Chapter 20 Pathology Flashcards
Allodynia
Pain sensitization (increased responsiveness) following normally non-painful and often repetitive stimulation.
Ankyloglossia
Tongue tie, and then usually short, text, or type band of tissue the tethers the bottom of the tongue to the floor of the mouth and restricts the tongues range of motion
Areola
The pigmented portion of the breast surrounding the nipple
Axilla
Armpit
Cooper’s ligaments
Fibrous bands that fix the breast to underline pectoral fascia
Eczema
Skin condition characterized by itching, typically occurs in response to a topical irritant
Erythema
Abnormal redness in the skin
Exudate
Fluid that extrude or seeps out of injured tissue
Fissure
A division, split, or grove in tissue (in Lactation, the term specifically refers to the nipple)
Fluctuant
Subject to change, variable, movable, compressible
Inferior pedicle technique
Breast reduction surgery in which some portion of the breast remains intact
Mastitis
Inflammation of the breast
Montgomery glands
Sebaceous glands within the areola, surrounding the nipple
Nipple bleb
A small white spot on the tip of the nipple that looks like a tiny milk filled blister
Nipple translocation
Surgery in which the nipple is removed, the breast tissue is reduced, and the nipple is reattached
Plugged duct
Localized area of milk stasis, with distention of the breast tissue
Psoriasis
Skin condition with clearly demarcated plaques
Vesicle
A small fluid filled sac or blister
Breast evaluation
When there are concerns about milk production good to ask if there was a noticeable change in breast size during pregnancy and after birth.
It is normal for there to be minor differences in breast sides with the left breast often larger than the right.
The breast forms along the embryologic milk line which extends from the axilla to the groin.
Approximately 2 to 6% of women have accessory mammory tissue.
Polythelia refers to accessory nipple tissue and polymastia refers to accessory breast tissue.
The breast is fixed to the underlined pectoral fascia by Cooper‘s ligaments. Weakening of the bands may result in breast sagging. Sagging may occur because of breast changes during pregnancy and does not affect lactation.
There is great diversity in the size of the nipple and areola.
Inverted nipples result when the epithelial pit (during development) fails to revert. Nipples that appear flatten may not actually be inverted and can be observed and protruding when compression is applied behind the areola.
It is important to assess the nipple for any lesions which may suggest infection or trauma. Nipple fissuring is suggestive of sub optimal latch and should prompt further observation and assessment of infant feeding.
Macgomery glands
Ductile openings of lactiferous and sebaceous glands that appear on the areola. May become more prominent in Pregnancy and Lactation. Some secretion from these glands may occur this is normal. Rare circumstances glands may become obstructed and painful.
Prior breast surgery
Should pay attention to the location of scars. Those in the periareolar region are most concerning for potential insufficient milk production. Breast biopsy scars are typically small and can be either in the periareolar region or elsewhere. Breast biopsies for benign disease can usually breast-feed fine.
Breast augmentation can be performed using a variety of incisions. Implants can be placed via laparoscopic tunneling from the Periumbilical region so there are no visible breast scars. More commonly breast implants are placed from incisions in the axilla or inframmatory fold (under the breast) or periarolar incisions are use. Inquire about breast augmentation because there may be implants because of developmental failure if there is no underlying breast tissue. Most are for aesthetic reasons. Silicone implants are not a contraindication to breast-feeding.
Breast reduction surgery can be performed with a number of different techniques. One technique includes nipple translocation and then the nipple is reattached in this procedure there is circumferential periareolar incision. All ducts and nerves to the nipple are severed. With this procedure milk may still exit the nipples personally due to re-canalization.
Another method is to use the inferior pedicle technique. This can be identified by surgical scars around the edges of the areola and additional scar line extending downward from the inferior areola to the mid breast. Breast reduction is routinely associated with decreased milk production although it may still be possible.
Observation of breast and all four categories should be done too
Divide the breast in four quadrants. Document findings according to observations noted in the upper outer upper inner lower outer and lower inner. Note any significant breast asymmetry, wide spacing of nipples or breast tissue, nipples or areola that appear disproportionately large in relation to the breast, visible scars, piercings, or skin retraction.
Some parents may not mention prior breast surgery because they are not aware of its potential.
Observing the breasts can be very important in assessing infection. Mastitis typically results in breast erythema and cellulitis over laying the affected portion of the breast. Early mastitis may have a subtle color change so useful to gently touch and release skin. The red color the blanches upon release suggest erythema.
Warmth of the overlying skin can be useful in assessing for infection.
Palpitation
Palpating the breast will says for any masses that could result in a plug duct or an abscess. Useful to document the size, location, and mobility of the mass in addition to noting if any of the masses are tender.
Nipple pain
A common reason many women end breast-feeding earlier than intended.
There are many causes of nipple pain: during early breast-feeding some degree of breast as comfort is common, 73% of breast-feeding mothers experience pain on the first day of breast-feeding. Unclear why so many experience pain but it is likely that hormones and trauma related to learning correct latch and positioning are contributors.
Trauma to the nipples worsen pain and predisposed to paired to other complications. If persist pass the first few weeks of breast-feeding it deserves further evaluation. Optimizing latch and positioning remains the mainstay of nipple pain management. If parents are pumping or manually expressing milk it is important to assess their technique.
There is not sufficient evidence to support a particular treatment for nipple pain.
A careful history should be done: when did the pain begin and the nature in details of the pain. History of medical and pregnancy complications. History of prior breast-feeding experiences. History about the infant. Assessment should include: examination of the breast. Examination of the infants oral anatomy and a suck assessment.
An observation of a breast-feeding session or pumping.
Other causes of pain include nipple damage and trauma, dermatologic conditions, infections, vasa spasm, pain syndrome’s and breast drainage tissues such as plug ducts and over supply.
Nipple trauma or fissuring
This is most likely due to poor latch or positioning. If the fissures are persistent or have yellow crusting a superficial bacterial infection should be suspected. An infection can be treated with a topical mpirocin and or bacitracim ointment and may be bloated off prior to the next feeding and are compatible with breast-feeding - recommendation of topical medication must come from a healthcare provider.
Ankyloglossia
Inspect the infants mouth for a tongue tie or short lingual frenulum (lip tie). Consider referring infant to a trained professional for a frenulotomy.
Nipple trauma and pain may result from pumping or manual expression
Should be assessed to assure the pump flanges fit correctly. Pain can result from pumping at inappropriate intervals or the suction set too high. Sometimes parents may massage the breasts or manual expressed milk in an overly vigorous way.
Dermatological conditions may cause discomfort
Eczema (atopic dermatitis) characterized by itching and may vary in appearance. May have vesicles with exudate and crusting, whereas chronic lesions are typically dry and scaly. Skin thickening may occur due to persistent scratching. Usually occurs in response to an irritant that is often topical.
Psoriasis appears as clearly demarcated plaques that may have overlying scale. Often a history of psoriasis elsewhere on the body. Parents should be referred to a healthcare provider who may prescribe a topical steroid. Usually are compatible with breast-feeding but any excess should be blotted off the nipple. May also prescribe a nonsedating antihistamine such as loratadine or certirizine that may be beneficial for itching and are compatible with breast-feeding.
Herpes Simplex virus (HSV)
HSV typically percents as a cluster of small vessicles that later burst and leave ulcers. Lesions are extremely painful. HSV-1 is most commonly responsible for oral lesions, and HSV-2 typically causes genital lesions.
HSV can cause lesions on the breast.
Oral and general lesions do not preclude breast-feeding but they do require meticulous hygiene and good handwashing to avoid spreading the virus to the infant.
HSV lesions on the breast require a temporary cessation of breast-feeding on the affected breast due to the risk of spreading.
Milk from the affected breast should not be given to the infant.
It is important to prevent contact because a life-threatening infection can occur.
Oral medication‘s for HSV such as ancyclovir or valacyclovir are prescribed to treat and prevent infection they are usually compatible with breast-feeding.
Herpes zoster
Caused by reactivation of the varicella zoster virus (VzV) which causes chickenpox. Initial infection with the VZV causes chickenpox which typically produces vesicles that are very pruritic or itchy. Mothers with acute chickenpox at the time of birth should be separated from infants because the infection is spread by respiratory contact or contact with lesions. Any lesions involving the breast could contaminate milk
VZV vaccination is available for infants older than one year of age. Vaccination after exposure is typically effective in preventing disease due to long incubation period. Reactivation of the VZV results in shingles or herpes zoster. Localized skin infection characterized by painful circular rash that occurs in a linear pattern along dermatomes. Form crust in 7-10 days and it’s no longer contagious.
If shingles outbreak is remote from the breast, covering the lesions, practicing good hygiene and diligent handwashing should prevent transmission and breast feeding can continue.
If involves the breast, nipple, or areola breast-feeding must be temporary avoided on the affected breast milk from that breast should be discarded.
Vasospasm is another potential cause of nipple pain
Vasospasm typically result in shooting, burning, or spasming pain associated with blanching and color change of the nipple. Onset of symptoms may be sudden. Nipple appears pale due to limited blood flow. Followed by a bluish discoloration due to lack of oxygen appears to turn to a red color with reperfusion. Cold exposure may trigger the symptoms.
Parents may have a history of Raynaud phenomenon where they may note similar symptoms in their fingers or toes with cold exposure.
Visualizing the nipple color changes associated with pain is typically diagnostic. Initial treatment includes keeping breast warm, apply warm compresses immediately after breast-feeding and avoiding cold.
The medication such as nifedipine may be prescribed for more severe cases.
Allodynia is a condition in which pain sensitization (increase responsiveness), follows normally non-painful and often repetitive stimulation. Even light touch is perceived as pain
Parents may note sensitivity to their bra or clothing. Useful to explore any history may have of chronic pain disorders, fibromyalgia or other painful condition. Over-the-counter pain medication such as ibuprofen may be helpful in managing symptoms. May need further evaluation. Plug ducks, engorgement, and oversupply may result in breast and nipple pain. Pay may be due to breast distention and inflammation associated with these conditions. Overproduction of milk and an over active milk ejection reflex may cause the infant to pinch the nipple to reduce flow causing pain and trauma.
Engorgement may interfere with the infants ability to latch and transfer milk
Engorgement is caused by increase vascular flow, tissue edema, and the onset of copious milk production that may exceed the infants ability to extract. Compression of the blood vessels and milk ducts can worsen the encouragement. Not uncommon for parent to experience a low-grade fever but fevers of 101 or higher should be investigated for infection.
Primary encouragement occurs with the onset of lactogenesis I I. This is typically 3 to 5 days after delivery although it may be delayed for additional 1 to 2 days due to cesarean delivery.
Approximately 36% of mothers experience engorgement.
Most effective management is proactive avoidance. Have a person who is knowledgeable about breast-feeding evaluate the feeding frequency, latch, and milk transfer early during lactation.
Secondary encouragement occurs later doing established lactation. Possible causes include the following; excessive pumping, intentional or unintentional change in feeding intervals, infant illness that affects infants ability to remove milk, latch difficulties.
Can lead to problems with latch difficulties infants have in attaching to an engorged breast. May lead to a cycle of worsening engorement due to poor milk removal. Treatment for engorgement includes adequate milk removal.
Massage the breaths prior to feeding or pumping may be helpful.
Reverse pressure softening of the nipple can be useful in resolving edema to improve latch.
Nonsteroidal anti-inflammatory drugs are important to minimize pain from engorgement because pain can interfere with milk let down.
Important for the parent to alternate feeding positions and to feed, pump or manual express frequently to keep the breast well drained. Some parents find a warm shower pride of feeding help soften the breast.
Plugged ducs can be painful and lead to a breast infection
A plugged duct is a localized area of milk stasis with distention of the involved mammary tissue. Parent often notes palpable lump or knot in the breast which sometimes may decrease in size with milk removal. Predisposing factors are similar to those for encouragement. May occur after missed feedings, prolongation of feeding intervals or poor infant latch. Parents with very abundant milk production may be at risk. Also pressure against a portion of the breast by a poorly fitted or overly restrictive bra can be a risk factor.
Treatment for plug ducts include frequent breast-feeding. Moist heat prior to feeding and gentle massage affected area during feedings may be helpful.
Alternating a feeding position to place the infants chin or nose in line with a plugged area may optimize milk extraction.
Lecithin 1200 mg three times daily has been suggested for recurrent plug ducts.
Hand expression between the areola and the plug duct can be effective.
If it does not resolved in approximately 72 hours refer to healthcare provider.
Nipple blebs, or milk blebs sometimes occur in association with plug ducts so an inquiry should be made regarding both.
