5/18/17

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Collabora'veBreas-eedingCare:SoreNipples,BreastPain&Tongue-Tie

May25,2017,Duluth,MN•  PamelaHeggieMD,IBCLC,FAAP,FABM•  JaneJohnsonRN,IBCLC,ANLC•  AddieLicari,MD,FAAFP•  HeatherWinese6,MD,FAAP,ABIHM

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Disclosure

•  WehavenofinancialorethicalconflictstodeclarerelatedtothiseducaHonalacHvity

Topicsforthissession_______________________________________________________

•  Sorenipples•  Breastpain•  Tongue-He•  Casestudies•  CollaboraHveteambasedcare

ObjecCves

•  DiscussthecollaboraHveevaluaHonandmanagementofsorenipplesandbreastpain

•  Provideanoverviewoftongue-HeandHghtfrenulumsinbabiesandreviewindicaHonsforfrenotomy

•  DiscussbreasPeedingcases-includingassessment,managementandhowateamapproachcanhelp

BreasPeedingPain•  ORendueto“cascade”ofevents

•  concurrent•  sequenHal

•  Nippledamage•  Dermatoses

– Eczema,Psoriasis,ContactDermaHHs,Paget’sdx•  InfecHon

– Bacterial,Candida,Viral•  Vasospasm/Raynaud’ssyndrome•  Mechanical

– Highsupply,pluggedducts,Hghtbra,pump•  HighpainsensiHvity/chronicpainsyndromes•  PPD/anxiety

BreastPain–Causes•  MasHHs•  Engorgement•  Pluggedducts•  Vasospasm•  Highmilksupply•  Nipplebleb•  Galactocele•  PPD/anxiety•  Abscess•  Posture/posiHoning•  Pectoraliscramping•  ChronicPainsyndrome

Collaborative Breastfeeding Care Heggie, Johnson, Licari, Winesett May 25 '17

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Sorenipples:causes

✓ Poorlatch✓ LATCH,LATCH,LATCH✓ Skinbreakdown/cracks-staphcolonizaHon✓ Engorgement✓ Traumafrompumping✓ NippleShields✓ Vasospasm✓ Blockednipplepore(nipplebleb)✓ Ankyloglossia(tongue-He)✓ EczemaorcontactdermaHHs✓ Thrush,candida(rarerthanpreviouslythought)✓ Oversupply/fastletdown✓ Shortinvertednipples-ligamentpain

AcademyofBreasPeedingMedicineClinicalProtocols

•  Engorgement•  MasHHs•  PersistentpainwithbreasPeeding•  SupplementaHon•  BreasPeedingtheLatepre-terminfant•  BreasPeedingFriendlyoffice•  Ankyloglossia•  Hypoglycemia•  .....Manymore

bfmed.org

Case1–SoreNipplesand“BFW”

•  Motherwithsorenipples.G1P1Vaginaldelivery,babyispostdates-41wksand8lb7oz.Day2inhospital-momsayshernipplesaresore,nocracksorbleeding

•  Nursesays“latchlooksgood”.Momgivenlanolinandhydrogels.Baby’sweight5%belowbirthweight,Normaloutput-stools/wets.NursereportstoMDduringrounds-“BFW-“breasPeedingwell”

•  Homeday2.Seenincliniconday5fornewbornexam-mothersHllhassorenipples–shesays“aliglebitsore”

Case1–5dayoldbaby–NBclinicvisit

•  11%weightloss,1green-blackstoolsince D/C,nostoolinlast24hrs,3wets/day

“redspot”indiapertoday-broughtindiaper

•  Alertvigorousbaby•  MMM,jaundicetoabdomen•  Normaltone,normalNBexam•  Bilitoday15.1

Collaborative Breastfeeding Care Heggie, Johnson, Licari, Winesett May 25 '17

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Case1–5dayoldNBclinicvisit-WatchbabybreasPeed

-ExaminebabyandmotherYouobserveafeedingandnoHcethatthebabyhasaveryshallowlatch,takingjustthenippleintohermouth,mostlynon-nutriHvesucking,minimalswallowingheard.■ Motherexam:Bothnippleshavemilderythema,nocracks.Breastsareengorged,moderatelytenderwithmilddiffuseerythema.

