Breast Is Best for Babies: MANAGEMENT OF COMMON BREASTFEEDING ISSUES

Breast Engorgement
Postpartum engorgement is a transitory condition due to lymphatic and vascular congestion, which prevents adequate milk flow. Engorgement can result in discomfort, difficulty in establishing milk flow and difficulty in latch-on. Engorgement can be prevented by early, effective and frequent nursing. Management includes rest and hand expression or pumping before nursing, to soften the breast and to enhance maternal comfort. The use of alternating warm and cold compresses and mild analgesics, such as ibuprofen, may sometimes be necessary.

Oversupply or Overactive Milk Ejection Reflex
Hyperactive let-down may result in premature weaning, gas and breast refusal when milk overwhelms the infant. Management includes removing the infant from the breast when let-down occurs and waiting for the milk flow to slow down before putting the infant to the breast. xenical medication

Plugged Ducts
Plugged ducts may result from an overly copious milk supply, a tight bra or incomplete emptying of the breast. Clinically, a plugged duct may manifest as a white spot on the nipple or as a breast lump. There may be mild, local tenderness. Treatment consists of application of heat and massage towards the nipple, together with frequent nursing in a variety of positions.

Inverted Nipples
Infants are breastfed and not nipple-fed. As long as the degree of inversion does not affect the ability of the infant to grasp the areolar tissue and draw the nipple into the mouth, there is no reason why a mother with inverted nipples should not be able to breastfeed. Treatment consists of gently rolling the nipples between the thumb and index finger before feeding to help the nipples stand up. Some breastfeeding experts believe that proper latch-on of the infant will overcome flat or inverted nipples.
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Sore Nipples
Nipple soreness is often the result of trauma from poor positioning and latch-on of the infant during breastfeeding and, if uncorrected, may lead to cracked nipples and breast infection. Sore nipples can be managed by proper positioning of the infant’s mouth on the nipple, alternating nursing positions with each feeding and optimizing nipple care. Engorgement and monilial infections of the nipple may also contribute to nipple soreness which, if present, should be treated appropriately.

Mastitis
Approximately 1-5% of nursing mothers experience mastitis. Predisposing factors include a decrease in nursing frequency leading to milk stasis, inadequate drainage in a mother with an abundant milk supply, cracked nipples and fatigue. The usual causative organism is Staphylococcus aureus? Less commonly, it may be caused by Escherichia coli, Klebsiella pneumoniae and Streptococcus species. Treatment consists of heat, massage, continued breastfeeding, rest and the judicious use of analgesics.

Monilial Infection
Monilial infection of the nipple has been associated with nipple damage, use of antibiotics, maternal monilial vaginitis during pregnancy and thrush in the infant. The condition usually presents as intense, burning pain in the nipples when nursing. The nipples and areolae also may be red and itchy. Treatment consists of topical application of nystatin cream. In resistant cases, fluconazole canadian can be used. Both the mother and the infant should be treated if monilial infection is diagnosed on either the mother’s breast or in the infant’s mouth.

Breast Abscess
Breast abscess may result from untreated mastitis or mastitis complicating a plugged duct. Treatment consists of incision and drainage, and analgesics. The affected breast should be emptied by gentle mechanical pumping, and the infant should continue to feed from the opposite breast.

Mammoplasty
In general, breastfeeding is usually possible with augmentation surgery or mastopexy. The ability to breastfeed after reduction surgery depends on whether the nerve and blood supply to the nipple and areola are completely severed.

Insufficient Milk
Insufficient milk may be secondary to congenital mammary hypoplasia/aplasia, postmastectomy or after reduction surgery, infrequent or incomplete breast emptying, anxiety, exhaustion, inadequate maternal diet, or heavy smoking. The condition is more common in primiparous women. The underlying cause should be treated if possible. One should always correct the latch first. Frequent nursing, i.e. once every two hours, should be encouraged. Breast compression can be used to increase milk supply. With a continued problem of supply, mechanical pumping and the use of domperidone may increase milk production, and this may be worth a trial. The recommended dose of domperidone is 20 mg QID. If there is no improvement within a few days, the dose may be increased to 30 mg QID. Once the mother’s milk production is sufficient for the baby to