A milk or nipple bleb appears as a small white spot on the tip of the nipple. A blister on the nipple can sometimes be mistaken for a milk blend. Data for the effectiveness of treatment options is limited. Initial therapy should be to optimize latch and positioning so good breast drainage. A parent incidentally noticed the bleb and is not in pain then you can ignore it. There is some evidence that topical steroids directly on the bleb may be beneficial. A referral to an experienced professional for unroofing, or opening, persistent blebs maybe considered if the parent continues to be in pain. Parents should be discouraged from doing this themselves.
Candida infection are relatively common and can affect breast-feeding for both parrot an infant
There is controversy regarding the diagnosis of candida infections of the breast. In immunocompetent people a superficial Canada infection may involve skin in other areas of the body such as the mucous membranes of the vagina or in the vulva and under the breast.
Candida albicans causes most clinical sections.
If the breast or nipple remains moist and warm a superficial candida infection of the breast can occur.
The infection is typically red and may have satellite lesions on the periphery of the redness. Infants may have a similar appearing diaper rash.
Canadida is a normal organism that can be culture from normal healthy tissue from skin, mucous membranes in the G.I. tract.
The superficial infection occurs with candida becomes overgrown and causes symptoms such as itching and burning.
Invasive candidal infections are rare in immunocompetent adults.
Newborn infants can get oral thrush or a candida infection of the oral mucous membranes. Characterized by white plaques on the inner cheeks palate or tongue. White plaques that are persistent and cannot be wiped off are indicative of thrush. Milk can be wiped out.
The infants mouth can be treated with a nystatin suspension or miconazole gel. Oral topical medication‘s require a prescription for the infants healthcare provider.
Treatment of the infant does not mandate treatment of the asymptomatic parent.
Risk factors include ia warm moist environment so objects to keep the breast unusually warm and moist can predisposed to infection. These can include breast-feeding pads with plastic backing.
Antibiotics increase the risk of candida infections.
Diabetes is a significant risk risk factor.
Also the use of steroids, immuno suppressant medication‘s, an immune deficiency diseases.
A superficial candida infection can be treated with a dilute solution of Gentian violet (less than 0.5% aqueous solution) for not more than seven days. Longer duration and higher doses have been associated with ulcerations.
Also topical antifungal ointment or cream can be applied. This medication‘s are poorly absorbed orally. Excessive amount should be blotted off the breast prior to feeding.
Oral fluconazole can be prescribed if the parent has difficulty complying with topical therapy.
Fluconazole should not be used with domperidone, or other medication‘s to prolong the cardiac QT interval as a potential side effect.
Association of candida with nipple and breast pain and a normal appearing nipple remains controversial. Some authors have suggested that candida may be responsible for deep, shooting pain in the breast. With nipple trauma or fissuring is present research suggested a bacterial infection is more likely and may benefit from topical antibiotics.
Mastitis is an inflammatory condition of the breast
The affected portion of the breast becomes painful, red, and swollen. Fever is common with mastitis and other flu like symptoms such as muscle aches, headache, fatigue, and nausea. Frequency of mastitis varies across studies from 9 to 20%.
Predisposing factors for mastitis include nipple damage, overproduction, plug duct, encouragement and use of a nipple shield. Appears to be more common in first time parents.
Treatment of early mastitis includes rest, fluid, and frequent thorough breast drainage. Must try to identify why the mastitis occurred and correct any predisposing factors.
If nipple trauma is present attention should be given to a optimizing latch. If engorgement is present focus should be on draining the breast and avoiding abrupt changes in breast-feeding frequency.
If symptoms worsen or unresolved after 12 to 24 hours of conservative measures consideration should be given to starting antibiotics.
Patients with more severe symptoms or high fever should start antibiotics promptly.. Ibuprofen can be used to treat mastitis pain. Pain can inhibit the letdown reflex and limit breast damage drainage which can worsen mastitis.
During mastitis milk is not harmful to a full-term healthy infant.
Weaning during mastitis can increase risk for developing a breast abscess.
Most common organisms that cause mastitis include staphylococcus aureus and streptococcus species and escheerichia coli.
First line antibiotics include a penicillin resistant penicillin such as the cloxacillin. First generation cephalosporin antibiotics are also a good choice.
Parents with severe penicillin allergy clindamycin can be used.
Possible reasons for hospital admission to the mastitis include: parent is extremely ill, an infection is not responding to oral antibiotics, an unclear source of the infection, parent was too ill to tolerate oral medication‘s, cases where there is a high suspicion for a breast abscess.
Milk culture should be considered for mastitis if conditions does not respond to antibiotics.
Prior to a culture, the nipple and areola must be cleansed before collecting milk. A small amount of milk is expressed and discarded. Milk need to be manual Xpress into a sterile collection cup or using a sterilize pump parts. The millk culture is not anticipated to be sterile. Purpose of culture is to assure that the resistant organism is not found.
Use of probiotics may be helpful in managing early mastitis. Recurrent mastitis requires investigation into the cause of occurrence: questions to consider include was the initial episode in completely treated, did the symptoms resolved and did the parent stop the therapy early, what is the initial anabiotic choice in adequate, did the infection result of the underlined predisposing factor persistent, does the parent continue to have an hour production of milk. Important to know if the recurrence is in the same breast in the same portion of the breast if in the same place a structural problem localized to that aspect of the breast, if recurrence is in a different location suggests a milk production or drainage issue.
If a parent is pumping it is important to evaluate the pump as a potential site of contamination: is pump been clean properly, parts maintained, what hygiene and cleaning practice parent using.
For recurrent infections a midstream milk culture should be preferred. They also need to have a more prolong course of 2 to 3 weeks of antibiotics. Importance to stress compliance with medication and to minimize any predisposing factors.
Breast abscess is a localized collection of pus in the breast tissue
Symptoms are similar to mastitis with the additional findings of a fluctuant mass in the breast.
Symptoms can be localized to the abscess in the breast if the infection is well encapsulated. Diagnosis is usually made by physical exam although ultrasound may be useful. Approximately 3% of women with mastitis develop a breast abscess. Predisposing factors include those that increase the risk of mastitis. Also delayed or inadequate treatment of mastitis increases likelihood of a breast abscess. Often caused by S. Aureus.
Initial management includes serial ultrasound guided aspirations and using antibiotics. Incision and drainage in addition to antibiotics may be required for abscesses larger than 10 cm for those that lack management with serial aspirations. Incision and drainage are likely to be associated with hospitalization, longer healing time, use of packing, pain, worse cosmetic result, and disruption of breast-feeding. Using smaller incisions and drains limit these disadvantages.
Milk fistula formation may be a rare complication of incision and drainage. In this situation, milk continues to drain through the surgical incision during lactation. This can be managed by occluding the incision site with something that can collect the leaked milk.
Pain management should be employed. Parents who require incision and drainage can use anti-inflammatory drugs but also may need narcotics.
During treatment, feeding from the unaffected breast can continue. Feeding from the effected breast depends on the clinical situation, method of transit, breast anatomy, and location of the abscess.
Breast masses
Although breast masses may be related to lactation (such as a plugged milk duck, lactating adenoma, or breast abscess) other masses can occur during lactation. Breast cancer is rare in breast-feeding women. If a persistent breast mass is noted in a lactating parent it can be safely evaluated while breast-feeding continues. Ultrasound is the preferred initial imaging technique. Ultrasound can determine if the mass is cystic or solid. Solid masses can be evaluated with a biopsy without weaninng. Mammography does not adversely affect milk. Parents should pump or breast-feed prior to mammogram so breast as well drained. A normal mammogram result is not a sufficient evaluation for a breast mass, a breast ultrasound should be performed. An MRI can be performed on breast-feeding parents but the radiologist should know that they are breast-feeding so an accurate interpretation can be performed. Breastfeedin can continue even if an excisional biopsy of a mass is required.
Hyperbilirubiemia
Elevated level of bilirubin in a neonatal’s blood. A sign of elevated bilirubin levels is jaundice or yellowing of the skin and whites of the neonate eyes
Hypoglycemia
A whole blood glucose value that is less than 45 mg/dL
Infants with perinatal stress
Infants with a five minute Apgar score or less than five. The score lets the healthcare team know how well the baby is doing outside the world.
Kernicterus
A disorder due to severe jaundice in the newborn. Deposition of the pigment bilirubin in the brain, which causes damage to the brain, potentially leading to sensory neural hearing loss, upward gaze palsy, dental enamel dysplasia, cerebral palsy, and cognitive impairment. Also called bilirubin encephalopathy
Large for gestational age (LGA)
An infant with a birthweight that is greater than the 90th percentile for gestational age
Low birthweight
Infants born weighing less than 2500 g (5 pounds, 8 ounces)
Pathologic jaundice
The condition that occurs within 24 hours after birth, with a rapidly rising total serum bilirubin concentration (increase of more than 5 mg/DL per day) and a total serum bilirubin level higher than 17 mg/DL in a full-term newborn.
Phototherapy
A treatment for reducing high bilirubin levels in which the infants dermal and subcutaneous bilirubin absorb light waves which convert the bilirubin into a more easily excreted form. In the standard form of phototherapy the baby lies in a bassinet or a close plastic crib (incubator) and is exposed to a type of fluorescent light that is absorbed by the babies skin, also called ultraviolet light therapy.
Physiologic jaundice
A condition caused by the breakdown of red blood cells (which release bilirubin into the blood) and the immaturity of the newborns liver (which cannot effectively metabolize bilirubin and prepared for excretion into the stool and urine).
Preterm
An infant born earlier than 37 completed weeks of gestation
Small for gestational age (SGA)
An infant with a Birth way that is less than the 10th percentile for gestational age
Transcutaneous Bilirubin (TCB)
Screening tool used to assess bilirubin levels in infants
Normal glucose regulation in the newborn
Glycogen reserves that are available for conversion to glucose during the immediate neonatal period or lai down during the latter part of the third trimester
glucose is the primary nutrient for brain metabolism and the placental supplement terminates at birth
newborns have a greater demand for glucose than children and adults because of their large brain to body weight.
Preterm infants have even greater demand for glucose and have limiteded absolute glycogen reserves depending on their gestational age.
Neonatal physiology is a factor in glucose levels. At birth there is a transition. As glucose homeostasis is established by the infant. The net affect is mobilization of glycogen and fatty acids. The collective activities that maintain glucose homeostasis are called counter regulation and they consist of: glycogenolysis which is the mobilization and release of glycogen from body stores to form glucose and gluconeogenesis which is the production of glucose by the liver and kidneys from non-carbohydrate substrates such as fatty acids and amino acids.
After 12 hours the baby is dependent on glucose made from dietary intake of milk components and glucose neogenesis to maintain blood glucose as well as free fatty acids.
Human milk is more ketogenic than formula enabling a breast-fed baby to create high levels of alternative fuels until the milk production increases sufficiently to draw on milk components for glucose synthesis.
High levels of Ketone bodies enable breast-fed babies to demonstrate lower measured blood glucose levels but still maintain the optimal production of brain fuels.
Glycogen stores are converted to glucose rapidly depleting glycogen stores over the first hours of life.
Fat metabolism provides glucose substrate beginning at 2 to 3 days of age.
Risk factors in clinical signs for hypoglycemia
Routine screening and monitoring of blood glucose concentrations is not indicated in healthy term newborns after a normal pregnancy and delivery.
Common symptoms of neonatal hypoglycemia include: jitteriness, tremors, feeding intolerance, seizures, apnea, bradycardia, hypotonia, listlessness, or limpness, hypothermia, respiratory distress, including grunting and tachypnea or apnea, high pitch cry, irritability, cyanosis.
Infants who may be at risk include: small for gestational age, large for gestational age, low birth weight, born to mothers who have pre-gestational or gestational diabetes, preterm infants, infants with perinatal stress, discordant twin (smaller twins weight is 10% less than larger twin), infants experiencing cold stress, infants exposed to mediations during labor that are known to cause decrease blood sugar(oral hypoglycemics, terbutaline, or propranolpl), infants with clinical evidence of wasting of fat or muscle bulk, an infant that is not feeling well.
Testing methods
Bedside glucose reagent test strips are inexpensive and practical. However they are not reliable because they have a significant variance from true blood glucose levels especially at low glucose concentration. Bedside glucose test done on a warmed heal may be use for screening. However laboratory levels must confirm the results before diagnosis is made.
General glucose management for all term newborns
Early and exclusive breast-feeding meets the nutritional and metabolic needs a healthy term newborns. Routine supplementation is unnecessary. Initiate breast-feeding within 30 to 60 minutes. Facilitate skin diskin in contact. Feeding should be frequent 10 to 12 times per 24 hours. Feeding should be assessed for adequacy of latch and to ensure effectiveness. Blood glucose screening and testing is performed only on at risk infants or infants with clinical signs. At risk infants should be screened for hypoglycemia with a frequency and duration related to the specific risk factors of the individual. Monitoring continues until normal prefeed levels (glucose greater than 45 MG/DL) are consistently obtained.
