UBC Objectives: Maternity Care & Priority Topic: Pregnancy

Key Feature 12: In a breastfeeding woman, screen for and characterize dysfunctional breastfeeding (ex: poor latch, poor production, poor letdown).
Skill: Clinical Reasoning, Patient Centered
Phase: Hypothesis generation, History

​Along with postpartum depression (see my last post), screening for problems with breastfeeding is standard of care when providing healthcare to women who are postpartum. Difficulties with breastfeeding are common and often lead to early termination of breastfeeding. This is unfortunate for two reasons: 1. There are many established benefits of breastfeeding, 2. The problems that lead to cessation of breastfeeding are often easily treatable. Being vigilant about assessing for and managing problems with breastfeeding can help address issues with breastfeeding before mom switches to formula-feeding, thereby increasing the opportunity for mom and baby to receive the many benefits that breastfeeding has to offer.

The most common problems with breastfeeding fall under 1 of 2 categories: 1. Inadequate milk intake or nipple/breast pain. An approach to concerns that fall within these categories are outlined below.

Inadequate milk intake:
DDx:

1. Insufficient feeding routine
2. Poor latch/technique
3. Insufficient milk production 
4. Combination of the above

History:                         

1. Feeding history
   1. Frequency and duration of feedings (Normal in the first month of life for full term infants is once every 2-3 hours. As baby's get older, they become more efficient feeders. At the start of life, they may spend around 20 minutes feeding on each breast, and later infancy this may decrease to only 5-10 minutes per breast.)
   2. Exclusive vs formula-supplemented feeding (Supplementing with formula hinders getting breastfeeding well-established. Breastfeeding is hard work for the baby at the start of its life, and if the infant learns that it can get formula much easier, it will naturally make less of an effort to breastfeed. This subsequently impairs the mom's ability to get her milk production going, since stimulation by baby is part of what drives mom's milk production.)
   3. Quality of latch (Does mom think baby has a good latch? Is there any reason to think baby may have a neurological or congenital issue that could lead to difficulty coordinating a good latch?)
2. Infant urine and stool output (By the end of the first week, infants normally void urine 6-8 times daily, and pass 3 or more mustard yellow stools daily. Less than this is concerning for insufficient milk intake.)
3. History of mom's milk production
   1. If and when she noticed her milk "come in."
      1. If there is a delay in the progression from expressing colostrum to the actual milk coming in around day 3-5 postpartum, this could be due to high androgen levels.
   2. Maternal risk factors predisposing her to producing insufficient milk
      1. If the mom's breasts didn't grow much during pregnancy, this could be a sign that she has limited glandular tissue to produce milk. 
      2. Some medications hinder milk production. These include oxytocin, dopamine agonists, decongestants, estrogens, and possibly SSRIs.   
      3. Previous breastfeeding experience that was either successful or unsuccessful is informative. 

Physical exam:

1. Infant weight (Full term infants normally lose weight after birth, with an average weight loss of 7% of their birth weight by day 3-5 of life. This is because the mom's breastmilk doesn't fully "come in" until around the time. Once the mom feels her breasts full with milk, the infant should not continue to lose weight. Infants then normally regain their birth weight after 1-2 weeks. If an infant has lost 10% or more of its birthweight, or if there is failure to regain birthweight by 2 weeks of life, inadequate milk intake should be suspected)
2. General examination of infant looking for signs of congenital or neurological abnormalities (ex: tight lingual frenulum, cleft lip and/or palate, or retrognathia)
3. Examination of mom's breasts (Some women have inverted nipples, which can make breastfeeding challenging.)
4. Observation of feeding technique (see this YouTube video for an example of what a good latch looks like)

Next steps:

1. If the infant is being fed less than every 2-3 hours, or if time on the breast seems too brief, frequency and/or duration of breastfeeding should be increased.
2. If the infant is seen to have (based on observed breastfeeding, by doctor or nurse), or suspected to have (based on history and risk factors) a poor latch, referral to a lactation consultant is recommended.
3. If mom is suspected of producing insufficient quantity of breastmilk, consider hyperandrogenism or other causes of insufficient milk production. This means taking a thorough history for symptoms suggestive of possible underlying disease processes, reviewing medications, and performing a focused physical exam. Using a breast pump or manually expressing any extra breastmilk after the infant is done feeding helps to provide extra stimulation to further increase milk production.
4. Regardless of the etiology, there will need to be close follow-up, in clinic or via home visits, by a physician, nurse, lactation specialist, or other qualified health professional. If the infant has lost 10% of birth weight or has not regained birth weight by 2 weeks, giving donor breast milk or formula feeding is needed to ensure baby is receiving adequate nutritional intake.