Table 5. Role of Physicians in Promoting and Protecting Breastfeeding
1. Promote, support and protect breastfeeding enthusiastically. In consideration of the extensively published evidence for improved health and developmental outcomes in breastfed infants and their mothers, a strong position on behalf of breastfeeding is warranted.
2. Promote breastfeeding as a cultural norm and encourage family and societal support for breastfeeding.
3. Recognize the effect of cultural diversity on breastfeeding attitudes and practices and encourage variations, if appropriate, that effectively promote and support breastfeeding in different cultures. Cialis Jelly
4. Become knowledgeable and skilled in the physiology and the current clinical management of breastfeeding.
5. Encourage development of formal training in breastfeeding and lactation in medical schools, in residency and fellowship training programs, and for practicing pediatricians.
6. Use every opportunity to provide age-appropriate breastfeeding education to children and adults in the medical setting and in outreach programs for student and parent groups.
7. Work collaboratively with the obstetric community to ensure that women receive accurate and sufficient information throughout the perinatal period to make a fully informed decision about infant feeding.
8. Work collaboratively with the dental community to ensure that women are encouraged to continue to breastfeed and use good oral health practices.
9. Promote hospital policies and procedures that facilitate breastfeeding. Work actively toward eliminating hospital policies and practices that discourage breastfeeding. Encourage hospitals to provide in-depth training in breastfeeding for all healthcare staff and have lactation experts available at all times.
10. Provide effective breast pumps and private lactation areas for all breastfeeding mothers in ambulatory and inpatient areas of the hospital.
11. Develop office practices that promote and support breastfeeding by using the guidelines and materials provided by the American Academy of Pediatrics Breastfeeding Promotion in Physicians’ Office Practices program.
12. Become familiar with local breastfeeding resources so that patients can be referred appropriately. When specialized breastfeeding services are used, the essential role of the pediatrician as the infant’s primary healthcare professional within the framework of the medical home needs to be clarified for parents.
13. Encourage adequate, routine insurance coverage for necessary breastfeeding services and supplies, including the time required by pediatricians and other licensed healthcare professionals to assess and manage breastfeeding and the cost for the rental of breast pumps.
14. Develop and maintain effective communication and coordination with other healthcare professionals to ensure optimal breastfeeding education, support and counseling.
15. Advise mothers to continue their breast self-examinations on a monthly basis throughout lactation and to continue to have annual clinical breast examinations by their physicians.
16. Encourage the media to portray breastfeeding as positive and normative.
17. Encourage employers to provide appropriate facilities and adequate time in the workplace for breastfeeding and/or milk expression.
18. Encourage child care providers to support breastfeeding and the use of expressed human milk provided by the parent.
19. Support the efforts of parents and the courts to ensure continuation of breastfeeding in separation and custody proceedings.
20. Provide counsel to adoptive mothers who decide to breastfeed through induced lactation, a process requiring professional support and encouragement.
21. Encourage development and approval of governmental policies and legislation that are supportive of a mother’s choice to breastfeed.
22. Promote continued basic and clinical research in the field of breastfeeding. Encourage investigators and funding agencies to pursue studies that further delineate the scientific understandings of lactation and breastfeeding that lead to improved clinical practice in this medical field.
Adapted from: Section on Breastfeeding, American Academy of Pediatrics. Breastfeeding and the use of human milk. Pediatrics 2005;115:496-506.77 gain weight without having to supplement with formula, the dose of domperidone can be gradually decreased. Supplementation with an appropriate formula is indicated if the infant’s weight gain is unsatisfactory or if the infant appears to be dehydrated.
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Breastfeeding and Breast Milk Jaundice
Two types of jaundice associated with breastfeeding are recognized. The first type is early-onset breastfeeding jaundice or “breast-nonfeeding jaundice” due to infrequent or ineffective breastfeeding. The caloric deprivation and reduced frequency of breastfeeding may increase the enterohepatic circulation of bilirubin and cause the jaundice. Breastfeeding jaundice can be prevented or treated by encouraging mothers to nurse as frequently as possible. The second type is later onset, prolonged jaundice, known as breast milk jaundice. Breast milk jaundice affects 2-4% of breastfed infants and is associated with one or more factors in the maternal milk itself. Pregnane-Зое, 20|3-diol, free fatty acids, P-glucuronidase and a factor in human milk that increases intestinal bilirubin absorption have been implicated as the possible culprits. The severity of jaundice can be reduced by phototherapy, when appropriate, and by early optimal breastfeeding. This latter step would minimize the accumulated effects of early breastfeeding jaundice. Supplementation with water or glucose water should be avoided, as this reduces breastfeeding frequency and milk production, leading to the infant’s decreased caloric intake or starvation. Breastfeeding should not be interrupted unless the unconjugated bilirubin level reaches 425. Bilirubin encephalopathy may occur if the unconjugated bilirubin exceeds that level. These nursing mothers should be provided with positive and enthusiastic support and encouraged to maintain lactation using a breast pump or manual expression during the period of interrupted nursing. When the serum bilirubin decreases to a reasonable level, breastfeeding may be resumed.

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