■  Babyexam:Mouth-strongsuck,normaltonguemovement-tonguetrackslaterally,elevateswellandextendspastgumlineandlowerlip,notethering,smallthinflexiblefrenulumatbaseoftongue,upperlipwithouttetheringandflangeswell

Case1–PlansforMomandBaby

•  Mom:•  helpwithcomfortablelatch•  Hpsaboutengorgement•  breasPeedoRen(8-10x/24hrs)•  expressmilk(byhandorpump)•  increasemilksupply

•  Baby:•  needsmoremilk(EBM,donormilk,formula)•  spoonfeedingorfingerfeeding•  avoidbogles•  feedfrequently,wakeq2-3hrsday,3-4hrsnight

LATCH:“Good”(deep)“Bad”(shallow)

Takes areola into

mouth, not just

on nipple = more milk and comfort Nipple only = No milk, Ouch!

PosiHoninghelpswithsorenipples

•  FootballHold •  CrossCradleHold

LaidbackPosiHonHelpswithlatching

Collaborative Breastfeeding Care Heggie, Johnson, Licari, Winesett May 25 '17

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Nipple“sandwich”UandCholdshelpwithdeeplatching

•  PhotosfromLactaHonEducaHonResourcesFreeHandoutsonline,2009

•  www.LERon-line.com

EngorgementTips

•  Reassurethatitonlylasts24-48hrs•  “Good”tohaveincreasingmilksupply-say“maturemilk”

NOT“milkcomingin”•  BFoRen-wakebabyq2-3hrsday,q3-4hrsnighttonurse•  Massagebreastsandusewarmcompressbeforenursing•  HandmassageduringbreasPeedingtohelpmilktoflowwell•  ColdpackoverclothingaRernursing•  Cabbageleafcompresses–aRernursing(directlyonbreasts)•  SoRenareolawithfingersifhardforbabytolatch

–  “reversepressuresoRening”technique•  Handexpressorpump-ifneeded-onlyexpresssmall

amounttorelievepressure,nottoempty

HANDEXPRESSIONforspoonfeeding

Fingerfeeding Case2–Sorenipples•  G3P3momwithsorenipples,baby5daysold,fullterm,yellowstools,outputnormalperBFlog,5%wtloss.

•  Motherexam:bothnippleswitherythema,crackedandscabbedatHp,areolamildlyswollen,breastsengorgedandmoderatelytender,milddiffuseerythema,nomass.

•  Babyexam:strongbut“chompy”suck,thickHghtfrenulumagachedtoHpoftongue,withrestrictedtonguemovement-poorlateraltracking,unabletoextendtonguepastgumlineorlowerlip,minimaltongueelevaHon.

•  Breas-eedingobserva'on:Babyhasdeeplatch,momwithgoodposiHoning,swallowsheardandalsointermigentclicking.Momreportspainduringfeeding.

Collaborative Breastfeeding Care Heggie, Johnson, Licari, Winesett May 25 '17

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Type1-Ankyloglossia Sorecrackednipple

Sore Nipples ▪  “Normal”nipplesorenessisveryminimalandokonlyif:

▪  Nipple“tugging”brief(<30sec)withlatch-onthenresolves▪  Nopainthroughoutfeedingorinbetweenfeeds▪  Noskindamage

▪  Somewomenaretold“thelatchlooksok”…buttheyareinpainandcurlingtheirtoes

▪  Itdoesn’tmagerhowit“looks”…ifmomisuncomfortableit’saproblemandbabynotgeqngmuchmilk…setupforlowmilksupply

▪  Nipplepainisnotnormal!!(espifnipplecracks,painalltheHmeduringorbetweenfeedings)

▪  Painisasigntodosomethingdifferent-changelatch,posiHon…gethelp!

▪  ManywomenstopbreasPeedingbecauseofnipplesoreness▪  Helpimprovesorenipplesrightaway!

Sorecrackednipple“PlasHcWrapTreatment”

•  MDwritesRxfor2%

mupirocinointmentformother•  Sig:Applythinlayertonipples

aRereveryfeedingorpumping,noneedtowashoffbeforenextfeeding–2weeks

•  PlacelargesquarepieceofPlasHcWrap(anybrand)onthenippleandareolaovertheointment

•  Moistwoundhealing•  HeaHngpad

Ankyloglossia–Tongue-He

•  Type1-classicheartshapedtongue,frenulumtoHpRef:hgp://www.posteriortongueHe.com

»  Type2-frenulumagaches2-4mmbehindtongueHp

Collaborative Breastfeeding Care Heggie, Johnson, Licari, Winesett May 25 '17

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Ankyloglossia-Tongue-HeType3-frenulumaNachesmid-tongue

Type4-frenulumatbaseoftongue-shinyandthick

hgp://www.posteriortongueHe.com

Tongue-HeAssessment

•  Fingerexamofmouth,tongueandsucking-checkforfrenulumandinserHon,thickness,elasHcity

•  LookattonguefuncHon-lateraltracking,extension,cupping,elevaHon

•  WatchbreasPeeding,ismomcomfortable?•  Examinemother’snipples–sore,cracks,creased?

