ROLE OF PHYSIOTHERAPIST IN LACTATING MOTHER

By Amrit kaur

HOW BREASTFEEDING WORKS• The breast is made of a network of ducts, fatty and

glandular tissue containing small ducts and alveoli. The milk is produced within the alveoli.

• Milk is produced by the glandular tissue contained within the fatty and fibrous supporting tissue of the breast. Prolactin is the hormone responsible for milk production. Small nerves in the areola, the coloured area surrounding the nipple, are stimulated as the baby suckles the nipple. This causes the release of the hormone prolactin which stimulates milk production.

• The ‘let-down reflex’ gets the milk from the breast tissue to the nipple for the baby to drink. Nipple stimulation signals the brain to trigger the release of oxytocin. This hormone causes cells surrounding the alveoli in the glandular tissue to contract and release milk into the ducts. The milk is transported through the ducts to openings in the nipple. Oxytocin also stimulates the uterus and it is quite common to have uterine cramps and increased blood flow during or following breastfeeding in the first days and weeks after giving birth.

• Babies suckle in a two phase pattern. As the baby starts to feed they suckle in a shallow and fast suck pattern. This progresses to a deeper suck and swallow action as let-down occurs. The stimulation of the nipple triggers further oxytocin and prolactin to be released so further milk is produced and let down. In this way the more the baby suckles, the more milk you make, so supply usually equals demand.

Why Breastfeed?• Early breast milk is liquid gold.-Known as liquid gold,

colostrum (coh-LOSS-trum) is the thick yellow first breast milk that you make during pregnancy and just after birth. This milk is very rich in nutrients and antibodies to protect your baby.

• Your breast milk changes as your baby grows.- Colostrum changes into what is called mature milk. By the third to fifth day after birth, this mature breast milk has just the right amount of fat, sugar, water, and protein to help your baby continue to grow. It is a thinner type of milk than colostrum, but it provides all of the nutrients and antibodies your baby needs.

• Breast milk is easier to digest.- For most babies – especially premature babies – breast milk is easier to digest than formula. The proteins in formula are made from cow’s milk, and it takes time for babies’ stomachs to adjust to digesting them.

• Breast milk fights disease- The cells, hormones, and antibodies in breast milk protect babies from illness. This protection is unique; formula cannot match the chemical makeup of human breast milk. In fact, among formula-fed babies, ear infections and diarrhea are more common.

Mothers Benefit from Breastfeeding• Breastfeeding may take a little more effort than formula

feeding at first. When you breastfeed, there are no bottles and nipples to sterilize. You do not have to buy, measure, and mix formula. And there are no bottles to warm in the middle of the night.

• Breastfeeding can feel great. Mothers can benefit from this closeness, as well. Breastfeeding requires a mother to take some quiet relaxed time to bond.

• Breastfeeding is linked to a lower risk of these health problems in women:

-Type 2 diabetes -Breast cancer-Ovarian cancer -Postpartum depression

Learning to BreastfeedInitiate breastfeeding immediately after birth preferably during

the first 30 minutes. Place the infant skin to-skin on her chest uninterrupted, until the first breastfeeding is accomplished. The baby may only lick and smell the breast and may not necessarily actively suck in the early stages of breastfeeding.

Breastfeed when the baby is showing Early Feeding Readiness Cues before the baby gets too hungry and is too eager to feed or is crying. Early Feeding Readiness include:

• Rapid eye movements, under the lids.• Soft cooing or sighing sounds.• Sucking or licking movement.• Sucking sounds.• Restlessness.• Hand-to-mouth movements

• Allow the baby to breastfeed on the first breast until the baby is no longer sucking and swallowing effectively (e.g., deep and slow sucks) .The second breast should then be offered. The average time of a breastfeeding is usually 20-40 minutes. Babies should effectively suck and swallow for at least 10-20 minutes in total at each feeding.

• Avoid supplementation with other fluids or foods in the first 6 months of life, unless medically indicated

LATCHING And POSITIONING• When feeding your baby it is important to maintain

a good posture. This positions your nipples straight ahead, which is easier for the baby to attach to. Bring the baby to your nipple height, and prop up their weight with pillows You should not feel you are taking the weight of the baby in your arms; rather you are guiding the baby into the correct position. It is tempting to lean forward and drop your nipple into the baby’s mouth. This is more difficult for the baby to attach to and feed from and can result in neck and back pain for you

• The baby should have good hold of your areola and the nipple well within his mouth. The baby draws the nipple and breast tissue into his mouth a long way. His tongue comes forward over the gums and the bottom lip rolls out. It should feel comfortable if the baby is well attached. Poor attachment is painful due to abnormal pressure on the nipple which can cause cracking or open areas.