Management of documented hypoglycemia
Infants with no clinical signs should be monitored. Continue breast-feeding every 1 to 2 hours or feed 1 to 5 ML/KG of expressed milk or substitute nutrition. Recheck blood glucose concentration before subsequent feed it until the value is acceptable and stable. Avoid forced feedings. If glucose level remains low despite feedings, begin intravenous glucose therapy. Breast-feeding make continue during intravenous glucose therapy.
Infants with clinical signs or blood glucose levels less than 20 to 25 MG/DL require intervention. Initiate intravenous 10% glucose solution with a mini bolus. Do not rely on oral or enteral feeding to correct extreme or clinically significant hypoglycemia. The blood glucose level in infants who have had clinical signs should be maintained at more than 45 MG/DL. Adjust the intravenous infusion rate based on response. Encourage frequent breast-feeding. Monitor blood glucose levels before feedings while weaning off IV.
Hyperbilirubinemia
Approximately 60% of full-term infants and 80% of preterm infants develop jaundice within several days of birth. Usually elaborate physiologic mechanisms for bilirubin detoxification and disposition are sufficient. There are clinical situations that increase the risk for elevated bilirubin levels. All infants are required to have an objective bilirubin assessment within 48 hours of birth. An objective assessment either by serum levels or transcutaneous bilirubin is the best way to determine levels and hence document infants who may be at risk for a rapid rise of levels. Bilirubin occurs in two forms in the bloodstream. Conjugated (direct) bilirubin occurs when bilirubin is attached to google annoyed by an enzymatic process in the liver. Elevated levels are not neurotoxic but may be indicative of a more serious illness (Possibly hepatitis). Unconjugated (indirect) Billy Rubin occurs with Billy Rubin has not yet attached to a clicker or night. Elevated levels of this form can cause neurotoxicity also known as bilirubin induced neurologic dysfunction (BIND).
Acute manifestations include lethargy, hypertonia, opus tetanus, seizures, high pitch cry, poor feeding and loss of the Moro (startle) reflex.
Kernicterus is diagnosed with there are chronic and permanent systems of BIND. These include sensory neural hearing loss, upward case palsy, dental enamel dysplasia, cerebral palsy and cognitive impairment. Those most at risk for this are preterm and sick.
Risk factors include for the mother: maternal diabetes, poor breast milk transfer, Asian or Hispanic ancestry, blood group incompatibilities or other hemolytic diseases, sibling with neonatal jaundice.
Newborn factors include: sepsis, male gender Cephalohematoma, prematurely, Trisomy 21, upper G.I. Obstruction, swallowed maternal blood, acidosis, polycythemia, delayed bowel movements, hypothyroidism.
Common types of jaundice
Physiologic jaundice is a condition caused by the breakdown of red blood cells and the immaturity of the newborns liver. About 60% of term infants and 80% of preterm infants who have jaundice usually experience physiologic jaundice. It is usually seen at 2 to 5 days of age when there is peak bilirubin concentration of 5 to 12 MG per DL.
Several factors contribute to the development of physiologic jaundice: unconjugated hyperbilirubinemia during the first week of life, decreased activity of the conjugating enzyme, short lifespan of the infants red blood cells.
Pathologic jaundice develops in the first 24 hours of life. Features of pathologic jaundice include the following: total serum bilirubin greater than 12 MG/DL in a term infant. Conjugated bilirubin greater than two MG/DL or greater than 20% of the total bilirubin level. Total serum bilirubin rate of rise greater than five MG/DL per day. Persistence of jaundice beyond 10 to 14 days.
Pathologic jaundice usually occurs in infants with a family history of hemolytic disease. The presence of any additional signs or symptoms such as concomitant hepatomega;u,, splenomegaly, failure of phototherapy, vomiting, lethargy, apnea, bradycardia or excessive weight loss can be indicative of potential underlying disease.
Pathologic jaundice causes include: septicemia, biliary atresia, hepatitis, galactosemia, hypothyroidism, cystic fibrosis, congenital hemolytic anemia, and drug induced hemolytic anemia.
There’s a new effort for moving away from the historic terminology of pathologic jaundice that’s associated with breast-feeding because breast-feeding per se has not been proven to be the cause of either.
Prolonged jaundice associated with breast-feeding is also known as prolonged unconjugated hyper bilirubinemia or breastmilk jaundice. It has been speculated the breastmilk inhibits uridine glucuronosyltransferase although the exact mechanism has not been identified. This type of jaundice is seen in about 2% of breast-fed full-term infants after day seven of life and usually presents in week two. During weeks 2 to 4 bilirubin levels go up to 30 MG/DL. These levels gradually decrease as breast-feeding continues with a more rapid decrese when formula is substitute it for 12 to 24 hours as a treatment. When breast-feeding interruption is selected as the treatment course it can be resumed without the return.
Sub optimal intake jaundice has historically been referred to as breast-feeding jaundice which is an inaccurate term to describe the underlying cause of insufficient feedings. When the quantity of milk is low infants do not have bowel movements as fast so the body reabsorbs bilirubin. Increased unconjugated bilirubin is typically seen because bilirubin must be unconjugated to be reabsorbed. Focused parental support to provide early and frequent breast-feeding increases the number of volume of feeds and a result and decrease in bilirubin levels as stolling increases.
Test to evaluate jaundice
When there is concern for pathologic jaundice test should be performed. These include blood smear may show hemolysis in cases where indirect bilirubin alone is elevated. Coombs test is used to distinguish between immune mediated hemolytic disorders and non-immune mediated hemolytic disorders. Liver function, alkaline phosphatase, bile acids and sweat test may identify a diagnosis if direct bilirubin is elevated. Sepsis work up (complete blood count and blood culture) is indicated in any jaundice neonate with fever, hypotension, and tachypnea. Maternal fetal ABO and Rh incompatibility’s may identify immune related hyper bilirubinemia.
Differential diagnosis
Within 24 hours assess for Mollasses. Within 48 hours access for: Hamada sis, infection, physiologic jaundice. After 48 hours access for the following: infection, analysis, sub optimal intake jaundice, congenital malformation, hepatitis.
Medical management
Usually no treatment is indicated for physiologic jaundice. However early and frequent breast-feeding or human milk feeds may help keep bilirubin levels down.
Phototherapy or ultraviolet light therapy is indicated with bilirubin levels are greater than 15 to 20 MG/DL regardless of cause. Photo therapy is typically use for unconjugated hyper bilirubin. During phototherapy Infant should be unclothed with her eyelids shield it. Phototherapy can delivered in two forms over bed lights or fiber optic blankets. Phototherapy lights can be used only in the hospital where there are professionals able to assess dehydration. Phototherapy blankets can be used at home but only under close monitoring. Photo therapy lights are preferred for efficient management of significant hyperbilirubinemia. Phototherapy blankets are often used to augment phototherapy lights. Specific nomograms exist to govern when UV light therapy is indicated.
Exchange transfusion may be indicated for very severe cases when there have been no improvement with conservative measures. There are risks associated with exchange transfusion, including: air embolism, volume inbalance, anemia, polycythemia, blood pressure fluctuation, infection and NEC.
Breastfeeding management of the jaundiced Infant during phototherapy
Explain to parents the reasons for the jaundice color and the implications related to breast-feeding. Teach parents how to determine whether their infant is feeding effectively. Assist the breast-feeding parent with techniques for the stimulation of milk production the supplement is required. Feed the baby frequently and effectively, express the breast through hand or mechanical expression as an adjunct if supplementation has been recommended. Advocate for the avoidance of separating the dyad. Work with a clinician to develop a feeding plan that is individualized. Provide a feeding diary to record feedings, supplement amounts, infant output.
Evaluation of successful resolution of hyperbilirubin
Normal infant weight gain should occur with 15 to 30 g of weight gain per day after the onset of copious milk production. Onset of effect of feeding will result in appropriate stooling for a baby. A stooling increases, the bilirubin level decrease. Milk production will develop normally or improve if it has been inefficient as evidenced by infant weight, hydration, stool patterns and the ability to decrease or eliminate supplements. Failure of the infant to improve within 12 to 24 hours indicates other underlying problems and a need for reappraisal of the infant by the clinician.
Low milk production
Calibration of milk production
The breast adjustment at the rate of milk synthesis to match the infants needs
Delayed Lactation
When the initiation of copious milk production takes longer than 72 hours. Also called delay onset of lactation or delayed secretory activation
Incomplete lactogenesis
Failure to reach for milk production despite effective frequent breastfeedingg
Primary Lactation problems
Poor milk synthesis due to maternal physiological issues
Secondary Lactation problems
Inadequate milk production do to outside interference
Identify the causes for weight issues
Listen to the whole story first then take a detailed history to collect information regarding the problem. Screen the infants health and analyzing infants weight history based on the WHO growth velocity charts. Determine whether the baby is fed exclusively at the breast or is also being supplemented. Assess the big picture. Was the weight gain within expected parameters. What role did supplementation play in this game. Screen the parents health, including reproductive, pregnancy history and examine the breast. Observe one or more feedings to assess latch and milk transfer.
If there is a problem take the following steps: one first and foremost make sure the baby is adequately fed. Second try to determine the root cause or causes. Has the problem been present since birth if no when did it become apparent. Screening for breast-feeding management problems. Screen for primary factors related to the parent. If milk remained in the breast after the feeding determine the cause for the babies inability to remove milk. Support milk production as needed.
Poor growth in breast-fed babies
Watch for red flags indicating weight loss in newborns. Fluids receive during labor may artificially increase the birthweight. The babies day 2 weight may be more appropriate. Transition stools should appear by day 3 to 4 with the onset of lactogenesis. Stools that are not turn yellow by day five indicate the baby is not taking in enough milk. This may be due to either delay in the onset of copious mill production or an impairment in the babies ability to transfer milk.
The lack of stools or persistent dark stools should trigger an immediate careful evaluation. Further investigation is warranted for any baby who has failed to regain birthweight by one week. A baby who lost significant weight but is now getting it back does not need immediate assistance but should be followed.
Chronically underfed babies who are not gaining become weak, ineffective feeders and may lose their appetite and feed sleepily.
Be alert for clinical signs of dehydration (poor skin turgor, dried mucous membranes in the mouth, scant or concentrated urine, urate crystals in the diaper past the first two days, or second fontanelle).
If an infant has no urine output in any given 24 hour period or in the case of weight loss greater than 12% the baby should be immediately seen by a healthcare provider. Careful rehydration should commence right away.
Be alert to red flags for failure to thrive. Failure to thrive is defined by any of the following: if it continues to lose weight 10 days after birth, if it does not regain birth weight by three weeks of age, infant gains at a rate below the 10th percentile for weight beyone one month of age, infant drops more than two standard deviations from a previously stable weight.
Infants who fail to thrive may have one or more of the following characteristics: apathetic or weak cry, poor muscle tone, concentrated and scant urine, urate crystals present after two days, and frequent and small bowel movements, very sleepy with infrequent feedings, parents may interpret this as being a good baby, constantly fussy with frequent feedings, poor erratic or no weight gain, swallow only when the milk ejection reflex or has sporadic swallowing. Too weak to take it enough milk by breast or bottle.
Other causes of poor weekend
Infants between the ages of two weeks and three months the situation must be assessed when weight gain is less than 200 g per week. For infants older than three months, the minimum acceptable gain is lower. Use the WHO growth charts.
Older babies may be skinny but still alert and happy leading parents to believe all is well. Yet these babies may constantly have their hands in their mouth (a feeding cue).
The baby may have an impaired suck due to a condition such as tongue mobility restriction.
The baby may demonstratee self limiting feeding behavior secondary to painful experiences such as reflux, allergies, illness, responding to high note flow.
The overuse of pacifiers can mask infant feeding cues and reduce milk intake.
A deficiency of vitamin B 12 in the milk due to a lack in the parents diet can lead to poor growth and brain damage in a breast-fed baby.
Infant factors that may contribute to slow weekend and low milk production. See table 22–1
Alterations and oral and facial anatomy. Can be such things as tongue tie cleft lip cleft of hard or soft palate or facial or other congenital anomalies. An infant with an impaired suck of any ideology will not remove milk well which may cause poor milk production. This is particularly true of infants with lower suck suction pressure had smaller prolactin surges and were more likely to report problems with milk production.
Peri partum factors affecting suck include cesarean delivery, labor medication‘s epidural analgesia, forceps and vacuum extraction can affect brain function, state control and anatomical structures in nerves that may lead to ineffective milk transfer.
