The Impact of Child Development on Breastfeeding by Elsa Quintana by Sue Jameson.

This session was presented at the 2020 ILCA Conference by Elsa Quintana BA, BCJ, IBCLC, CLE  and Jan Tedder BSN, FNP, IBCLC, and this review was written by ALCI President Sue Jameson.

 

Elsa had worked with Jan in New Mexico to improve breastfeeding outcomes by referencing Child Development Milestones.  As this is an area that I have read and presented on, on many occasions I was interested to learn how they had used Jan’s HUG programme to make changes. HUG stands for Help, Understanding and Guidance and from this Jan has developed a Parent Information Sheet that provides anticipatory guidance for what to expect in the early months. She uses the term GPS – Great Parenting  Skills  and the road map analogy is used throughout. This is very good as it follows the theme that breastfeeding and parenting is a journey with many twists and turns and that some of these can be avoided or planned for if one has a map.

 

Brazletons Touchpoint Theory is used to underpin the programme as it identifies significant events or Touchpoints  (referred to as Leaps in the more familiar Wonder Weeks materials by Frans X. Plooij &  Hetty van de Rijt-Plooij  seen in Europe) which signal change is on the way.

 

Often surges or leaps  in development cause changes in baby’s eating and sleeping patterns, which are often misunderstood by parents and can cause them considerable distress. The other point to note  is that these developmental surges are predictable. Research has shown that understanding infant behaviour and responding effectively to infant cues contributes  to longer breastfeeding duration (Shloim et al., 2017); promotes positive interactions between parent and child (Nugent et al., 2007); boosts parental confidence, reduces risk of postnatal depression, and positively impacts both attachment of baby to parents and baby’s development (Lester & Sparrow, 2010).

 

The materials were used to educate health professionals so that they had an increased awareness and confidence in discussing all aspects of normal developmental behaviours with parents and providing anticipatory guidance to them from an increased knowledge base. Over the areas the scores on all aspects were improved see slide showing results.

 

The HUG programme is available to purchase and training is available for anyone wishing to be a HUG consultant.  Referring to the material, it mirrors what community based support groups in Ireland provide by way of trained breastfeeding helpers and Peer support.

 

The studies confirm what we know – that is parents do better when they receive timely skilled help and information about infant behaviour to help them understand what’s happening for their little ones. 

 

It was reassuring to hear from another country that similar programmes make a difference to all population groups and to those in the lower SE groups in particular.  The HUG programme is child centred and optimizes parent responsiveness to their infant’s needs.

 

Listening to this talk and speaking to the presenters afterwards I noted that it was an approach that any of us working in the voluntary sector would immediately recognise. Working on improving parents’ knowledge of the normal newborn’s behaviour makes breastfeeding a more enjoyable experience as anticipatory guidance provides them with a road map for the journey over the first year.

 

Further information on HUG here https://hugyourbaby.org/jan-tedder-bsn-fnp-ibclc/

 

Sue Jameson, ALCI President, October 2019.

Sue attended the ILCA Conference, representing and funded by ALCI.

Painful Nipples by Kay Hoover reviewed by Jennifer Ashcroft

Kay Hoover, MEd and IBCLC, was the keynote speaker at the recent ACLI conference held in Limerick. Kay’s presentation on the Friday was titled “Painful nipples during breastfeeding” where she addressed the multiple root causes for nipple pain and highlighted the need to not just manage the symptoms.

 

Kay’s objectives for the presentation were that the delegates could;

  • List 5 causes of nipple pain
  • List 5 dermatological conditions
  • Draw up a care plan for damaged nipples

 

Kay spoke from her experience that it can be normal for mums to experience approximately 20 seconds of discomfort with the initial latch but that after this mothers should be able to relax and be less tense throughout the duration of the feed. Days 3-5 post-partum are often the peak of nipple pain and that this is expected to subside by days 7-10 however from experience it is seen that a large percentage of mothers have ongoing pain for a significant period of time.

