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2/16/2012
1
Red Flags for Breastfeeding Helpers
Catherine Watson Genna, BS, [email protected]
Some breastfeeding difficulties can signal dangerous problems.Maternal Red Flags:�Engorgement�Damaged Nipples�Recurrent Mastitis or Plugged Ducts�Breast surgery�Little/no breast changes during pregnancy and postpartum.
Red Flags, cont’d
Infant Problems:�Uric acid in urine after day 3�“Constipation” or few stools�Never happy�Too Sleepy�Funny Noises�Color Changes
Engorgement
Ask: How often does baby feed?
How many wet and dirty diapers?
What color is the urine and stool?
How is feeding going?
Engorgement
Treatment:Ice and pumping (alternating
every 5-10 minutes until milk flows well).
Reverse Pressure SofteningCabbage compresses?Get baby latched on and
sucking well.
Sore & Damaged Nipples
Sign of:
Poor Latch
Poor sucking skills
Low milk supply.
Pain puts breastfeeding in jeopardy.
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Soreness without Damage
• Assist with positioning and latch (asymmetrical latch)
• Recommend comfort measures –hydrogels, lansinoh
• Reassure - temporary
If relief is not immediate, refer! Breastfeeding should not hurt.
Self Latch
Helping baby latch better Damaged Nipples
Ask about:• Location of soreness• Cracking • Bleeding• Color changes on or around nipple• Baby’s diaper output
Damaged Nipples
Cracks/fissures – from nipple compression –shallow latch, tongue tie, sucking problem.
Recommend- moist wound healing –soothies, hydrogels, frequent lansinoh.
Soap and water wash 2-3x day to prevent mastitis.
Refer if not immediately better with positioning help.
Mild Fissure – treat with comfort measures and improved latch
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Severe injury – refer! Damage from low milk supply
Ask about breast surgery –this mom had a breast reduction.
Make sure baby is being adequately nourished
Mom should see IBCLC
Damage from Tongue tieBlood or milk filled blisters on nipple
Fissured nipple
Bruised areola
Bacterial Infection
Yellowish discoloration of a wound signals bacterial infection.
•Refer to physician.
•Give anticipatory guidance about antibiotics – most are compatible with breastfeeding according to the AAP.
Necrotic TissueGranulation tissue (normal healing) is pink.
Use moist wound healing for autolytic debridement
Information –Medication Safety
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http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Recurrent Mastitis Poor sucking, poor drainage of breast
Incomplete treatment of previous mastitis
Thrush from antibiotic disruption of normal flora
Oversupply of milk
Yeast Depigmentation from yeast
Yeast – friable skin Thrush
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Yeast on baby’s bottom Vasospasm is NOT thrush
Sore nipple that doesn’t healPaget’s disease
Advanced Paget’s disease
Orange Peel Skin Mastitis
• Treatment: bedrest, frequent breastfeeding, hot compresses, perhaps pumping.
• Anticipatory guidance about antibiotics and compatibility with breastfeeding
• Refer to OB/gyn /midwife/breastfeeding medicine physician.
• IBCLC to help with root cause
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Abscess
• Abscess may destroy breast tissue.
• Very painful.
Older Abscess
Breast shape red flags
hypoplasia
PCOS – acanthosis nigricans PCOS Wide spaced breasts
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Asymmetry
Immature breast shape (persistent Tanner stage 4)
Infant Red Flags
Concentrated Urine
• Parents may describe as blood in diaper �Was baby circumcised?
�Is baby girl bleeding from vagina (normal)
�Brickdust urine= uric acid crystals, orange color
• Normal for first 2 days, should be gone by 72 hours postpartum
• If lasts longer than 3 days, make sure baby is being fed, refer.
Uric acid diaper, scant stool ‘Constipation’
• Stools most important indicator baby is feeding. By day 5, 5-8 or more a day until 6 weeks.
• Explore breastfeeding management, latch, suck, tongue attachment, hormonal hx.
• Refer to physician if milk transferis good but growth is poor.
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Green stools
• Occasional green stools are fine• Only small green stools – low intake• Mucousy green stools – gut irritation
Stinky Stools
• Has baby gotten formula?• Has baby just gotten over diarrhea?• Does baby have lots of very stinky, greasy
stools (steatorrhea)?