• Good attachment looks like this:• The baby’s mouth is wide open and the lips are

turned outwards. The lower lip especially can be seen to be curled right back and the baby’s chin is touching the mother’s breast.

• The nipple will be deep into the baby’s mouth, with the tip touching the baby’s palate.

• The baby suck by making two simultaneous movements: the lower jaw goes up and down and a muscular wave (like peristalsis) goes from the tip to the back of the tongue. You can sometimes see the tongue above the lower lip. This action presses the milk out of the lactiferous sinuses, through the nipple into the back of the baby’s mouth.

• The baby suckles with short quick movements at first, but changes the rhythm to a more continuous deep suckling as the milk flows. The baby pauses throughout with the pauses getting longer as the feed continues.

• The baby’s cheeks will be rounded and not drawn in and sometimes the baby’s ears will move as it suckles.

Poor attachment:• The baby sucks or “chews” on

the nipple only, with lips, gums or tongue.

• The mouth is not wide open and the lips are sucked in.

• The lips and gums press against the nipple instead of the areola.

• The tongue may be misplaced, blocking the protrusion of the nipple into the baby’s mouth.

• The cheeks are pulled in.

signs of a good latch:• Baby’s mouth is opened wide.• Baby’s lips are curled out and cover about 1-1½ inches of the

area below the nipple (this may be less for a small or premature baby).

• Baby’s lower lip covers more of the areola than the upper lip.• Baby’s chin is pressed into the breast.• Tip of baby’s nose lightly touches the breast.• Baby’s cheeks appear to be full and rounded (not dimpling in)• Baby’s mouth does not slip off the breast.• Baby is supported in chest-to-chest position and baby’s neck is

not turned.• Mother feels a strong tugging sensation with no pain.• Breastfeeding is pain-free.• Baby shows signs of sucking and swallowing breast milk

Interrupting the Latch• Press down on her breast near to the baby’s

mouth.• Bring the baby in closer to the breast so that

the nose is covered with breast tissue.• Pull down on the baby’s chin.• Insert a finger into the corner of the baby’s

mouth.

Breastfeeding Holds and positioningCheckpoints - For each position encourage the mother to

check that:• She is relaxed and comfortable with good posture. She

has correct body alignment.• Her back and arms are well supported.• Baby’s head and body are supported.• The baby’s head is at the level of the breast.• Baby’s ear, shoulder, and hip are in a straight line.• Baby’s chest is facing the mother’s chest (chest-to-

chest).• Baby’s nose is facing the nipple. Baby’s chin touches

the breast.

• CRADLE HOLD – an easy, common hold that is comfortable for most mothers and babies. Hold your baby with his or her head on your forearm and his or her whole body facing yours.

• Sit in a chair that has supportive armrests or on a bed with lots of pillows. Rest your feet on a stool, coffee table, or other raised surface to avoid leaning down toward your baby. Hold her in your lap (or on a pillow on your lap) so that she’s lying on her side with her face, stomach, and knees directly facing you. Her pelvis should line up with your stomach, and her nose should line up with your nipple. Tuck her lower arm under your own. If she’s feeding on the right breast, rest her head in the crook of your right arm. Extend your forearm and hand down her back to support her neck, spine, and bottom. Secure her knees against your body, across or just below your left breast.

• Best for: The cradle hold often works well for full-term babies who were delivered vaginally. Some mothers say this hold makes it hard to guide their newborn’s mouth to the nipple, so you may prefer to use this position once your baby has stronger neck muscles at about 1 month old. Women who have had a caesarean section may find it puts too much pressure on their abdomen.

• The Cross-Over Hold or Cross cradle or transitional hold -this position differs from the cradle hold in that you don’t support your baby’s head with the crook of your arm. Instead, your arms switch roles. If you’re feeding from your right breast, use your left hand.and arm to hold your baby. Turn her body so her chest and tummy are directly facing you. With your thumb and fingers behind her head and below her ears, guide her mouth to your breast.

• This position allows the mother to have maximum control of the baby’s head while latching.

• Best for: This hold may work well for small babies and for infants who have trouble latching on.

• If baby is premature or small.• If baby has low muscle tone.• If baby has a weak rooting reflex or weak suck.