Neurologic problems, muscle tone issues, airway restrictions or sensory integration problems. Hypertonia, hypertonia, neurologic pathology or physiology may interfere with a performance, strength or stamina of the structures involved with the suck, swallow and breathe cycle.
High energy requirements cardiac defects often put an infant at risk for poor growth because of the combination of low endurance for feeding and high metabolic demands. Respiratory involvement and metabolic disorders can create a need for increase caloric intake.
Gestational age. Infants born preterm, late preterm, post term, small for gestational age with intrauterine growth restriction and large for gestational age may lack mature feeding skills and have difficulty with sucking or feeding stamina.
Syndromes, illnesses, infections, injuries, allergies and G.I. metabolic or malabsorption problems. Chromosomal defects cystic fibrosis, infections or sepsis, infant botulism, injuries during birth or brain bleeds from vacuum or forceps extraction, meconium aspiration or deep suctionning, atopic dermatitis or growth altering may be apparent in the early months. Reflux disease or other conditions that limit intake and affect nutrient absorption or metabolism.
Unsubstantiated low milk production
Parents often miss judge their milk production based on infant behavior or personal experiences it may perceive insufficiency when there’s actually plenty of milk. This may lead to the introduction of a necessary supplementation, less feeding at the breast, and ultimately a decrease in the rate of milk production.
Secondary causes for insufficient milk production
Secondary causes for insufficient milk production include one or more forces that interfere with the normal process of breast-feeding. Iatrogenic factors in the process of treating a parent or baby for a condition can result in a negative impact on lactation. Formula supplementation can disrupt frequent breast-feeding.
Delays in the initiation of breast-feeding for any reason.
Sub optimal hospital practices may restrict the length or frequency of feedings. Encouraging families to send the baby to the nursery at night.
Parents may delay feedings or milk expression because they aren’t comfortable doing so in front of visitors and hospital.
Incorrect instructions to discontinue breast-feeding because of medication‘s or anesthesia.
Failure to understand the concept of demand and supply.
Failure to remove residual milk from the baby is not feeding effectively.
Pain from latch or births squelae.
Prolonged, unrelieved breast engorgement leads to cessation.
Combining breast-feeding with formula feeding compromises milk production. Scheduled feedings or sleep training often impose longer intervals than babies would normally use.
Working parents may not express milk as often as their baby feeds at home.
A parent of a preterm baby may not expressed milk to the peak level but only to the transient and limited needs of the small baby of the time.
Other causes of low milk production
Nipple anomalies can affect a baby‘s ability to latcher remove milk.
Unsupervised use of, or an appropriate reliance on nipple shields may lead to lower milk production.
Sub optimal milk expression methods and equipment can negatively impact milk production. Note parents who combine manual expression along with pumping produce more milk and those who only use expression.
Some medications can reduce milk production including pseudoephedrine first generation antihistamines diphenhydramine, chlorothiamine administered in high doses may have an inhibitory effect on lactation, hormonal birth control pills or other hormonal treatment should be avoided until at least six weeks postpartum. Estrogen has a stronger inhibitory effect in the early postpartum months. Progesterone is less risky but still may reduce my production in the early weeks and months.
Prolactin inhibiting dopaminergic drugs such as levodopa bromocriptine etc. can inhibit Lactation.
Bupropion which is an anti-depressant and smoking cessation can suppress lactation. Cigarette smoking reduces milk volume and the duration of Lactation.
Some nutritional factors in the maternal diet may cause insufficient milk: deficiency of certain lactation critical nutrients such as zinc, iodine, iron and proteins.
Eating disorders are associated with shorter duration of lactation. Anorexia nervosa‘s during pubertal breast development can cause a reduction of the fat pad and subsequent breast shrink it. Current anorexia may result in an adequate nutrition of body. The active binge and purge cycle of bulimia can cause lower prolactin levels. Severe restriction of food intake during pregnancy or lactation particular events below 1500 cal daily on a regular basis can lead to milk production problems.
Gastric bypass surgery is associated with lactation problems. These individuals who have had the surgery should eat at least 25 g of protein daily and will need extra vitamin B 12.
Anytime milk injection reflux is chronically impaired poor milk removal can lead to down regulation. Factors include stress, thyroid dysfunction, and cigarettes smoking also a new pregnancy or ingesting large amounts of anti-galactagogue herbs such a sage, parsley and mint. and high doses of vitamin B6 can reduce milk production.
Delayed lactogenesis II as a cause of insufficient milk production
Defined as delayed beyond 72 hours. Can still have sufficient milk for the baby. Problem is temporary and usually resolves with improve breast-feeding management.
Incomplete lactogenesis is different because full milk production is never reached despite appropriate management.
If lactation takes longer than 72 hours the long-term survival rate of breast-feeding drops below that of individuals of the normal onset.
Risk factors that can cause delayed lactation: primiparous mothers, factors surrounding the birth including stress during labor to long stage two of labor greater than one hour, labor analgesics and anastaesia, significant adema of extremities especially when pregnancy edema worsens after delivery, cesarean birth, the use of forceps or vacuum delivery, augmentation of labor with synthetic oxytocin administration during labor, preterm labor treatments and preterm birth increased risk of delayed onset probably caused by: beta agonist tocolytics such as terbutaline, corticosteroid treatment prior to delivery delayed and inadequate milk removal with the baby is not at the breast, stress related to the preterm experience. SSRI antidepressant during pregnancy can affect the onset of lactation. Retained placental tissue may continue to issue progesterone and interfere with full milk production until the tissue passes or is removed.
Gestational ovarian theca lutein cysts a condition that causes highest testosterone levels during pregnancy will delay secretory activation. In some cases that says may also cause virilizationn (balding common deepening of the voice, facial or abdpminal hair growth, pimples on the face or back or enlargement of the clitoris). High testosterone gradually resolves on its own days to weeks after birth. With continued breast stimulation full milk production may eventually be a cheat.
Primary physical causes of insufficient milk production
Breast anatomy variations anomalies or other physically damaging events can chronically limit the secretary capacity of the breast.
Breast surgery including augmentation and reduction carries the risk of disrupting nerves and ducts and interfering with Lactation. The longer the time since surgery better the chance for dogs to re-canalize and nerves to reinnervate.
Primary hypoplasia, condition of insufficient glandular tissue results in sub optimal milk production rating for mild to severe. Insufficient glandular tissue is not always visually evidence but is usually more evident on palpation. Risk factors for poor lactation related to insufficient glandular tissue include: interbreast space in greater than 1.5 inches, lack of significant visible veining on the breast, stretch marks on the breast in the absence of growth, higher hyperplasia of breast type, severity increases from 1 to 4. Insufficient glandular tissue poses a high risk for losing even a small amount of milk a mother may be producing.
A number of damaging events can impair milk production: mastitis, can cause a drop in milk production with gap junctions temporarily open to clear out the infection. This usually reverses within a few days.
Anecdotal cases say abscess and mastitis may have permanently damaged milk production.
Trauma or other insults to the breas including radiation, burns, repeated chest x-rays or chemotherapy for breast cancer can disrupt mammory development.
Spinal cord injuries can potentially inhibit milk production. The breast is innervated through thoracic vertebrae T3 to T6 if damage occurs a T6 or above Lactation may be affected.
Endocrine disruptors or chemicals that interfere with hormones can inhibit memory development or milk production.
Pregnancy complications including placental insufficiency can negatively affect mammory development of the breast but can contain to grow after birth with sufficient breast-feeding stimulation.
When delivery occurs between 22 and 34 weeks breast development may or may not be sufficiently complete for full lactation at the time of birth.
Primary physiological causes of insufficient milk production
Older parents defined as 30 to 40 years are greater risk of producing less milk.
History of hypertension in pregnancy induced hypertension is a risk.
Obesity defined as body mass index greater than 27 is associated with a higher risk. Excessive weight gain during pregnancy is a risk.
Insulin dysregulation of any type can potentially interfere with mammary development. Type one insulin-dependent diabetes mellitus may cause a delayed onset of Lactation for up to 24 hours and milk production may continue to struggle.
Insulin resistance including non-insulin-dependent type 2 diabetes mellitus and gestational diabetes mellitus is associated with more difficulty in initiating and sustaining Lactation.
Insulin treatment during pregnancy multiplies the risk for lactation problems.
Elevated values for hemoglobin A1c, body mass index, oral glucose tolerance test, and subscapular thickness are associated with shorter lactation duration.
Infants of mothers with gestational diabetes have less mature sucking patterns and do not remove milk as efficiently.
Treatment with metformin has reportedly helped increase milk supply with women with polycystic ovarian syndrome.
Thyroid dysfunction may affect both oxytocin and prolactin. Only animal such studies today.
Milk production is not likely to improve with normal measures if an underlying thyroid problem is not addressed. Proactive is essential to the start up and maintenance of milk production. Low baseline prolactin can be the simple result of infrequent milk removal or breast stimulation. It may also develop as the result of poor prolactin surges secondary to other conditions such as obesity or poor infant suck.
Mothers with a family history of alcoholism have lower prolactin responses to sucklling and their infants fed more frequently.
If baseline prolactin is low increasing prolactin should result in higher milk production. Drugs such as domperidone can be used to stimulate the pituitary to release more prolactin.
Hypopituitary issues result in loss of prolactin secretion. This can include radiation to the brain, Sheehan syndrome an empty sella syndrome. Hypertension or pregnancy induced hypertension are associated with lactation problems HELLP syndrome is a severe form of this condition.
Hyper androgynous , an excess of male hormones is a risk factor. Women with a history of infertility especially those requiring assisted reproductive technology have more difficulty. Polycystic ovarian syndrome is the leading cause of infertility in women. It can cause low progesterone, insulin resistance, elevated estrogen or hyperandrogenesism all of which are the potential to negatively affect Lactation.
Management of low milk production and poor weight gain
First step gauge the adequacy of the babies overall weight gain and rate of growth. If growth falls below the 25th percentile further investigation should be done. Most babies fall between the 25th and 75th percentile.
If the baby is not gaining weight appropriately consider: massage for breast before breast-feeding to trigger faster milk injection and increase the cream contact of the milk, increase the number of effective breast-feeding‘s and verify that the baby is removing milk, ensure that baby feeds on both breasts at each feeding, if the baby is sleeping or not sucking actively use breast compressions to increase milk flow, avoid bottles pacifiers and nipple shields and less clinically indicated, remind the parent to practice good self-care including rest drink plenty of fluids and eat a balanced diet.
Supplemental feedings might be necessary
Temporary or permanent supplementation may be required for recovery after malnutrition. First choice should be parents expressed milk. In some cases high calorie weaning foods may be introduced earlier than six months. Recommendations about the type of method of supplemental feedings depending on the parents motivation and condition as well as the availability of human milk banks.
If extra milk is available, expressed hindmilk can be used as a high calorie supplement. An alternative is to skim the cream layer from extra milk that has been allowed to settle and separate.
Supplementation in the first four days after birth can include:
24 hours from birth use 2 to 10 ML per feed,
24 to 48 hours from birth 5 to 15 ML per feed,
48 to 72 hours from birth 15 to 30 ML per feed,
72 to 96 hours from birth 30 to 60 ML per feed.
Infants intake begins to stabilize after the first week. From month one to six months most babies taken approximately 26 to 32 ounces per 24 hours rising approximately 4 ounces from the first month to the six month. Supplementation for beta babies age one week to six month can vary in amount it must be adjusted for results. Many underfed babies cannot take much at the start and they need coaxing. A baby who has been getting weight slowly usually will have the energy to take 60 mL or more after each breast-feeding session and will quickly reach the appropriate growth curve. A baby whose weight has maintained a drop may not have the energy at first to take more than 20 to 30 mL per feeding. The amount of milk the baby needs daily to regain weight and grow appropriately varies depending on the caloric value of the milk, the babies sex, and the babies individual metabolic needs. Most babies need additional milk for only a few days.
Improve milk production starts with optimal position and good milk transfer
Teach parents how to position their baby at the breast what constitutes an effective latch and how to know when the baby is swallowing milk.
Nipple pain during a feeding can indicate that the baby is not positioned effectively, not latched optimally or is not sucking correctly.
Teach parents to feed on demand following infant behavioral cues.
Hand expression is usually the most effective method in the first 48 hours or until lactogenesis II.
Breast massage an application of warmth to the breast prior to expressing help increase milk yield. Holding the baby skin to skin prior to her during milk expression can increase the amount of milk removed. To avoid being excessively time consuming, breast-feeding, supplementation and expression preferably should take no longer than one hour all together. The goal of post feed expression is to remove residual milk and provide a strong stimulus check encourage greater milk production. Encourage milk expression immediately or as soon as baby is settled.
Power pumping, which involves short very frequent pumping sessions for 1 to 2 days has been successful in some cases for increasing the production.
