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Red Flags for Breastfeeding Helpers

Catherine Watson Genna, BS, IBCLCcwgspeak@gmail.com

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.

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