Breastfeeding_Problems_Flashcards
Is frequent feeding in a breastfed infant a sign of low milk supply?
No, frequent feeding is not alone a sign of low milk supply.
What may cause nipple pain in breastfeeding?
A poor latch.
What is a blocked duct (‘milk bleb’) and how is it managed?
It causes nipple pain when breastfeeding. Breastfeeding should continue. Advice should be sought regarding the positioning of the baby, and breast massage may also be tried.
How is nipple candidiasis treated in breastfeeding?
Miconazole cream for the mother and nystatin suspension for the baby.
How common is mastitis in breastfeeding women?
Mastitis affects around 1 in 10 breastfeeding women.
When should mastitis be treated?
If systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal, or if culture indicates infection.
What is the first-line antibiotic for treating mastitis?
Flucloxacillin for 10-14 days.
What should be done if mastitis is left untreated?
It may develop into a breast abscess, which generally requires incision and drainage.
What is breast engorgement and when does it typically occur?
It is one of the causes of breast pain in breastfeeding women, usually occurring in the first few days after the infant is born and almost always affecting both breasts.
What is Raynaud’s disease of the nipple?
Pain is often intermittent and present during and immediately after feeding, with blanching of the nipple followed by cyanosis and/or erythema. Pain resolves when nipples return to normal colour.
How is Raynaud’s disease of the nipple managed?
Minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine, stopping smoking, and considering specialist referral for a trial of oral nifedipine (off-license) if symptoms persist.
What should be done if there are concerns about poor infant weight gain?
Consider the above breastfeeding problems, examine the infant for any underlying problems, and conduct an ‘expert’ review of feeding (e.g., midwife-led breastfeeding clinics) and monitor weight until weight gain is satisfactory.
summarise breastfeeding problems
Breastfeeding problems
‘Minor’ breastfeeding problems
frequent feeding in a breastfed infant is not alone a sign of low milk supply
nipple pain: may be caused by a poor latch
blocked duct (‘milk bleb’): causes nipple pain when breastfeeding. Breastfeeding should continue. Advice should be sought regarding the positioning of the baby. Breast massage may also be tried
nipple candidiasis: treatment for nipple candidiasis whilst breastfeeding should involve miconazole cream for the mother and nystatin suspension for the baby
Mastitis
Mastitis affects around 1 in 10 breastfeeding women. The BNF advises to treat ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection’. The first-line antibiotic is flucloxacillin for 10-14 days. Breastfeeding or expressing should continue during treatment.
If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.
Engorgement
Breast engorgement is one of the causes of breast pain in breastfeeding women. It usually occurs in the first few days after the infant is born and almost always affects both breasts. The pain or discomfort is typically worse just before a feed. Milk tends to not flow well from an engorged breast and the infant may find it difficult to attach and suckle. Fever may be present but usually settles within 24 hours. The breasts may appear red. Complications include blocked milk ducts, mastitis and difficulties with breastfeeding and, subsequently, milk supply.
Although it may initially be painful, hand expression of milk may help relieve the discomfort of engorgement.
Raynaud’s disease of the nipple
In Raynaud’s disease of the nipple, pain is often intermittent and present during and immediately after feeding. Blanching of the nipple may be followed by cyanosis and/or erythema. Nipple pain resolves when nipples return to normal colour.
Options of treatment for Raynaud’s disease of the nipple include advice on minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking. If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).
Concerns about poor infant weight gain
Around 1 in 10 breastfed babies lose more than the ‘cut-off’ 10% threshold in the first week of life. This should prompt consideration of the above breastfeeding problems. The infant should also be examined to look for any underlying problems. NICE recommends an ‘expert’ review of feeding if this occurs (e.g. midwife-led breastfeeding clinics) and monitoring of weight until weight gain is satisfactory
A 27 year old woman attends her GP with breast pain. She is 2 weeks postpartum and is exclusively breastfeeding. She complains of a 3 day history of worsening right sided breast pain, which has not improved with continued feeding and expressing. On examination, she appears well, her temperature is 38ºC. There is a small area of erythema superior to the right nipple, which is tender to touch. She has no known allergies.
What would be the most appropriate management?
Oral flucloxacillin & stop breastfeeding temporarily
Oral flucloxacillin & encourage to continue breastfeeding
Oral cefalexin & encourage to continue breastfeeding
Topical fusidic acid cream & encourage to continue breastfeeding
Paracetamol & ibuprofen & encourage to continue breastfeeding
Oral flucloxacillin & encourage to continue breastfeeding
Lactation mastitis is a common inflammatory condition of the breast, it may be infectious or non-infectious in origin. The main cause is milk stasis, due to overproduction or insufficient removal.
In non-infectious mastitis, the accumulated milk causes an inflammatory response. Sometimes an infection may develop via retrograde spread through a lactiferous duct or a traumatised nipple. The most common organism is Staphylococcus aureus.
Clinical features include breast pain (most commonly unilateral) with an associated erythematous, warm and tender area. Fever and flu-like symptoms may be noted.
First-line conservative management includes analgesia and encouraging effective milk removal (continue breastfeeding or expressing from affected side) in order to prevent further milk stasis. It is also important to ensure that there is correct positioning and attachment when feeding.
If symptoms do not improve after 12-24 hours of conservative management then antibiotics should be prescribed. First-line choice is oral flucloxacillin (500mg four times a day for 14 days) or erythromycin if penicillin allergic. Second-line choice is co-amoxiclav.
Other more serious causes, such as inflammatory breast cancer should be considered in cases that do not improve with conservative and antibiotic management.
(Source - CKS mastitis)
A 28-year-old woman gives birth to her first child. The baby is born via normal vaginal delivery and weighs 3.6 kg. The baby has a normal Newborn and Infant Physical Examination (NIPE) after birth and the mother recovers well following the delivery. The mother wishes to breastfeed her baby and is supported to do so by the midwives on the ward.
They are visited at home by the health visitor a week later. The health visitor asks how they have been getting on and the mother explains that she has been experiencing problems with breastfeeding and that her baby often struggles to latch on to her breast. She explains that this has made her very anxious that she is doing something wrong and has made her feel like she is failing as a mother. When her baby does manage to latch on to feed he occasionally gets reflux and vomits afterward. The health visitor weighs the baby who is now 3.2kg.
What is the next most appropriate step?
Advise her to start using formula instead of breast feeding
Consider notifying the local safeguarding team as you have concerns about the safety of the baby
Provide reassurance to the mother that all babies lose weight after birth and that is is normal to struggle with breastfeeding
Refer her to a midwife-led breastfeeding clinic
Refer her to the local perinatal mental health service for psychological support
Refer her to a midwife-led breastfeeding clinic
If a breastfed baby loses > 10% of birth weight in the first week of life then referral to a midwife-led breastfeeding clinic may be appropriate
Formula milk can be used in addition to breastfeeding to ensure that the baby is putting on enough weight whilst any breastfeeding issues are being addressed. However, it should not be suggested as an alternative to breastfeeding, if the mother wants to breastfeed she should be supported in doing so.
Failure to thrive, weight loss, or delayed growth of a baby or a child can be a sign of neglect and might raise safety concerns about the welfare of the baby. However, weight loss in the first few days of life is normal and the mother’s response to her child’s weight loss is appropriate. She is concerned about the welfare of her child. Therefore this situation does not raise any safeguarding concerns.
Weight loss of between 7-10% in the few days after birth is normal and most babies will return to their birth weight within the first 2 weeks of life. However, this baby has lost >10% of its birth weight therefore mother and baby need to be referred for midwife support in helping the baby gain weight.
This baby has lost >10% of its birthweight therefore this mother and her baby should be referred to a midwife-led breastfeeding clinic.
The mother is anxious about her baby’s weight loss. This anxiety will hopefully improve as she gets the support she needs with breastfeeding and the baby starts to gain weight. However, if her anxieties and feelings of inadequacy persist and she is showing signs of post-partum depression then it would be sensible to refer her to her GP to access psychological support.