Additional therapies to increase milk production
Pharmacologic galatogogues maybe helpful when corrective measures are not enough. No drug is manufactured specifically for the purpose of increasing milk production.
Domperidone (Motilium) is used for the treatment of certain G.I. disorders and increases milk production without the side effects of metoclopramide. Usually 10 to 20 mg 3 to 4 times daily.
Metoclopramide (Reglan and Maxeran) is a similar drug that also stimulates lactation by increasing serum prolactin. Depression and anxiety are possible side effects and more serious acute symptoms have also been reported. The most common dosage is 10 to 15 mg three times daily.
Sulpiride an antipsychotic drug is used in some African and South American countries. It also works by increasing serum prolactin levels. Typical dosage is 50 mg 2 to 3 times daily.
Botanical galactagogue seven used for millennia to support an increase milk production, they are controversial in the western world. Limited formal research. When effective should be used in conjunction with good breast-feeding management quality, the quality of these agents can vary among manufacturers, doses are largely anecdotal,.
Oxytocin nasal spray has been used to stimulate milk milk production by a stronger milk ejection reflex. There’s doubt of whether this improves lactation.
Complementary therapies are used in conjunction with main stream therapies and may address in underline problem and away the standard treatment is not. Imagery, relaxation, Hypnosis, music and biofeedback have helped some parents increase milk production,. Acupuncture, acupressure and reflexology have been used in China for low milk production. Chiropractic adjustments have helped correct some subluxations that interfere with lactation nerve pathways. Placentophagy has been shown to both increase and decrease production in some women.
Birth trauma
Injury or damage of the tissues or organs of a newborn that were sustained during labor and delivery
Congenital anomaly
A physical or structure of malformation or disease that developed in Eudora
Inborn errors of metabolism
Action genital disorder resoling from genetic defects that lead to enzyme deficiency. Some enzyme deficiencies impair the infant ability to breakdown and metabolize various nutrients or they resolve in a buildup of toxins.
Neurologic impairment
A deficit related to any disorder of the nervous system from infection or structural, bio chemical, or electrical abnormalities.
Post mature infants
A post mature infant is a fully mature infant born after the onset of 47 weeks of gestation. Aging of the placentq and reduce placental function impair nutrients and oxygen transport to the fetus placing the fetus at risk. In response to hypoxia, meconium might be passed increasing the risk for meconium aspiration. Amniotic fluid might be decreased increasing the risk for meconium aspiration and umbilical cord compression.
If the placenta continues to function well the infant might become large for gestational age which increases the risk for shoulder dystocia and possible fractured clavicle.
Post mature infants are characterized by the following: loss of weight in utero, dry, peeling skin that appears to hang as a result of losing subcutaneous fat and muscle mass, a wrinkled wide-eyed appearance, lack of vernix caseosa, reduce glycogen stores in the liver. Might be at higher risk for hypoglycemia as a result of lower glycogen reserves. Important to maintain skin to skin and feeding of colostrum if not latching. Might feed poorly, appear lethargic and require a considerable effort to sustain suckling. Incentives include the following: alternate massage and breast compression, express colostrum, skin to skin contact, avoidance of crying episodes which can further drop their glucose levels.
Birth trauma
Forcept use result in small areas of bruising or ecchymosis on the sides of the face where the blades were placed. Forcepts can also cause neurological injuries. Trauma to the facial nerves can occur. Any muscles innervated by these nerves may be temporarily hypertonic, making latching and sucking difficult. Look for asymmetric movement of the mouth, drooping mouth, or a drooping eyelid.
Forceps, vacuum and especially failure of one followed by the use of the other can result in shoulder dystocia and brachial plexus injury causing paralysis or weakness of the hand or arm. These can interfere with stable positioning.
Vacuum assisted deliveries can pose an increase risk of cranial hemorrhage in term and preterm infants.
Extracranial hemorrhage: bleeding between the skin and cranial bone. Capursuccedaneum: hemorrhagic edema of the soft tissues of the scalp and usually resolves within the first week of life.
Cephalhematoma: bleeding that is contained within the subperiosteal space preventing it from crossing the suture lines.
Subgaleal hemorrhage can represent a significant blood loss to the infant. It presents as a fluctuant area of the scalp sometimes increasing in size to the point of blood dissecting into the subcutaneous tissue of the back of the neck. These infants need special help and positioning to keep pressure off the hammer Rogic area. Some infants feed poorly or not at all until some of the hemorrhage has resolved increasing the risk of high bilirubin level.
Intracranial hemorrhage is not visible externally. May present with common signs such sleepiness, feeding intolerance, apnea, and decrease muscle tone.
Subdural (cerebral) hemorrhage is the most common intracranial hemorrhage resulting from a traumatic delivery. This occurs more often after vacuum deliveries then forceps and both carry higher risk than unassisted vaginal deliveries. Some infants symptoms only become evident after discharge where they demonstrate lethargy, feeding problems hypertonia, increased irritability, don’t feel swelling of the head and pallor and need immeiate medical care. Infants with intracranial hemorrhage might be treated therapeutically with hypothermia which precludes direct Breastfeeding. But trophic feedings of colostrum can be given during hypothermia. Parent should be assisted with manual expression of colostrum.
A fractured clavicle can occur with a large for gestational age. The infant may display a decrease movement of the arm or distress with arm movements. The arm and shoulder are immobilized and special positioning might be needed for breast-feeding. Sometimes these are not diagnosed until after discharge in certain positions are associated with crying. Using the clutch hold and feeding on the unaffected side using both breasts might be helpful.
Fetal distress and hypoxia and ischemia
Infants are vulnerable to brain cell death from hypoxia and ischemia.
Neonatal encephalopathy is the current term for altered level of consciousness, seizures, apnea, and reduce brainstem function including impaired feeding ability. A blood pH lower than 7 and a base deficit at birth indicate an acute hypoxic ischemic event.
Normal pH of newborns is 7.26 to 7.30. Recovery begins after 3 to 4 days. Some infants remain compromised. Low Apgar scores combined with an inability to suck that requires tube feeding are the most sensitive indicators of later disability.
Hypoxia decreases the motility of the gut and reduces the gut stimulating hormones. These infants may have a depressed suck that is not well coordinated with a swallow and may have difficulty bottlefeeding.
Colostrum is very important to these infants because their G.I. tract might’ve suffered hypoxic damage. Colostrum should be expressed and used as soon as the infant can tolerate feedings by mouth.
Breast-feeding interventions are similar to those for infants who have down syndrome. You can use a supplementary device, cup or other feeding device. Milk expression will be necessary when the infant is unable to remove milk.
Hypotonic (low muscle tone) Infant may breastfeed better in a clutch hold with trunk stabilized against the parent side or prone on a semi reclined parent.
A hypertonic (high muscle tone) infant should be held in a flex, well supported position to reduce the overall extensor pattern.
Cheek and jaw support (dancer hold) will help with maintaining the latch. These infants have increased effort of feeding, fatigue easily and may require very short frequent feedings. Recovery usually proceeds for many months.
Neurological disorders
Infants who have neurologic impairments often have extremely complex needs. Infants nervous system can be damaged, abnormally developed, immature, or temporally incapacitated from insults such as intrauterine infection, asphyxia, sepsis, trauma or drugs. Infants may have an absent or depressed feedin response, gag reflex, sucking reflex or difficulty swallowing.
Giving a bottle to an infant who is breast-fed provides inconsistent sensory input that additionally disorganized nervous system.
There may be a depressed or absent suck reflex with limited response to stimulation of the palate and tongue. These infants might also have decreased muscle tone. The weak or poorly sustained sucking reflex denotes an oral musculature that has been weakened. Rhythm is interrupted by irregular pauses and sometimes lacks the one to one suck to swallow ratio.
Adequate negative intraoral pressure is not generated causing the nipple to fall out of the mouth. The lips do not form a complete seal. The hypertonic tongue might remain flat and not cup around the breast.
Uncoordinated sucking includes a mistiming of the component muscle movements of the suck swallow breathe cycle. There may be extraneous movements of the mouth, head, or neck. Supportive techniques can help reduce these abnormal movements.
The infant might have difficulty organizing feeding behavior. Gentle organizing input before feeds improves feeding.
Hypersensitivity or hypo sensitivity might be seen in other areas of the body.
There may be dysfunctional tongue movements and uncoordinated swallowing increasing the risk of aspiration.
Inborn errors of Metabolism
Galactosemia
Caused by a deficiency of the enzyme GALT, causing an inability the infant to metabolize galactose. Can have severe and persistent jaundice, vomiting, diarrhea, electrolyte imbalance, cerebral involvement, cataracts and weight loss. Infants are weaned from the breast to Latus and the lactose free formula.
Duarte galactosemia is a condition in which low but functional levels of GLT allow breast-feeding to continue.
Phenylketonuria (PKU)
PKU is the most common of the amino acid metabolic disorders. Is an autosomal recessive, inherited disorder in which the amino acid phenylalanine accumulates because of the absence or reduced activity of the enzyme phenylalanine hydroxylase which converts phenylalanine to tyrosine for further breakdown.
Infants with PKU can continue to breast-feed when a balance is maintained between the use of phenylalanine free formula and breastmilk.
Human milk has lower levels of phenylalanine than standard commercial formulas do. The amount of phenylalanine free formula and breast milk can be calculated related by weight, age, blood levels and need for growth and the amount of suggested weekly. Another approach is to feed the infant 10 to 30 mL of the special formula followed by breast-feeding.
Breastfeeding before diagnosis and dietary intervention has been shown to produce a 14 point higher IQ there in infants who are artificially fed before diagnosis.
Supplementation of BH4, a phenylalanine hydroxylase cofactor, increases the amount of phenylalanine and human milk that is tolerated in some individuals with PKU.
Challenges for breast-feeding infants with PKU include: maintaining milk production in the context of constantly changing amounts of milk, difficulties integrating pumping into the work at caring for the child, issues with nipple confusion when using a bottle to feed the phenylalanine free formula.
Other inborn errors of metabolism
Infants with metabolic disorders are at risk of failure to thrive, neurologic injury, acid base balance disturbances, and other life-threatening complications if not identified and treated.
Many infants require dietary supplements to help circumvent a blocked metabolic pathway or reduce the levels of toxicity of products of abnormal metabolism.
If they can safely consume lactose and intact proteins they can at least partially breast-feed.
Breast-feeding is recommended as the source of intact proteins for infants with maple syrup urine disease as long as they can be appropriately monitored. Maple syrup disease is a rare metabolic disorder that some babies are born with. Caused by a defect in the enzyme that breakdown some amino acids.
Breast-feeding should be encouraged with other rare metabolic sydromes if compatible.
Cystic fibrosis
CF is a congenital disease involving a generalized dysfunction of exocrine glands resulting from a mutation in the gene coding for the CF transmembrane conductance regulator protein
Glands produce abnormally thick and sticky secretions that block the flow of pancreatic digestive enzymes, clog hepatic ducts and affect the movement of the cilia in the lungs. Increase sodium chloride in the child’s sweat is frequently the first indicator of this condition, the infant taste salty when nuzzled. Also an early indicator is intestinal obstruction or ileus. Meconium blocks the small intestine resulting in abnormal abdominal distention, violent vomiting and failure to pass stools.
Infants who have CF produce normal amounts of gastric lipase which when combine with lipase in milk enhances fat absorption. Breast-fed infants with CF are less likely to need intravenous antibiotics and have improve lung function. Breast-fed infants with CF can present with protein malnutrition (edema) and reduced weight gain but may escape the characteristic infections confounding diagnosis.
Breast-feeding is recommended for infants with CF. Breast-fed infants with CF retain normal gut flora longer which is associated with later time to first exacerbation. These infants may show a failure to thrive do to increase metabolism principally from increased work of breathing, malabsorption do to pancreatic enzyme dysfunction and fat loss in the intestines and poor appetite secondary to GI reflux and G.I. pain. Short frequent breast-feeds with enzyme and fat soluble vitamin supplements help compensate for these difficulties.
Down syndrome
Results from an extra chromosome 21 (trisomy 21). Flaccid tongue that appears too large for the mouth as a result of reduce growth of the mandible. Generalized hypotonia, including oral musculature. Heart defects that decrease aerobic capacity for feeding and might require surgery.
Larygomalacia, tracheomalacia, or bronchomalacia that destabilize the airway and further stress respiratory function.
Incomplete development of the G.I. tract. Vomiting can be the first sign of an intestinal blockage.
Hyperbilirubinemia is common in newborn infants with down. Also have increased susceptibility to infection. Possible depressed sucking reflects a weak suck or both may be present.
