Early Breastfeeding Concerns

Early Breastfeeding Concerns
Birth & Beyond California: Breastfeeding Training & QI Project With funding from the federal Title V Block Grant

BBC 8: Early Concerns 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 Birth and Beyond California addresses normal, full-term healthy babies and normal, healthy mothers The strategies presented in this session are the responsibility of the bedside nurse When difficulties persist, the nurse should refer to the lactation team and/or a lactation consultant 2 Rev. March 2009 2

Assessment is Key to Problem Solving
BBC 8: Early Concerns Assessment is Key to Problem Solving Observe the feeding Physical assessment Ask open ended questions Validate mother’s feelings Photograph: nurse assisting a mother Note to Trainer: Refer to Session 7: Assessment & Documentation Assessment is the key to problem solving It is the responsibility of the staff to include an observation of a feeding in the physical assessment of their patient (s) Refer to Session 3: Promoting Breastfeeding Communication skills are important for obtaining accurate patient information Ask open ended questions: - What makes you think your baby is not getting enough breastmilk? - What makes you think your baby needs a bottle? - What happens when you pick your baby up? - What have you tried to help your baby latch better? Acknowledge and validate her feelings: - It is frustrating when he cries - You are tired 3 Rev. March 2009 3

Early Concerns Activity
BBC 8: Early Concerns 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? Photographs: 1) crying baby 2) baby with poor latch technique Atlas Photograph 149 3) visible nipple trauma Atlas Photograph 254 4) engorgement (nipple trauma and engorgement Wilson-Clay B, Hoover K. (2005). The Breastfeeding Atlas (3rd edition). Austin, Texas: LactNews Press. Refer to these photographs when making the small group assignments for Activity 1 Activity 1: Group Problem Solving Refer to Session Plan for Activity material, time and instructions Background Nurses attending this training are experienced in patient care This activity is designed to boost their confidence The participants are divided into 5 smaller groups to discuss each of the 5 early concerns identified in this session Debrief Activity This activity is to be completed in phases using the wall/ flip charts completed during the small group brainstorming sessions to initiate discussion about the possible causes and strategies to prevent and /or correct each of the early concerns listed on this slide (4) Slides 5-20, 23 & 24 provide additional information for each of these 5 concerns - latch difficulties: slides 5,6,7 - sore nipples: slides 8,9,10 - engorgement: slides 11,12, 13, 14, 15, 16 - Insufficient milk supply- actual: slides 17, 23, 24 - Insufficient milk supply- perceived: slides 18, 19, 20 4 Rev. March 2009 4

Latch Difficulties Why is baby not latching?
BBC 8: Early Concerns Latch Difficulties Why is baby not latching? How can you address her concerns? What will you do or say? Nursing Plan of Care? Debrief Activity 1- Latch difficulties Note to Trainer: Use questions on this slide to guide your discussion of latch difficulties Ask group assigned latch difficulties to refer to their wall/ flip chart to identify: Possible causes of / reasons for latch difficulties Strategies for preventing and/ or correcting the problem (s) - refer to slide 5 & 6 5 Rev. March 2009 5

Latch Difficulties Management
BBC 8: Early Concerns Latch Difficulties Management Assist with correct positioning & latch Skin-to-skin may allow the baby to ‘reboot’ Strategies for management of latch difficulties include: Place baby skin-to-skin Start with the basics Observe mother and baby readiness to breastfeed Allow baby time to “reboot” - to “reboot” the baby means to start over again - note to trainer: use this analogy to explain how to reboot a baby: when a computer “crashes or freezes”, the directions are to stop, turn it off and then begin again Patient Education Correct both mother and baby position - refer to session 6: Putting Baby to Breast: part 1- Positioning Instruct the mother how to identify and elicit the key elements for latch - refer to session 6: Putting baby to Breast: part 2 - Latch Assessment Identify the problem Determine how it can be resolved Ask yourself: Is outside assistance needed? 6 Rev. March 2009 6

