Dr Jenni Goold 2015

Introduction to Supporting BreastfeedingOSC Accreditation Seminar

Take home messages

• All women (almost) are able to breastfeed

• Provide information about benefits of breastfeeding

• Provide accurate information & improved supports especially if artificially fed last time

• Provide Support, or refer these women & babies

Common Breast feeding consultation discussion topics:

Are these statements true/false?• BF provides significant reduction in morbidity and mortality and

has implications for adult health• Weighing babies pre/post feed is a useful tool to assess supply• The quality of breast milk can be assessed by its appearance• Supply can be gauged by amount expressed• An unsettled baby generally indicates low supply• Average weight gain for healthy babies is 150 gm per week• If supply is low offering a complimentary feed of formula is helpful• Best predictor of successful BF is the women's attitude to BF

Common reasons for giving up breastfeeding

(And for women to seek help from their GP) • Breast and nipple pain

• Unsettled babies

‘Poor weight gain’

‘Not enough milk’

• Mastitis

Rebecca’s Presentation

• 30 year old female, G3 P1,NVD 3.1kg Baby girl at term, discharged after 24 hrs

• 4 days postnatal: baby attaching but nipples sore. Thought this was

‘normal' as first baby but now nipples cracked, bleeding & painful. Worried as Breast feel very full since yesterday & baby fussing at attachment.

What would you like to know?What are the issues?

What would you do?

Full history of:- feeding - sleep- development - does the baby have times when settled?

Assess the baby’s well being - full examination especially hydration & percentiles

Mothers mental health & supports

Issues to consider

• Baby gaining weight appropriately (av 150 gms per week)issues;

• First baby (3rd pregnancy)• supports?• Fatigue• Normal process- Milk coming in• Early discharge• Position/ attachment?• Mood?• Reassurance - this is a normal healthy baby

Attachment, Attachment, Attachment!

Painful BF, think attachment until proven other wise!

• Observe attachment

• Consider referral to lactation services if beyond individual GP skill level

The K sign:

Baby’s body contact with mother’s bodyHead tilt backWide mouthSignificant amount of breast in mouthNipple is well back in area of soft palate

Poor attachment= cracked nipples

If attachment not corrected, painful BF will result in cracked nipples

Cracked Nipples

• Causes nipple & shooting pain in the breast during and between feeds• Correct attachment: may be able to continue feeding despite cracks• Expose to air• Topical application: hindmilk, ?balms- beware of contact dermatitis• Consider resting nipples: 24 hrs of expressing- beware further trauma• ?Nipple shields- beware reducing supply

• Consider infection• Swab & anti-septic measures• Antibiotics (eg Cephalexin) or Bactroban (Mupirocin) ointment tds after feeds

until healed

Rebecca Re-presents

Now at 3 weeks post partum

‘I feel awful and my right breast is sore’

What else do you want to know?

Further History

• Rebecca says ‘Two nights ago, my baby slept through the night and my R breast still felt a bit full after I fed her in the morning

• My breast felt uncomfortable all day

• This morning, I started to develop shivers, aching muscles and a very sore R breast’

What are you thinking?

Examination Findings

What is the diagnosis?

Mastitis

Causes: Area of milk stasis or a blockage that was not resolved, leading to systemic symptoms

• Possible contributing Factors:

Anything that prolongs time between emptying of breast such as• Baby sleeping through the night, or mother going out and not expressing,

Spacing feeds (overuse of dummy)

Incomplete emptying• Tight bra, poor positioning and attachment

Infection• Infection entering through cracked nipple

Mastitis Management

• Symptomatic treatment:• Analgesia• Hot & cold compresses

• Relieve blockage:• Good positioning and attachment• Offer affected side first• Change position to drain affected side better• Massage • Express

• Resolve Infection (staph aureus):• Dicloxacillin/Flucloxacilllin 500mg qid• Cephalexin 500mg qid (if penicillin allergy) • Clindamycin 450mg tds for 10 days

Untreated

If left untreated, what is possible outcome?

