Management of Common Breastfeeding Problems

Breastfeeding Residency Curriculum

Prepared by

Andrew Hsi MD, MPH

and

Larry Leeman MD, MPH

University of New Mexico School of Medicine

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.

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

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 babys mouth assesses function

Nail bed placed at lower gum ridge to assess excursion

Rule out inability to compress milk ducts

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

Breast Assessment Uncommon Conditions

Primary Hypoplasia:
- insufficient mammary glandular tissue - nulliparous state (adopted infant) - unilateral or bilateral breast anomalies

Secondary Displasia:
s/p radiation Rx s/p breast surgery s/p severe mastitis/abscess

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

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

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 mothers nipples to prevent injuries

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

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

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

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 moms 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

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

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

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 23 hours Use of LATCH score, similar objective tool Direct observation of latching for near term Screen every baby for jaundice

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 Mothers body tone relaxes

Auditory confirmation of swallowing

Weight gain around arrival of mothers milk 090 days; median gain 2631 g 90180 days; median gain 1718 g

Reference 15, 27

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

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

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

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

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 3040 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

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

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

Causes of Failed Lactogenesis II

Breast surgery or injury

Retained placenta
Hypothyroidism Theca lutein ovarian cysts

Mammary hypoplasia (congenital)

Polycystic ovarian syndrome Sheehans syndrome secondary to postpartum hemorrhage

Reference 24, 33

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

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

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: 13 weeks is common. No evidence supporting long-term use. Usually wean after 1014 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

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

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

Plugged Ducts
Tender lump Predisposing factors Positions that dont 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

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

Mastitis History and Physical Exam

Fever, diffuse myalgias, flu-like symptoms, breast pain
Wedge-shaped, tender, erythematous, usually unilateral Upper, outer quadrant most common

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

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

Methicillin Resistant Staph Aureus and Breast Abscess in Lactating Women

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

Reference 26, 31, 36, 40, 46

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

Causes of Nipple Candida

Predisposed factors Diabetes Steroid use Immune deficiency Antibiotic use Nipple trauma Use of plastic-line breast pads that trap moisture

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 mothers 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

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

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

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

Treatment of Ductal Yeast Infection

Will not respond to topical medicines
Treatment is usually fluconazole 100200 mg po qd for 1421 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

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

References
1. Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #4: mastitis. Revision, May 2008. Breastfeed Med. 2008;3(3):177-180. 2. Alpay F, Sarici SU, Tosuncuk HD, Serdar MA, Inanc N, Gokcay E. The value of first-day bilirubin measurement in predicting the development of significant hyperbilirubinemia in healthy term newborns. Pediatrics. 2000;106(2): e16. 3. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114(1):297-316. 4. Amir LH, Forster DA, Lumley J, McLachlan H. A descriptive study of mastitis in Australian breastfeeding women: incidence and determinants. BMC Public Health. 2007;7:62. 5. Amir LH, James JP, Donath SM. Reliability of the hazelbaker assessment tool for lingual frenulum function. Int Breastfeed J. 2006;1(1):3. 6. Andrews JI, Fleener DK, Messer SA, Hansen WF, Pfaller MA, Diekema DJ. The yeast connection: is Candida linked to breastfeeding associated pain? Am J Obstet Gynecol. 2007;197(4):424.e1-e4. 7. Ballard JL, Auer CE, Khoury JC. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad. Pediatrics. 2002;110(5):e63. 8. Barbosa-Cesnik C, Schwartz K, Foxman B. Lactation mastitis. JAMA. 2003;289(13):1609-1612. 9. Betzold CM. Galactagogues. J Midwifery Womens Health. 2004;49(2):151-154. 10. Betzold CM. An update on the recognition and management of lactational breast inflammation. J Midwifery Womens Health. 2007;52(6):595-605. 11. Betzold CM, Hoover KL, Snyder CL. Delayed lactogenesis II: a comparison of four cases. J Midwifery Womens Health. 2004;49(2):132-137. 12. Bhutani VK, Johnson L. Kernicterus in late preterm infants cared for as term healthy infants. Semin Perinatol. 2006;30(2):89-97. 13. Bhutani VK, Johnson L, Sivieri EM. Predictive ability of a predischarge hour-specific serum bilirubin for subsequent significant hyperbilirubinemia in healthy term and near-term newborns. Pediatrics. 1999;103(1):6-14. 14. Bishop J. Is domperidone safe for breastfeeding mothers? J Midwifery Womens Health. 2004;49(5):461. 15. Cadwell K. Maternal and Infant Assessment for Breastfeeding and Human Lactation: A Guide for the Practitioner, 2nd ed. Sudbury, MA: Jones and Bartlett Publishers; 2006.

