Special circumstances

Question 1

Most common reason for stopping breastfeeding in the first two weeks

Answer 1

Breast refusal as it undermines their confidence in their ability to breastfeed

Question 2

Signs of breast refusal

Answer 2

Arching of the back
Stiffening of the body when approaching the breast
Pushing the breast away with arms and legs
Crying
Extending and turning the head away from the breast

Question 3

What is breast refusal commonly associated with?

Answer 3

With an unpleasant event involving breastfeeding such as pushing the head into the breast
Some mothers report the infant biting them and a startled reaction leading to breat refusal
Other causes may due to smell such as changed perfume, washing powder or soap, or the taste of milk due to diet or medication

Question 4

What to do when there is breast refusal?

Answer 4

Don’t exacerbate the problem. The aim is to create a relaxed mother- infant dyad by encouraging a calm and relaxing environment

Maximise skin to skin - not only at feeding times; recommend co bathing
Closely observe for feeding cues and initiate breastfeeding before the infant starts crying
If the infant protests, discontinue the feeding and calm the infant down. Try again once again the infant is calm and displaying feeding cues
If the infant does not BF, express and give via cup or syringe
Breastfeed in a relaxed and quiet environment with no interruptions

Question 5

Normal healthy infants who are reluctant to feed

Answer 5

Are not at risk as they are able to mobilise glycogen and ketones for energy

Question 6

Why is it important to encourage a sleepy healthy infant to feed?

Answer 6

Promote the production of prolactin

Question 7

If the infant does not suckle

Answer 7

The mother should hand express at regular intervals

Question 8

Reasons infants are sleepy?

Answer 8

Maternal analgesia in childbirth
Birth complications that lead to increased levels of endorphins 
Congenital anomalies or illness
Birth trauma 
Operative delivery
Jaundice
Prematurity

Question 9

What is normal sensations for nipples in the early days?

Answer 9

Sensitive and tender but not painful

Question 10

What are painful nipples associated with?

Answer 10

Sore or cracked nipples which may have a fissure, blisters and bleeding

Question 11

What causes painful nipples?

Answer 11

It is likely to do with positioning and attachment in the first few days. However, pain can be a symptom of thrust and other problems which need to be ruled out. Other reasons include Raynaud’s disease, eczema, dermatitis or impetigo.

Question 12

What can an open wound on the nipple lead to?

Answer 12

It is a portal of entry for infection

Question 13

Practice recommendations for nipple trauma

Answer 13

Encourage skin to skin
Attempt to put the infant regularly to the breast followed by hand expression which can be given by cup or syringe
Reinforce how to recognise feeding cues
Ensure the infant is not hot or cold when feeding
If required, use hand expression to encourage the flow of milk
Main aim is to alleviate pain while maintaining lactation
First line treatment is always to correct positioning and attachment
Can consider lanolin or expressed breastmilk

Question 14

What other problems can nipple pain cause?

Answer 14

Can be very distressing resulting in anxiety (adrenaline and cortisol) preventing the let down reflex
Reduction in the frequency and length of breastfeeds or exclusivity of one side, resulting in ineffective removal or even discontinuation

Question 15

Nipple shields

Answer 15

Been suggested for nipple pain. Evidence suggests they reduce milk supply by 22%. However evidence found there was no significant difference in weight gain for babies who fed with or without nipple shields and they may be helpful for a temporary measure.

Question 16

What often causes concerns about insufficient milk supply?

Answer 16

Due to a lack of confidence as a result of influences inherent in a bottle feeding culture, where the amounts of formula milk are measured and regulated

Question 17

Failed lactation can be classified as primary or secondary

Answer 17

Primary is the inability to produce breastmilk

Secondary due to poor techniques or management of breastfeeding problems

Question 18

Common causes of failed lactation

Answer 18

Hormonal imbalance due to conditions such as diabetes, hypothyroidism and obesity.
Birthing complications such as preterm labour, CS and retained placenta may also contribute
Other issues include breast trauma, surgery, anxiety, PPH and polycystic ovaries

