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Elaine Webber DNP, PPCNP-BC, IBCLC
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Approached in orderly diagnostic process◦ Complete history and PE◦ Details of feeding◦ Observation of feeding◦ Appropriate labs
Data organization Will help identify factors that appear under maternal
and infant cases separately
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Weight loss after 10 days
Birth weight not regained by three weeks Rate of weight gain below 10th% beyond
one month of age
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Weight gain slow but consistent
Weight, length and HC proportional
Developmental milestones normal
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Infant who is slow to gain weight
AlertGood muscle toneAt least six wet diapers/dayPale, dilute urineStools frequent, seedy (or if infrequent, large and soft)Eight or more nursings/day of active feedsWeight gain consistent by slow
Infant with failure to thrive
Apathetic or cryingPoor tonePoor turgorFew wet diapers“Strong” urine odorStools infrequent, scantyFewer than eight feedings, often briefNo evidence of milk-ejection reflex (no swallowing noted)Weight erratic, may be losing weight
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Initial weight loss
◦ Normal 7-10% of birth weight
◦ What might impact excessive weight loss?
Expected weight gain
◦ “Normal” daily weight gain?
◦ Regain birth weight by 2-3 weeks
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Differences in growth charts◦ Breastfed infants grow more rapidly first 2 months
of life◦ Less rapidly from 3-12 months
Weight gain only one parameter◦ Length and HC also important
Familial considerations
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Underlying physical problems◦ Metabolic conditions◦ Congestive Heart Failure◦ Cystic fibrosis
Mechanical Abnormalities of the Mouth ◦ Ankyloglossia◦ Short tongue◦ Bubble palate◦ Tight jaw
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Neurologic◦ability to root, suck and coordinate swallows
Acute infections◦ Septic, GI issues
Chronic fetal infections◦ CMV, HIV, Toxoplasmosis, etc.
High energy requirements◦ Some CNS disorders, fetal exposure to stimulants,
stimulants transferred in breast milk,
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Absent or diminished suck
Maternal anesthesia or analgesiaAnoxia or hypoxiaHigh bilirubinPrematurityTrisomy 21HypothyroidismNeuromuscular abnormality
◦ Werdnig-Hoffmann◦ Muscular dystrophy
Central nervous system infections
◦ Toxoplamosis◦ CMV◦ Meningitis
Mechanical factors interfering with
sucking
Macroglossia
Cleft lip
Fusion of gums
Tumors of mouth or gums
Ankylossia (tongue or labial)
Disorders of swallowing
Choanal atresia
Cleft palate
Micrognathia
Post-intubation dysphagia
Pharyngeal tumors
Familial dysautonomia
Adapted from Lawrence & Lawrence (2005)
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Slightly hypotonic infants may demonstrate:
Weak SuckPoor lip closureFrequent slipping off the breast
Hypotonia Normal Tone Hypertonia
Slightly hypertonic infants may demonstrate:
Extended postureExcessive irritabilityStrong bite reflex
Note that some infants show “soft signs” or very mild indications of either hypo or hyper tone. These infants are often missed because they appear more “normal” than “abnormal”. Tone should always be assessed with any feeding difficulty.
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Causes milk production
Circadian rhythm
Can be increased by emotional and physical stress
Inhibited by dopamine, nicotine and alcohol
Pharmacologic stimulation
Prolactin levels
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Released from the posterior pituitary
Immediate reaction to nipple stimulation
Causes contraction of smooth muscle epithelial
cells surrounding the mammary alveoli
Largely influenced by psychological
factors
Pharmacologic stimulation?