Persistent Latch Difficulties Management
BBC 8: Early Concerns Persistent Latch Difficulties Management Refer to lactation consultant Feed the baby Protect mother's milk supply Strategies for management of persistent latch difficulties include: Refer to lactation consultant - pending discharge status both in-patient and community referrals should be provided Feed the baby - supplementation will be discussed: - later in this session on slides 21,22, 25,26, 27 & 28 - in Session 9: Expressing & Feeding Breastmilk Protect mother’s milk supply - instruct mother to hand express and/or begin mechanical pumping to establish and maintain milk supply - both mechanical and hand expression will be discussed in Session 9: Expressing & Feeding Breastmilk 7 Rev. March 2009 7

Sore Nipples Why are her nipples sore?
BBC 8: Early Concerns 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? Debrief Activity 1- Sore Nipples Atlas Photograph 149 Wilson-Clay B, Hoover K. (2005). The Breastfeeding Atlas (3rd edition). Austin, Texas: LactNews Press. Note to Trainer: Use questions on this slide to guide your discussion of sore nipples Ask group assigned sore nipples to refer to their wall/ flip chart to identify: Possible causes of / reasons for sore nipples Strategies for preventing and/ or correcting the problem (s) - refer to slide 9 & 10 Overview Possible causes for sore nipples identified by the group should include poor positioning, poor latch, problems with suck, nipple preference/ nipple confusion Many mothers fear sore nipples more than any other aspect of breastfeeding Prenatal breast preparation is unrelated to sore or cracked nipples Nipples that are sore, abraded and/or cracked are most often the result of breast and nipple trauma due to incorrect positioning and latch Refer to slide 9 for causes of sore nipples Strategies The nurse should be able to handle basic latch problems leading to sore nipples - recommend changing sides/positions as needed to help the mother be more comfortable - demonstrate correct positioning for the mother and have her return the demonstration until she can do it herself comfortably The nurse should help the mother with positioning, treat the sore nipples, start her pumping if the pain is not tolerable - a referral is needed if the problem persists or the strategies are taking more time than the nurse is able to manage 8 Rev. March 2009 8

Sore Nipples Fix the problem!
BBC 8: Early Concerns 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! Sore nipples are a symptom of an underlying problem Examples of underlying problems may include : Poor positioning - nipple sucking- not taking enough of non-nipple breast tissue into the baby’s mouth, is an example of incorrect latch due to poor positioning - it is associated with sore and cracked nipples Incorrect latch - shallow latch - lip sucking- a baby who sucks in lower lip while nursing - a latch that is not asymmetrical Irritants to breast and nipple tissue - washing the nipple/areola using soap, water or other drying agents - application of allergens in creams and ointments - may occur even when using products designed for breastfeeding - plastic backed breast pads - excessive heat ie. using a hair dryer Infant oral motor challenges - may need referral to a lactation consultant 9 Rev. March 2009 9

Sore Nipples Management
BBC 8: Early Concerns 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 Most sore nipples are caused by poor positioning and are easily resolved Strategies for management of sore nipples include: Baby-led feedings - when a baby is allowed to initiate feeding, move to the breast on his own he will open wide and latch with less difficulty - when a baby is forced to feed on somebody else’s schedule they do not open as wide and typically cause nipple pain Moist wound care for sore nipples - start with expressed breastmilk or colostrum rubbed into the nipple - let air dry, then depending on the protocol at each hospital they may use lanolin ointment or hydrogel pads for moist wound healing Nipples that are increasing painful in spite of corrections to latch and positioning can pose serious problems to mother and baby Damaged nipples are an entry point for infection that can lead to mastitis If the mother cannot tolerate breastfeed pumping/hand expression should be initiated to protect the milk supply Refer to a lactation consultant - pending discharge status both in-patient and community referrals should be provided 10 Rev. March 2009 10

