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

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 baby’s 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 < 8 and Function score < 11 Attention to changing position on breast Care of mother’s 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 mom’s 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 2–3 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 • Mother’s body tone relaxes • Auditory confirmation of swallowing • Weight gain around arrival of mother’s milk • 0–90 days; median gain 26–31 g • 90–180 days; median gain 17–18 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 > 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 30–40 hours postpartum • Subjective feeling of breast fullness • Day five term infant receive 500 to 750 cc of milk compared to < 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 • Sheehan’s 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: 1–3 weeks is common. No evidence supporting long-term use. Usually wean after 10–14 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 don’t 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 5%–10% of breastfeeding women • Most common in first month • Recurrences occur in 8%–19% 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. Incidence of mastitis and breast abscess from community acquired MRSA appears to be increasing with up to 50% in some studies > 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 Methicillin Resistant Staph Aureus and Breast Abscess in Lactating Women 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 mother’s 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 0.25%–1% 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 • > 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

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 100–200 mg po qd for 14–21 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

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