breastfeeding management in primary care- part 1-final · pdf file5/15/17 1 breaseeding...
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5/15/17
1
Breas+eedingManagementin
PrimaryCare-Part1
May25,2017,Duluth,MNPamelaHeggieMD,IBCLC,FAAP,FABMAddieLicari,MD,FAAFPLorraineTurner,MD,ABIHM
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Disclosure
• WehavenofinancialorethicalconflictstodeclarerelatedtothiseducaLonalacLvity
Topicsthismorning_______________________________________________________
• Sorenipples• Breastpain• UnderweightBaby• SupplementaLon• IncreasingMilkSupply• Ankyloglossiaandfrenotomy• MedicaLonsandbreas+eeding• Casestudies
Objec3ves
1. Discusstheassessmentandmanagementofsorenipplesandbreastpain
2. Outlinetheapproachtoabreas+eedingbabywithslowweightgainorweightloss
3. Definewaystoincreasemilk
4. DiscussankyloglossiaandindicaLonsforfrenotomy
5. DescribehowtodeterminethesafetyofmaternalmedicaLonsduringbreas+eeding
o Improveshealthoutcomesinchildren
o Improveshealthoutcomesinmothers
o Savesmoney
WhyBreas+eeding?
• Improveshealthofchildren• LessinfecLon(OM,diarrhea,pneumonia)• Lessobesity• ReducedriskofSIDSandNEC• Lowerratesofallergyanddiabetes
• Improveshealthofmothers• Lowercancerrates-breastandovarian• Lesslong-termobesity,DM,heartdisease• Fasterpost-pregnancyweightloss
• Goodforfamiliesandcommunity• LessLmeoffofworkforsickkids• “Green”-lowcarbonfootprint,lesspolluLon• Savesmoneyforfamily-$2000formula/yr• BarLckarLcleinPediatrics,2010
– If90%babiesBFfor6mo– USwouldsave$13billion/year– Prevent911deaths
BarLck,Pediatrics2010;125:e1048–e1056
WhyBreas+eeding?
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RisksofNotBreas+eeding
100
178
257
6732
6423 18
56
138
427
0
50
100
150
200
250
300
ExcessRiskAssociatedwithNotBreastfeeding(%)
Adapted from Surgeon General’s Call to Action. http://www.surgeongeneral.gov/topics/breastfeeding/
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“Breas+eedingisapublichealthissuenotjustalifestylechoice”
…exclusivebreas+eedingfor6months&conLnueamerbabyfoodintroducedfor1yearorlongerasmutuallydesiredbymotherandinfant….
Breas+eedingasaPublicHealthissue
AAP2012Breas+eedingPolicyStatementPEDIATRICSVolume129,Number3,March2012e827
Breas+eedingRates MostcommonBreas+eedingConcerns_______________________________________________
• DoIhaveenoughmilk?• Sorenipplesorbreastpain• CanIbreas+eedwiththismedicaLon?• Slowweightgaininbaby• Lowmilksupply
GreenLights-Breas+eedinggoingwell
• Momcomfortable• Babyhasnormalweightgain/loss• BabysaLsfiedandwakesforfeedings• Familyfeelsconfidentandthatchoicesarebeinghonored
• Urineandstoolsokforage• Nouratecrystalsamer2-3days
Whatis“normal”weightforbabies?