• THE CLUTCH OR RUGBY BALL HOLD OR FOOTBALL POSITION- in this position you tuck your baby under your arm (on the same side that you’re feeding from) like a rugby ball or handbag. First, position your baby at your side, under your arm. She should be facing you with her nose level with your nipple and her feet pointing toward your back. Rest your arm on a pillow in your lap or right beside you, and support your baby’s shoulders, neck, and head with your hand. Using a C-hold, guide her to your nipple, chin first. But be careful—don’t push her toward your breast so much that she resists and arches her head against your hand. Use your forearm to support her upper back.

• Best for -useful for mothers who had a c-section and mothers with large breasts, flat or inverted nipples, or a strong let-down reflex and for mothers of twins. . It is also helpful for babies who prefer to be more upright. This hold allows you to better see and control your baby’s head and to keep the baby away from a c-section incision.

• The Reclining Position or Side-Lying Position-To breastfeed while lying on your side in bed, ask your partner or helper to place several pillows behind your back for support. You can put a pillow under your head and shoulders, and one between your bent knees, too.

• The goal is to keep your back and hips in a straight line. With your baby facing you, draw her close and cradle her head with the hand of your bottom arm. Or, cradle her head with your top arm, tucking your bottom arm under your head, out of the way. If your baby needs to be higher and closer to your breast, place a small pillow or folded blanket under her head. baby shouldn’t strain to reach your nipple, and you shouldn’t bend down toward baby.

Best for - If mother finds it too painful to sit.• If mother wants to rest when breastfeeding

(e.g., night feedings).• If mother had a caesarean birth.• If mother has large breasts.

• Baby Upright- Helpful for older babies who want to nurse sitting bolt upright because of congestion, reflux, or an ear infection. (Use pillows to prop babies too young to sit up on their own.) Sit the baby on your lap, facing you, and bring his head to your breast.

• Australian Hold -It’s best to do this in the family bed. Lie in bed with the baby latched onto your breast, and her feet near your ears, and her belly opposite your chin. This position works well when the baby is little.

• Upside down -Best for older babies with some head and neck control, and good for overactive letdown at any age. Lying flat on your back, latch the baby onto your breast, holding the baby at an angle to your body. He will be halfway on your chest, with his bottom and legs trailing into the air or onto the bed.

Nutritive vs. Non-nutritive Sucking:Nutritive sucking promotes the transfer of breast milk. Non-nutritive sucking promotes little or no breast

milk transfer but has other purposes.• Increases peristalsis.• Increases the secretion of digestive fluids.• Decreases crying; increases calming and comforting

for the infant. e.g., an infant sucking on a finger is using non-nutritive sucking as a self-directed, calming mechanism.

Guidelines for Assessing Effectiveness• Alignment - Correct positioning; baby facing mother, and nose

at level of nipple.• Areolar Grasp - Latch. Peristaltic motions of tongue result in

effective areolar compression.Mouth wide, lips flanged, complete seal, covers areolar and surrounding tissue.

• Areolar Compression - Removal of breast milk from the breast. Mandible moves in rhythmic motion. Cheeks are full and rounded when sucking.

• Audible Swallowing- Quiet sound or pause is noted during suck cycle.- May increase after breast milk ejection reflex occurs.- Co-ordinated pattern of suck-swallow-breathe (1:1:1).- May be preceded by several sucking motions during initiation of

feeding.

COMMON PROBLEMS AND PHYSIOTHERAPY MANAGEMENT

• Sore Nipples-Sore nipples is one of the most common complaints of new mothers and is one of the most frequent reasons that mothers stop breastfeeding sooner than they intended Sore nipples may have one or more underlying causes that may be mother and/or baby related. The two most common causes of sore nipples are incorrect latching and incorrect positioning.

OBSERVATION AND ASSESSMENTAssess the pain and appearance of the nipples:• Nipples that feel sore, painful, burning and/or itchy.• Nipples that appear to be pink or red, bruised, blistered,

cracked, shiny, flaky and/or bleeding.• Discharge from cracks or sores on the nipple.• A white blister at the opening of one of the ducts on

the nipples. • Timing of the pain. Nipple pain that may decrease after

the initial latch and/or may persist throughout the breastfeeding and between breast feedings.

• Nipples that appear blanched and are painful after breastfeeding.

• Location of the nipple pain.

Possible Causes or Contributing Factors• Incorrect latching and positioning techniques • Poor latching or tongue thrusting may result in soreness on the

top or tip of the nipple.• Pressure from the mother’s hand on the breast may tip up the

nipple which then rubs the hard palate.• The position of the mother’s hands on the breast may tip the

nipple so that the infant ‘strokes’ the underside of the breast with the tongue.