The dancer hand position may stabilize the jaw and support the masseter muscles which decreases the intraoral space and enhances the generation of negative pressure. In the dancer hand position the breast is supported by the third fourth and fifth fingers so the webbing between the thumb and index fingers forms a U-shaped cup that the infants chin restaurant. The thumb and index finger support the cheeks and produce gentle traction towards the corner of the lips. Infant should be in a quiet alert state to feed.
Infant might need hindmilk supplementation to gain weight. Feeding in a prone or semi prone position on a recliner may help gravity stabilize the infant.
Do not overly flex or extend the infants head. Lacks connection between the base of the skull and upper spine or between the first his cervical vertebrae occurs in 10 to 20% of children with down syndrome. Abnormal movement in the trap and injure the spinal cord.
Gastrointestinal tract disorders Esophageal atresia (EA)
EA is a congenital defective the esophagus. Most cases the upper esophagus does not connect with the lower esophagus and stomach. May be associated with other birth defects. Tracheoesophageal fistula (TEF) is a common variation of EA that occurs when the esophagus communicates with the trachea. Occurs in one of every 3000 to 5000 live births. EA is usually detected in the first few hours of life and it’s considered a surgical emergency. Symptoms can include excess amniotic fluid during pregnancy and difficulties with feeding such as coughing, spilling fluid from the lips, gagging, choking and cyanosis.
Gastroesophageal reflux (GER)
Persistent, nonprojectile regurgitation after feeds. This can be mild and self-limiting. Can’t be more severe with worsening regurgitation and weight gain or weight loss problems.
Can present as follows: fussiness at the breast as the stomach contents contact the lower section of the esophagus, might be more apparent in certain side lying positions at the breast, parents report increase fussiness at the breast, arching off or pulling away, infant mouths reflux milk between feedings (cud chewing), upper respiratory infections and congestion, feeding refusal is common, micro and macro aspiration or nasal pharyngeal reflux may manifest as nasal congestion that increases throughout the feeding with coughing or wheezing during or between feed.
Parents are encouraged to continue breast-feeding. Feed with the infant in an upright position. Feed on one breast at each feeding to keep from overexstending the stomach. Keep the infant upright for 10 to 20 minutes after feedings.
Reflux needs to be differentiated from hyper lactation with overfeeding or lactose overload. Generally if the infant is gaining rapidly, has signs of gut irritation and rapid intestinal transit time (green, mucousy stools) and is fussy hyperLactation might be responsible. Reduced milk production by gradually increasing the amount of time between changing breast is generally successful (block feeding).
If the reflux is associated with esophageal irritation or respiratory complications the infant might undergo diagnostic test and be placed on medication.
Pyloric stenosis
Stricture or narrowing of the pylorus (muscular tissue controlling outlet of the stomach) caused by muscular hyper trophy). This hyper trophy might be felt as an olive shaped mass in the infants lower abdomen. Usually occurs between the second and sixth week of life although it can occur at any time. More common in formula fed then breast-fed infants. Vomiting is characteristic. Intermittent at first and progresses to after every feeding and becomes projectile in nature.
Dehydration, electrolyte inbalance and weight loss can occur in extreme situations. If infant does not outgrow the condition or it is severe, surgery can be performed after rehydration and correction of electrolyte balance. Breast-feeding can resume after surgery. Positioning the infant upright in a straddle position helps avoid stress on the incision.
Congenital heart defects of the most common types of birth defects in newborns
Congenital heart defects are seen along a continuing for mild with no symptoms to severe with synosis, rapid breathing, shortness of breath, and lowered oxygen levels that require surgical correction.
This is not a medical indication to interrupt or stop breast-feeding.
Congenital heart disease increases vulnerability to NEC increasing the importance of breast-feeding.
Feeding at the breast presents less work for the infant, keeps oxygen levels higher than with bottlefeeding and keeps heart and respiratory rate stable when the infant is at the breast.
Unrestricted breast-feeding on cue results in the best growth in affected infants.
If has more serious heart involvement might be unable to sustain sucking at the breast or might need to pause frequently to rest. If untreated cardiac disease often results in increase caloric requirements which normalize after surgery.
Infant behavior and symptoms include: able to sustain sucking for only short periods of time, pulling off the breast frequently, turning blue around the lips, rapid breathing, panting or breathlessness, rapid heart rate, sweating while at the breast, need for very frequent feedings, vomiting after feeding.
Surgery is usually planned after an infant reaches a desired weight or age. Small frequent unilateral feeds might be necessary. Upright or prone feeding positions improve coordination of swallowing and breathing.
If additional calories are needed consider hindmilk supplementation at the breast with a supplement or device or breast massage before breast-feeding. These infants benefit from immediate skin to skin contact if they are sufficiently awake.
Respiratory disorders can impact in infants ability to feed affectively
Common features include: increased effort of breathing leaves less energy for feeding, increase base respiratory rate reduces the amount of swallowing they could be done, short sucking burst are typical signs of respiratory disorders.
Laryngomalacia
Laryngomalaxia where the epiglottis lacks normal stiffness, neural intervention, muscle tone or sensory motor integration.
The epiglottis collapses into the airway on inspiration causing inspiratory strider, and increased work of breathing particularly during crying, feeding and supine positioning.
Laryngeal vestibule itself may be overly small or high or low tone creating difficulty with breathing and feeding..
The pharynx may be low tone creating problems with a smooth coordination of the epiglottis and larynx during the protection phase of the cycle.
Associated with increase risk of dysphasia (abnormal swallowing) regardless of severity, I strongly associate with GER because it increases pressure on the lower esophageal sphincter
Head extension and prone positioning during feeding reduce airway with resistance. Short frequent feeds may be necessary to prevent failure to thrive. Generally peaks at age 6 months and start to resolve by age 8 to 24 months as the neck elongates and structures become anatomically separated.
Tracheomalacia
Increases work of respiration and feeding. Cartilage rings in the trachea may be malformed enter insufficiently stiff so that rapid airflow during expiration causes a partial collapse of the trachea. Can be seen as a sternal retraction and heard as strider. Usually outgrown in the first year or two of life.
Laryngeal webs
Persistence of tissue in the lumen of the airway. Can cause significant respiratory distress. May have great difficulty feeding. Very careful pacing of feeding is necessary to prevent hypoxia
Laryngeal clefts
Openings of variable size and position between the larynx and esophagus. Result in strider or aspiration during feeding. Interfere with normal function and all phases of swallowing. Usually require repair to allow the infant to feed safely. Can be comorbid with other issues
Vocal fold paresis or paralysis
Weakness (paresis) or paralysis of a vocal cord is usually unilateral from injury to the vocal fold or it’s nerve supply. May have a horse or wek cry. If the cord is unable to close well it will reduce airway protection on the affected side. Will usually coordinate swallowing and breathing better if the weak or paralyzed cord is oriented upward.
Velopharyngeal insufficiency or incompetence
Characterized by hyperplasia or dysfunction of the soft palate or pharyngeal constrictor muscles that prevent milk from entering the nasal pharynx, sometimes resulting from submucosal cleft palete.
Nasal regurgitation, harsh respiration in feeding pauses, apnea from milk in the nasopharynx and feeding resistance can be consequences of the velopharyngeal incompetence. Careful pacing and upright positioning (straddle) may help infants have less reflux.
Cardio respiratory disorders
Create tension between the infants needs for oxygen and food. Short frequent feedings reduce fatigue and oxygen debt. Prone feeding positions with mild head extension can improve the infants ability to coordinate swallowing and breathing. Infants with cardiac malformation may feel better in upright positions. Flow during breast-feeding can be reduced by pre-pumping the breast and using manual pressure to block milk ducks.
General Breastfeeding implications for respiratory disorders
Very careful careful pacing of the feed, head extension to reduce airway resistance to airflow, prone feeding positions with parent reclined, and more frequent feedings. Pressing on the breast to block some ducts can also reduce the flow. Growth should be monitored closely and expressed milk should be provided by slow flow methods if the infant is unable to meet the needs at the breast.
Acute and systemic illness
Acute illnes: gastroenteritis, respiratory infections, otitis media, candidiasis,
Illness can reduce appetite, causing transient growth flattening or even weight loss. Infants receive active and passive immunity through human milk, including leukocytes in immunoglobulins.
Lactoferrin and secretory immunoglobulin A are both present in breastmilk and provide immune protection to infants.
Lactoferrin levels in the milk or higher in the month before and the month after an illness to get an infant.
Gastroenteritis can be a serious in illness in infants and young children. Particularly important to maintain breast-feeding during diarrhea and vomiting to prevent dehydration. Oral rehydration can be used with breast-feeding need it.
Respiratory infections can increase the work of breathing and make breast-feeding more difficult. Sterile saline nasal spray may reduce the nasal blockage. Infants with lower respiratory infections may use shorter sucking bouts during feeding.
Prone feeding positions with mild head extension improve infants ability to coordinate swallowing and breathing.
Otitis media or middle ear infections are very common. Ear infections are painful and a common cause of breast-feeding strikes. Positioning changes to avoid pressure in affected ear may allow the infant to feed more comfortably. Exclusive or predominant breast-feeding is protective against ear infections in the early years of life.
Candidiasis is the result of an overgrowth of candida species or yeast. May develop painful white plaques on the oral mucosa. Can be comorbid with diaper rash typically with red shiny skin that becomes friable and cracks or peels. Oral candidiasis can be difficult to treat because the plaques contained biofilms to protect against medication. Medication should be used twice the time after symptoms are gone. Gentian violet can cause painful mouth and throat lesions in infants and should only be used under medical supervision. Pacifiers and bottle nipples may need to be disinfected and bleach.
Allergy symptoms in infants have a wide presentation from changes in stools, vomiting skin rashes and respiratory symptoms.
Management of these will depend on the type of allergy.
Allergic proctocolitis causes bloody stools with mucus in infants who are generally growing well. Removal of the allergen from the infants diet and sometimes in the mothers diet, resolve symptoms in 48 to 72 hours.
Food protein induced enterocolitis syndrome causes severe vomiting 1 to 3 hours after ingestion and diarrhea 2 to 10 hours after ingestion and is rare in exclusively breast-fed infants.
Eosinophilic gastroenteritis can cause altered gastrointestinal permeability and proteins loss leading to peripheral and periorbital edema and growth failure. Avoidance of the allergen involved generally resolves the condition. CF and a breast-fed infant can present with the same symptoms.
Eczema (atopic dermatitis) risk is increase if solids are delayed past nine months of life. The severity of eczema predicts food and respiratory allergy and exclusively breast-fed children.
Chapter 24 Breastfeeding Devices and Topical Treatments
Complementary feeding
A feeding in addition to breast-feeding
Milk ejection reflex
The release of milk in response to brest stimulation. Also called letdown reflex or milk release.
Nonnutritive sucking
Infants sucking without nutrition, pacifier used to increase physiologic stability and nutrition in pre-term infants.
Philtrum
Area of skin above the upper lip
Postmenstrual age
Age of an infant from the first day of the last menstrual period to the day of delivery
Supplementary feeding
I Feeding that replaces a breastfeeding
Nipple shields: design, sizing, purpose, positives, negatives, teach how to use, follow up and discontinue use.
Design has advanced over the years from lead, wax, silver, wood, pewter and animal skins to rubber, latex and nail silicone. Now use thin silicone devices that allow some tactile stimulation to the nerves of the nipple and areola through the shield.
Sizes of nipple shields vary with manufacture: height of the nipple portion ranges from 16 to 26 mm, width of nipple base varies from 15.7 to 25.4 mm, the nipple portion is a conical shape and has one to five holes, milk flows best through nipple shields that have multiple holes.
Purpose of nipple shield: useful when infant has difficulty latching because of flat or inverted nipples and when changes in position are ineffective. The nipple shield provides shape to a flat or inverted nipple. The shield stimulates the infants palate when their parents nipples are unable to do so. Parents who have a higher body mass index are more likely to have flat nipples and require the use of nipple shields. A nipple shield can help stretch and improve the elasticity of a flat or inverted nipple when the infant sucked strongly over the shield.
Sometimes use when parents nipples or areola are very sore. However ascertain in reason it’s important.
Can be used when there’s nipple confusion or breast refusal and when the parent is at risk for early termination due to breast-feeding problems.
Sometimes used when a parent has an overactive milk ejection reflects or overproduction of milk and the infant has difficulty handling the milk flow.
Can assist with latch if infant is tongue tied until treatment can be obtained.
Can be useful when the infant has a weak, disorganized, or dysfunctional suck.
May be useful in solving the typical problems of small preterm infants including failure to latch sucking for an insufficient time immature feeding behaviors etc.
Can be helpful in circumstances were infant has certain congenital conditions such as a cleft palate.
Can be helpful with upper airway problems.
Can be helpful to keep the Infant on breast during remediation of the problem which can prevent premature weaning.