Engorgement Why is she engorged?
BBC 8: Early Concerns Engorgement Why is she engorged? How could engorgement have been prevented? What will you do or say? Nursing Plan of Care? Debrief Activity 1- Engorgement Atlas Photograph 154 Wilson-Clay B, Hoover K. (2005). The Breastfeeding Atlas (3rd edition). Austin, Texas: LactNews Press. Note to Trainer: Use questions on this slide to guide your discussion of engorgement Ask group assigned engorgement to refer to their wall/ flip chart to identify: Possible causes of / reasons for engorgement Strategies for preventing and/ or correcting the problem (s) - refer to slides 12-16 Overview Possible causes for engorgement identified by the group should include poor positioning, infrequent feeding, too many bottles in the first days, mother-baby separation/ baby in nursery Engorgement must be identified and managed Engorgement that prevents latch can undermine the success of breastfeeding Some hospitals consider a mother’s engorgement as a sign that breastfeeding assessments and/or assistance was not done correctly and that basic problems were missed Engorgement that is not corrected can lead to more problems later on and ultimately an untimely weaning - when a mother is severely engorged, she may run a low grade fever (below 37.8C or 100 F) 11 Rev. March 2009 11

Engorgement Management
BBC 8: Early Concerns 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 Strategies for management of engorgement include: Assist with latch and positioning Make sure the baby is swallowing when feeding - engorgement that is becoming severe may impact milk flow and makes it difficult or impossible for the baby to get adequate milk Place baby skin-to-skin to encourage mother’s hormones to help release milk Allow the breasts to drip between feedings - warm, moist compresses, warm showers and back rubs all help to relax the milk ducts and help milk to flow Pumping may be necessary if baby is not able to latch or is latching but the breast is not softening The nurse can assist with all of these strategies and then plan to refer if mother does not experience relief 12 Rev. March 2009 12

BBC 8: Early Concerns 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 Note to Trainer: Slides 13 & 14 discuss how to recognize the difference between edema and engorgement Refer to the following articles for additional information Cotterman KJ. (2004) Reverse Pressure Softening: A Simple Tool to Prepare Areola for Easier Latch During Engorgement. Journal of Human Lactation, 20( 2): Guyton AC. (1977) Basic Human Physiology: Normal Function and Mechanisms of Disease (pp. 321) 2nd Ed. W. B. Saunders Co. Philadelphia. Miller V, Riordan J. (2004) Case Study: Treating Postpartum Breast Edema With Areolar Compression. Journal of Human Lactation, 20(2): 13 13 Rev. March 2009 13

EDEMA ENGORGEMENT Onset At birth or shortly thereafter Day 3 to 5
BBC 8: Early Concerns EDEMA ENGORGEMENT Onset At birth or shortly thereafter Day 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 Pain Not generally at start Yes Chart: Edema vs Engorgement 14 14 Rev. March 2009 14

BBC 8: Early Concerns 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 Treatment for Edema Note to Trainer Read bullets on slide Refer to slide 16: How do I do Reverse Pressure Softening? 15 Rev. March 2009 15

Reverse Pressure Softening
BBC 8: Early Concerns Reverse Pressure Softening How do I do REVERSE PRESSURE SOFTENING? K. Jean Cotterman RNC, IBCLC Illustrations by Kyle Cotterman, Dayton, Ohio English and Spanish handouts are available at: See: Dealing with breast edema and engorgement: Reverse Pressure Softening - English (PDF)...Spanish You (or your helper, from in front, or behind you) choose one of the patterns pictured Place the fingers/thumbs on the circle touching the nipple ( If swelling is very firm, lie down on your back, and/or ask someone to help by pressing his or her fingers on top of your fingers) Push gently but firmly straight inward toward your ribs Hold the pressure steady for a period of 1 to 3 full minutes Relax, breathe easy, sing a lullaby, listen to a favorite song or have someone else watch a clock or set a timer. To see your areola better, try using a hand mirror It’s OK to repeat the inward pressure again as often as you need. Deep “dimples” may form, lasting long enough for easy latching. Keep testing how soft your areola feels You may also press with a soft ring made by cutting off half of an artificial nipple Offer your baby your breast promptly while the circle is soft 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. K. Jean Cotterman RNC, IBCLC & Illustrations by Kyle Cotterman Rev. March 2009 16

