thrush Flashcards
Situation
Jasmine is 12 days postnatal following universal midwifery care and an elective caesarean section birth in the local maternity unit. She has been breastfeeding her baby Caleb since he was born. You are community midwife who is routinely visiting her at home today
Demonstrate your initial introduction and assessments please
Introduce myself
Explain doing a postnatal check
Gain consent for examination
Apply PPE
Ask how she is feeling
Ask how her breast feeding is going
Jasmine tells you “Celeb has been really unsettled this last few days. He seems to have terrible nappy rash, and i just can’t keep him feeding at the breast for long at all. Although, maybe its my fault, i am in agony when he attaches- its like a deep stabbing pain- maybe i’m scaring him off me?
what may be the breastfeeding problem?
From what you have described I think you may have thrush
Can you explain to Jasmine what thrush is and some if it’s signs and symptoms of thrush
Thrush is fungal infections caused by Candida Albicans that can affect mums nipple and babies mouth.
Commonly known as nipple or breast thrush in mothers and oral thrush in babies. It can also migrate to genital area.
Thrush is contagious and can be passed from mother and baby during feeding. It is important to treat both effectively to prevent reinfections
Signs and Symptoms of breast thrush;
Nipple and breast pain
Itching, burning and stabbing pains deep in breast
Redness and flakiness with nipple trauma that wont heel
No visible signs however a white plaque can present around nipple
No pyrexia
No red areas
Signs and Symptoms of oral thrush in baby;
White plagues on tongue, gums and mouth that do not go away (if goes away when rub most likely milk coating and not thrush)
A pearl-like sheen on lips
Unsettles baby when feeding and less keen to feed
Signs and Symptoms Genitial thrush
A nappy rash appears after oral thrush present
Irritable of baby if sore
Rash can present as redand white spots
Rash can flare quickly
Causes of breast thrush
Oral thrush is usually due to poor hygiene. Candida thrives in warm, moist environments (Vagina,nappy, mouth)
If babies mouths overgrowth of candida their immune system is less developed and can’t resist the infection. It can also affect babies if they have been on a course of antibiotics.
Antibiotics can kill good bacteria giving space for bad bacteria to grow
If there is nipple trauma there is more popular area to develop thrush
Jasmine tells you “i never knew thrush was something to lookout for. Antenatal class were to far away from me so didn’t make it to any.
Educate Jasmine on anatomy and physiology of breastfeeding to her?
External structures
Fatty adipose tissue- create shape and size
Areola- Darker central part of the breast to allow a guild for baby to get to breast
Montgomery tissue- Raised spots that excrete sebum to keep nipple moisturised and create a small for baby to move to
Nipple- central part of the breast that expels the milk
Internal structure
Ribs- create a structure for body and breast
Alveoli cluster - contain multiple alveoli
Alveoli- lined with lactoytes
lactoytes- milk producing cells
Myoepithial cells- contractile cells
Lactiferous ducts-transport milk to exit the nipple
Hormones
Oxytocin- feel good hormone that creates a bond with baby and mother. When baby suckles it sends a signal to the brain to release oxytocin from the posterior pituitary gland stimulating the let-down reflex. Oxytocin causes the myoepithial cells surrounding the alveoli to contract and push milk towards nipple. Emotional bonding can come from touch, taste, scent, sight and sound to help stimulate oxytocin
Prolactin- Milk producing cell that is stimulated once the delivery of placenta, progesterone levels fall and stimulates prolactin. When baby suckles signal is trigger the release of prolactin from the anterior pituitary gland. Th hormone acts on the lactoytes promoting production of milk. Prolactin levels are highest when baby is suckling and rise at night with sleep.
Feedback inhibitor of lactation (FIL)- Regulatory role in breastfeeding and milk production. FIL is a whey protein. Fil sends signals to lactocytes to slow down production when breast fill up and is an example of negative feedback mechanism. When milk is being emptied from breast FIL decreases and productions continue. It helps to prevent overproduction.
What management strategies to support jasmine with thrush
Routine postnatal checks
Inspect breast with consent
Inspection babies mouth and genital areas
Observe a feed and rule out ineffective attachment causing the pain
Take a pain history
Give support methods to family to prevent in future
Take swabs to send to labs for diagnosis
Consider treatment options
Methods of support would you discuss with Jasmine
Reassure breastfeeding can continue while being treated if mum is comfy enough.
Educate on ways to keep up milk supply
Breast milk can be expressed and given the same, just take out of fridge just before giving
Change breast pads each time they get wet
Teach good hand hygiene
Give everything that may have come in contact with thrush a hot wash cycle
Sterilse toys
Dress baby in loose fitting clothing
Mum in loose clothing
Change nappies regularly- use absorbent nappies
No fragrant wipes
Good quality probiotic
Dietary adjustments - reduce sugar and processed foods
Jasmine tells you that she wants to continue breastfeeding but feels lost and doesn’t know where to begin as he is wanting to feed again.
Explain methods of attachment and different feeding positions
Attachment
Attachment is to ensure breast is in the mouth appropriately
Nipple should be at the back of the mouth at the soft pale to reduce change of nipple trauma
Chin leading, wide mouth, asymmetrical attachment
C- close into mother
H-heads free to allow baby to attach
I - Babies body should be in line to allow her to swallow
N- nose to mouth allowing baby to open mouth wide and get a good amount of breast tissue into mouth
S- sustainable position for baby and mum as feeding can be long
More areola should be above than below visible
Cheeks full
Mouth open
Shouldn’t be painful
Positions
Cross cradle
Rugby ball hold
Upright
Side lying
laidback
Treatments to ease Jasmine’s discomfort
Symptoms of thrush should improve in 48 hrs following commencing treatment
offer follow up visit within this time
It can take around 7 days to completely clear but pain can last couple of days after
Before administering any drugs you should check;
Name and dob
Name band
Compare with notes and drug kardex
Up to date weight
Any allergies
Prescription is signed and dated by correct healthcare professional
Correct dose is prescribed
Route is appropriate
Consent for taken
Watch patient taken the medication at appropriate time
Paracetamol- Maternal
Taken orally for pain
<50kg 500mg every 4hrs up to 6 times in 24hrs with max 3g in 24hrs
or
1g every 3 times in 24 hrs with max 3g in 24 hrs
>50kg 1g every 4 hours up to 4 times in 24hrs with max 4g in 24hrs
Don’t give is sensitive to drug
Ibuprofen- Maternal
Taken orally for pain and inflammation
400mg 3 times a day taken 6 hourly with max 1.2g in 24 hrs
Don’t take is allergy to ibuprofen or asthmatic
Miconzole 2%
Tropical (cream) for anti-fungal treatment
Small amounts to nipple after every feed and gently removed before next feed
Don’t give if allergic
Fluconazole- maternal
Taken orally for anti-fungal treatment
150mg as initial dose and then 100-200mg daily for 10days
don’t give if known allergy
Nystatin- Neonatal
Orally for anti-fungal treatment
1ml 4 times daily after feeds- continue for 7 days after symptoms disappear
Don’t give if known allergies