• Gainingweightby5daysandbacktobirthweightby2weeks
• Normalnewbornweightloss~5-7%belowbirthweight,“lessthan10%”
• 1ozperdayand“Lmeoffforweekends”
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Red flags: Breastfeeding NOT going well
§ ELIMINATIONPATTERNS stoolsandwetdiapers
§ WEIGHTGAIN/LOSSinBABY§ MOMwithSORENIPPLES/PAIN§ SLEEPYBABY/INCONSOLABLEBABY
Red flags: Weight
• “Excessiveweightloss”inbaby• >“10%”belowbirthweight• ConLnuedweightlossamer5days
• “Slowweightgain”inbaby• lessthan0.5-1ozperday• babynotbacktobirthweightby2weeks• crossingWHOgrowthchartpercenLles
Red flags: Elimination Patterns
STOOLSØ Dark,blackstoolsamer4thdayØ Infrequentstools<3yellowstoolsatday5
URINEOUTPUTØ Fewwetdiapers<4-5/dayamerday5Ø pink/salmoncoloreduratecrystalsindiaperamer3rdday
Red flags: Frequency and Quality of feeds
• < 8 feedings in 24 hrs, (should be 8-12 feedings per
24 hours, swallowing heard)
• Baby not satisfied after feeding, “always hungry”
• Baby feeding “constantly”
• “Good” baby – “too good”, rare cry and sleeps 5-6 hrs, infrequent feeding, sleepy at breast
Case1–SoreNipplesand“BFW”
• Motherwithsorenipples.G1P1Vaginaldelivery,babyispostdates-41wksand8lb7oz.Day2inhospital-momsayshernipplesaresore,nocracksorbleeding
• Nursesays“latchlooksgood”.Momgivenlanolinandhydrogels.Baby’sweight5%belowbirthweight,Normaloutput-stools/wets.NursereportstoMDduringrounds-“BFW-“breas+eedingwell”
• Homeday2.Seenincliniconday5fornewbornexam-mothersLllhassorenipples–shesays“alivlebitsore”
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Case1–5dayoldbaby–NBclinicvisit
• 11%weightloss,1green-blackstoolsince D/C,nostoolinlast24hrs,3wets/day“redspot”indiapertoday-broughtin diaper
• Alertvigorousbaby• MMM,jaundicetoabdomen• Normaltone,normalNBexam• Bilitoday15.1
Case1–5dayoldNBclinicvisit-Watchbabybreas+eed
-Examinebabyandmother
YouobserveafeedingandnoLcethatthebabyhasaveryshallowlatch,takingjustthenippleintohermouth,mostlynon-nutriLvesucking,minimalswallowingheard.n Motherexam:Bothnippleshavemilderythema,nocracks.Breastsareengorged,moderatelytenderwithmilddiffuseerythema.
n Babyexam:Mouth-strongsuck,normaltonguemovement-tonguetrackslaterally,elevateswellandextendspastgumlineandlowerlip,notethering,smallthinflexiblefrenulumatbaseoftongue,upperlipwithouttetheringandflangeswell
Planforthisbabyandfamily
Whattodo?① Breas+eed② Fingerfeed③ Pump/handexpress
• Giveallexpressedmilktobaby–don’tsaveany
• Feedevery2-3hrs(8/day)• Engorgement/latchLps• Sleepwhenbabysleeps• F/utomorrow
Breas+eedingPhysiology
-Why?ThinkPhysiology
Breas+eeding:AGuidefortheMedicalProfession.RuthLawrence
Breas+eedingPhysiology• Makingmilkrequires:
– Latch– Letdown– Milkremoval– MilkproducLon– ThinkaboutsupplementaLoninthecontextofbreas<eedingphysiology...PUMPwhensupplemen3ng
EngorgementTips
• Reassurethatitonlylasts24-48hrs• “Good”tohaveincreasingmilksupply-say“maturemilk”
NOT“milkcomingin”• BFomen-wakebabyq2-3hrsday,q3-4hrsnighttonurse• Massagebreastsandusewarmcompressbeforenursing• Handmassageduringbreas+eedingtohelpmilktoflowwell• Coldpackoverclothingamernursing• Cabbageleafcompresses–amernursing(directlyonbreasts)• Somenareolawithfingersifhardforbabytolatch
– “reversepressuresomening”technique• Handexpressorpump-ifneeded-onlyexpresssmall
amounttorelievepressure,nottoempty
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LATCH:“Good”(deep)“Bad”(shallow)
Takes areola into
mouth, not just
on nipple = more milk and comfort Nipple only = No milk, Ouch!
“Good” Deep Latch (but only “good” if feels comfortable to mother)
Nipple“sandwich”UandCholdshelpwithdeeplatching
• PhotosfromLactaLonEducaLonResourcesFreeHandoutsonline,2009
• www.LERon-line.com
PosiLoninghelpswithsorenipples
• FootballHold • CrossCradleHold
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LaidbackPosiLonHelpswithlatching
Case1–followup
• Babyandfamilybacktoclinicthenextday,babylatchingbever,momsLllengorged,butimproved
• Weightgain2oz,inonedayand2stools-mompumped6Lmessinceyesterday-gets1-2oz,dadisfingerfeeding1ozEBMamerbreas+eedingwhilemompumps,babylatchingwell,moreawake
• Plantograduallyreducepumpingandfingerfeedingovernextfewdaysandf/uin1weekwhenbabyis2weeksofage.
• 2weekFollowupweightcheck-babyabovebirthweightanddoingwell.