Actual Insufficient Milk Supply
BBC 8: Early Concerns Actual Insufficient Milk Supply Why are you or others concerned about her milk supply? How will you address those concerns? Nursing Plan of Care? Debrief Activity 1- Insufficient Milk Supply- Actual Note to Trainer: Use questions on this slide to guide your discussion of actual insufficient milk supply Ask group assigned actual insufficient milk supply to refer to their wall/ flip chart to identify: Possible causes of / reasons for actual insufficient milk supply Strategies for preventing and/or correcting the problems Overview Possible causes for actual insufficient milk supply include: Infant concerns - hypoglycemia - jaundice - gestational age: late preterm infant Maternal concerns - severe illness - intolerable pain during feedings - previous breast surgeries or trauma Strategies Both maternal and infant concerns will be discussed in Session 10: Special Situations Supplementation guidelines for medical indications will be discussed in this session on slides 23 & 24 17 Rev. March 2009 17

Perceived Insufficient Milk Supply
BBC 8: Early Concerns Perceived Insufficient Milk Supply Why does she think she doesn’t have any milk? How will you address her concerns? Nursing Plan of Care? Debrief Activity 1- Insufficient Milk Supply- Perceived Note to Trainer: Use questions on this slide to guide your discussion of perceived insufficient milk supply Ask group assigned perceived insufficient milk supply to refer to their wall/ flip chart to identify: Possible causes of / reasons for perceived insufficient milk supply Strategies for preventing and/or correcting the problems Overview Possible causes/ reasons are listed on next slide (19) 18 Rev. March 2009 18

BBC 8: Early Concerns 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? Possible causes of / reasons for perceived insufficient milk supply Use reasons listed on slide to reinforce discussion initiated with the small group wall/ flip chart Ask all participants to contribute Affirm that the staff nurses are first responders and they are already familiar with most of the concerns identified by mothers Reinforce that what they do and say will make a difference 19 Rev. March 2009 19

BBC 8: Early Concerns 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 Strategies Note to Trainer: Begin this discussion by asking: As caregivers, What can you do help a mother to change her perceptions about her milk supply? Validate the mother's feedings Provide education for her concerns by emphasizing normal expectations Activity 2- Bell Ball Cards Refer to Session Plan for Activity materials, time and instructions Background The diagram on the Belly Ball card shows the actual sizes of a baby’s tummy and is use to to reinforce the concept of stomach size and capacity Debrief activity Refer to the Bell Ball card while continuing the discussion of perceived insufficient milk supply strategies including - the value of early colostrum to the newborn - the importance of frequent feeding for milk supply - establishes milk supply in the early days - maintains milk supply in the future - promote exclusive breastfeeding - whenever possible include family and friends to help focus education and clarify any myths or misunderstandings about breastfeeding initiation and maintenance 20 Rev. March 2009 20

Avoid Casual Supplementation
BBC 8: Early Concerns Avoid Casual Supplementation The strongest risk factors for early breastfeeding termination were: Late breastfeeding initiation Supplementing the baby DiGirolamo, Birth, 2001 Kramer, JAMA, 2001 The studies referenced on this slide looked at early termination of breastfeeding The slide bullets list the risk factors We can remedy these issues Remember – to achieve breastfeeding success: - breastfeed early - breastfeed often - breastfeed exclusively No supplementation without medical necessity Note to Trainer: The next slide (22) lists the most commonly stated reasons for supplementation 21 Rev. March 2009 21

Supplement Is NOT Needed For
BBC 8: Early Concerns 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 This is a list of several of the most often stated reasons for offering supplementation They are not supported in the research 22 Rev. March 2009 22

BBC 8: Early Concerns 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 Slide lists infant medical reasons for supplementation. (ABM, Protocol #3, 2002) Note to Trainer: - Hypoglycemia and jaundice are discussed in Session 10: Special Situations AAP Recommendations for healthy term infants Formal evaluation of breastfeeding performance should be undertaken by trained caregivers at least twice daily and fully documented in the record during each day in the hospital after birth Weight Loss: physiologic weight loss is normal - weight is lowest by Day 5, return to birth weight by Day 7-10 Strategies for managing weight loss: Current Breastfeeding Research Walker, Breastfeeding Management for the Clinician: Using the Evidence, 2006 Breastfed babies on the average lose 5-7% of their birth weight in the first few days of life A weight loss of more than 7% in the first 72 hours should trigger an assessment of mother and baby in regard to breastfeeding Weight loss of 7-10% from birth weight in the first 96 hours requires close observation for possible intervention and maternal support A weight loss greater than 10% must be addressed Pending MD/ HCP findings interventions, including supplementation may/ may not be required Current Formula Feeding Research (Martens, JHL, 2007) Exclusive formula-fed babies lose 3.1% less weight than exclusive breastfed babies during hospital stay Conclusion: Hospital policy needs to include criteria for supplementation based on gestational age and weight loss ABM, Protocol #3, 2002 23 Rev. March 2009 23

