3. AUTHORS
• NEHA MARIYA RAPHEAL,1 BALAKRISHNAN RAJAIAH,1 RAJENDRAN
KARUPANAN,2 THANGARAJ ABIRAMALATHA,2 SRINIVAS
RAMAKRISHNAN1
• 1NEONATAL INTENSIVE CARE UNIT, KOVAI MEDICAL CENTER AND
HOSPITAL (KMCH), COIMBATORE, TAMIL NADU.
• 2DEPARTMENT OF PEDIATRICS AND NEONATOLOGY, KMCH
INSTITUTE OF HEALTH SCIENCES AND RESEARCH, COIMBATORE,
TAMIL NADU.
• CORRESPONDENCE TO: DR BALAKRISHNAN RAJAIAH, CONSULTANT,
NEONATAL INTENSIVE CARE UNIT, KOVAI MEDICAL CENTER AND
HOSPITAL (KMCH), COIMBATORE 641 014, TAMIL NADU.
4. • JOURNAL:- INDIAN PEDIATRICS
• (VOLUME 60__JANUARY 15, 2023)
• RECEIVED: APRIL 29, 2022;
• INITIAL REVIEW: JUNE 23, 2022;
• ACCEPTED: SEPT 19, 2022.
5. INTRODUCTION
• BREASTFEEDING IS CONSIDERED AN IMPORTANT INTERVENTION TO
REDUCE INFANT AND UNDER-5 MORTALITY.
• THOUGH BREASTFEEDING IS A NATURAL PROCESS, SOME
MOTHER-INFANT DYADS MAY HAVE PROBLEMS IN BREASTFEEDING,
PARTICULARLY DURING THE INITIAL DAYS AFTER CHILDBIRTH.
• IMPROPER BREASTFEEDING TECHNIQUE MAY RESULT IN
INADEQUATE FEEDS LEADING TO EXCESSIVE WEIGHT LOSS,
HYPERNATREMIC DEHYDRATION, JAUNDICE AND
REHOSPITALIZATION.
6. • EVIDENCE SUGGESTS THAT EARLY INITIATION OF
BREASTFEEDING AND EXCLUSIVE BREASTFEEDING AT
HOSPITAL DISCHARGE ARE ASSOCIATED WITH
IMPROVED RATES OF EXCLUSIVE BREASTFEEDING UNTIL
SIX MONTHS AND INCREASED DURATION OF
BREASTFEEDING.
• AS WE ARDENTLY PROMOTE INSTITUTIONAL
DELIVERIES, THE INITIAL HOSPITALIZATION PERIOD IS A
GOOD OPPORTUNITY FOR HEALTH CARE WORKERS TO
ASSESS BREASTFEEDING, EDUCATE MOTHERS ON
CORRECT BREASTFEEDING TECHNIQUES, AND BOOST
THEIR CONFIDENCE IN BREASTFEEDING BEFORE
DISCHARGE FROM HOSPITAL.
7. • THERE IS A NEED FOR A SYSTEMATIC WAY TO EVALUATE
THE BREASTFEEDING TECHNIQUE, IDENTIFY PROBLEMS
RELATED TO BREASTFEEDING AND TAKE APPROPRIATE
CORRECTIVE ACTIONS IN A TIMELY MANNER.
• IN THIS STUDY, THEY AIMED TO DETERMINE THE
INCIDENCE AND NATURE OF EARLY BREASTFEEDING
PROBLEMS USING LATCH TOOL, AND TO ANALYZE THE
IMPACT OF BREASTFEEDING SUPPORT IN IMPROVING THE
LATCH SCORE.
8. • OBJECTIVE: TO DETERMINE EARLY BREASTFEEDING
PROBLEMS USING LATCH TOOL, AND ANALYZE THE
IMPACT OF BREASTFEEDING SUPPORTIVE MEASURES IN
IMPROVING LATCH SCORE.
• STUDY DESIGN:- PROSPECTIVE OBSERVATIONAL STUDY
9. • SETTING:- THIS PROSPECTIVE OBSERVATIONAL STUDY
WAS CONDUCTED IN A TERTIARY CARE NEONATAL
CENTRE FROM SEPTEMBER, 2019 TO MARCH, 2020,
INCLUDING ALL INBORN TERM NEONATES.
• PARTICIPANTS:- ALL INBORN TERM NEONATES.
10. EXCLUSION CRITERIA
• THE EXCLUSION CRITERIA WERE NEONATES WHO
REQUIRED NEONATAL INTENSIVE CARE UNIT (NICU)
ADMISSION, MULTIPLE BIRTHS AND SICK MOTHERS WHERE
LATCH SCORE COULD NOT BE ASSESSED WITHIN
STIPULATED TIME.
• ETHICAL COMMITTEE:- THE STUDY WAS APPROVED BY
THE INSTITUTIONAL ETHICS COMMITTEE.KMCH ETHICS
COMMITTEE; NO. EC/AP/762/08/2019, DATED AUGUST
24, 2019.
11. LIMITATIONS
• THE STUDY HAS SOME LIMITATIONS. THEY DID NOT FOLLOW THE
MOTHER-INFANT PAIRS BEYOND 48 HOURS. HENCE, SEVERAL
PROBLEMS RELATED TO BREASTFEEDING THAT APPEAR LATER WERE
NOT ASSESSED.