• Baby is not facing the breast and has to turn his head to swallow.

• Baby’s nose is not level with the nipple and cannot tip his head back to latch correctly.

• Engorged breast or Inverted or flat nipples • Taking the baby off the breast incorrectly.• Incorrect or excessive use of breast pumps

• Wet breast pads or pads with plastic lining.• Use of poorly ventilated breast shells.• Washing the nipple with soap or with water before every

breastfeeding.• Detergent residue on bra or clothing.• Menstruation or Extremely sensitive nipples.• Sensitivity to and/or excessive use of nipple creams and ointments.• Dermatitis, eczema, impetigo, scabies, herpes, or other skin

conditions. . Candidiasis, mastitis, or other infections. • Nipple vasospasm ( when the baby comes off the breast the nipple

is blanched and has a burning pain. After several minutes the nipple returns to its normal colour and the burning sensation changes to a throbbing pain. Further assessment is needed to determine if the cause is possible thrush or Raynaud’s phenomena).

Assess the baby for possible causes:• Ineffective suck • A very aggressive and strong suck. This may be

associated with hypertonicity.• High, arched palate.• Candidiasis• Receding chin.• Use of artificial nipples and other devices (e.g.,

bottle nipples, soothers, nipple shields).• Teething and biting down on the breast by an older

baby.

What you can do• A good latch is key, If your baby is sucking only on the

nipple, gently break your baby’s suction to your breast by placing a clean finger in the corner of your baby’s mouth and try again. (Your nipple should not look flat or compressed when it comes out of your baby’s mouth. It should look round and long, or the same shape as it was before the feeding.)

• Ensure that the letdown or milk ejection reflex is initiated. The baby’s rooting and sucking are the natural stimuli for letdown when breastfeeding is initiated early and the baby is calm, before the baby is overly hungry, and begins crying

• Try changing positions each time you breastfeed. This puts the pressure on a different part of the breast.

• After breastfeeding, express a few drops of milk and gently rub it on your nipples with clean hands. Human milk has natural healing properties and emollients that soothe. Also try letting your nipples air-dry after feeding, or wear a soft cotton clothes.

• Avoid wearing bras or clothes that are too tight and put pressure on your nipples.

• Avoid using soap or ointments that contain astringents or other chemicals on your nipples. Washing with clean water is all that is needed to keep your nipples and breasts clean.

• If necessary gently massage the breasts. Apply moist or dry heat to the breasts for a few minutes before or during massage until letdown occurs.

• If only one nipple is sore and the breastfeeding is to be started on that side, breastfeed on the pain free side first until letdown occurs then switch to the sore side.

• Numb the nipple just before latching by applying ice wrapped in a cloth on the sore nipple for a few seconds. Avoid prolonged exposure to the ice as this can inhibit the letdown reflex or damage the nipple.

ENGORGEMENT

• Engorgement can occur when your milk comes in. This is uncomfortable swelling of your breasts that tends to happen between 2 to 4 days after delivery. The swelling may restrict the flow of milk by compressing the ducts. The breast may be very hard making it difficult for the baby to attach and feed well.

• Engorgement can lead to plugged ducts or a breast infection

Possible Contributing Factors or CausesAssess the mother for:• Poor latching and positioning techniques • Use of supplements and pacifiers.• Restricting the frequency and length of breast feedings.• Temporarily stopping breastfeeding without expressing

for the missed breastfeeds.• Weaning abruptly.• Underlying abnormal breast pathology (e.g., non-patent milk

ducts).

• • Stress and Fatigue.Assess the baby for:• Ineffective suck • Use of pacifiers.

• The best management of engorgement is prevention• Check first for incorrect latching and positioning• Compress the breast when the baby’s sucking becomes

less effective• Apply cold to the softened breasts for a few minutes

after breastfeeding• Hand express or pump a little milk to first soften the

breast, areola, and nipple before breastfeeding• Wear a well-fitting, supportive bra that is not too tight.

PHYSIOTHERAPY MANAGEMENT• Ultrasound• Demand feeding and using heat just before

feeding to help the milk flow, and cold between feeds to reduce swelling is helpful. Cabbage leaves are said to be comforting, especially if kept in the freezer and slipped into your maternity bra between feeds.

PLUGGED DUCTS

• Plugged or blocked ducts occur when one or more of the collecting ducts within the breast become plugged with cells and other breast milk components. Contributing factors may include milk stasis or external pressure applied on specific areas of the breast.