IndicaHonsforFrenotomy

•  BreasPeedingproblems***– Sorenipples,poorlatch,reducedmilktransfer,clicking,lowsucHon,slidesoffbreast,chompsonnipple,lowmilksupply,weightloss...

•  SpeecharHculaHon–oRennotaffected,frenulumstretches

•  Dentalproblems-aRerteetherupt...doitlater•  Social–cosmeHc,“forkedtongue”,noicecreamlicking–sHllconsiderlater

FrenotomyProcedureOp'onsPresentopHonstofamily–benefits,risks,outcome

NoFrenotomy

•  Observe,supportbreasPeeding,helpwithdeepercomfortablelatch,posiHoning

Frenotomy

•  Scissors–Peds,FP,ENT•  Laser–manydenHsts,ENTs•  Benefits:latch,milktransfer,momlesssore•  Risks:bleeding,infecHon,mildpain(usesucrose)•  Outcome:oRenhelps,notalways

Video of Frenotomy procedure on YouTube

http://www.youtube.com/watch?v=XN-vVYd1m-o Irisscissorsandtongueelevator

Frenotomy:BeforeandARer

hgp://med.stanford.edu/newborns/professional-educaHon/frenotomy.html

Collaborative Breastfeeding Care Heggie, Johnson, Licari, Winesett May 25 '17

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Case3-Breast&Nipplepain

•  1moBFbaby,Mothercallsclinicwithconcerns:–  “shooHngpaininmybreasts”–  “leRnippleissore”

•  Nipplesareturningpurple-someHmeswhiteaRerbreasPeedingorpumping.Then“shooHngpains”occurgoingfromnippleintobreast-“enHrebreastisthrobbingsomeHmes”

•  OccursaRernursing,pumpingorinbetweenfeedings.Motherreportsnofever,nobreastredness,orlumpsinbreastsbutdoeshaveawhitespotontheleRnipplethatisverypainfulwithlatch-butgetsbegerduringthefeeding

•  Nocrackednipplesnow–butdidhavesorecrackednipplesinfirstweek-startedinhospital–thenbegerwithcoconutoilandnowcrackshavehealed

Case3–morehx

•  Motherispumping4x/dayandissavingallthemilkinthefreezerforwhenshegoesbacktoworkat3mopostpartum.

•  Pumpingvolume–getsmoremilkfromleRside4-5ozonleRand1-2ozonrightaRerBF

•  Babyisonlynursing-nobogles.Momwantstostartboglessoon,geqngreadyforgoingbacktowork.

Case3–MotherExamMotherExam:•  Nipples-evertedandintact-nocracksorabrasions,leRnipplewith1mmwhiteglisteningnoduleatlateraledgeofnippleat3o’clock,mildlytender,noerythemaofnippleorareola,notshiny,nosatellitelesions.

•  Breasts-fullbreastsbutnotengorged,non-tender,nomasses,noerythema

Case3–BabyExamBabyExam:•  Excellentgrowth54%ile-followingWHOcurve•  Normaloralmucosa-nowhitepatches.Skinwithscagerederythematouspapulesandpustulesoncheeks,nodiaperrash.

•  Strongsuck,normaltonguetracking,frenulumisagachedtothebaseoftongue,verythinandelasHc,tonguenottethered.Noheartshape,babycanelevatetonguetohardpalateandextendstonguebeyondgingivalridgeandlowerlip.

•  Upperlipnottethered,normalupperlipfrenuluminserHontosuperiorgingiva.Lipflangeswell

Case3–BreasPeeding

Breas-eedingobserva'oninclinicexamroom:•  motherlatchesbabywell-withdeeplatchincrosscradleposiHon,babyhasrhythmicsuckandswallowing,motherhaspainwithlatchandduringfeeding-onleRside

•  aRernursing–bothnipplesblanchwhiteandnippleshavelinearcreaseatHps–leRmorethanright.MotherreportsnipplepainandbreastpaininbothbreastsaRerfeeding,moreintenseonleRside.