• THEY DID NOT INCLUDE NEONATES WHO REQUIRED NICU
ADMISSION AND LATE PRETERM NEONATES, WHO MAY BE AT
GREATER RISK OF IMPROPER BREASTFEEDING.
• THEY DID NOT ASSESS INTER-OBSERVER AGREEMENT IN
ASSESSMENT OF THE LATCH SCORE AMONG THE STUDY NURSES.
12. METHODS
• LATCH IS AN ACRONYM THAT STANDS FOR LATCH, AUDIBLE
SWALLOWING, TYPE OF NIPPLE, COMFORT AND HOLD.
• EACH COMPONENT IS SCORED FROM 0-2 AND THE TOTAL SCORE
RANGES FROM 0-10.
• A TOTAL SCORE LESS THAN 8 IS CONSIDERED LOW/
UNSATISFACTORY.
• LATCH SCORE WAS ASSESSED AT 6-12 HOUR AFTER BIRTH.
13. • THE SCORING WAS PERFORMED BY A GROUP OF EIGHT
SENIOR NURSES (TWO IN EACH POSTNATAL WARD), WHO
HAD BEEN TRAINED IN LATCH SCORE ASSESSMENT AND
BREASTFEEDING SUPPORT,BEFORE COMMENCING THE
STUDY.
• THE TRAINING WAS PROVIDED IN MULTIPLE SESSIONS
USING IMAGES AND VIDEOS, AND BY HANDSON TRAINING
UNDER DIRECT OBSERVATION BY THE STUDY
INVESTIGATORS.
14. • DEPENDING ON THE PROBLEM IN BREASTFEEDING THAT
WAS IDENTIFIED DURING THE INITIAL ASSESSMENT,
COUNSELLING, EDUCATION AND SUPPORT WERE PROVIDED
TO THE MOTHERS BY THE STUDY TEAM.
• MOTHERS WERE TRAINED IN CRADLE OR CROSSCRADLE
HOLD OF THE BABY WHILE BREASTFEEDING.
• MOTHERS WHO HAD UNDERGONE CAESAREAN DELIVERY
WERE TAUGHT BREASTFEEDING IN SIDE-LYING POSITION.
15. • SIGNS OF GOOD ATTACHMENT WERE EXPLAINED TO THE MOTHERS
USING VISUAL AIDS.
• MOTHERS WERE ENCOURAGED TO EVALUATE AND CORRECT THE
POSITIONING AND ATTACHMENT OF THE BABY BY THEMSELVES
DURING SUBSEQUENT FEEDING SESSIONS, WHICH WAS SUPERVISED
BY THE STUDY TEAM.
• TACTILE STIMULATION AND/OR NIPPLE PULLERS WERE PRESCRIBED
TO MOTHERS WITH FLAT OR INVERTED NIPPLES.
16. • FOLLOWING THE INTERVENTIONS, LATCH SCORES WERE
REASSESSED AT 24-48 HOUR FROM THE TIME OF
DELIVERY.
• FOR MOST MOTHER-INFANT DYADS, BOTH THE INITIAL
ASSESSMENT AND POST INTERVENTION ASSESSMENT
WERE PERFORMED BY THE SAME NURSE.
17. • DEMOGRAPHIC AND CLINICAL DETAILS OF THE MOTHER
AND THE BABY WERE COLLECTED IN A PRETESTED STUDY
FORM.
• SAMPLE SIZE OBTAINED WAS 400 MOTHER-INFANT PAIRS,
ASSUMING A 50% INCIDENCE OF BREASTFEEDING
PROBLEMS IN TERM NEONATES, TAKING PRECISION OF 5%.
18. STATISTICAL ANALYSIS
• DESCRIPTIVE STATISTICS ARE PRESENTED AS MEDIAN AND
INTERQUARTILE RANGE (IQR) OR NUMBER AND PERCENTAGE, AS
APPROPRIATE.
• CHI-SQUARE TEST WAS USED TO COMPARE CATEGORICAL DATA
BETWEEN INDEPENDENT SAMPLES,MCNEMAR TEST FOR
CATEGORICAL DATA BETWEEN PAIREDSAMPLES, AND WILCOXON
SIGNED RANK TEST FOR ORDINAL DATA BETWEEN PAIRED SAMPLES.
• ALL STATISTICAL ANALYSES WEREPERFORMED USING SPSS 20.0. A P
VALUE <0.05 WASCONSIDERED STATISTICALLY SIGNIFICANT.
19. RESULTS
• AMONG THE 400 STUDY NEONATES, 217 (54.2%) WERE BOYS AND
19 (4.8%) HAD A BIRTH WEIGHT <2500 G.
• NEARLY HALF OF THE MOTHERS (197, 49.2%) WERE PRIMIPAROUS,
AND 252 (63%) HAD DELIVERY BY CESAREAN SECTION.
• MATERNAL AGE WAS <20, 20-30 AND > 30 YEARS IN 4 (1%), 290
(72.5%) AND 106 (26.5%), RESPECTIVELY. OF THESE, 29 (7.2%)
MOTHERS HAD HIGH-SCHOOL EDUCATION, 342 (85.6%) WERE
GRADUATES AND 29 (7.2%) WERE PROFESSIONALS.