BBC 8: Early Concerns Insufficient Milk Supply: Valid Medical Reasons to Supplement (Maternal Concerns) Breastfeeding is contraindicated Severe illness Intolerable pain during feedings Slide lists maternal medical reasons for supplementation Walker, Breastfeeding Management for the Clinician: Using the Evidence, 2006 ABM, Protocol #3, 2002 Note to Trainer: Contraindications to breastfeeding will be covered in Session 10: Special Situations Delayed lactogenesis II Hospital based nurses rarely see this due to the short lengths of stay Excessive weight loss in the first 2 days may signal a potential problem Complications leading to delayed lactogenesis II include: - obesity - emergency C-section - thyroid conditions - Polycystic Ovarian Syndrome (PCOS) in some women - insufficient mammary tissue or poorly developed breasts - retained placenta - the decline in plasma progesterone levels secondary to the complete delivery of the placenta is necessary to trigger lactogenesis II. ABM, Protocol #3, 2002 24 Rev. March 2009 24

Supplementation Mother may insist on supplementing
BBC 8: Early Concerns 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 Perceived Insufficient Milk supply Not enough milk is the number one (#1) concern of most new mothers Some mothers just will not be reassured until their breasts are full and dripping For psychological reassurance, it may be necessary to show her how to supplement the baby AS A TEMPORARY MEASURE! Note to Trainer: Supplementation may also be medically indicated It should be discussed with the family as a temporary intervention - analogy: just as using crutches is a temporary intervention for a broken leg: once no longer needed, the person walks without the crutch Once no longer needed, the baby can breastfeed without supplementation Reinforce importance of stimulating mother’s milk production any time supplements are given to baby - if a mother is supplementing without any/ adequate breast stimulus from breastfeeding, then the milk supply needs to be protected by pumping and/ or hand expression - it is the nurse’s responsibility to teach hand expression and/ or arrange for the use of the breast pump Use of Alternate Feeding Methods will be discussed in Session 9: Expressing and Feeding Breast Milk 25 Rev. March 2009 25

How Much To Supplement? 1st Day - 5 to 15 cc per feeding
BBC 8: Early Concerns How Much To Supplement? 1st Day to 15 cc per feeding 2nd Day – up to 30 cc per feeding 3rd Day – up to 45 cc per feeding 4th Day – ad lib To allow for appropriate stomach accommodation Note to Trainer: These amounts are based on the discussion of the physiological capacity of the newborn stomach Remind participants about the Belly Balls Activity Zangen, Pediatr Res. 2001 26 Rev. March 2009 26

What to Supplement? Quality in order of preference:
BBC 8: Early Concerns What to Supplement? Quality in order of preference: Mother’s expressed breast milk Pasteurized donor breast milk Hydrolyzed formula Cow or soy formula Read in order listed on slide Academy of Breastfeeding Medicine Protocol #3, 2002 27 Rev. March 2009 27

Documentation If infant is supplemented, the nurse should:
BBC 8: Early Concerns 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 Note to Trainer: Ask if this hospital has consent forms for supplementation Some hospitals have consent forms and have parents sign that they have made an informed decision to supplement their baby Staff guidelines for documentation of supplementation Babies should never be given formula without the mother’s knowledge and consent - discuss with the mother the need for supplementation - explain the risk factor associated with supplementation Document education: expression of breast milk - type of expression the mother has been taught, ie hand, type of pump - include the frequency and amount expressed and fed to baby Document the reason for supplementation - A mother informed about the potential risks of supplementation has the right to decide how to feed her baby - it is the nurses responsibility to provide education and then support the mother’s decision - This documentation is required for Baby Friendly Certification 28 Rev. March 2009 28