• HappyfamilyJ
Case2RouLnebabyweightcheck–2wksold
• Weightgainof2ozin7days• Hasnotregainedbirthweight(3ozbelow)• History:37wks,vaginaldelivery,uncomplicatedpregnancy,exclusivelybreas+eeding
• Breas+eedsfrequently,q1-2hrsbutgoestosleepatbreastamer5minutes.Soonwakeshungryagain.Repeat.
• Yellowstools1/dayand6wets/day• Momhassorenipples.WasiniLallyengorgedbutnotnow,breastsfeellessfull.
• Babyexam-vigorous,T-97R,normalexam,noTT
SupplementaLon:BabyneedsCalories
What?
• Mother’smilk-expressedbreastmilk• Pasteurizedhumandonormilk–milkbank• Hydrolyzed,hypoallergenicformula• Cow’smilkformula
How?
• BestpracLceistodelaybovlesfor3-4weeks• Usemethodthatleastinterfereswithbreas+eeding• Feedthebaby,protectorincreasethemilksupply• Startsupplement-1ozamerbreas+eedingwhilemompumps• Momtopumporhandexpress–anyLmebabygetssupplement
GuidelinesforSupplementaLon• SupplementaLononlywhenmedicallyindicated• Mom’smilkisbest...trytouseorincrease• Protectbreastmilksupplyandencouragepumping-same
numberofLmesbabygetssupplement• “Milkout=Milkmade”(supplyanddemand)
• Ifsupplementsgiven-momneedstopump/handexpressthesamevolumeornumberofLmesin24hrs
• Ifsupplementsgivenwithoutmilkexpression,milksupplygoesdown
• Mommaynotreachherbreas+eedinggoalsiflowsupply• Usefeedingmethodthatminimizesimpacton
breas+eeding(usuallynotbovle)
SupplementaLonOpLons:fingerfeeding,SNS,spoon,cup,bovle
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SupplemenLngwithoutbovles
Why• AlternaLvefeedingmethodallowsbabytolearntobreas+eed• Avoidsfastmilkflow&nipplebiLngorfirmnipplepreference• LactaLonaid/SNSallows“pracLce”feedingatbreast• FingerFeeding
• UsessuckingandtonguemoLonsimilartobreas+eeding• Easytouseinclinicse|ng,teachfamily
• Cup,spoon,dropper-usedmoreinhospital(smallvolumes)• WaitforbovleintrounLlbreas+eedingwellestablished(3-4wks)What• Mother’smilk–expressedbreastmilk• Pasteurizeddonormilk–milkbank• Formula-hydrolyzedformula• Cow’smilkformula
FingerFeeding
Fingerfeeding
• Bovle,nippleandtubetapedtofinger
• Feedingtubeonfingerwithsomsideup,justpast1stknuckle,strokinghardpalatewhilebabysucks
Supplementwithfeedingtubeatbreast(lactaLonaid,SNS)
LactaLonAidorSupplementalNursingSystem(SNS)
_____________________________________________________________
• Feedingtubetapedtobreastandbabylatchesoverit
• Supplementatbreastwhenlowmilksupplyandslowflow
IncreasingMilkSupply#1
• Remembersupplyanddemand.... moremilkismadeifmoremilkisremoved
PUMPING• Ifsupplements(EBM,donormilk,formula)aregiventobaby,mom
needstopump• Rentalhospitalgradepumpisbest–higherefficiency• Motherpumpsamernursing6-8Lmes/24hrs(onceduringnight)• “Hands-onpumping”–helpsexpressmoremilk
– seevideoonStanfordMedicinewebsite-MaximizingMilkProducLon
• “Mini-pumps”inbetweenfeedsfor3-5min• Oktonotwashpumppartsfor5-6hrs-makesthingseasierandmore
efficient,orpumppartsinfridgefor24hrsbeforeneedingtowash
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IncreasingMilkSupply#2
OTHERTHINGStodoto“Helpthepumpworkbever”• Frequentbreas+eeding,thenpumpingx10-15min• Lotsofskin-to-skincuddling–increasesoxytocinand
prolacLn• Fenugreekherb:3capsules(about1500mg)TID-variable
dosagepermanufacturer• ConsidermetoclopramidetohelpincreaseprolacLn
(domperidoneoffthemarketnow)-don’tusewithdepressionoranxiety
• Somemomshavealveolarhypoplasia,breastreducLon,hypothyroidism…orothermedicalreasonforlowmilksupply,someLmesdolabs(hgb,TSH,testosterone,HCG,prolacLn)
GotoPart2–2ndhalfofPPT
Breastfeeding Management in Primary Care Pt 1 Heggie, Licari, Turner May 25 '17