20. • DURING THE INITIAL ASSESSMENT AT 6-12 HOUR, 399 (99.7%)
MOTHERS REQUIRED SUPPORT TO POSITION THE NEONATE,
• 190 (47.5%) MOTHER-INFANT DYADS HAD A POOR LATCH WITH A
SCORE OF 0 OR 1,
• AND 52 (13%) MOTHERS HAD A FLAT OR INVERTED NIPPLE.
• WHILE 288 (72%) MOTHER-INFANT DYADS HAD A LATCH SCORE
OF < 8 AT 6-12 HOUR AFTER DELIVERY, THIS REDUCED
SIGNIFICANTLY TO 63 (15.8%) AT 24-48 HOUR AFTER THE
BREASTFEEDING SUPPORT AND TRAINING (P< 0.001).
• THE MEDIAN (IQR) LATCH SCORES ALSO IMPROVED SIGNIFICANTLY
[7 (5,8) VS 8 (8,8); P<0.001].
21. • THE SCORES OF INDIVIDUAL COMPONENTS ARE GIVEN IN
TABLE.
• THE ‘LATCH’ COMPONENT IMPROVED SIGNIFICANTLY WITH
95.5% MOTHER-INFANT PAIRS HAVING A SCORE OF 2 AT 24-
48 HOUR.
• THOUGH THERE WAS IMPROVEMENT IN ‘AUDIBLE
SWALLOWING’ AND ‘HOLD’ COMPONENTS, THE PROPORTION
OF MOTHER-INFANT PAIRS ACHIEVING A SCORE OF 2 WAS
LESS EVEN AFTER THE TRAINING.
• MOST OF THE MOTHERS HAD A SCORE OF 2 FOR ‘COMFORT
DURING BREASTFEEDING.’ NUMBER OF MOTHERS WHO HAVE
A FLAT OR AN INVERTED NIPPLE DECREASED FROM 13% TO
22.
23. • ANALYSIS OF THE ASSOCIATION BETWEEN
DEMOGRAPHIC CHARACTERISTICS AND LATCH SCORES
SHOWED THAT CAESAREAN DELIVERY, PRIMIPARITY
AND MOTHER’S EDUCATION WERE RISK FACTORS FOR
A LOWER LATCH SCORE AT 6-12 HOURS.
• THOUGH, THE SCORES IMPROVED SIGNIFICANTLY
AFTER BREASTFEEDING SUPPORT IN ALL THESE
SUBGROUPS, THEY HAD PERSISTENTLY LOWER SCORES
AT 24-48 HOURS WHEN COMPARED TO THEIR FELLOW
GROUPS.
24.
25. CONCLUSION:
• LATCH IS A COMPREHENSIVE YET SIMPLE TOOL TO IDENTIFY
BREASTFEEDING PROBLEMS.
• GIVEN THE HIGH INCIDENCE OF BREASTFEEDING PROBLEMS
DURING EARLY POSTPARTUM PERIOD, SYSTEMATIC
ASSESSMENT OF BREASTFEEDING RELATED PROBLEMS USING
LATCH TOOL CAN HELP TIMELY INTERVENTION AND
IMPROVEMENT IN THE BREASTFEEDING TECHNIQUE.
26.
27.
28. DISCUSSION
• THEIR STUDY SHOWED THAT ALMOST ALL THE MOTHERS
REQUIRED ASSISTANCE IN POSITIONING THE NEONATE
DURING BREASTFEEDING AND ALMOST HALF OF MOTHER-
INFANT DYADS HAD PROBLEMS RELATED TO LATCHING,
WITH 13% MOTHERS HAVING NIPPLE ISSUES SOON AFTER
DELIVERY.
• WE FOUND A SIGNIFICANT REDUCTION IN BREASTFEEDING
PROBLEMS WITH TIMELY SUPPORT, TRAINING AND
COUNSELLING OF MOTHERS.
29. • LATCH SCORE PROVIDES A SYSTEMATIC METHOD TO
EVALUATE FIVE KEY COMPONENTS OF THE
BREASTFEEDING TECHNIQUE.
• IT HELPS TO IDENTIFY THE NATURE OF THE PROBLEM,
SO THAT APPROPRIATE CORRECTIVE MEASURES CAN BE
TAKEN BY COUNSELLING AND TRAINING THE MOTHERS
WITH SIMPLE VISUAL AIDS.
• IMPROPER LATCHING AND POSITIONING OF THE
NEONATE DURING BREASTFEEDING MAY RESULT IN THE
BABY SUCKING ONLY ON THE NIPPLE, WHICH IN TURN
WILL LEAD TO INADEQUATE FEEDS TO THE NEONATE
AND SORE/CRACKED NIPPLES AND BREAST
ENGORGEMENT IN THE MOTHER.
30. • THEY FOUND A SIGNIFICANT IMPROVEMENT IN NIPPLE
PROBLEMS SUCH AS FLAT OR INVERTED NIPPLES BY 24 HOURS
AFTER DELIVERY WITH SIMPLE INTERVENTIONS SUCH AS
TACTILE STIMULATION OR NIPPLE PULLER.
