gokcay E. The value of first-day bilirubin measurement in predicting the development of significant hyperbilirubinemia in healthy term newborns. Pediatrics. 2000;106(2): e16.American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. 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