Case3–What’sgoingon?

•  Motherwithpainfulbreasts,blanching&creasednipplesaRerfeeding,nipplebleb

•  Highmilksupply•  Historyofcrackednipplesfirstweek,nowresolved

•  Baby-normalexam,notongue-Heorthrush

Collaborative Breastfeeding Care Heggie, Johnson, Licari, Winesett May 25 '17

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Case3-Vasospasmandnipplebleb

hgp://www.mother-2-mother.com/nipplepain.htm#MilkBlister

Case3–VasospasmManagement•  AdjustposiHontoreducefastflow

– laidbackposiHon,footballholdwithbabyuprightandmomreclining•  Startwithlesspainfulsidefirst•  HeaHngpadonlow(orhandwarmer,ricesock)placedoverclothing

onbreastsrightaRerpumpingornursing•  Keepnipplesmoistandwarmandnoairdrying,protectfrom

fricHon,lighttouch• Nifedipine30mgQDx2weeks,ifnotimproving •  Considerlargerpumpingflange-(ifrubbing)•  PumponesideatHmeandcoverotherbreastwithheaHngpad•  Mindfulness,meditaHon,othercalmingstrategies•  Ibuprofen/Acetaminophen•  GiveHmecourseforpain

– willresolve...notlasHngenHrebreasPeedingjourney•  Closef/u-supportformom

Case3-NippleBlebManagement

•  Betamethasoneointment0.2%onbleb(thinlayer)•  OliveoiloncogonballonnippleandcoverwithplasHcwrap

•  Warmcompressesorsoakinbowlofwarmwaterbeforenursingorpumping

•  Handexpression/massage•  Noneedleun-roofing,canmakeitworse•  Lecithin1200mg3x/day–helpspreventrecurrentnippleblebs

•  Ibuprofen6-800mg3Hmesadayfor1-2weeks

Case4–Breastpain•  34yoG1P1callsclinic-rightbreasthurts,has“redspot”•  fever(101)todayand“achyeverywhere”•  4mobaby,growingwell•  Mombacktoworkx1wk,pumpingtwiceatwork–gets5ozeachside

•  Haslargefreezerstashofmilk•  Babysleeping7hours

– Whatisgoingon?–  Howtomanage?CollaboraHvecare...

Case4–MasHHsManagement

•  FrequentbreasPeeding,startonaffectedside•  Frequentbreastdrainage-pump,handexpress•  WarmfirstthencoldcompressaRernursing•  Non-infecHousvsinfecHous(**Staph,Strep,E.Coli)•  Dicloxicillin-500mgQID,cephalexin500mgTID–14d•  Considermilkcultureifnotbegerin48hrs,?MRSA•  Paincontrol-ibuprofen,maternalselfcare-rest!•  ProbioHcs,fluids•  “YeastmasHHs”-bigcontroversy-trialofdiflucanONLYif

unresolvingbreastpainAND– momwithcandidarash,babywiththrushonexam– firstaddressvasospasm,oversupply,iniHaltrialanHbioHcs(+/-)

•  BabiescansHlldrinkthebreastmilk•  Closef/u-ifrecurrent,mass-needsU/S,etc

CandidarashandThrushinbaby

Collaborative Breastfeeding Care Heggie, Johnson, Licari, Winesett May 25 '17

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LactaHonConsultantReferral•  Slowweightgain•  Lowmaternalmilksupply–perceivedoractual•  Breastconcerns–nippledamage,masHHs,thrush,plugs,

vasospasm,painwithbreasPeeding(incl.neck,shoulder,breast)•  ComplexbreasPeedingissues-motherorbabywithmedical

issues•  Latchproblems,invertednipples,nippleshieldconcerns•  Ankyloglossia,breasPeedingevaluaHon•  BreastreducHon,hypoplasia,abnormalbreastappearance•  MaternalmedicaHonquesHon&lactaHonmanagement•  Babywithspecialneedsincludingprematureandearlyterm

infants•  Pumpingissues–backtowork,painwithpumping•  Twin,triplets,ormore

Collaborative Breastfeeding Care Heggie, Johnson, Licari, Winesett May 25 '17