1 Early Breastfeeding Concerns Birth & Beyond California: Breastfeeding Training & QI Project

2 Objectives Identify at least two nursing interventions that support breastfeeding in the following situations: –Insufficient milk supply: perceived or actual –Latch difficulties –Sore nipples –Engorgement

3 Assessment is Key to Problem Solving Observe the feeding Physical assessment Ask open ended questions Validate mother’s feelings

4 Early Concerns Activity Insufficient milk supply: perceived or actual Latch difficulties Sore nipples Engorgement Why does the concern exist? How will you address her concerns? Nursing Plan of Care?

5 Latch Difficulties Why is baby not latching? How can you address her concerns? What will you do or say? Nursing Plan of Care?

6 Latch Difficulties Management Assist with correct positioning & latch Skin-to-skin may allow the baby to ‘reboot’

7 Persistent Latch Difficulties Management Refer to lactation consultant Feed the baby Protect mother's milk supply

8 Sore Nipples Why are her nipples sore? How will you help her to be more comfortable? What will you do or say? Nursing Plan of Care?

9 Sore Nipples Are sore nipples a breastfeeding problem? NO, they are merely a symptom of an underlying problem Don’t just treat the symptoms Fix the problem !

10 Sore Nipples Management Assist with correct positioning & latch Skin-to-skin may allow the baby to ‘reboot’ Moist wound care and pain relief may be needed for damaged nipples Refer to lactation consultant if sore nipples are severe or persist

11 Engorgement Why is she engorged? How could engorgement have been prevented? What will you do or say? Nursing Plan of Care?

12 Engorgement Management Assist with correct positioning & latch Skin-to-skin may allow the baby to ‘reboot’ Moist warm compresses prior to breastfeeding or milk expression Refer to lactation consultant if unresolved or severe

13 Edema Recognition Interstitial fluid volume increases by 30% before edema becomes visible Long labors with IV fluids and pitocin use are risk factors Swollen breasts early on in postpartum period and may not resolve for up to 2 weeks

14 EDEMAENGORGEMENT OnsetAt birth or shortly thereafterDay 3 to 5 Appearance Full or have orange peel appearance Shiny & tight Palpation When areola area is pressed (~10 sec.) indents are left Hard Pumping Does not help alleviate, little to no milk removed May soften, milk generally flows unless severe PainNot generally at startYes

15 Treatment for Edema Soften areola with reverse pressure softening, hand expression –Pumping can create edema with high vacuum –Pumping with edema typically results in no milk removal Assess latch and document –Educate patient: have mom start, you assist, she repeats Engorgement has added treatments not related to edema

K. Jean Cotterman RNC, IBCLC & Illustrations by Kyle Cotterman Reverse Pressure Softening Two step, two hands. Use straight thumbs, base of thumbnail even with side of nipple. Move ¼ turn, repeat, thumbs above and below nipple. Two handed, one step. Fingernails short, fingertips curved, each one touching the side of the nipple.

17 Actual Insufficient Milk Supply Why are you or others concerned about her milk supply? How will you address those concerns? Nursing Plan of Care?

18 Perceived Insufficient Milk Supply Why does she think she doesn’t have any milk? How will you address her concerns? Nursing Plan of Care?

19 Perceived Insufficient Milk Supply Why does mother think there is no milk? Her breasts are soft She thinks the milk comes in later Baby is fussy Baby breastfeeds frequently Baby takes a bottle after breastfeeding Her family thinks this Additional reasons?

20 Perceived Insufficient Milk Supply How can you address her concerns? Validate her feelings and provide education about her concerns –Stomach size –The value and volume of colostrum –The value of skin to skin –How to calm her fussy baby –How cluster feeding is normal –Sucking on a bottle is a response to the hard nipple and flow of formula, not hunger –Teach her family also

21 Avoid Casual Supplementation The strongest risk factors for early breastfeeding termination were: –Late breastfeeding initiation –Supplementing the baby DiGirolamo, Birth, 2001 Kramer, JAMA, 2001

22 Supplement Is NOT Needed For Colostral phase To let the mother rest or sleep To quiet a fussy baby To wake a sleepy baby For a big baby For a little baby To prevent sore nipples To teach baby to take bottle

23 Insufficient Milk Supply: Valid Medical Reasons to Supplement (Baby Concerns) Hypoglycemia Jaundice Weight loss of 7-10% within the first 3-4 days of life ABM, Protocol #3, 2002

24 Insufficient Milk Supply: Valid Medical Reasons to Supplement (Maternal Concerns) Breastfeeding is contraindicated Severe illness Intolerable pain during feedings ABM, Protocol #3, 2002

25 Supplementation Mother may insist on supplementing Supplementation may be medically indicated Teach mother how to supplement If baby is supplemented, mother needs to pump and/or hand express to protect her milk supply

26 How Much To Supplement? 1 st Day - 5 to 15 cc per feeding 2 nd Day – up to 30 cc per feeding 3 rd Day – up to 45 cc per feeding 4 th Day – ad lib To allow for appropriate stomach accommodation Zangen, Pediatr Res. 2001

27 What to Supplement? Quality in order of preference: –Mother’s expressed breast milk –Pasteurized donor breast milk –Hydrolyzed formula –Cow or soy formula Academy of Breastfeeding Medicine Protocol #3, 2002

28 Documentation If infant is supplemented, the nurse should: –Inform mother of the potential risks of formula supplementation –Document type of expression mother has been taught, i.e. hand, pump –Document the reason for supplementation in the infant’s medical record

29 When Early Concerns are Not Addressed or Resolved Severe engorgement Plugged ducts Mastitis Premature weaning Readmissions

30 Plugged Duct A benign lump in the breast caused by: –Infrequent breastfeeding and milk stasis –Inadequate removal of milk from one area of the breast Management –Continue breastfeeding, feed frequently on affected side –Try different feeding positions –Massage area to encourage drainage

31 Mastitis An inflammation or infection of the breast that produces systemic flu-like symptoms and is characterized by extreme tenderness, swelling, redness and heat in a section of the breast Management: –Antibiotics –Continue breastfeeding –Rest (lying down whenever possible) –Lots of fluids

32 Conclusion Many mothers have early concerns that are easily addressed with encouragement, support and education Some mothers will need referral to a lactation specialist and/or to WIC Proper management of breastfeeding in the first week of life can prevent many breastfeeding problems

33 Sing Along Breastfeed early Breastfeed often Breastfeed long Breastfeed well Breastfeed exclusively, Breastfeed well

34 Photo Credits Slide 1 – Motherhood by Petrov Vodkin c Slide 3 – by JAWarren Slide 6 – by JAWarren Slide 17 – by Sean Drelinger Slide 18 – by Sean Drelinger Slide 33 – by Carnaval King 08’s