Clinical/Comm Skills - Week 5 - Managing Breastfeeding Challenges - Attachment&Position, sore/cracked nipples, engorgement, mastitis, thrush

Question 1

How long should infants be exclusively breastfed?

Answer 1

Infants should be exclusively breast fed up until 6 months of age to achieve optimal growth, development and health and continue up to two years of age or beyond

Question 2

Why has there been a fall in breastfeeding rates?

Answer 2

This is due to an aggressive marketing of formula feeding Poor hospital practices - not enough breastfeeding information Better infant formulas also now exist

Question 3

What is the initiative revised in 2012 by WHO and UNICEF to educate mothers on the benefits of breastfeeding?

Answer 3

This would be the Baby Friendly Initiative (revised 2012)

Question 4

Almost all women can produce enough breastmilkand yet … Insufficient milk” is the commonest reason given for stopping breastfeeding” What are considered the two most important aspects of breast feeding by many?

Answer 4

This would be positioning and attachment

Question 5

Good attachment is essential for effective pain free breast feeding What can poor attachment lead to?

Answer 5

Poor attachment can lead to: Sore nipples Engorgement Mastitis Unsettled baby as there may be insufficient milk production due to the poor attachment

Question 6

How should the nipple be placed in the babies mouth?

Answer 6

The nipple should be at the junction between the hard and soft palate of the babys mouth

Question 7

When the baby attaches to the nipple, should the babies nose or chin be indenting in the mothers breast? Should more areola be visible above the top lip or below the bottom? Should the babies cheeks be pulled in or rounded?

Answer 7

The baby should have a large mouthful of breast with cheeks full and rounded The chin should be indenting into the mothers breast - NOT the nose If areola visible, more should be visible above top lip

Question 8

Position refers to the mother and baby positioning to ensure good feed and ample opportunity for a good attachment How should the baby be positioned?

Answer 8

The mother should be comfortable and well supported The babies neck should not be flexed - head neck and back in a straight line - babies windpipe/oesophagus fully patent when head is at rest

Question 9

Poor attachment can lead to: Sore nipples Engorgement Lactating mastitis Lactating thrush And An unsettled baby - not a good milk supply and therefore failure to thrive How can poor attachment cause these?

Answer 9

Poor attachment can causes sore nipples and also cracks The sore nipples can lead to milk not being removed efficiently which can lead to engorgement and the stasis of mouth - (the stasis of mouth along with cracks provides an opportunity for bacteria to enter the breast causing mastitis) The breast-milk not being adequately removed leads to an insufficient milk supply to the baby - baby is frustrated and baby fails to gain weight and breast-milk production declines

Question 10

Sore and craked nipples Causes: Poor positioning and incorrect attachment Mechanical pumping, Tearing the nipple/ areola junction Detaching the baby or pump from the breast incorrectly. What are the signs and symptoms of sore and cracked nipples?

Answer 10

Signs and symptoms Sore nipples May have engorgement Worse at start of feeding Red, blistered nipples Baby may vomit blood

Question 11

Can see the cracked nipple due to poor attachement What are the causes of engorgement?

Answer 11

Delay for the first feed Poor positioning and attachment Restricted feeding Ineffective emptying Supplementing

Question 12

What are the signs and symptoms of engorgement?

Answer 12

The breasts look shiny due to the oedema and can be painful Milk does not flow as well due to the increased pressure Breasts may be red and the mother may feverish

Question 13

Engorgement occurs when normal breast fullness develops into oedema, increased lymphatic, blood supply and milk flattening nipple leading to attachment difficulties. What can engorgement frequently lead to?

Answer 13

Engorgement can frequently lead to an insufficient milk supply and the opportunity to have breast infections Severely engorged breasts

Question 14

Poor management of engorgement leads to mastitis and a rise in Feedback Inhibitor of Lactation and suppression of lactation. What can be done to manage engorgement?