Most commonly associated with a lack of skin to skin, infrequent feeding and ineffective removal of milk for reasons such as tongue tie, maternal infant separation, poor attachment, supplementary feeds and use of teats and pacifiers

Question 19

Signs of inadequate milk transfer

Answer 19

Few than 3 wet nappies per day by the third day
Few than 6 wet nappies by the fifth day
No evidence of changing stools by the third or fourth day
Greater than 7% weight loss at day 5
Poor weight gain
Infant not satiated
Soft breasts
No signs of milk transfer during feed; swallowing signs and visible milk
Persistent jaundice

Question 20

Recognising inadequate milk transfer early is crucial and the first steps in supporting mothers with problems are …

Answer 20

Observe a complete feed
Take a breastfeeding history and assessment:
- Frequency of feeds + pattern of feeds
- Use of supplementary feeds, teats or dummies
- Birth history
- Wet + dirty nappies

Question 21

Plan for inadequate feeding

Answer 21

1. Skin to skin
2. Increasing the number of feeds, ensuring at least one night feed. Switching between breasts may keep the infant awake
3. Ideally give breastmilk rather than formula following a breastfeed, if supplementation is required. This should be ideally not be given by bottle or teat to avoid nipple confusion
4. Teaching the mother to correct any positioning and attachment issues
5. Solve any problems like tongue tie
6. Additional breast stimulation and complete breast emptying using a mechanical breast pump

Question 22

PPH impact of milk supply

Answer 22

Can impede lactogenesis II by inhibiting the production of prolactin

Question 23

Why should inverted nipples not affect BF?

Answer 23

With correct positioning and attachment, the infant laches on to the breast not the nipple. However, many mothers do find it a challenge, but it is possible to successfully breastfeed.

Question 24

How to assess inverted nipples?

Answer 24

It has been recommended that the pinch test will see if the nipples are truly inverted, by squeezing the areola 2.5 cm behind the nipple. If it protrudes it is not a true inverted nipple.

Question 25

What is breast engorgement most often associated with?

Answer 25

Delayed or infrequent feeding or ineffective removal of breastmilk

Question 26

What is engorgement often confused with?

Answer 26

Breast fullness which occurs in the early days due to increased prolactin levels, increased blood flow to the breast and an increase in milk volume.

Question 27

What does engorgement present as?

Answer 27

Can extend from the breast to include the areola and nipple and some women may experience a low-grade pyrexia. The mother may also complain of pain, particularly before a feed and during the night.

Question 28

What happens if engorgement isn’t resolved?

Answer 28

The milk storage capacity of the breast is exceeded, it can cause the over distension of the milk secreting cells, altering their shape, which will decrease further milk production.
If there is a build-up of breastmilk and FIL, this will also contribute to a decrease in milk production.
The congestion can also inhibit lymphatic drainage of toxins and bacteria and predispose the mother to mastitis.

Question 29

Difference between breast fullness which is normal and engorgement which is abnormal

Answer 29

Breast fullness:

• Warm
• Tender
• Full
• Skin; possible marbling
• Milk flows

Engorgement:

• Painful
• Full
• Shiny; possibly inflamed
• Milk does not flow easily
• Congestion and increased vascularity

Question 30

Blocked ducts

Answer 30

Blocked ducts are usually caused by ineffective removal of breastmilk, resulting in milk stasis in the lactiferous ducts, or by restrictive clothing such as tight bra, causing pressure on the outside of the breast. Blocked ducts present as localised tenderness and redness in an area of the breast.

Question 31

What is mastitis?

Answer 31

Is the inflammation of the mammary gland. Mastitis is an inflammatory response to breastmilk leaking into the tissue from a blocked duct, may or may not involve infection.

Question 32

What causes mastitis?

Answer 32

If engorgement or blocked ducts are not corrected and milk stasis persists it may lead to mastitis and ultimately cessation of breastfeeding. Other causes include infrequent or poor emptying of the breasts, sore or cracked nipples (which can be a portal for infection), blocked milk ducts, thrush and restrictive clothing.