Steatorrhea can be normal after diarrhea, is not normal if frequent and persistent
Cystic fibrosis, Schwachman syn
No stools with vomiting
• Imperforate anus• Meconium Ileus• Hirschsprung’s Disease• Pyloric stenosis
Refer to physician – Surgical Emergency
Pale colored stools
Billiary atresia
Chen, et al Pediatrics 2006
Refer to physician –Surgical Emergency
Giving anything but breast milk < 6 months
Increased risk of allergies/asthmaIncreased risk of diabetesBalance of nutrients (absorption)
and protection is disrupted: iron, calcium, PUFA:vit E
Lower IQ! Rau et al Effect of Breastfeeding on Cognitive Development of Infants Born Small for Gestational Age. Acta Paediatr 91(3):258-60. 2002
Using Gripe Water, etc?
• ONLY HUMAN MILK FOR THE FIRST 6 MONTHS!
• Babies in distress deserve help!• Try more frequent feeding, more skin to
skin contact (sling, carrying).• Consider hyperlactation (if gaining more
than 2 lb/month) allergy, reflux.• Colic Solved by Dr. Bryan Vartabedian
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“Can’t be put down”
• Babies normally need human contact and holding. Explore parents expectations, feeding management.
• Aerobic capacity – some newborns need to rest a few minutes and then finish the meal.
• Babies who are never happy may be ill, refer to physician!
Lethargy
• Metabolic disorders• Congenital
Hypothyroidism• Starvation• Hypernatremia
Hypernatremia
• High sodium level in blood• High ketone body level in brain (keeps
fluid in brain despite dehydration, energy)• Extreme lethargy, evidence of weight loss• DO NOT feed large amounts. • Get baby to Emergency Room• Get mom pumping to rescue supply
Skinny and fussy is better than skinny and sleepy!
Feed underweight baby until caught up, then reassess breastfeeding skills.
“Always Feeding” “Sleeps too much” or ‘GOOD baby’
• Starvation from scheduled feeds (Babywise)
• Interferes with maternal infant accommodation
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Tongue tie (Ankyloglossia) Normal Tongue Movements
extension
lateralization
elevation
Effect of Ankyloglossia on Tongue Mobility - Lateralization
elevationNormal lateralization
Restricted lateralization, twisting of tongue body
Effect of Ankyloglossia on Tongue mobility - Elevation
Restricted elevationNormal elevation
Effect of Ankyloglossia on Tongue mobility - extension
Restricted extensionNormal extension
Tongue mobility determines effect on breastfeeding and speech
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Less obvious, but more restrictive
Sneakier still…
Even tightness very far back can make tongue movement poor
Tongue tie treatment
Jaundice
Assessing jaundice
• Press skin to disrupt capillary blood flow• Release• Immediately view underlying color
• If yellow below waist, refer to physician.• If baby is yellow and lethargic, send to
emergency room• Kernicterus – bilirubin brain injury
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Funny Noises – Breathing Effortful
Sternal retractions
Respiratory problems cause inefficient feeding
Supra-sternal retractions
Color changes after feeding
Cardiac Symptoms
• Color changes – blue or dusky around lips, eyes, hands and feet
• Rapid breathing• Panting or struggling
to breathe during or after feeding
Aortic Stenosis• Ductus arteriosus protects
baby first few days• As ductus closes,
symptoms get much worse• Feeding is aerobic
exercise• Baby may look ok at rest,
can fool doctor• Lower extremities more
affectedSurgical EMERGENCY!
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Birth Red Flags
• The more difficult the birth, the more likely mother and or baby need help breastfeeding.
• “It’s the birth, silly” – Diane Wiessinger
C-section moms
• Help mom initiate bf ASAP, she may be more comfortable immediately after surgery
• FIL and calibration of milk production• Show mom how to hand express, start
feeding baby
Vacuum extractor or forceps = headache
Spoon feeding colostrum Hand expression
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Communication
Explore Mother’s concerns
Validate
Give information
Recommend consulting physician
Handling Emergencies
• Trust your ‘gut’.• Call physician from mother’s home, ask
whether to send baby to office or ER• Try to talk from another room (ask mom to
pack diaper bag/overnight bag)• Keep voice calm• Frame as “just in case”
Summary
.• Know when moms and babies need extra
help.• Identify “red flags” and explore them fully
and refer to avoid poor outcomes.
For More Information: