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Breastfeeding

Course #33353 - $90 -

#33353: Breastfeeding

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CASE ONE: SORE NIPPLES

Presenting concern.

Patient A and her son K, 6 days of age, were seen in the lactation clinic for sore nipples.

History of Presenting Concern

Baby K was initially ABM-fed in the nursery. First nursing was at 26 hours of age. Nipple pain began with the first breastfeeding. Patient A experienced moderate engorgement on postpartum day 4. Following engorgement, her nipples began to crack. Nipples now "seem to hurt all the time." Patient A reports that severe nipple pain occurs with latch-on. Nipple cracks began bleeding bilaterally yesterday. The infant vomited blood after this morning's feeding.

Patient A is 28 years of age, gravida 2 para 2. Pregnancy was uneventful except for a herpes outbreak at 36 weeks. Patient A reports breast changes accompanied pregnancy. The infant was born by elective cesarean section at 39 and 3/7 weeks for active genital herpes. The cesarean was done under epidural anesthesia. K's birth weight was 8 pounds, 7.5 ounces. Hospital discharge weight at 3 days of age was 7 pounds, 15 ounces. Bilirubin level was 10 mg/dL. Patient A has a daughter, 3 years of age, at home whom she attempted to nurse for three weeks but quit because of severely sore nipples. Family history is noncontributory except for a tendency toward allergies. Father is allergic to milk, wheat, and pollen. Patient A is allergic to codeine, penicillin, and sulfa. Three-year-old sibling has asthma. Patient A desires to nurse this child as long as possible to help prevent asthma and other allergies. Father was present during the consultation and appears very supportive. The couple did not attend breastfeeding classes.

During the last 24 hours, K has nursed every 2.5 hours; mother is switching breasts every 10 minutes. Feedings take 20 to 40 minutes. Patient A reports eight damp diapers and two semi-runny, yellow stools since this time yesterday.

Infant appears slightly jaundiced. Sclerae are white. Weight today is 8 pounds. Hydration status: good tissue turgor, level fontanelles, and mucous membranes slightly dry. Respirations easy. Has a lusty cry. Oral anatomy is within normal parameters. Soft and hard palate intact. Lingual frenulum visible, but tongue moves freely.

Maternal breast examination revealed moderately engorged breasts. Nipples are everted, approximately 1 cm in size with a linear fissure diagonally from 2 to 8 o'clock on the left side and 10 to 4 o'clock on the right. Areolae, approximately 3.5 cm, appear moist and intact.

Observation of a Nursing Session

Patient A positioned K on his back in cradle hold. Breast support technique was C-hold; however, mother pinched the nipple between the thumb and forefinger and placed the nipple into the baby's mouth before any evidence of a rooting response. K latched on to nipple only. The latch was immediately broken by the consultant.

Interventions

Patient A was shown how to position the baby, proper breast support, and latch-on technique. K latched on with minimal assistance, wide-open mouth well back on the areola. Active suckling with a one-to-one suck-swallow ratio was observed. Milk ejection response was noted as dripping from the opposite breast. Patient A stated after slight initial nipple stretching pain, the remainder of the feeding was pain free. K nursed for eight minutes before suckling slowed and he began to twist and squirm. Patient A was told that K's slower suckling rate and movements might be his signals that he needed to burp. Patient A inserted her finger into K's mouth to take him off the breast. The nipple was round and of normal color immediately after nursing. Following burping, mother latched K on to the opposite breast without assistance. He nursed for approximately three minutes before falling asleep and releasing the breast on his own. Patient A was instructed to start the next feeding at that breast.

Sore nipples due to knowledge deficit of latch-on technique.

Engorgement related to normal Stage II lactogenesis and inadequate feedings (breast emptying).

Poor weight gain due to inadequate intake related to nipple pinching.

Possibility for mastitis due to nipple fissures.

Remember the steps of latch-on.

Positioning the baby: Turn the baby entirely toward you. Place the baby's head in the crook of your arm. Support the baby and your arm with pillows.