Breast Abscess

Breast Abscess

• Treatment:• Antibiotics

• Alternate daily aspiration

• Or, if loculated, ultrasound guided aspiration

• Can continue to breast feed

Rebecca returns returns 2 weeks later

Presentation:• ‘I think that I have mastitis again’• Improved after antibiotics• Then sore R nipple • Worked hard on correct attachment• Pain during and after feeds shooting through the

breast • No fever

What are you thinking?

Examination reveals:

What is the diagnosis?

Poor attachment results in trauma & cracks, then allows infection, such as thrush or other bacterial infection such as staph

Thrush in the breast

Possible presenting history & examination findings:

• Shooting pain in breast during and after feeds

• Sore nipples with good positioning and attachment

• Recent mastitis/antibiotic use/thrush in baby

• No fever

• Nothing to see on examination of nipple

• Examine babies mouth

Thrush Management

• Baby: • Miconazole gel ¼ tsp qid after feeds or Nystatin oral drops 1ml qid for 7 to

10 days• Avoid dummy use. If used, sterilize daily and change weekly

• Mother:• Miconazole gel qid after feeds to nipples or Nystatin ointment for 7 to 10

days and change breast pads after every feed • ? place of systemic treatment

• However:• Beware over diagnosed and overuse of anti-fungals• Long term use of Miconazole can cause contact dermatitis• Always consider an alternative cause of nipple pain

Other Causes of nipple/breast pain?

Attachment, trauma & infection commonly cause painful BF

Consider other pathology:

• Eczema/Contact Dermatitis

• Vasospasm

Dermatitis/Eczema

• May be a past history of skin problems• Woman may have been using a cream on the nipples (Miconazole,

Paw Paw, Lanolin based)

• May occur after the introduction of solids• Responds very well to the removal of the offending agent and

topical steroid eg Advantan (methylprednisolone aceponate) ointment daily for few days

Vasospasm of nipple

• Pain caused by blood vessels tighten and go into spasm, so that blood does not flow to the nipple.

• Can be accompanied by sudden whitening of the nipple• Two main contributors:• Response to trauma• Associated with Raynaud’s phenomenon

Vasospasm of nipple

• Treatment:• Correct any contributors to trauma- positioning & attachment• Apply warmth after feeding-

cover up ; warm pack; breast-warmers; massage with olive oil under clothing

• Vit B6 and magnesium- nil evidence base

• Nifedipine- 30 mg SR 1 tab daily for 2 weeks and cease• 10% recurrence rate- recommence another 2 weeks• Can use increased dose if 30 mg inadequate• Side effects: postural hypotension, headache, flushing

• Nitroglycerine paste no longer recommended50 % efficacy & high incidence of severe headache

Resources for Breastfeeding Problems (Section 19 Protocols)

• National BF helpline 1800686268 www.breastfeeding.asn.au• Domiciliary Midwives• Breastfeeding Clinics

LMHS, Gawler, FMC, Mt Barker, Giles plains, Parks • CYWHS: 24 hr parent helpline 1300364100• Drop in service- no appointment required• day clinics: self referral- 1300 733 606• Residential (Torrens House): referral through CaFHS staff

• Australian Breastfeeding Association Counsellor• Find a GP/LC: http://www.lcanz.org/find-a-consultant.htm • Online resources• Want further skills- IBCLC qualification

Online Resources

• Royal Children’s Hospital: Clinical Practice Guidelines (links to Royal Women’s breastfeeding management site) http://www.rch.org.au/rchcpg/index.cfm?doc_id=9790• Australian Breastfeeding Association Fact Sheethttp://www.breastfeeding.asn.au/bfinfo/index.html • SA College of LCs, list of local breastfeeding support serviceshttp://www.lactation.org.au/sa/index.html • NHMRC: Infant feeding guidelines for health workers. (Publication is still under review) http://www.nhmrc.gov.au/publications/synopses/n20syn.htm • Mothers direct shop: all kinds of parenting books and breastfeeding resources & aidshttp://www.mothersdirect.com.au • Sensible parenting advice from Melbourne midwife/LChttp://www.pinky-mychild.com • Very good pregnancy, breastfeeding and parenting books

http://www.capersbookstore.com.au