Question 33

What reduces the risk of mastitis?

Answer 33

Frequent breastfeeding

Question 34

Mastitis is usually diagnosed clinically from the following symptoms …

Answer 34

Erythema or inflammation of an area of the breast: a hot, red, swollen wedge-shaped area
Breast pain
Flu like symptoms including fever, headache, fatigue and general aches and pains in response to the inflammatory process

Question 35

Practice recommendations for mastitis

Answer 35

1. Continue breastfeeding more frequently than usual to ensure the breast is effectively emptied, as not doing so may exacerbate the condition. No risk to infant however, some babies appears to dislike the taste which may be due to the increased sodium content.
2. Changing positions for feeding may be helpful. CHIN
3. Teaching the mother to recognise the signs of an effective feed
4. Feed from the affected side first and express milk at the end to ensure the breasts are kept as empty as possible, because, on average, babies only fully empty the breast at one or two feeds per day.
5. If unable to feed, express regularly. Milk production may increase at first, but this is temporary and the number of times she expresses can be reduced as the symptoms subside
6. Rest and fluids
7. Warm compress or shower prior to a feed and cold compress after a feed
8. Non-steroidal anti-inflammatory medications such as ibuprofen 400mg 3 times a day (avoid id asthmatic or stomach ulcers) or paracetamol 1g four times a day to reduce pyrexia – aspirin should not be taken while breastfeeding
9. Antibiotics are required is symptoms persists and the mastitis is thought to be due to an infection

Question 36

When may admission to hospital be required?

Answer 36

Signs of sepsis (tachycardia, fever, chills)
Infection progresses rapidly
Mother is haemodynamically unstable or immunocompromised

Question 37

Importance of breastfeeding preterm infants

Answer 37

Preterm infants who are not breastfeed are at increased risk of morbidity and mortality.
They have an immature gastrointestinal tract with increased permeability and susceptibility to infection.
Breastmilk has high levels of anti-infective properties and prebiotics, which reduces the incidence of NEC, diarrhoea, respiratory infection and development of allergies.
It is more readily digested than formula.

Question 38

Lactogenesis II in mothers of preterm infants

Answer 38

Is significantly delayed in mothers of extremely premature infants for a number of reasons, such as incomplete mammary growth and stress.
It has also been suggested that corticosteroids given in the antenatal period between 28-34 weeks can delay lactation.

Question 39

Problems with feeding preterm infants

Answer 39

May have a poor or absent suck-swallow-breathe coordination (dependant on gestational age)
Lack cheek pads leading to a weak suck
May have nasal prongs, feeding tubes etc, leading to a poor oral experience
May have lung disease or other impairments of a physical or neurological nature
May lack the energy to complete a feed
Require medically indicated supplementary feeds

Question 40

Environment for feeding preterm infants

Answer 40

Supportive and positive environment that is private, warm and quiet, with reduced light and noise levels and encourage skin to skin.

Question 41

When can an infant suck from the breast?

Answer 41

Approximately 32 weeks

Although the rooting reflex is underdeveloped and will therefore require extra support with positioning and attachment

Question 42

Between 30 and 34 weeks

Answer 42

Preterm infants are able to lap milk from a cup, which gives the advantages of providing satisfying oral experience and gastric stimulation. With cup feeding the infant is able to control the amount and rate of the feed similar to breastfeeding.

Question 43

Jaundice and breastfeeding

Answer 43

Breastfeeding has been associated with jaundice; however this may be due to poor breastfeeding practices that restrict breastfeeds and encourage maternal infant separation, with the effect of infrequent feeds, weight loss and delay in meconium evacuation.

Question 44

Feeding and physiological jaundice

Answer 44

Physiological jaundice can become worse if the infant does not feed frequently. This is further exacerbated by the fact that jaundice infants tend to be sleepy and reluctant to feed. Lots of skin to skin means there is easy access to the breast which facilitates rooting behaviour and prolactin surges for the maintenance of milk production. Regular breastmilk expression should also be encouraged and given to the infant by cup or spoon.