References
16. Caglar MK, Ozer I, Altugan FS. Risk factors for excess weight loss and hypernatremia in exclusively breast-fed infants. Braz J Med Biol Res. 2006;39(4):539-544. 17. Chou SC, Palmer RH, Ezhuthachan S, et al. Management of hyperbilirubinemia in newborns: measuring performance by using a benchmarking model. Pediatrics. 2003;112(6 Pt 1):1264-1273. 18. da Silva OP, Knoppert DC, Angelini MM, Forret PA. Effect of domperidone on milk production in mothers of premature newborns: a randomized, double-blind, placebo-controlled trial. CMAJ. 2001;164(1):17-21. 19. Dancey A, Khan M, Dawson J, Peart F. Gigantomastia--a classification and review of the literature. J Plast Reconstr Aesthet Surg. 2008;61(5):493-502. 20. Foxman B, D'Arcy H, Gillespie B, Bobo JK, Schwartz K. Lactation mastitis: occurrence and medical management among 946 breastfeeding women in the United States. Am J Epidemiol. 2002;155(2):103-114. 21. Francis-Morrill J, Heinig MJ, Pappagianis D, Dewey KG. Diagnostic value of signs and symptoms of mammary candidosis among lactating women. J Hum Lact. Aug 2004;20(3):288-299. 22. Gabay MP. Galactogogues: medications that induce lactation. J Hum Lact. 2002;18(3):274-279. 23. Geddes DT, Langton DB, Gollow I, Jacobs LA, Hartmann PE, Simmer K. Frenulotomy for breastfeeding infants with ankyloglossia: effect on milk removal and sucking mechanism as imaged by ultrasound. Pediatrics. 2008;122(1):e188e194. 24. Hurst NM. Recognizing and treating delayed or failed lactogenesis II. J Midwifery Womens Health. 2007;52(6):588-594. 25. Kauppila A, Arvela P, Koivisto M, Kiniven S, Ylikorkala O, Pelkonen O. Metoclopramide and breast feeding: transfer into milk and the newborn. Eur J Clin Pharmacol 1983;25(6):819-823. 26. Kriebs JM. Methicillin-resistant Staphylococcus aureus infection in the obstetric setting. J Midwifery Womens Health. 2008;53(3):247-250. 27. Lawrence RA, Lawrence RM. Breastfeeding: A Guide for the Medical Profession. 6th ed. Philadelphia, PA: Mosby, Inc.; 2005:46, 436-437, 538-540, 607. 28. Lawrence RA. Mastitis while breastfeeding: old theories and new evidence. Am J Epidemiol. 2002;155(2):115-116. 29. Macdonald, PD, Ross, SR, Grant, L, Young, D. Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonatal Ed 2003;88(6):F472F476 30. Moazzez A, Kelso RL, Towfigh S, Sohn H, Berne TV, Mason RJ. Breast abscess bacteriologic features in the era of community-acquired methicillin-resistant Staphylococcus aureus epidemics. Arch Surg. 2007;142(9):881-884.

References
31. Mohrbacher N, Stock J. The Breastfeeding Answer Book. Rev. ed. Schaumburg, IL: La Leche League International; 1997. 32. Morton J. Salty milk-- when to worry. West J Med. 1995;163(5):164:488-489. 33. Neifert MR. Prevention of breastfeeding tragedies. Pediatr Clin North Am. 2001;48(2):273-297. 34. Neville MC, Morton J. Physiology and endocrine changes underlying human lactogenesis II. J Nutr. 2001;131(11):3005S-3008S. 35. Neville MC, Morton J, Umemura S. Lactogenesis. The transition from pregnancy to lactation. Pediatr Clin North Am. Feb 2001;48(1):35-52. 36. Reddy P, Qi C, Zembower T, Noskin GA, Bolon M. Postpartum mastitis and community-acquired methicillin-resistant Staphylococcus aureus. Emerg Infect Dis. 2007;13(2):298-301. 37. Scanlon KS, Alexander MP, Serdula MK, Davis MK, Bowman BA. Assessment of infant feeding: the validity of measuring milk intake. Nutr Rev. 2002; 60(8):235-251 38. Schanler RJ, Dooley S. Breastfeeding Handbook for Physicians. Elk Grove Village, IL: American Academy of Pediatrics, Washington, DC: American College of Obstetricians and Gynecologists; 2006. 39. Spencer JP. Management of mastitis in breastfeeding women. Am Fam Physician. 2008;78(6):727-731. 40. Stafford I, Hernandez J, Laibl V, Sheffield J, Roberts S, Wendel G, Jr. Community-acquired methicillin-resistant Staphylococcus aureus among patients with puerperal mastitis requiring hospitalization. Obstet Gynecol. 2008;112(3):533-537. 41. The Academy of Breastfeeding Medicine. Protocol #9: Use of Galactogogues in Initiating or Augmenting Maternal Milk Supply. 2004. http://www.bfmed.org/ace-files/protocol/prot9galactogoguesEnglish.pdf. Accessed October 13, 2008. 42. Unal S, Arhan E, Kara N, Uncu N, Aliefendioglu D. Breast-feeding-associated hypernatremia: retrospective analysis of 169 term newborns. Pediatr Int. 2008;50(1):29-34. 43. van Veldhuizen-Staas CG. Overabundant milk supply: an alternative way to intervene by full drainage and block feeding. Int Breastfeed J. 2007;2:11. 44. Vogel, A, Hutchinson, B, Mitchell, E, Mastitis in the first year postpartum. Birth. 1999;26(4)218-225. 45. Wiener S. Diagnosis and management of Candida of the nipple and breast. J Midwifery Womens Health. 2006;51(2):125-128. 46. Wilson-Clay B. Case report of methicillin-resistant Staphylococcus aureus (MRSA) mastitis with abscess formation in a breastfeeding woman. J Hum Lact. 2008;24(3):326-329.