May be a solution for parents who may not otherwise tolerate the intimacy of breast-feeding.
Positive outcomes include about 18% of mothers experience breast-feeding problems in the first weeks postpartum find nipple shields to be useful.
It is simple to use and will not overwhelm parents.
Some parents think their infant learns to breast-feed quicker with a nipple shield. Prolactin and cortisol levels seem unaffected by the use of a thin silicon nipple shield.
An increase in milk intake was found with the use of a nipple shield in preterm infants. The suction created in the nipple shield may allow the milk to be accumulated in a shield tip during pauses and sucking this milk available immediately to the infant.
Use of almost any aid to breast-feeding can reduce a parent’s breast-feeding self efficacy.
There are precautions that must be taken with a nipple shield: tempting to use nipple shield as a quick fix, can damage nipple tissue if not fitted and applied correctly, may learn to associate smell of the nipple shield with getting milk, edge of the nipple shield may block the infants nose, applying may require two hands, if not a good seal may inadvertently dislodge making it cumbersome, some parents don’t like something between them and the infant, the teat portion of the nipple shield has a different feel and texture than a breast nipple which may make transition to the breast difficult,
How to teach parents to use a nipple shield appropriately: when sizing consider the size of the infants mouth and the size of the nipple. Smaller sizes are appropriate for preterm or small infants. Teat height should not exceed the length of the infants mouth from the lips to the junction of a hard and soft palate. Excess of length can also trigger gag reflex and an aversion to feeding. Some small shields are not wide enough at the base to accommodate larger nipples. If there is pain when the infant sucks on the nipple shield then the nipple is not deeply positioned into the shield or the shield is too small for the nipple. To pull it in further the infant can suck on and after a few minutes of sucking can pull it in. If expressed milk is put it will stimulate the infant to suck.
In many cases the shield may be removed when vigourous sucking is achieved.
A feeding tube can be used in conjunction with the nipples shield to temporary increase milk flow.
Follow up as essential when a nipple shield is used. Ensure that the shield is washed thoroughly dry and stored in a clean place until the next use to prevent nipple infection. Monitor the infants output and weigh the infant often. Assessment transfer by assessing a suck to swallow ratio, performing test weights and observing milk in the tip of the shield.
Help parents discontinue using a shield: mean duration of use is 14 to 33 days, when it’s determined it can be discontinued to start a feeding with the shield and remove it, avoid cutting pieces of the tip of the shield to try and wean the infant because blunt uncomfortable edges might remain, infants may refuse the breast without the shield but using increase skin to skin contact for breast-feeding may help the process of weaning.
BREAST SHELL
Two-piece device consisting of a vented dome or cup and a concave back contour to fit the shape of the breast. Usually placed inside the bra over the nipple and aeriola. Can provide protection for painful, tender nipples. Can help air to circulate. Also can be used to revert flat or inverted nipples either prenatally or postpartum. Most research has found shells to be a little value. Can be used to reduce areolar edema. Precautions on the use of this device: effectiveness of breast cells is limited, theoretical risk of stimulating preterm labor when use prenatally, my cause irritation to the nipple or areola, some are obvious under the clothing it may cause embarrassment, may cause plugged ducts and mastitis. Teach parents how to use shells appropriately: place the shell inside the bra, center the opening over the nipple and close the bra to hold the shell in place, wearing showers for gradually longer periods of time during the day will help parents become comfortable wearing them, shells should be removed when lying down for naps and at bedtime to avoid duct obstruction, in hot weather or or if moisture builds up remove the shells and allow the breast to dry before reapplying, use of shells in conjunction with lanolin or Xpress milk on the nipples may promote healing.
Silver impregnated metal caps
Solid caps worn over the nipple. The bra holds it in place. Caps can be used for healing sore or crack nipples. Silver ions in the cap make contact with the skin and prevent infection from bacteria and fungi. Intended to be worn continuously until healing about 3 to 15 days. Made from natural material and are recyclable. May not be available everywhere and may because prohibitive.
Nipple everters
Syringe like devices that are placed over the nipple with a plunger to gently create suction that pulls the nipple outward. A commercially available everter has a soft, flexible areolar car. A thimble shaped silicone dome is placed over the nipple prenatally, suction is generated by pulling on a syringe and sealing off the dome, a device remains in place for extended periods of time. Another thimble shaped everter placed over the nipple and squeeze to apply it over the nipple and draw jtout, it is worn for several hours daily or prior to feedings, may be worn under breast shells beginning at the 37th week of gestation period, a small bulb syringe is used to pull the nipple out prior to feedings. It’s a simple low cost that allows suction control to maintain comfort. Invert a flat or retracted nipple in the prenatal or postnatal., Forms a nipple to make the latch easier for infant to grab.
Precautions include: limited research on the use of nipple everters, if used too vigorously or incorrectly can cause pain or skin damage, nipple may not remain everted long enough for the infant to achieve a latch. Teach how to use: apply suction to the nipple and hold the everted nipple for about 30 seconds prior to each breastfeeding, assure proper cleaning between uses.
Droppers
Plastic or glass tubes with a squeeze bulb, some in child size. Quick way for an infant to receive a small amount of milk while learning to breast-feed. Maybe used with finger feeding to take the edge off hunger before attempting to latch the baby. Can be used as an incentive to achieve latch put one or two drops in side of mouth while starting latch. Infant must be alert and have a functioning swallow reflex. Should not be squirted into the infants mouth it should drip at a rate the infant can swallow comfortably. Avoid the use of artificial nipples. Inexpensive and widely available. Can be difficult to clean between uses I must be continually refilled can be time consuming and messy. Infant is not learn to stock unless the drivers used in conjunction with finger feeling.
Spoons
Can be used to feed a small amount of colostrum or milk to the infant. Several uses for spoon feeding: used when breast-feeding is interrupted or when the parent is unavailable, used to prime the infant for feeding out the grass, feed infant colostrum that has been hand expressed or pumped to complement early feedings and prevent hypoglycemia, used to feed an infant after cleft lip repair if wound opening is a concern. Avoids the use of artificial nipples, can be a temporary aid to initiate breast-feeding for infants who have not latched, it’s quicker than bottlefeeding after breath feeding, Kenneth minister small amounts efficiently same muscle groups are involved as with cups and breast-feeding, inexpensive and readily available, and easy to clean, infants may be more eager to breast-feed because their sucky needs are not met through spoon feeding, is safety years with preterm infants older than 29 weeks. Downsides include, hold little volume must be continually refill, does not teach the infant to suck at the breast, deprive Infant of normal oral experience, spillage may be a problem. Teaching how do use infancy be alert and have a function swallow flex, position the infant in a semi upright position, place the spoon on the infants lower lip over the tongue allow the infant to pace feeding by sipping or lapping the milk, avoid pouring the milk into the infants mouth.
Cups
A variety of cups can be used including common small medicine cups to small flexible drinking cups. There are also some commercial cups available with an extended lip or edge a paladai is a small pither shaped device from India that is similar to a cup it has a long spout.
Uses for a cup include preferred by many clinicians as the first choice for an alternate feeding method, can be used to feed the infant when breast-feeding is interrupted, can be used with both term and preterm infants to avoid bottle nipple preference, can be useful for feeding infants with cleft lip and palate repair, is not appropriate for the infant who has recently been extubated has a poor gag reflex or as neurologic deficit. Is well supported in the literature with positive outcomes.
Positive outcomes include: avoid potential nipple confusion, may want to continue to breast-feed because sucking needs are not met, allows infant to pace the feeding quick way to supplement or complement breast-feeding, inexpensive, easy to teach parents cup feeding easy to clean, utilizes masseter muscle activity similar to breast-feeding, help babies learn to extend their tongue over the lower edge of the gun, has been shown to be safe for low birthweight infants, promotes breast-feeding and preterm infants who have difficulty with latching or bottlefeeding, may be an increase breast rate of breast-feeding in the hospital.
Precautions include must be frequently refilled, infant can dribble much milk reducing intake and risking poor weight gain, does not learn to suck with a cup, can become dependent on using the cup, risk of aspiration if cup feeding is performed improperly.
Teaching her feeding includes infant should become alert state position nearly upright, fill the cup about half full, put the rim of the cup lightly on the infants lower lip with a cup to adjust to the point of the milk coming into contact with the upper lip, let the infant pace the feeding by sipping or lapping the milk, do not pour the milk into the infants mouth, leave the cup in the same position of the infants left during pauses so if it does not need to continually re-organize oral confirmation, demonstrate technique, spillage can be measured by weighing the bid if intake is concerned.
Syringes
Syringes can deliver up to 10 ML of milk at a feeding. Common types include periodontal syringe which has a curved tip, a regular syringe without a needle is usually not used because the infant may have difficulty forming a complete seal, or a tuberculin syringe other the volume is limited.
Uses include to provide an incentive at the breast to encourage latch, to initiate suckling, or to aid in sustaining the suckling pattern, it can be used to provide complementary or supplementary feeding while the infant simultaneously sucks on the caregivers finger, can be used to feed an infant with a cleft palate who is placed in a prone position. Positives include: avoids use of artificial nipples and keeps the infant at the breast, provides a source of milk flow that will work to regulate the sub, technique might help improve uncoordinated mouth and tongue movements by encouraging correct tongue peristalsis, easy to teach parents.
Precautions: more intrusive than other alternative feeding methods and may cause aspiration, avoid the tendency to hasten the feedin by pushing the plunger, supplies may not be readily available everywhere, infant can become dependent on the method, may demonstrate poor jaw excursion while sucking on an adult finger, parents with long fingernails may need to cut them, periodontal syringes have a pointed tip that could irritate the infants mouth, some professionals have legal concerns about using equipment for a purpose that it was not originally intended.
Teach parents: insert the tip of the syringe just inside the infants lips at the corner of the mouth while infant is feeding, give a small bolus of milk (0.25 to 0.5 ML) when the infant sucks, increase the volume of the bolus as the infant tolerates flow, when finger feeding place the infant in a semi upright position in the caregivers arms or in an inclined infant seat use the finger that is closest in size to the circumference of the parents nipple, the finger should be inserted in the infants mouth with the pad up, placed the periodontal syringe next to the finger making sure it is positioned parallel to the finger so it will not poke the infant, reward the correct suck emotions with a small bolus of milk. If tongue lies below behind the lower gum Ridge apply slight pressure to the back of the tongue to stroke it gently forward over the lower gun Ridge. Feeding time should take about 15 to 20 minutes. If infant stops for more than 10 to 20 seconds give a small bolus to stimulate, if used to entice infant to the breast place the infant at the breast but he or she demonstrates a sucking rhythm on the finger a few drops of milk dripped onto the nipple during latch may be enough to direct the infant to the milk source.
Tube feeding devices
Provide supplemental nutrition at the breast. Options for these devices include: commercially available devices, a device can be made by placing a bottle with a standard artificial nipple on a nearby table and threading a feeding tube through it, the tubing can be attached with tape to the parents nipple or areola for supplementing at the breast. Tube can also be taped to the caregivers finger for finger feeding.
Uses: provide complementary feeding to an infant at the breast to address low milk production, inefficient sucking, or slow weight gain. Can be used for relactating or inducing lactation, can be attached to a finger for others to feed the infant or to prime the infant for going to the breast.
Positives: enables the delivery of needed supplements while preserving breast-feeding by maintaining skin to skin contact and parental breast stimulation by not exposing the infant to artificial nipples: increasing the flow rate at the breast may encourage a reluctant infant to breast-feed it may help improve sucking organization and patterns.
Precautions: may be more intrusive and complex to learn how to use and repeat many times per day, may not work with an infant who has an ineffective sucking pattern for a weak suck, feeding supplies may not be widely available, infants can become dependent on tube feeding, may exhibit shallow jar excursions while sucking on an adult finger, some parents find it awkward to get both the tubing and nipple into the infants mouth, do not allow the infant to suck on the tubing like a straw without also latching onto the nipple, if milk container is position too low the infant may not receive milk, some parents might be allergic to the tape that is used to secure the tubing, expressed milk or infant formula will flow through the tubing but fortified liquids might not.
Teaching: tube feeding on a finger proceeds in a similar manner as syringe feeding, tickle the infants mouth to the mouth opens place your finger deeply into the infants mouth to near the juncture of the hard and soft palate, when used at the breast the milk reservoir can be elevated or lower to control the flow the infant though should suck to pull the milk out, infants are taking the nipple areola and tubing, tubing can be taped so it enters the infants mouth in the corner or under the nipple over the infants tongue, if tubing enters on the roof of the infants mouth they can be irritating, lower the container to increase flow for small or weaker babies, use largest size for a preterm infant, a disorganized infant or an infant who needs an easier flow, advance if to a smaller size as sucking becomes more robust, need frequent follow up with weight checks, control flow by raising or lowering milk Reservoir, may only allowed flow beginning of feeding then turn off or slow down after a substantial feeding has been completed to encourage more vigorous sucking, clean the feeding tube device with hot soapy water rinse it well and allowed to drive for the next feeding, often handy to have two sets so one is drying, blow air through the tube to clear it - a curved tip syringe works well for blowing air into it.
