3. Milk Production
• Generally mature milk begins within 72H. MR
feel that the breast is heavier and fuller
• Occasionally some MR experience delayed
onset of milk production. Causes include
– overhydration with IV fluids
– retained placental fragments(cos of hormones
secreted by the fragments)
4. Delayed Onset of Milk
Production
• Review the hydration status of the baby- weight,
IO, NNJ
• Solutions for MR
– Nurse frequently 2H or more depending on baby
– Massage the breast while nursing
– KIV pump after nursing to stimulate the breast
– KIV herbal secretagogues(fenugreek), medications
(domperidone 10mg TDS)
– Consider weighing baby EOD
5. Breast Pain
If the MR complains of breast pain, ddx
breast engorgement
galactocele
mastitis
breast abscess
Breast engorgement
Usually occurs D2-3 as the milk production occurs and there
is increased blood flow to the breast
Problems
Breast becomes swollen and tender
Nipples may flatten, difficult to latch
Nursing may be infrequent or ineffective and milk supply
subsequently drops
6. Breast Pain
• Breast engorgement
– Solutions
• Nurse frequently 1-3H
• Nurse until breast is fully emptied (preferable to
nurse 1 side till emptied then the other, rather than
limit nursing on the first side in bid to nurse both)
• Gently massage during nursing to encourage milk
flow
• If MR still feels full after nursing, can further
express after nursing
• Consider cold cabbage to relief pain and swelling
• KIV analgesia(eg panadol) if pain is severe
7. Breast Pain
• Galactocele/Blocked ducts
– Cyst in the mammary duct containing milk
– Encourage massage during nursing or expressing
– Consider alternating positions for nursing to ensure the whole breast is
well emptied.
• Sore nipples
– Types
• traumatized nipples: blistered, scabbed or cracked
• irritated nipples: pink with burning sensation
– DDx
• Nipple thrush: treat MR and BB with miconazole/nystatin
• Contact dermatitis: vit E containing creams, preps with cocoa butter, lanolin
• Eczema
• Impetigo
• Improper positioning (fail to open mouth wide or mouth slides off areola to
nipple due to breast engorgement or unsupported nipple)
8. Breast Pain
• Sore nipples
– Solutions
• Do not delay nursing, consider Q1-2H nursing for a shorter period
• Start on the less tender side
• Massage during nursing to speed up emptying
• Release the suction carefully after the feed
• In between feeds, squeeze some EBM and apply on nipple and
areola(contains Ig), then apply lanolin
• Consider pumping on the tender side
• Consider analgesia
• Wear cotton, microfiber bras(better air circulation)
• Avoid excessive washing of nipples
9. Breast Pain
• Traumatized nipples
– Solutions
• Consider alternative nursing position
• If the breast is full and BB is unable to take whole areola into
mouth, then compress with finger or manually express some
milk before nursing
• If BB does not open her mouth wide then wait for her or let
her suck on MR’s finger to stimulate the sucking reflex before
latching
• Take the BB off once the position is suboptimal and
reposition(may require help from partner)
• KIV ABX if there is any evidence of infection.
10. Breast Pain
Mastitis
Inflammation of the breast ducts +/- infection
Treatment
Frequent nursing to drain the ducts KIV expressing
Analgesia +/- antibiotics
Breast abscess
Seek medical attention for drainage
Breast pain
Ddx
Let down
Refilling after nursing
Blocked ducts
Nipple irritation
11. Flow of the Milk
• Let down difficulty
– Stimulation
• best stimulator is the suckling of the BB
• MR encouraged to be relaxed and think of BB
during pumping
– Ddx
• problem with BB latching or sucking
• low milk supply
• Leaking milk
– Solutions
• at home, open both bra flaps and lay a cloth for it
12. Difficult Latch-on
• Nipple issues
– flat nipple
– dimpled nipple
– inverted nipple
• Problems that may arise
– frustrated MR and BB
– Poor latch may lead to nipple soreness
• Solutions
– Encourage nursing within 2h of birth as BB tend to latch better
then to problem nipples
– Get help to position the BB for nursing
– Avoid artificial teats in the first few days
– Consider pumping for a short while before nursing as it can help
to pull nipple out for better nursing
15. NNJ
• Physiological jaundice
– contributed by inadequate intake -> dehydration and inadequate
calories
– continue to breastfeeding even during phototherapy, either via
direct latching or EBM
• Breast milk jaundice
– many factors implicated: metabolite of progesterone in breast
milk that inhibit enzymes in the metabolism of bilirubin,
inflammatory cytokines contributing to cholestasis
– work-up to rule out prolonged conjugated hyperbilirubinemia
– no indication to stop breast feeding
16. Underfeeding and Weight Loss
• Significant if BB loses >10% body weight
• Consider pumping when the feed is due to estimate the
amount of breast milk taken and reasses for the need to
supplement
• Ddx
– Inaqeuate milk production
– Poor latch
• Solutions
– Nurse often KIV supplement
– Weigh BB every few days
– Review BB’s latch
17. PU and BO
• PU: it is acceptable to PU x 1 on D1, x2 on
D2
• BO
– D1-3: passing meconium
– D5 onwards: passing breastfeeding stools, mustard colour
18.
19. Sleepy Baby
• Typically occurs in the 1st
week of life
• Ensure that BB is fed every Q3H
• Solutions:
– Stimulate BB when its feeding time by rubbing her back, or
placing on the bare chest
– If BB falls asleep latching, compress the breast to
encourage more milk flow, as this may help arouse BB
– Burp BB well after each feed
– If unable to rouse BB, KIV feed after 1H
21. Difficult Latch On
• Preference for teat
– Ensure that the breast is not too full->pump
some before feeding, or firm it by applying ice
for a few minutes
– Good positioning
22. Difficult Latch On
• Micronagthia
– Ensure breast not too full
– Tilt the BB’s head slightly backwards so that
the chin touches the breast 1st
• Tongue tied
– May make nursing painful even with good
positioning, may have “clicking” sound during
suck
– Consider frenotomy
23. Difficult Latch On
• Protruding tongue
– Encourage BB to open mouth wide and hold the
tongue down
– Football hold offers the best control and visibility
• Tongue sucking
– Latch on when the BB has his mouth open and his
tongue down
– Slightly depressing the lower chin may help the tongue
to drop