• THE ‘COMFORT’ COMPONENT HAD GOOD SCORES AT BOTH 6-
12 AND 24-48 HOURS POST-DELIVERY, PROBABLY BECAUSE
PROBLEMS CAUSING DISCOMFORT WHILE BREASTFEEDING,
SUCH AS BREAST ENGORGEMENT OR SORE/CRACKED NIPPLES
USUALLY DEVELOP LATER DURING THE POSTPARTUM PERIOD.
31. • ‘AUDIBLE SWALLOWING’ COMPONENT SCORED LOW AT
BOTH ASSESSMENTS AND THIS IS PROBABLY DUE TO
THE LESS QUANTITY OF MILK SECRETED BY MOTHERS
ON DAY 1 AND 2 AFTER DELIVERY.
• THE FREQUENCY OF AUDIBLE SWALLOWING IMPROVES
AFTER THE SECONDARY LACTOGENESIS, WHEN MOTHER
STARTS SECRETING MORE MILK
32. • PRIMIPARA MOTHERS WHO HAVE NO PREVIOUS
EXPERIENCE WITH BREASTFEEDING AND MOTHERS WHO
HAVE A CAESAREAN DELIVERY AND HENCE HAVE PAIN
AND CANNOT SIT UP ARE MORE LIKELY TO HAVE
PROBLEMS IN BREASTFEEDING, AS SHOWN BY OUR STUDY
AND PREVIOUS STUDIES.
• THESE SUBGROUPS OF MOTHERS WOULD REQUIRE MORE
SUPPORT TO ESTABLISH BREASTFEEDING
33. • BETTER LATCH SCORES IN THE EARLY POSTNATAL PERIOD
WERE SHOWN TO CORRELATE POSITIVELY WITH EXCLUSIVE
BREASTFEEDING RATES AT DISCHARGE AND AT 6-8 WEEKS
OF LIFE.
• HENCE, WE ARE OF THE VIEW THAT SYSTEMATIC
ASSESSMENT OF BREASTFEEDING USING THE LATCH TOOL
AND TIMELY INITIATION OF APPROPRIATE MEASURES TO
ADDRESS THE PROBLEMS THAT ARE IDENTIFIED WILL HELP
TO IMPROVE EXCLUSIVE BREASTFEEDING RATES AT AND
AFTER HOSPITAL DISCHARGE.
34. REFERENCES
• 1. SANKAR MJ, SINHA B, CHOWDHURY R, ET AL. OPTIMAL BREASTFEEDING
PRACTICES AND INFANT AND CHILD MORTALITY: A SYSTEMATIC REVIEW AND
META-ANALYSIS. ACTA PAEDIATR. 2015; 104:3-13.
• 2. AZUINE RE, MURRAY J, ALSAFI N, SINGH GK. EXCLUSIVE BREASTFEEDING AND
UNDER-FIVE MORTALITY, 2006-2014: A CROSSNATIONAL ANALYSIS OF 57 LOW-
AND-MIDDLE INCOME COUNTRIES. INT J MCH AIDS. 2015;4:13-21.
• 3. FEENSTRA MM, JØRGINE KIRKEBY M, THYGESEN M, ET AL. EARLY BREASTFEEDING
PROBLEMS: A MIXED METHOD STUDY OF MOTHERS’ EXPERIENCES. SEX REPROD
HEALTHC. 2018;16:167-74.
• 4. SURESH S, SHARMA KK, SAKSENA M, ET AL. PREDICTORS OF BREASTFEEDING
PROBLEMS IN THE FIRST POSTNATAL WEEK AND ITS EFFECT ON EXCLUSIVE
BREASTFEEDING RATE AT SIX MONTHS: EXPERIENCE IN A TERTIARY CARE CENTRE IN
NORTHERN INDIA. INDIAN J PUBLIC HEALTH. 2014;58:270-3.
35. • 5. VAN DELLEN SA, WISSE B, MOBACH MP, DIJKSTRA A. THE EFFECT OF A
BREASTFEEDING SUPPORT PROGRAMME ON BREASTFEEDING DURATION AND
EXCLUSIVITY: A QUASI-EXPERIMENT. BMC PUBLIC HEALTH. 2019;19:993.
• 6. FADILOGLU E, KARATAS E, TEZ R, ET AL. ASSESSMENT OF FACTORS AFFECTING
BREASTFEEDING PERFORMANCE AND LATCH SCORE: A PROSPECTIVE COHORT STUDY. Z
GEBURTSHILFE NEONATOL. 2021; 225:353-60.
• 7. HOBBS AJ, MANNION CA, MCDONALD SW, ET AL. THE IMPACT OF CAESAREAN
SECTION ON BREASTFEEDING INITIATION, DURATION AND DIFFICULTIES IN THE FIRST
FOUR MONTHS POSTPARTUM. BMC PREGNANCY CHILDBIRTH. 2016;16:90.
• 8. SOWJANYA SVNS, VENUGOPALAN L. LATCH SCORE AS A PREDICTOR OF EXCLUSIVE
BREASTFEEDING AT 6 WEEKS POSTPARTUM: A PROSPECTIVE COHORT STUDY.
BREASTFEED MED. 2018;13:444-9.