Answer 14

Express prior to feed to release the pressure in the breast Hand expressing is less painful and traumatic and warm baths or compressors are soothing and help with the expression Ensure good attachment and fully emptying one breast before moving to another Antibiotics are not helpful in engorgement and can lead to Candida infections

Question 15

The causes of mastitis * plugged milk duct * breast infection * Poor positioning and attachment * Infrequent feeds * Consistent breast pressure (bra, clothing) * Dummies Supplementation * Trauma What are the signs and symptoms of mastitis?: how to differ between a blocked duct and breast infection?

Answer 15

Signs and symptoms Blocked duct - tender spot, redness, sore lump without fever Breast infection - tender spot, redness, sore lump wit fever Also may have nausea and vomiting Infective mastitis may have cracks, pus and bleeding

Question 16

Highlight that there is a difference between a plugged duct and an infection Remember if untreated, likely that a plugged dill become infected Describe the differences?

Answer 16

Plugged duct * Comes on gradually with a sore lump without the mother having a fever * The breast is red but not flaming hot and usually the pain is mild, mother is generally well Infection Comes on suddenly, with breast red hot and swollen, mother has flu-like symptoms and has a fever In both - the pain is localised to the area of infection

Question 17

What is the most important treatment of mastitis?

Answer 17

Encourage the mother to continue breastfeeding / expressing even if they are not wanting Massage and express if needed and anti-inflammatory medication

Question 18

What medication for symptoms relief is usually given to the mother?

Answer 18

Symptom relief with NSAIDs - ibuprofen or paracetamol

Question 19

Tender spot, redness, sore lump without fever – blocked duct A tender spot or lump and a low grade fever – breast infection When are antibiotics considered in mastitis?

Answer 19

If symptoms relief with medication + the expressing before feeds with warm bath or warm compressors fail to improve symptoms or symptoms worsen after 12-24 hours - consider antibiotics

Question 20

What antibiotics are recommended in mastitis? What is second line? What is usually the causative organism?

Answer 20

Flucloxacillin is recommended for 7-10 days first line Clindamycin is second line if pen allergic Usually staph aureus is the causative organism

Question 21

A breast abscess is a localised collection of pus which forms in an area of the breast that has no opening for drainage ands so must either be aspirated or surgically drained. It is a serious and painful;l condition that need immediate medical attention. It can be differentiated from mastitis by the more localised inflammation and the presence of a regularly-shaped lump. How is a breast abscess treated?

Answer 21

An abscess is a localised collection of pus which forms in an area of the breast that has no opening for drainage ands so must either be aspirated or surgically drained. The aspiration fluid is then sent for cilture and flucloxacillin is gain (obviously change if a different bacterial cause)

Question 22

Lactating thrush can affect the mother or baby What are the signs of thrush in the mother?

Answer 22

Intense pain in the nipple or pain that does not change when changing attachment Sudden pain in breast/nipple after a long period of pain free feeding Cracks that will not heal Nipple may be red, flaky, or sensitive to touch

Question 23

What are the signs of thrush in the baby?

Answer 23

Nappy rash Oral thrush Baby pulling off breast while feeding Baby windy, fretful or difficult to settle

Question 24

This picture shows a topical candida (thrush) infection of the breast. It can be distinguished from trauma by the lack of cracks and the spread of the inflamed area, as well as by the mother’s account of the pain. What is the treatment for the mother with thrush?

Answer 24

For mother cream For baby oral gel Mother - miconazole 2% cream applied to nipple and areola after each feed for 7 days

Question 25

What is the treatment for thrush in the baby? What age does the treatment change?

Answer 25

Treatment changes before and after 4 months before 4 months Miconzaole oral gel applied gently to mucosa after feeds After 4 months Nystatin oral suspension after feeds

Question 26

What is the different treatment of thrush in the mother and baby?

Answer 26

Mother * Miconazole 2% cream applied to nipple and areola after feeds for 7 days Baby Before 4 months * Miconzole oral gel applied gently to oral mucosa after feeds After 4 months * Nystatin oral suspension after feeds