5/15/17

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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