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Modulated by the complex interplay of many hormones
System which requires significant exploration when faced with a an unknown cause of poor milk production
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Initial milk production governed by prolactin production, activation of prolactin receptors and oxytocin release
Eventually prolactin levels decline and milk production is governed by milk removal
Early stimulation and milk removal are essential in the establishment and continuation of a robust milk supply
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Potential maternal causes of FTT
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Endocrine History◦Difficulty conceiving◦Thyroid problems◦Pituitary problems◦PCOS
Previous Breast Surgery
Prenatal History◦Breast changes during pregnancy◦Leaking colostrum
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Delivery
◦ Length of labor
◦ Drugs during labor
◦ Epidural
◦ Delivery of Placenta
Placental fragments
◦ Excessive bleeding/hemorrhage
Sheehan’s syndrome
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Postpartum◦ Stress and exhaustion◦ Maternal illness◦ Maternal medications
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Breast inspection
Assessment of nipple and areola
Scars
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Firm, fibrous breast tissue◦ nipple and areolar compressibility
Nipple protractility◦ Flat
◦ Dimpled
◦ Inverted
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Breast Turgor
Large Nipples
Flat/Fibrous Nipples
Inverted/dimpled Nipples
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Management of FTT or slow Weight Gain◦ Complex cause-and-effect relationship
◦ Direct attention to both mother and baby
There is NO substitute for direct
observation of the breastfeeding couplet
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Inadequate Milk Production◦ Breastfeeding Mismanagement
Positioning
Frequency/duration of feeds
Engorgement
Use of nipple shields
Complimentary/supplemental feeds
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Measuring Prolactin◦ Varies based on stage of lactation◦ Draw baseline (prior to a feed), then 45 minutes
after nursing or pumping to measure the surge◦ In early months; should at least double◦ If cost an issue – baseline is more important
Adapted from Lawrence & Lawrence 2005.
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PCOS◦ Metformin –◦ Informal feedback- variable impact on milk production◦ Dosages vary (500mg-2500mg daily)◦ Goat’s Rue
Hypothyroid◦ Be alert for “low normal” TSH and T3◦ Has been correlated with low milk production◦ Low thyroid during pregnancy should always be
rechecked after delivery (2 weeks, 4-5 weeks)
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Secondary Factors (Physiologic/psycho-emotional)◦ Maternal Illness/fatigue/diet
◦ Mental illness (PP depression)
◦ Emotional disturbances
◦ Impaired maternal-infant attachment
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Impaired Milk Ejection reflex◦ Primary factors (pituitary disease, surgery)◦ Secondary factors (pain, smoking, alcohol, meds)
Milk Composition◦ Vegan diet◦ Extreme maternal malnourishment (can also lead
to decreased milk production)◦ Low fat content of milk
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Inappropriate Suckling Response◦ Identify problem
Tongue tie◦ Identify provider who will clip
NP, ENT, Dentist, etc.
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Uncoordinated suck swallow
Active feeding
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Diagnose the problem (methodical)◦ Remember interplay of various conditions◦ Various problems can lead to same effect
Don’t make assumptions
Evaluate Mom and baby and OBSERVE THE FEEDING!
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Support/improve mom’s milk supply
Increase intake for the baby
When to follow up?
When to refer?
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Accurate Electronic Scale
Supplemental Nursing System or other tube
feeding devises
Cup/syringe feeds
Nipple Shields
Piston Action Electric Breastpump
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Galactagogues:
◦Metaclopromide
◦Domperidone
◦Goat’s rue
◦Fenugreek
◦Brewers Yeast
◦Homeopathics
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Improve Milk Removal
◦ Correct latch
◦ Correct suck
◦ frequency and/or length of time nursing
◦ Discontinue pacifiers
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Leads to milk removal, then supply Stategies
◦ Improve latch
◦ Finger feed (suck training)
◦ SNS
◦ Referrals
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Improve Milk Removal
◦ Correct suck
◦ length of time nursing
◦ Correct latch
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Deep latch Shallow latch
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Labs◦ Thyroid ◦ Prolactin
Term pregnancy 200-500ng/ml
During lactation:
1st 10 days up to 500
10-90 days ranges from 60-110
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Metaclopromide (rx required)◦ 10mg TID 7-10 days
Fenugreek Brewers Yeast Homeopathics
◦ Lactuca Virosa◦ Alfalfa Tablets
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Accurate Electronic Scale
Supplemental Nursing System
Nipple Shields
Piston Action Electric Breastpump
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Ask what kind of breastpump
After every nursing session
8-10 x daily if not nursing
Night-time pumping very important
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Psychological approach Artificial oxytocin
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Get rid of the pacifier!!!
Switch nursing
◦ Takes advantage of MER
Bring baby into bed throughout the day
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Frequent feeds One sided feeds
◦ fat content of milk
Lengthy active feeds Pump first to elicit MER Maternal diet
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Scale rental for home use
Expectation for weight gain
Weight checks (don’t wait too long)
◦ daily, q other day, weekly
Phone contact and encouragement
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Making More Milk : Diane West & Lisa Marasco
Breastfeeding: A Guide for the Medical Profession : Ruth Lawrence
Breastfeeding management for the Clinician: Marcia Walker
Medications and Mother’s Milk : Thomas Hale