Specially design bottles formally called Haberman feeders
These are available for infants with special needs. No research on the efficacy of these bottles but they may be useful for preterm infants or those with severe feeding problems such as infants with down syndrome, cleft lip or palate, neurological dysfunction or disorganized sucking, cardiac defects or cystic fibrosis. One kind has a valve and teat mechanism to adjust the milk flow for an infant with a weak suck, three indicators on the bottle correspond to three flow rates from the slit in the nipple, nipple can be squeezed to provide positive pressure for infants with severe suction deficits. Devices for severe cleft feeding problems are also available, soft squeeze bottles and seem to work better than regular bottles for these infants. Special-needs may be affective in conjunction with advice from an occupational therapist for speech language therapist.
Precautions: expose the infant to an artificial nipple which may promote a shallow latch, may be difficult to obtain in some geographic area, deliver milk to compromised infants but do little for normal Feeding development.
Teach: press the nipple on infants lip and allow the infant to draw into the mouth, gently pull back on the nipple if needed to initiate sucking, teat may be squeezed to assist the milk flow for infants, rotate the bottle to achieve the 1:1:1 representing suck swallow breed ratio.
Artificial nipples
Made from silicone rubber or latex rubber, silicone is more expensive but longer lasting, latex may become gummy.
Variety of shapes including wider base and tapering. Some require suction only and not compression while others require compression.
Openings can vary including crosscuts and holes either on the top of the shank rather than nipple and some are no drip nipples. Nipple dripping is not related to flow. Hole size is one of the major determinants of flow rate, crosscut nipples have the fastest flow and are designed for older babies or babies who have thickened milk, manufacturers may claim that the nipples have high medium and low flow rates depending on number of holes and size of holes however whole diameter can vary among manufacturers and from nipple to nipple from the same manufacturer.
Nipples vary in length, human nipples should be placed about five MM in front of the hard and soft palate ideally a bottle nipples should also reached as deeply. Long nipples made trigger gag reflex and some infants, with short nipples may alter tongue movements if they are kept in the front portion of the mouth.
Positives: parents are familiar with bottles and are easily obtained, feedings can be quick, in certain situations can assist infants in learning sucking patterns, may be useful for twins or higher order multiples who are rotated between breast and bottle feedings.
Precautions nipple preference can occur, no way to predict which infants will have a preference or switch easily, some bottles release milk immediately while breast takes several seconds to several minutes, fast flow can contribute to apnea and bradycardia in preterm or stressed infants, different facial muscles are activated during bottlefeeding, some bottle nipples encourage infants to close their moths rather than opening wide, depending on the venting mechanism many bottles develop an internal vacuum as milk is removed which then can lead to the infant developing a pattern of releasing the bottle to allow air into it so the flow rate will increase, may use latex bottle nipples which can place them and the infant at risk for latex allergy, parents may have reduced self efficacy and ability to successfully breast-feed, may shorten the duration of breast-feeding‘s, may lead to obesity and may lead to excessive weight gain, can lead to dental caries in infants who are placed in bed with a bottle.
There is debate about the preferred type of bottle nipple: one thinks it should be a nipple with a long shank, wide base and slow flow of milk. A second opinion recommends a nipple with a cylindrical shape and a smooth graduated slope of the nipple from the base to the nipple tit. The third opinion recommends a nipple shape that allows the infant to obtain a seal to suck and to maintain a natural gape similar to breastfeeding.
Teach: position infant nearly upright, simulate attachment to the breast by resting the nipple on the infants philtrum, position bottle horizontally can aid in pacing and lowering the bottle quickly if the milk is flowing too fast, observe a good latch, observe for signs of milk flow that is too fast or too slow and for stress cues, pace the feeding for the same suck swallow breath and pause ratio as in breast-feeding, choose a nipple with a slower flow to match the infants ability to suck swallow and breathe, during pacing the bottle can be lowered so there is no fluid in the nipple until the infant shows readiness then can be raised again, sometimes equalization in air pressure inside and outside the bottle can affect the flow rate from the nipple.
Cons parents who bottlefeed more frequently tend to encourage finishing a battle, when are bottles offer to a breast-fed baby return the infant to the breast as soon as possible mimic breast-feeding when feeding with a bottle including initiating in response to hunger cues hold infant upright position in skin to skin talk gently and pace the feeding maintain eye contact throughout the feeding and do not prop the bottle refrain from distracting activities like television switch sides halfway through the feeding offer breaks snuggle and hold the infant, end the feeding when a infant indicates that is full.
Pacifiers also called dummies
Even though research has linked reduced milk production and shorter duration of breast-feeding pacifiers are used by 50 to 80% of mothers for an average of 13 months. Most commonly used to soothe a crying infant, to encourage sleepiness, and to stretch out the time between breast-feeding sessions.
Research has shown a profound positive role of pacifiers and sudden infant death prevention and for this reason it is recommended that infants be put to sleep with a pacifier after breast-feeding is well-established in about 3 to 4 weeks of age.
Pacifiers can provide relief during painful procedures, can be useful in a structured program for enhancing sucking function to increase oral tone and improve lips sealed on the breast, may promote continued breastfeedingg among new parents experiencing depressive symptoms, can provide non-nutritive sucking practice for preterm infants, nonnutritive sucking prior to or during tube feeding did not show shorter hospital duration, pacifiers have not been shown to benefit G.I. reflux disease in preterm and low birthweight infants.
Precautions: may be a marker for breast-feeding difficulties, many studies found in association between pacifier use and shorten duration of breast-feeding, newborns learn to recognize and prefer parents breast through oral, tactile, early exclusive exposure pacifier used can interfere with this ability, time at breast is reduced, breastfeeding strengthens the weak oral musculature of infants with Down syndrome and pacifier use interferes with this process, can harbor bacteria, virus and yeast, may cause infant drowsiness and missed feedings, can contribute to changes in dental arch and tooth position increasing rates of malocclusion and dental problems with prolonged use, (Prolonged breast-feeding may have a positive affect in reducing malocclusion), can increase risk of otitis media, use of a latex pacifier can increase the risk of latex allergies, have been implicated in oral injuries.
Teaching: should be avoided until after the first month of life when breast-feeding is well established choose a pacifier that is not a potential choking hazard, avoid pacifiers that have a handle because they could be forced into the child’s mouth it falls forward, choose a pacifier that has a mouth guard wider than the infants mouth and has breathing holes, do not tie the pacifier around the infants neck, wrist, or crib rung, avoid rubber due to possible allergies and phthalates which are industrial chemicals, do not dip the pacifier in sugar due to risk of tooth decay, do not dip the pacifier in honey due to risk of botulism, do not share pacifiers with other children, and instruct parents in routine cleaning.
Pacifier should be discontinued after all primary teeth have a ruptured or by six months or one year of age.
Infant scale
Two types: digital scale with an accuracy within 2 g which is appropriate for determining milk intake, balance scale is useful for serial weights but does not have the accuracy needed for test weights.
Uses: determine milk intake a feeding (test weight), can be used to determine whether supplementation is necessary, test weight can contribute to a decision to discharge a preterm infant, can validate accuracy of milk production, used to monitor feeding adequacy in compromised infants.
Positive outcomes: test weights are more accurate for determining milk transfer than observation, can be used to determine adequate intake which is reassuring to parents of late preterm and preterm infants, support accurate determination of how much supplementation is needed, and used for hospital discharge is protective to exclusive breast-feeding.
Precautions: digital scales are expensive, possibility of error if tubing or wires are attached to the infant, there is disagreement among clinicians about using test weights.
Appropriate use: must be placed on a flat surface and be sure the leveling bubble is centered, periodically check the accuracy must be clean between infants, ensure that all parameters the same for the before feeding weight and the after feeding weight, do not drape blankets or clothing over the edge of the scale, disconnect any tubing or wire that may be safely disconnected, obtain a prefeed weight two times for accuracy, Reweigh the infant after each breast and at the end of the feeding two times for accuracy.
Determine the weight gain: weight gain in grams is equal to volume in milliliters consumed by the infant
To get a reliable average do test week weights at each feeding for three days.
Topical treatments
Can enhance the healing of damage nipples and promote breast-feeding. Nipple pain is one of the main reasons why mothers stop nursing.
Trauma or pain may present as a lesion, crack, fissure, eroded skin, ulcer erythema, edema, blister, bleeding, Ekhymosis or the skin looking white or yellow instead of pink.
Options to heal the damage: help the dyad with correct latch and position, human milk, lanolin, hydrogel pads, breast shells, ointment, olive oil, and nipple shield and warm compresses are chosen by parents to decrease and heal nipple trauma but there’s little evidence regarding their efficacy.
Must help the parents discover the cause of the pain.
Moist wound healing is the most effective treatment to heal broken skin: creams, ointments‘s and dressings provide various levels of treatment.
Repair with moist treatments occur at twice the rate of dry treatments, express milk can be used to treat painful and cracked nipples, many factors in human milk protect against tissue damage including secretory immunoglobulin, immunoglobulin M immunoglobulin G, lactoferrin, lysosome complement component three etc., other factors protects against inflammation.
Human milk has been shown to improve healing within 3 to 6 days, teach parents to use good hygiene to rub on any topical agent, apply a generous amount of expressed milk to the damaged area of the nipple after each feeding, allow the milk to air dry using a breast shell over the air dried milk to enhance healing.
Creams and ointments: hypo allergenic, medical grade anhydrous, or modified lanolin has been shown to provide a moist wound healing environment, lanolin is easy to apply but it can remain sticky and messy extra virgin olive oil has been shown to have trophic, anti-inflammatory and antioxidant properties that aid in decreasing pain and increasing healing, and moisturizing gel made from peppermint oil shows promise in soothing and healing sore nipples. Peppermint oil contains menthol and in small doses has been found to be soothing and to have antibacterial properties and safe for babies.
All purpose nipple appointment contains an antibiotic and an antifungal and a steroid can aid in the healing of sore nipples but research shows it may not be any more effective than lanolin and reducing pain scores or increasing breast-feeding duration.
Some creams have questionable ingredients and are not recommended: these include vitamin E oil, cocoa butter, bag balm, vitamin a and D pointman petroleum jelly, and baby oil.
Appropriate to use: maintain good handwashing and hygiene read all manufacturing details.
Positive outcomes: have been shown to promote healing within 5 to 6 days which may reduce pain and have a soothing effect, widely available and inexpensive, most do not need to be washed up prior to feeding.
Precautions: nipple and the areola breathe and perspire like all skin and then I got my grounds gland secrete lubrication that protects the area of a nipple, creams and ointments decrease the breathing and lubrication. Some products may need to be washed off before each feeding, some combination creams such as those containing pain in oil have ingredients that could provoke an allergy in the infant, some topical treatments with petroleum bases could irritate the nipple skin and even clog pores, creams can’t be disrupted to the natural environment of the skin, pores and glands.
Commercial dressings can be used for healing nipples: there are three types:
Water-based hydrogel dressing or insoluble hydrophilic materials made from synthetic polymers, promote granulation of tissue and epithelium,
Glycerin-based dressings have a humectant that binds and holds moisture, also demonstrate antibacterial antifungal fungal qualities
Gel dressings are available in gel, gauze and pre-cut sheet forms. These dressings have some positive aspects: provide a moist environment provided a barrier against contamination and friction maintain an appropriate wound temperature to increase blood flow to the site, or non-irritating.
Precautions in using these dressings: expensive, hydrogel dressing may increase the risk of wound infection and should not be used if there is infection.
Teach how do use dressings appropriately: good handwashing and hygiene, read directions, peel the back of the dressing and apply directly to wound, remove the dressing during breast-feeding and reapply directly to the wound, dressings can be used for several days if rinsed after use and kept in clean environment when not in use, can be chilled when not in use.
Teabags used to heal sore cracked nipples, low-cost and easily available, warm tea bag can be applied a sore nipples for 15 minutes after breast-feeding, some herbal teas are known to be anti-inflammatory antimicrobial and contain healing properties, black tea in parts bitter taste of the nipple whereas green tea is much milder. Warm compresses bring blood to the area of trauma and aid in healing, and also can decrease pain,.
Precautions: should not be used as the first choice for treatment because they can change the smell and taste of the nipple, may have an astringent effect that can promote more drying and cracking, uses more of a ritual then an evidence-based treatment.