• 9. TORNESE G, RONFANI L, PAVAN C, ET AL. DOES THE LATCH SCORE ASSESSED IN THE
FIRST 24 HOURS AFTER DELIVERY PREDICT NON-EXCLUSIVE BREASTFEEDING AT
HOSPITAL DISCHARGE? BREASTFEED MED. 2012;7:423-30.
• 10. RIORDAN J, BIBB D, MILLER M, RAWLINS T. PREDICTING BREASTFEEDING DURATION
USING THE LATCH BREASTFEEDING ASSESSMENT TOOL. J HUM LACT. 2001;17:20-3.
36. LATCH SCORING
• THE LATCH CHARTING SYSTEM ASSIGNS A NUMERICAL
SCORE (0, 1, OR 2) TO 5 KEY.
• BREASTFEEDING COMPONENTS IDENTIFIED BY THE LETTERS
OF THE ACRONYM LATCH:
• ‘‘L’’ IS FOR HOW WELL THE INFANT LATCHES ONTO THE
BREAST,
• ‘‘A’’ IS FOR THE AMOUNT OF AUDIBLE SWALLOWING NOTED,
• ‘‘T’’ IS FOR THETYPE OF NIPPLE,
37. • ‘‘C’’ IS FOR MATERNAL COMFORT DURING FEEDING, AND
• ‘‘H’’ IS FOR THE AMOUNT OF HELP THE MOTHER NEEDS
TO HOLD HER INFANT TOTHE BREAST.
• THE TOTAL SCORE RANGES FROM 0 TO 10; THE HIGHER
THE SCORE,THE MORE THE CHANCES OF SUCCESSFUL
BREASTFEEDING .
• A LATCH SCORE OF 0–3 IS REGARDED AS POOR, 4–7 AS
MODERATE, AND8–10 AS GOOD
38.
39. BREAST FEEDING
• WHO RECOMMENDS THAT INFANTS SHOULD BE EXCLUSIVELY
BREASTFED FOR THE FIRST 6 MONTHS. THEREAFTER,
COMPLEMENTARY FOOD SHOULD BE INTRODUCED WHILE
CONTINUING BREASTFEEDING FOR 2 YEARS OR BEYOND.
• BREASTFEEDING MAY CONTRIBUTE TOWARDS A LIFETIME OF GOOD
HEALTH AND IS ALSO CONSIDERED TO BENEFIT MOTHERS.
• THE MILK TRANSFER TO THE INFANT PRECEDES THE MATERNAL
REPORT BY NEARLY 12 TO 24 H.
40. • THE SYMPTOMS OF “COMING IN OF MILK” AS REPORTED BY THE
MOTHERS INCLUDE BREAST FULLNESS, MILK LEAKAGE FROM THE
NIPPLE, INFANT CUES, AND BREAST TINGLING.’
• ON AVERAGE, MOTHERS PERCEIVE “COMING IN OF MILK” AT 59
TO 67 H AFTER DELIVERY, EARLIER IN MULTIPAROUS COMPARED
TO PRIMIPAROUS MOTHERS.
• THE TOUCHING OF NIPPLE, AREOLA AND BREAST SKIN AND
INFANT’S SUCKLING INCREASE PLASMA OXYTOCIN LEVEL, WHICH
MEDIATES LET- DOWN OF MILK (MILK EJECTION REFLEX).”
• ACUTE PHYSICAL AND MENTAL STRESS REDUCE THE OXYTOCIN
RELEASE.
41. • THE KEY POINTS OF GOOD POSITIONING ARE
• 1. THE HEAD AND BODY OF THE BABY ARE IN A
STRAIGHT LINE
• 2. THE BABY’S WHOLE BODY (NOT ONLY THE NECK
AND SHOULDERS) ARE WELL SUPPORTED
• 3. THE BABY FACES THE BREAST WITH NOSE BEING
OPPOSITE THE NIPPLE OF THE MOTHER
• 4. BABY’S ABDOMEN TOUCHING THE MOTHER’S
ABDOMEN
42. • TO TEACH THE MOTHER TO HOLD HER BREAST CORRECTLY. THE
THUMB AND FOREFINGER SHOULD BE AT THE RIGHT AND LEFT
OF HER BREAST AS OPPOSED TO AT THE TOP AND BOTTOM.
• THE THUMBS AND FINGERS SHOULD NOT BE CLOSE TO THE
NIPPLE AND AREOLA.
43. • ADVISE HER NOT TO HOLD THE BREAST BETWEEN HER INDEX AND MIDDLE
FINGER (SCISSOR HOLD).
• THE MOTHER SHOULD TOUCH. THE BABY’S LIPS WITH HER NIPPLE AND WAIT
UNTIL BABY OPENS HER MONTH WIDELY.
• AT THIS POINT, THE BABY BE BROUGHT TO THE BREAST AIMING FOR A GOOD
ATTACHMENT.
• THE MOTHER SHOULD NOT LEAN ON THE BABY.
44. • THE FOUR KEY POINTS OF ATTACHMENT DURING
BREASTFEEDING:
• 1. BABY’S MOUTH IS WIDE OPEN.