• A plugged milk duct feels like a tender and sore lump in the breast. It is not accompanied by a fever or other symptoms. It happens when a milk duct does not properly drain and becomes inflamed. Then, pressure builds up behind the plug, and surrounding tissue becomes inflamed. A plugged duct usually only occurs in one breast at a time.

Possible Contributing Factors or Causes

• Ineffective removal of breastmilk and inadequate drainage of the breast

• Engorgement (• Overabundant breast milk supply • External pressure on a specific area of the breaste.g., - mother’s finger pressing the breast- constrictive bra or clothing- straps on a baby carrier- always sleeping on the same side or- always holding the baby the same way.• Positioning difficulties.• Poorly managed plugged ducts can develop into mastitis

What you can do

• Breastfeed often on the affected side, as often . as every two hours. This helps loosen the plug, and keeps the milk moving freely.

• Massage the area, starting behind the sore spot. Use your fingers in a circular motion and massage toward the nipple.

• Use a warm compress on the sore area. • Get extra sleep or relax with your feet up to help speed

healing. Often a plugged duct is the first sign that a mother is doing too much.

• Physiotherapy treatment consists of ultrasound and effleurage or draining massage to clear the ducts.

MASTITIS• Mastitis is an inflammatory condition of the breast,

which may or may not be accompanied by infection.• Assess the mother for possible symptoms:• Unilateral symptoms most often in the upper, outer

quadrant but may occur anywhere, including under the axilla.

• Red, hot, swollen.• Intense pain.• Flu-like symptoms (e.g., chills, aches, fatigue).• Fever • Possible sudden onset.

MANAGEMENT Promote Effective & Regular Milk Removal. • Do not stop feeding the baby. • Promote milk flow with a hot bath or a warm compress or pack.

Follow this (or during a bath or shower) with gentle massage towards the chest, ensure blocked areas are covered.

• Start the feed on the affected breast. • If pain inhibits let down, feeding may begin on unaffected breast,

then switch to the affected side once let down is achieved; breast feeding is often more comfortable once the milk is flowing

• If pain prevents breast-feeding, remove milk by hand or pump • Position the baby on the breast so the chin is over the blockage • Vary the baby's position on the breast so that all ducts are emptied • Ensure breast is fully drained after baby has finished feeding • Once the breast is drained massage the breast toward the nipple

Decrease Pain & Swelling • Cold Packs (specifically after feeding) and/or

Cold Cabbage leaves • Identify and effectively massage blocked

ducts • Ultrasound opens the ducts and promotes

circulation • In addition to effective breast milk removal of

the breast, infectious mastitis may also need treatment with antibiotics

Flat and Inverted Nipples• Some women have nipples that turn inward instead of

protruding or that are flat and do not protrude. Nipples can also sometimes be flattened temporarily due to engorgement or swelling while breastfeeding. Inverted or flat nipples can sometimes make it harder to breastfeed.

• The nipple pinch test can be done to clarify if a nipple is flat or inverted.

• Nipple pinch test: Gently compress the areola about one inch from the base of the nipple, placing the thumb on one side of the areola and the index finger on the opposite side. nipple may appear to be protruding, flat, or inverted before the nipple pinch test is done.

Possible Contributing Causes or Factors

• An areola that is non-elastic and difficult to compress. This type of areola will make it more difficult for the baby to latch on the breast.

• An engorged areola that may flatten a normally protruding nipple. This is most likely the case if the mother did not have a flat nipple until after birth.

• Adhesions that connect the nipple to the inner breast tissue.

• Less dense connective tissue located beneath the nipple.

• History of breast surgery or nipple piercing.

MANAGEMENT • Breast shells and nipple preparation (the Hoffman Technique)

are often recommended to help evert flat or inverted nipples. • Hoffman Technique is intended to loosen adhesions. Place

your two thumbs opposite each other at the base of your nipple. Press firmly and at the same time, pull the thumbs away from each other. Rotate the thumbs around the base of your nipple.

• Breast Shells – Breast shells are two-piece plastic devices that may be worn over the nipple and areola to evert flat or retracted nipples.

• Nipple Shields-A nipple shield is an artificial nipple and areola shaped like a floppy sun hat and is made of a synthetic material like silicone.

Possible contraindications to breastfeeding related to the mother

• active herpes lesion on her breast or nipple.• HIV positive• Mothers who have severe psychosis, eclampsia or

shock may not be able to manage breastfeeding for a period of time.

• Mothers who are taking a medication which is contraindicated when breastfeeding (e.g. cytotoxic drugs, radioactive drugs, and anti-thyroid drugs other than propylthiouracil) cannot breastfeed while the drugs are present and active.

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