Common Breastfeeding Challenges and its

ManagementDr. Varsha Atul Shah

CONCERNS ABOUT MUMMY

Milk Production• Generally mature milk begins within 72H. MR

feel that the breast is heavier and fuller• Occasionally some MR experience delayed

onset of milk production. Causes include– overhydration with IV fluids– retained placental fragments(cos of hormones

secreted by the fragments)

Delayed Onset of Milk Production

• Review the hydration status of the baby- weight, IO, NNJ

• Solutions for MR– Nurse frequently 2H or more depending on baby– Massage the breast while nursing– KIV pump after nursing to stimulate the breast– KIV herbal secretagogues(fenugreek), medications

(domperidone 10mg TDS)– Consider weighing baby EOD

Breast Pain If the MR complains of breast pain, ddx

breast engorgement galactocele mastitis breast abscess

Breast engorgement Usually occurs D2-3 as the milk production occurs and there

is increased blood flow to the breast Problems

Breast becomes swollen and tender Nipples may flatten, difficult to latch Nursing may be infrequent or ineffective and milk supply

subsequently drops

Breast Pain

• Breast engorgement– Solutions

• Nurse frequently 1-3H• Nurse until breast is fully emptied (preferable to nurse

1 side till emptied then the other, rather than limit nursing on the first side in bid to nurse both)

• Gently massage during nursing to encourage milk flow• If MR still feels full after nursing, can further express

after nursing • Consider cold cabbage to relief pain and swelling• KIV analgesia(eg panadol) if pain is severe

Breast Pain• Galactocele/Blocked ducts

– Cyst in the mammary duct containing milk– Encourage massage during nursing or expressing– Consider alternating positions for nursing to ensure the whole breast is

well emptied.• Sore nipples

– Types • traumatized nipples: blistered, scabbed or cracked• irritated nipples: pink with burning sensation

– DDx• Nipple thrush: treat MR and BB with miconazole/nystatin• Contact dermatitis: vit E containing creams, preps with cocoa butter, lanolin• Eczema• Impetigo• Improper positioning (fail to open mouth wide or mouth slides off areola to

nipple due to breast engorgement or unsupported nipple)

Breast Pain• Sore nipples

– Solutions• Do not delay nursing, consider Q1-2H nursing for a shorter period

• Start on the less tender side

• Massage during nursing to speed up emptying

• Release the suction carefully after the feed

• In between feeds, squeeze some EBM and apply on nipple and areola(contains Ig), then apply lanolin

• Consider pumping on the tender side

• Consider analgesia

• Wear cotton, microfiber bras(better air circulation)

• Avoid excessive washing of nipples

Breast Pain• Traumatized nipples

– Solutions• Consider alternative nursing position • If the breast is full and BB is unable to take whole areola into

mouth, then compress with finger or manually express some milk before nursing

• If BB does not open her mouth wide then wait for her or let her suck on MR’s finger to stimulate the sucking reflex before latching

• Take the BB off once the position is suboptimal and reposition(may require help from partner)

• KIV ABX if there is any evidence of infection.

Breast Pain Mastitis

Inflammation of the breast ducts +/- infection Treatment

Frequent nursing to drain the ducts KIV expressing Analgesia +/- antibiotics

Breast abscess Seek medical attention for drainage

Breast pain Ddx

Let down Refilling after nursing Blocked ducts Nipple irritation

Flow of the Milk

• Let down difficulty– Stimulation

• best stimulator is the suckling of the BB• MR encouraged to be relaxed and think of BB during pumping

– Ddx• problem with BB latching or sucking• low milk supply

• Leaking milk – Solutions

• at home, open both bra flaps and lay a cloth for it to drip down• use breast pads• Never pump to relief leaking as it will stimulate more milk supply

Difficult Latch-on• Nipple issues

– flat nipple– dimpled nipple– inverted nipple

• Problems that may arise– frustrated MR and BB– Poor latch may lead to nipple soreness

• Solutions– Encourage nursing within 2h of birth as BB tend to latch better

then to problem nipples– Get help to position the BB for nursing– Avoid artificial teats in the first few days – Consider pumping for a short while before nursing as it can help

to pull nipple out for better nursing

Fatigue

• Immediate post-partum period, MR tired from labour and taking care of BB

• Enough rest and help is essential

CONCERNS ABOUT BABY

NNJ• Physiological jaundice

– contributed by inadequate intake -> dehydration and inadequate calories

– continue to breastfeeding even during phototherapy, either via direct latching or EBM

• Breast milk jaundice– many factors implicated: metabolite of progesterone in breast

milk that inhibit enzymes in the metabolism of bilirubin, inflammatory cytokines contributing to cholestasis

– work-up to rule out prolonged conjugated hyperbilirubinemia– no indication to stop breast feeding

Underfeeding and Weight Loss• Significant if BB loses >10% body weight • Consider pumping when the feed is due to estimate the

amount of breast milk taken and reasses for the need to supplement

• Ddx– Inaqeuate milk production

– Poor latch

• Solutions– Nurse often KIV supplement

– Weigh BB every few days

– Review BB’s latch

PU and BO

• PU: it is acceptable to PU x 1 on D1, x2 on D2

• BO– D1-3: passing meconium

– D5 onwards: passing breastfeeding stools, mustard colour

Sleepy Baby

• Typically occurs in the 1st week of life

• Ensure that BB is fed every Q3H

• Solutions:– Stimulate BB when its feeding time by rubbing her back, or

placing on the bare chest

– If BB falls asleep latching, compress the breast to encourage more milk flow, as this may help arouse BB

– Burp BB well after each feed

– If unable to rouse BB, KIV feed after 1H

Difficult Latch On

Difficult Latch On

• Preference for teat– Ensure that the breast is not too full->pump

some before feeding, or firm it by applying ice for a few minutes

– Good positioning

Difficult Latch On • Micronagthia

– Ensure breast not too full– Tilt the BB’s head slightly backwards so that

the chin touches the breast 1st

• Tongue tied– May make nursing painful even with good

positioning, may have “clicking” sound during suck

– Consider frenotomy

Difficult Latch On • Protruding tongue

– Encourage BB to open mouth wide and hold the tongue down

– Football hold offers the best control and visibility

• Tongue sucking– Latch on when the BB has his mouth open and his

tongue down– Slightly depressing the lower chin may help the tongue

to drop

»Thank You