• 2. THE NIPPLE AND THE MOST AREOLA MUST BE IN BABY’S
MOUTH MORE AREOLA SHOULD BE VISIBLE ABOVE BABY’S
MOUTH THAN BELOW IT
• 3. BABY’S LOWER LIP IS TURN OUTWARD
• 4. BABY’S CHIN IS TOUCHING THE MOTHER’S BREAST
45. • THE NEWBORN RESPONDS BY OPENING EYES AND SEEKING THE
BREAST.
• THE BABY TURNS THE HEAD BACK SLIGHTLY AND OPENS THE
MOUTH WHEN READY TO BREASTFEED.
• THE TONGUE USUALLY MOVES DOWN ANDFORWARD;
• THE NEONATE TRIES TO LICK AND THE SALIVA MAY ALSO
DRIP.
• AN INFANT WHO SUCKS EFFECTIVELY TAKES SEVERAL SLOW
DEEP SUCKS AND THEN SWALLOWS.
• AN INFANT WHO SUCKS FOR A SHORT TIME BUT TIRES OUT
AND IS UNABLE TO CONTINUE LONG ENOUGH IS SUCKING
INEFFECTIVELY.
48. ASSESSING BREASTFEEDING ADEQUACY
• BREASTFEEDING IS CONSIDERED ADEQUATE.
• IF THERE IS SOFTENING OF BREAST AFTER A FEEDING SESSION AND
• THE NEONATE SLEEPS WELL BETWEEN THE BREASTFEEDING
SESSIONS,
• PASSES URINE AT LEAST 6 TO 8 TIMES IN A DAY,
• CROSSES BIRTH WEIGHT BY 7 TO 10 DAYS AND
• GAINS AT LEAST 25 TO 40 G PER DAY THEREAFTER.
49. COMMON ISSUES IN BREASTFEEDING IN THE
FIRST FEW DAYS
• AFRANTIC NEWBORN THIS BABY FEEDS INCESSANTLY AND DOES
NOT GET SATISFIED. THE MOTHER GETS EXHAUSTED THUS
AFFECTING HER ABILITY TO BREASTFEED THE BABY.
• THIS USUALLY HAPPENS IF THE BABY IS NOT OPTIMALLY
ATTACHED AND IS SUCKING ONLY ON THE NIPPLE.
• ALSO, IF THE BABY IS FEEDING FOR A SHORT DURATION ON ONE
BREAST AND THE MOTHER SWITCHES THE BABY TO THE OTHER
THE BABY MAY END UP GETTINGS ONLY FOREMILK AND HENCE
MAY NOT BE SATISFIED.
50. • MANAGEMENT
• ENSURE OPTIMAL POSITION AND LATCH. LEAVE THE
MOTHER AND BABY TOGETHER IN SKIN-TO-SKIN
POSITION AND RESPOND TO EARLY FEEDING CUES.
• EXPLAIN THE MOTHER TO ENSURE FEEDING FROM ONE
BREAST IN ONE SESSION SO THAT THE BABY GETS BOTH
FOREMILK AND HINDMILK.
• REASSURE THE MOTHER THAT THE BABY WILL SETTLE
WHEN MILK VOLUME INCREASES.
51. • A SLEEPY NEWBORN
• A SLEEPY NEWBORN HAS DIFFICULTY IN WAKING UP
FOR FEEDS OR NOT FEEDING ADEQUATELY EVEN
AFTER APPROPRIATE LATCHING AND MAY HAVE
INADEQUATE WEIGHT GAIN OR EVEN WEIGHT LOSS.
• A NORMAL NEWBORN MAY SLEEP MOST OF 24 HOURS
AND GET UP ONLY FOR FEEDING. HOWEVER, IF THE
NEWBORN DOES NOT ASK FOR FEED, ONE SHOULD
SEEK THE HELP. AVOID SUPPLEMENTAL FEEDING
UNLESS MEDICALLY INDICATED.
52. • MANAGEMENT
• THE MOTHER AND BABY SHOULD BE PUT TOGETHER IN SKIN-
TO-SKIN POSITION AND THE MOTHER SHOULD RESPOND TO
EARLY FEEDING CUES.
• THE MOTHER HAS TO BE EXPLAINED TO ENSURE ADEQUATE
LATCH DURING BREAST FEEDING, ONCE THE NEONATE HAS
SURPASSED THE BIRTH WEIGHT, THE FEEDING CAN BE EASILY
GIVEN ON DEMAND FOR TERM, OTHERWISE NORMAL
NEONATES.
53. • FLAT/INVERTED NIPPLE
• THE NIPPLE CAN BE PULLED OUT WITH A NIPPLE EVERTER WHICH IS
MADE FROM A PLASTIC SYRINGE (20 ML SYRINGE).
• THE MOTHER IS ADVISED TO APPLY THE PLUNGER AND GENTLY
PULL BACK TO APPLY SUCTION TO THE NIPPLE.
• THE NEGATIVE SUCTION PRESSURE ON THE NIPPLE SHOULD BE JUST
ENOUGH TO PULL OUT THE NIPPLE WITHOUT CAUSING PAIN OR
DISCOMFORT TO THE MOTHER.
54.
55. • MANAGEMENT
• THE MOTHER SHOULD DO IT BY HERSELF.
• THE NEGATIVE SUCTION IS CONTINUED TILL A COUNT OF 10.