Offering the breast: Thumb on top; all fingers below the areola. Keep fingers away from the areola. Bring the baby to the breast—not the breast to the baby.

Latching-on: Tickle the baby's lower lip with your nipple. Wait for the wide "ah" before latching on. Latch the baby on correctly at each feeding. If there is nipple pain, take a deep breath, let it out slowly; if the pain continues after the cleansing breath, break the latch and begin again.

Additional recommendations for this patient include:

Nurse every two or three hours on demand. Allow the baby to signal the timing of the feeding.

If the baby nurses minimally on the second breast, begin the next feeding on that breast.

Keep a written record of feedings and urine and stool output. Bring it to the next appointment.

Apply cool, moist compresses to breasts after nursing to help with engorgement.

Manual expression before latch-on if areola is too firm for proper latch-on.

Watch for signs and symptoms of mastitis.

Return to clinic in two days for weight check, or sooner if condition worsens or does not improve.

At his second visit, K weighed 8 pounds, 7 ounces, a gain of 7 ounces in 48 hours. Maternal nipples were healing. Breasts were soft. A nursing session was observed. K and his mother were not seen in the lactation clinic again. However, Patient A called the clinic for weaning information when K was 2 years of age. She stated they had no further breastfeeding problems.

CASE TWO: LOW MILK SUPPLY

Patient M and her daughter J, 16 days of age, were seen in the lactation clinic for low milk supply.

Due to the severity of her postpartum condition, Patient M was unable to breastfeed her infant. The mother was followed by the lactation team during her complicated hospital course.

She was started on a two-hour pumping schedule seven days postpartum using a commercial-grade electric pump with a double pumping set up. Milk yield was 0.5 to 1 ounce per session, and the milk remained colostral throughout her hospital stay. She never experienced any postpartum breast fullness. All expressed milk was fed to the infant in addition to ABM. Bottle feedings were always done by someone other than the mother. M wants to be able to breastfeed this infant "forever, because nothing else went right."

She was discharged home on postpartum day 14 with instructions to continue pumping, provide lots of skin-to-skin contact, and patiently wait to see if J would latch-on by herself.

Patient M is 42 years of age, primigravida, with no history of fertility problems. M reports breast changes accompanied pregnancy, growing two full cup sizes. The pregnancy was difficult. During the first trimester she was hospitalized three times for dehydration resulting from hyperemesis gravidarum. M had an episode of pyelonephritis during the second trimester. Elevated blood pressure and proteinuria began at 31 weeks' gestation. The infant was born by cesarean section at 37 weeks due to pregnancy-induced hypertension and HELLP syndrome. Due to the low platelet count, a postpartum hemorrhage resulted. Her hemoglobin was 6.5 on postpartum day 3 and 8.2 at hospital discharge. M received transfusions of 2 units of packed cells and 4 units of platelets. She was diagnosed with a collapsed lung on postpartum day 5 and required chest tubes for decompression.

J's birth weight was 6 pounds, 12 ounces. Hospital discharge weight was 8 pounds, 2 ounces. J's hospital course was uneventful. The father remained in the hospital during the postpartum course and gave J most of her feedings.

Family history is noncontributory except that M and her husband are newly wed (one year). This is the first marriage for both. The father was present during the consultation and appears very supportive. They were unable to attend any prenatal classes.

During the last 48 hours, J has been fed every three hours. She takes an average of 3 ounces of expressed mother's milk and ABM at each feeding. The baby latched-on spontaneously for three to four minutes during skin-to-skin contact twice in the last 24 hours.

Infant appears healthy and well nourished. Weight today is 8 pounds, 6 ounces. She is alert and active. Oral anatomy is within normal parameters. Soft and hard palate intact. Tongue has normal wave motion on digital assessment.

Maternal breast examination reveals soft breasts. Nipples are everted and intact, approximately 2 cm in size. Large areola appears dry. Milk will express in drops. Appears to be of transitional quality rather than colostral. Patient M reports that her milk yield with double pumping remained the same.

Mother positioned the baby in a clutch hold with pillows for support. J latched-on and suckled vigorously. However, there were infrequent swallows.

Patient M was shown how to fill and set up the SNS. The SNS was filled with 3 ounces of expressed mother's milk. The medium tube was placed at the breast, and the baby latched-on and suckled with a one-to-one suck-swallow ratio. No milk ejection response was observed. The feeding was pain free. J nursed for 15 minutes, taking 2.5 ounces from the SNS.

A dietician was consulted for diet suggestions to include high-protein, high-iron, and high-vitamin C foods for healing and anemia. A written list of appropriate foods was given to the mother.

Actual low milk supply probably related to poor maternal physical condition.

Potential for Sheehan syndrome due to postpartum hemorrhage.

Use the SNS with the medium tube at each nursing. Fill to 3-ounce level (adding more if needed). The bottom of the bottle should be level with the nipple line. Tape tubing in place as needed. Handout given for the care and use of the SNS.

Keep a written record of feedings, intake from SNS, and urine and stool output. Bring it to the next appointment.

Follow each feeding with a five-minute pumping session.

Use breast massage during feedings and pumpings.

Apply ultra-purified lanolin sparingly to areola after pumpings. Do not wash off before feedings.

Rest as much as possible. (Mother was given permission to skip feedings as needed if she felt she was not getting enough rest.)

Add foods recommended by dietician to meals.

Continue vitamin supplements. Add brewer's yeast to diet, three times a day with meals.

Return to clinic in two days.

At the second visit, J weighed 8 pounds, 7 ounces, a gain of 1 ounce in 48 hours. M had nursed the baby at the breast with the SNS every three hours. J averaged 2 ounces per feeding. Patient M stated her breasts felt fuller and firmer, which was confirmed by breast examination. A nursing session was observed. Patient M demonstrated proper use of the SNS and latch-on technique.

Continued low milk supply.

Signs of Stage II lactogenesis beginning.

Continue the SNS at each nursing. Fill to 2-ounce level (adding more if needed). Lower the bottom of the bottle to one inch below the nipple line.

Continue previous plan of care.

Return to clinic in three days.

At the third visit, J weighed 8 pounds, 10 ounces, a gain of 3 ounces in 72 hours. M had nursed the baby at the breast with the SNS every three hours. J averaged 1 to 1.5 ounces per feeding. Urine and stool output were within normal limits. Mother stated her breasts were engorged this morning, which was confirmed by breast examination. A nursing session was observed with the SNS in place. J gulped at the breast after about one minute. Milk ejection response was observed as large drips from the opposite breast. The SNS tubing was clamped and J continued to nurse vigorously with a one-to-one suck-swallow ratio.

Low milk supply resolved.

Stage II lactogenesis evident as engorgement.

Sheehan's syndrome ruled out due to presence of milk ejection response and engorgement.

Start each feeding with the SNS; clamp tubing after one minute.

At the fourth visit, J weighed 8 pounds, 15 ounces, a gain of 5 ounces in 72 hours. M had breastfed the baby at the breast with the SNS for the first 24 hours only. Urine and stool output were within normal limits. A feeding session was observed without the SNS. J nursed vigorously with a one-to-one suck-swallow ratio.

Normal nursing couple. Low milk supply resolved.

Adequate infant weight gain.

Discontinue the SNS.

Nurse every three hours or on demand.

M and J were followed for three weeks with weight checks every three days. J continued to gain well. Mother and infant were discharged from lactation clinic follow-up at 45 days postpartum. J's weight at the last visit was 12 pounds, 10 ounces. The couple was still nursing well at six months.

CASE THREE: FOURTEEN WEEKS TO LATCH-ON

Patient B and her infant C, 7 days of age, were seen in the lactation clinic because her baby had not latched on since birth.

Patient B is 44 years of age, primigravida, with a history of fertility problems. In her words, this will most likely be her only biologic child. C was delivered by cesarean section at 32 weeks' gestation because of high blood pressure and HELLP syndrome. Cesarean section was done under epidural anesthesia. Baby C's birth weight was 4 pounds, 8 ounces. She was discharged from the hospital with her mother at 15 days of age. C is bottle fed with expressed mother's milk, taking approximately 90 cc every three hours. Patient B has been trying to maintain her milk supply using a small electric pump. In the last few days, B reports that she is pumping smaller and smaller amounts of milk at each session. Currently pumping 10 to 15 cc every two hours.

C is a healthy newborn with good color. Slightly hypertonic muscle toned is noted, probably related to crying state. Last feeding was 3.5 hours ago. Maternal breasts appear normal. Nipples are intact, and the breasts feel soft, not filling.

Unable to latch on for more than a few seconds without baby becoming visibly upset. Infant was bottle fed at this appointment.

Severe latch-on problem related to hunger state. Actual low maternal milk supply related to inefficient breast pump.

Increase milk supply. Decrease maternal stress level regarding latch-on.

Hospital-grade electric double pump every two hours.

Herbal supplements: fenugreek, blessed thistle, and brewer's yeast as instructed.

Do not attempt latch-on but do a lot of holding and skin-to-skin contact without asking baby to latch on.

Return to clinic in two days. Bring baby hungry but not starving.

Patient B has been pumping every two hours and noticed increase in milk supply yesterday. Enough milk pumped so she could have some extra expressed milk in the freezer. Baby C is calm with adequate two-day weight gain.

Physical exam is remarkable for hypertonia. When held in mother's arms, C's back arches. C has a stiff quality and is easily upset. C would not root to the breast; she arched, pushed the breast away with her fists, and screamed after only a few minutes of trying. She did not cuddle; C turned her whole body away from her mom when held. C's body looks like an arch, with only her head and bottom touching her mom across her mom's arm. When laid down she immediately flips to her right side and holds herself in a tight fetal position. Is extremely difficult to bottle feed, taking nearly an hour to finish a feeding of 45–60 cc.

Severe latch-on problem related to hypertonic muscle tone.

Low maternal milk supply resolving.

Continue present plan. Offer breast but do not insist. Stop if baby gets upset. Referral to neurodevelopmental therapist made. To follow-up in one week after appointment.

Patient B and C returned once a week for 16 weeks. C was gaining well and increasing her intake with mom now over-supplied.

At one visit, B confessed that she often worried that C hated her. She was assured that C's behavior was not directed at her, but the result of an immature nervous system. She was also warned that C might never latch on, but help and support would be available for whatever she wanted to do. B said she had 12 weeks of maternity leave left, and she would continue to pump her milk for at least that long. "My husband and I have been talking about how my body couldn't allow her to finish growing inside so now she has to grow outside, and the best way is with my milk. I will pump for as long as I can if that is what we have to do."

B was doing a lot of skin-to-skin contact, co-bathing, and sleeping with C and attempting latch-on if C showed any interest. On the day C would have been 6 weeks of age if she was born on her due date, C began rooting toward the breast. So, mom leaned over, and C latched on and nursed for more than an hour. B stated she nursed like she had been doing it all along. She was still nursing at six months. Mother plans to nurse her until she self-weans.

CASE FOUR: BREAST ABSCESS

"I don't think this breast infection is getting any better."

Patient V was seen in urgent care five days ago. The diagnosis was mastitis of the right breast. She received a prescription for dicloxacillin 500 mg four times a day for 10 days. The patient was told at urgent care not to breastfeed on the affected side. She has been taking dicloxacillin "kind of hit and miss, but at least four per day" and is pumping "when the breast feels full." She is currently nursing on left side only, every two to three hours. Patient V has a history of nipple fissures with early engorgement. She states that she has not had a fever in the last two days; temperature is 98.7°F oral now. She feels "well" and denies headache or body aches. The infant, 22 days of age, is not present at this appointment.

Breast Exam

Right breast severely engorged. Healing, linear crack noted horizontally across the right nipple face. Bright-red, wedge-shaped area in upper inner quadrant of right breast covering the 12 to 3 o'clock position. Area is exquisitely tender. Oval induration approximately 3–4 cm in size palpated central to inflamed area. There is a 1 cm area within the indurated region, slightly below surface, that is soft and mushy. Skin intact over the area.

Probable breast abscess related to inadequate breast emptying, delay in antibiotic treatment for apparent ascending mastitis, and inadequate use of antibiotics ( Table 14 ).

COMPARISON OF PLUGGED DUCTS, MASTITIS, AND BREAST ABSCESS

To urgent care immediately.

Pump breast with hospital-grade electric pump or nurse every two hours.

Follow up in two days.

Call if weaning information is desired.

Hospitalized for incision and drainage of breast abscess and IV antibiotic therapy. Patient V contacted the clinic as she desired weaning. Instructions were given for using breast pump to gradually reduce milk supply.

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Breastfeeding Curriculum

Why use this curriculum?

• Breastfeeding is best for the health of infants and mothers.
• As more mothers are choosing to breastfeed, more physicians need to have the skills to support them.
• Being able to successfully handle any issue related to breastfeeding leads to a stronger doctor-patient bond, and better outcomes.
• When families get the help they need, the more we reduce health disparities that impact infants from the start.

This curriculum was developed to help all residents develop confidence and skills in breastfeeding care.

Presentations, videos, case studies and other resources can be incorporated into existing Pediatric, Family Medicine, Internal Medicine, Obstetric/Gynecologic and other residency or fellowship program curricula. Parts of the curriculum may be appropriate for medical school, advanced practice provider and allied health curricula.

Webinar - Implementing the Breastfeeding Curriculum - April 18th, 2024

The Breastfeeding Curriculum

Select a curriculum topic below to get started.

Medical Knowledge

Learners will understand the anatomy of the breast, the physiology of lactogenesis and the challenges of breastfeeding.

Learners will be able to educate families about breastfeeding, provide peripartum breastfeeding support for routine care and common problems, recognize and be able to address breastfeeding challenges and special situations after discharge and throughout infancy and understand the unique needs of LGBTQ+ families as it relates to infant feeding.

System Based Practice

Learners will be able to coordinate services with other professionals, laypersons and community groups, consistent with an interprofessional and team-based approach to care.

Practice Based Learning

Learners will investigate breastfeeding rates, identify and describe site-specific disparities in breastfeeding rates and implement a quality improvement project on breastfeeding rates.

Interpersonal Communication Skills

Learners will communicate effectively with patients, families and other medical providers regarding breastfeeding.

Guide to Curriculum

The curriculum has been organized based on the Accreditation Council for Graduate Medical Education Core Competencies. Whether you implement 1 activity or 20, you are helping trainees to develop confidence and skills to help breastfeeding infants and families.

Each curriculum topic has the following structure:

Essential Activities

The Essential Activities are what you should strive to complete with every resident.

Additional Activities

The Additional Activities are provided to give more options if time allows. It is strongly encouraged that you evaluate residents on these activities.

Evaluation will help residents know how they are doing and will help you keep track of their progress. The evaluation tools are effective in evaluating residents as well as the breastfeeding residency curriculum as a whole.

Helpful Tools

The following tools are here to help you along the way.

Data Collection Guide

Patient care evaluation: acgme core competencies, objective structured clinical examination case study, breastfeeding curriculum resources.

Residency or school faculty: Tell us about your program's current breastfeeding education.

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LATEST UPDATES

Updated case studies in breastfeeding published.

Originally published in 2003, HCP faculty members Karin Cadwell and Cynthia Turner-Maffei recently published an updated 2019 edition of Case Studies in Breastfeeding: Problem-Solving Skills and Strategies. The new book, which is 220 pages long, shares a step-by-step, consultative framework for addressing both common and uncommon issues and includes new real-world case study examples to highlight the approach in action. Combining logic, wisdom, and theory, the text is intended to convey a deeper understanding of how to act in accordance with the highest needs of the breastfeeding mother and baby to increase the practitioner’s knowledge about managing complex breastfeeding cases. Case Studies in Breastfeeding: Problem-Solving Skills and Strategies can be purchased through Health Education Associates or on Amazon.

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