Nipple/breast pain
DDx: A differential diagnosis for nipple and/or breast pain is provided below. Note that the reasons that nipple and/or breast pain occur are often at least in part consequences of poor feeding technique. So when it comes to the approach to nipple/breast pain in a woman who is breastfeeding, you pretty much do the same as above but also clinical assess for features suggesting any of the following issues may be occurring:

1. Nipple injury 
   1. Breastfeeding technique (ex: poor latch)
   2. Trauma from breast pump
2. Nipple dermatitis/psoriasis
3. Nipple vasoconstriction
4. Engorgement
5. Plugged ducts
6. Infection of breast +/or nipple

History:

• If the pain started within the first few days of starting breastfeeding, it more likely to be caused by poor latch. If it began later on once breastfeeding was already established, there is a greater chance it is due to infection as opposed to feeding technique. It is also important to differentiate nipple sensitivity from pain associated with nipple injury. The former occurs with the onset of feeding and subsides after about a minute or so into the feed, and it should completely resolve around day 7 of breastfeeding, while nipple injury associated with breastfeeding would be expected to worsen as the feed wears on, and to continue to occur as time wears on. Obviously there is more history to gather than what I've written here, but these are just a few points to help sort through what may be going on.

Physical exam: Along with the physical exam maneuvers for concern of decreased milk intake, also perform the following:

1. ​Inspect infant's oral cavity and diaper area for mucocutaneous candidiasis 
2. More thorough maternal breast exam looking for signs of trauma, infection, vasospasm, and masses or fullness.

Next steps:

1. Manage suspected feeding issues as outlined in the approach to inadequate milk intake
2. For suspected nipple sensitivity, mothers can take acetaminophen about half an hour before feeding. 
3. For suspected nipple injury, correcting the reason for the trauma is important (ex: improving latch or breastfeeding position, perhaps with the help of a lactation consultant, or changing type of breast pump). Suspected infection may be treated with antibiotics or antifungals. Other interventions include: using an antibiotic ointment with overlying nonstick pads inside the bra (to moisturize and protect against infection), and cool or warm compresses and acetaminophen or ibuprofen for symptomatic relief. For any ointments applied to the nipple therapeutically (and more are mentioned in the treatment of etiologies that follow, always advise mom to clean off her nipples before the next feed and reapply after feeding is done)
4. For suspected nipple dermatitis or psoriasis, advise the woman to avoid potential irritants and allergens, and prescribe a medium potency topical steroid cream. Beware of infections that can masquerade with the appearance of dermatitis, including herpes and impetigo. If there is suspicion for either and unruptured vesicles or pustules, collect a swab for viral or bacterial culture. If HSV is suspected, the mom should not breastfeed from the affected breast, and she should cover any lesions that could come into contact with the infant. For suspected impetigo, antibiotic treatment is indicated. 
5. For suspected vasoconstriction, recommend breastfeeding in warm conditions and avoiding medications that can worsen vasoconstriction (such as nicotine and caffeine). If vasoconstriction occurs, warm the nipple as soon as it starts. Consider using a topical nifedipine cream.
6. For suspected engorgement, it is important to ensure good feeding technique so that the breasts are emptied with each feed. Breast milk can also be manually expressed to relieve some of the pressure, but going as far as to breast pump is not recommended as this more forceful expression tends to further stimulate increased breastmilk production. For symptomatic relief, the woman may try warm compresses to facilitate let-down, cold compresses after or between feeding to reduce swelling and discomfort, and analgesia with acetaminophen or ibuprofen. Apparently applying cold green cabbage leaves can also be soothing, lol.
7. For suspected plugged ducts (diagnosed clinically as a tender lump without any associated systemic features of infection), it is important to ensure good feeding technique so that the breasts are emptied with each feed. Hand expressing breast milk and applying warm compresses can also help, along with massaging the area under a warm shower. Acetaminophen and ibuprofen can also be taken for symptomatic relief. If not resolved in 48 hours or so, consider obtaining an ultrasound to assess for an abscess or mass. If a benign galactocele forms, it can be aspirated for symptomatic relief.
8. For suspected mastitis (systemic features of infection typically present), obtain a culture of the breastmilk and begin empiric antibiotic therapy that covers Staph aureus, the most likely infectious agent. The choice of antibiotic should take into account whether the patient has risk factors for MRSA. Other strategies include continuing to feed (although this may seem counterintuitive) and ensuring good feeding technique, along with ibuprofen and cold compresses to reduce swelling and provide symptomatic relief.
9. For suspected candidal infection (pain out of proportion to the physical exam, especially with an infant with thrush or maternal history of vaginal candidiasis), prescribe a topical antifungal agent. Also inspect the infant for thrush and if present, treat with a nystatin suspension.