• THIS SHOULD BE CARRIED OUT PRIOR TO EACH FEEDING OR
REPEATED BETWEEN FEEDINGS AS REQUIRED.
• APPLICATION OF A BREAST PUMP MAY BE USED TO APPLY GENTLE
PRESSURE BEFORE FEEDINGS. THIS MAY ASSIST WITH NIPPLE
EVERSION AND ASSIST LATCH-ON.
• NOTE: NIPPLE SHIELD SHOULD NOT BE USED FOR THIS PURPOSE OF
BREASTFEEDING.
56.
57. • SORE NIPPLES
• MANY MOTHER EXPERIENCE SLIGHT DISCOMFORT JUST AT START
OF FEEDING; HOWEVER, THIS SUBSIDES SOON AFTER FEEDING”.
• THE GOOD POSITIONING AND ATTACHMENT HELP PAIN SUBSIDE.
HOWEVER, SOME MOTHERS DEVELOP SORENESS OF NIPPLE MAKING
BREASTFEEDING PAINFUL.
• THE MOST COMMON CAUSE OF SORE NIPPLES IS POOR
ATTACHMENT AND, CONSEQUENTLY, THE BABY IS SUCKLING ON
THE NIPPLE RATHER THAN AREOLA.
58. • AS THE BABY DOES NOT GET ENOUGH MILK WHILE
SUCKING ON THE NIPPLE, HE SUCKS EVEN HARDER MAKING
THINGS WORSE FOR THE MOTHER.
• RARELY, SORENESS MAY HAPPEN DUE TO EXCESSIVE
WASHING OF NIPPLE OR A CANDIDA INFECTION.
60. • TREATMENT INCLUDES ENSURING PROPER POSITIONING
AND ATTACHMENT.
• IN MOST CASES OF SORE NIPPLES, THE MOTHER IS ABLE TO
FEED THE BABY IF PROPER ATTACHMENT IS ENSURED.
• THE MOTHER CAN APPLY HIND MILK TO THE SORE NIPPLE
AFTER BREASTFEEDING THE INFANT. THERE IS NO NEED
FOR USING ANY MEDICATED OINTMENT FOR TREATING
SORE NIPPLE.
61. • IF THE NIPPLE IS TOO SORE, CESSATION OF DIRECT
BREASTFEEDING FOR 24 TO 48 HOURS, PUMPING THE
BREAST AND FEEDING EXPRESSED MILK TO THE INFANT
MAY HELP.
• MOTHER SHOULD AVOID FREQUENT WASHING OF THE
NIPPLE; JUST ROUTINE CLEANING DURING BATH
SUFFICES.
• CANDIDA INFECTION, IF PRESENT, MAY REQUIRE LOCAL
APPLICATION OF CLOTRIMAZOLE CREAM
62. • BREAST ENGORGEMENT
• BREAST ENGORGEMENT MUST BE DIFFERENTIATED FROM THE
ENGORGED BREASTS.
• WITH ENGORGEMENT, THE BREASTS ARE TIGHT AND PAINFUL.
THERE MAY BE FEVER AND MALAISE IN THE MOTHER.
• THE OVERLYING SKIN IS RED AND HOT AND NODULES CAN BE FELT
IN THE BREAST TISSUE.
• THESE SYMPTOMS AND SIGNS ARE ABSENT WHEN BREASTS ARE
JUST FULL.
• THE ENGORGEMENT CAN INTERFERE WITH MILK FLOW.
64. • MANAGEMENT
• THE CONDITION IS TREATED BY ENSURING OPTIMUM
ATTACHMENT, INCREASED FREQUENCY OF FEEDS AND
COMPLETE EMPTYING OF THE BREAST.
• A WARM SHOWER/ FOMENTATION FOLLOWED BY BREAST
MASSAGE (LIKE KNEADING THE FLOUR FROM BASE TO
NIPPLE COVERING ALL SIDES) BEFORE BREASTFEEDING WILL
ALSO ENCOURAGE MILK FLOW.
• COLD FOMENTATION AFTER BREASTFEEDING HELPS IN
REDUCING INFLAMMATION.
65. • THE MOTHER CAN ALSO PUMP OR HAND EXPRESS MILK
TO SOFTEN BREASTS PRIOR TO FEEDING.
• BREASTFEEDING EVERY TWO HOURS PREVENTS
ENGORGEMENT IN THE BREAST.
• ENGORGEMENT TENDS TO BE LESS SEVERE IF BABY IS
ALLOWED TO NURSE ON THE FIRST BREAST UNTIL THE
BABY COMES OFF ON ITS OWN RATHER THAN SWITCHING
BREASTS SOONER.
66. • MASTITIS
• RISK FACTORS FOR DEVELOPING MASTITIS ARE BLOCKED
DUCTS, CRACKED NIPPLES AND PAST HISTORY OF
MASTITIS”.
• BREASTFEEDING MOTHERS WITH MASTITIS COMPLAIN OF
SUDDEN ONSET WITH INTENSE LOCALISED PAIN.
• ON EXAMINATION, REDNESS MAY APPEAR IN A WEDGE-
SHAPED AREA ON THE BREAST WHICH IS RED, HOT,
TENDER AND SWOLLEN.