When Early Concerns are Not Addressed or Resolved
BBC 8: Early Concerns When Early Concerns are Not Addressed or Resolved Severe engorgement Plugged ducts Mastitis Premature weaning Readmissions Photograph 285 – severe engorgement Wilson-Clay B, Hoover K. (2005). The Breastfeeding Atlas (3rd edition). Austin, Texas: LactNews Press. Severe engorgement prevents the milk from flowing When the milk doesn’t flow the baby doesn’t feed adequately With inadequate draining of the breast the milk supply will quickly decrease and premature weaning may occur Causes of severe engorgement Casual supplementation in the early days prevents the breasts from being drained Untreated nipple pain can lead to nipple damage - sore nipples may cause mother to shorten feedings or stop breastfeeding before breast is adequately drained Delaying assessment of breastfeeding status and treatment for mild engorgement - if the breasts are too engorged then the baby can not latch - any time a baby is given a supplement via an alternate feeding method the mother’s breast must be stimulated to promote milk production - frequent draining of the breast by either the baby, hand expression or a pump is critical for initiating milk production and keeping mother comfortable Complications of severe engorgement include: Plugged ducts, mastitis, abscess - Hospital readmissions can be prevented when breastfeeding is managed well from the beginning - early identification and treatment of potential problems can prevent most if not all of these complications for most women 29 Rev. March 2009 29

Plugged Duct A benign lump in the breast caused by: Management
BBC 8: Early Concerns 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 Common Causes of Plugged Ducts Infrequent breastfeeding and milk stasis Inadequate removal of milk from one area of the breast Local pressure on one area of the breast causing a blockage, as in a bra that is too tight Exhaustion and fatigue High calcium diets may play a role Management Strategies Continue to breastfeed, feeding frequently on the affected side Vary feeding positions to stimulate different areas of the breast Massage the affected area, trying to move the lump towards the nipple to assure drainage of the area - this can be done before and during a feeding Apply warm moist compresses as comfort measures Check that clothing is not restricting flow from the affected area 30 Rev. March 2009 30

BBC 8: Early Concerns 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 Photograph 283 : mother with mastitis nursing baby on unaffected breast Wilson-Clay B, Hoover K. (2005). The Breastfeeding Atlas (3rd edition). Austin, Texas: LactNews Press. Mastitis Usually unilateral but may occur in both breasts May be infective or non-infective Contributing factors are: - lowered resistance to infection, as from stress, exhaustion or anemia - insufficient drainage of the area or obstruction of ducts - untreated plugged duct or unresolved engorgement Treatment Strategies for mastitis Antibiotics should be given for at least days The mother may take a mild analgesic such as acetaminophen or ibuprofen Breastfeeding plan - continue to breastfeed - additional pumping or feeding may be needed for adequate drainage Maternal wellbeing - rest, get help with other children and household chores, drink lots of fluids Comfort measures - ice packs or warm packs – whatever mother finds most comfortable and is culturally appropriate - the bra should not restrict milk flow or cause painful pressure 31 Rev. March 2009 31 31

BBC 8: Early Concerns 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 Concluding statements Mothers need information and support to successfully breastfeed Most the problems they may encounter or worry they will encounter can be easily resolved with proper management Persistent problems require a referral to a lactation cspecialist and/or WIC Education basics to establish and maintain a good milk supply include: Early and on going skin-to-skin contact between mother and baby Early and frequent feedings Night feedings Formula supplementation for medical indications only 24 hour rooming-in with frequent feedings on cue Limited separation of mother and baby Sucking unlimited by the clock Teaching mother about infant behavior and lactation management Feeding on cue Education of staff about advantages of breastfeeding and lactation management 32 Rev. March 2009 32

Sing Along Breastfeed early Breastfeed often Breastfeed long
BBC 8: Early Concerns Sing Along Breastfeed early Breastfeed often Breastfeed long Breastfeed well Breastfeed exclusively, Breastfeed exclusively, Photograph: mother and baby breastfeeding Note: to Trainer Lead group in sing along to the tune of Frere Jacques The Ten Steps to Successful Breastfeeding that form the central core of the UNICEF Baby-Friendly Hospital Initiative are directed toward implementing hospital routines which support adequate milk production and infant growth. 33 Rev. March 2009 33

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