• MOTHER HAS FLU-LIKE SYMPTOMS AND FEVER.
68. • ANTIBIOTICS SHOULD BE STARTED AND ANALGESIA
SHOULD BE ENCOURAGED WITH AN ANTI-INFLAMMATORY
AGENT.
• THE PREFERRED ANTIBIOTICS ARE PENICILLINASE
RESISTANT PENICILLINS, (E.G, FLUCLOXACILLIN,
AMOXYCYCLIN WITH CLAVULANIC ACID, OR MACROLIDES
SUCH AS ERYTHROMYCIN OR CLARITHROMYCIN).
• HELP THE MOTHER EMPTY OUT THE BREAST
(BREASTFEEDING OR HAND-EXPRESSION)
69. • THE MOTHER CAN USE WARMTH AND MASSAGE. WITH
WARM BREAST, MILK FLOW WOULD BE EASIER.
• THIS WOULD HELP THOROUGHLY DRAIN AFFECTED
AREA. FREQUENT BREASTFEEDING ALSO HELPS.
• THE MOTHER SHOULD WEAR A BRA WHICH IS A SIZE
LARGER TO RELIEVE PRESSURE ON THE AFFECTED AREA.
• PROPER LATCH-ON IS ESSENTIAL TO EFFECTIVE
BREASTFEEDING.
70. • ULTRASOUND EXAMINATION SHOULD BE PERFORMED IN
ANY PATIENT WHOSE INFECTION DOES NOT SUBSIDE EVEN
AFTER ANTIBIOTIC THERAPY HAD BEEN IMPLEMENTED.
• THE TRADITIONAL MANAGEMENT OF A BREAST ABSCESS
WAS A SURGICAL INCISION AND DRAINAGE.
• A MODERN AND LESS INVASIVE APPROACH IS TO ASPIRATE
THE PUS UNDER ULTRASONIC GUIDANCE AND IF
REQUIRED, TO IRRIGATE THE CAVITY WITH NORMAL
SALINE UNTIL IT COLLAPSES.”
71. • INADEQUATE MILK SUPPLY
• PRIMARY FAILURE OF LACTOGENESIS IS A VERY RARE.
• THE COMMON CAUSES INCLUDE DELAYED ONSET OF
LACTATION IS DEFINED AS THE “COMING IN OF MILK”
LATER THAN 72 H.
• THIS CONDITION IS OBSERVED MORE OFTEN IN
PRIMIPAROUS MOTHERS, AFTER A STRESSFUL,
PROLONGED OR CESAREAN DELIVERY, IN OVERWEIGHT,
ELERLY OR DIABETIC MOTHERS, AFTER DELAYED
INITIATION OF BREASTFEEDING, AND WITH PRELACTEAL
OR SUPPLEMENTAL FEEDS OF THE NEWBORN” .
72. • IN ADDITION, INSUFFICIENT MILK SUPPLY OCCURS WITH
INCOMPLETE EMPTYING OF BREASTS DUE TO
INAPPROPRIATE BREASTFEEDING TECHNIQUE, OBESITY AND
LARGE BREASTS, MATERNAL OR INFANT ILLNESS, GIVING
TOP FEEDS TO THE INFANT OR PAINFUL LATCH-ON.
• CONVERSELY, MILK PRODUCTION CAN BE INCREASED WITH
FREQUENT FEEDINGS INCLUDING NIGHT FEEDING.
• MATERNAL FEAR OF NOT HAVING ENOUGH MILK MAY BE AN
ADDITIONAL STRESS INHIBITING THE LET-DOWN REFLEX,
THE REMOVAL OF MILK, AND CONSEQUENTLY THE MILK
PRODUCTION.”
• CONVERSELY, AT 2 WEEKS, A SIGNIFICANT FACTOR FOR THE
CONTINUATION OF BREASTFEEDING IS THE MOTHERS’
73. INDICATIONS FOR SUPPLEMENTATION IN THE
HOSPITAL SETTING
• SUPPLEMENTAL FEEDINGS ARE NOT NECESSARY IN MOST
SITUATIONS BUT MAY BE REQUIRED IN CASES OF MATERNAL
INFANT SEPARATION, MATERNAL ILLNESS OR CERTAIN
MATERNAL MEDICATION.
• INFANT DEMONSTRATING CLINICAL SIGNS OF DEHYDRATION
WITH MOTHER HAVING DECREASED MILK OUTPUT, WITH
HYPOGLYCEMIA OR AT HIGH-RISK FOR HYPOGLYCEMIA AND
NOT FEEDING EFFECTIVELY ARE RELATIVE INDICATIONS FOR
SUPPLEMENTAL FEEDING.
74. • RECENTLY WHO IN 2018 HAS RELEASED UPDATED
BREAST FEEDING HOSPITAL INITIATIVE GUIDELINES.
• THE TOPIC OF EACH OF 10 STEPS REMAINS SAME BUT
EACH ONE HAS BEEN UPDATED AS PER LATEST
EVIDENCE. THE STEPS CAN BE BROADLY SUBDIVIDED
INTO (I) STEPS OF CRITICAL MANAGEMENT
PROCEDURES AND (II) KEY CLINICAL PRACTICES.