 

Kay highlighted that we know hormonal changes such as the menstrual cycle causes breast changes and nipple tenderness, so therefore with the post-partum hormonal shift it is not surprising that we see this peak at days 3-5 post-partum in nipple pain. Kay spoke that there is limited research to back up this theory, however from what we understand about hormones and their impact we can better equip mothers in their expectations in these early post-partum days.

 

Maternal problems that can lead to nipple pain include the following:

 

  • Long nipples – causing infant to gag or pull off the breast frequently
  • Large nipples (diameter) making it more difficult to achieve a deep latch
  • Inverted nipples – pain in extracting the nipple to feed
  • Skin tags on nipples – potential for repeated trauma each time infant feeds
  • Blebs and blocked ducts
  • Vasospasm (Raynaud’s syndrome) – often seen on the face of then nipple, unusual to be the whole nipple – can cause a burning sensation in both the nipple and breast. Once blood flow restores the pain is expected to settle

 

Kay stressed the importance of asking the mother “how does that feel for you?” as our interpretation of what would cause pain during a feed may not be significant for the mother experiencing it.

 

Trauma can cause blanching, alongside a stinging or burning sensation. Amir et al., (2014) found vasospasm was the reason in 22-23% of breastfeeding mothers as a cause of pain.

 

Blanching can be on part of the nipple with the associated pain – squeezing blood back into the nipple (which often looks like hand expression) reduces the time the mother is in pain as it increases the blood flow to the affected area and is found to work quicker than warm compresses. These mothers are advised to keep warm – hats, sweaters etc. to minimise risk.

 

Medications that reduce vasoconstriction could be considered for these mothers – fish oil and evening primrose oil are longer term treatments and don’t provide immediate relief.

Oral Nephetamine (30mg slow release OD x 4 weeks or 5mg TDS) has been used with good effect

 

Injury or trauma – unrelated to breastfeeding

  • The baby with a strong suck – nipple shields as a temporary solution have been used in studies as increased vacuum is cause of pain, however this could cause further pain as the nipple can be pulled through the shield – always important to solve the cause of the pain
  • Incorrect use of a pump at its highest suction – pump should be used at highest “comfortable” setting. Also important to ensure appropriately sized flange and that the nipple is centred in the flange
  • Pre-natal “preparation” – i.e. rolling of nipples to “toughen them”
  • Baby not unlatched properly
  • Long distance runners can have chaffing
  • Incorrect fitting bra/seam or pressure
  • Breast pads sticking to nipple
  • “Spot” on nipple (sebaceous cyst) or varicose vein causing pain near nipple

 

Dermatological conditions on nipple causing pain

  • Dry skin (irritation)
  • Moisture – causing tissue breakdown
  • Infant food/medication causing maternal eczema due to change in saliva
  • Teething – acidic saliva (nappy rash and nipple pain)
  • Reaction to treatment
  • Poison Ivy of nipple
  • Psoriasis of nipple or breast tissue – some mothers require steroid cream or light treatment, others might not have any problems
  • Bloody discharge from nipple – 3% Breast cancer diagnosis (Paget’s disease)
  • Staph infection or streptococcus infection (could be on one or both breast – get cultures)
  • Herpes simplex (cold sore virus) – baby to mum transfer is ok, but if herpes lesion on mum could be fatal to infant (handwashing, not kissing baby as treatment)
  • Hand foot and mouth from toddler
  • Yeast infection – shooting pain, feels like “shards of glass” burning sensation, some mums cannot hold baby, or describe it hurts to wear clothing (shells can be helpful)

 

Key question to ask “Is this the normal look of your breasts or nipple?”

 

Kay then moved on to explain how to draw up a treatment plan for healing damaged nipples.

 

If nipples are lipstick shaped post feed work on a deeper latch, teach mum how to do suck training with baby, work on positioning to reduce pinching (Kay explained she uses plasters to show placement of hands for shaping breast).

 

If infant gagging and coming off too soon work on desensitising gag reflect with finger exercises in infant mouth moving back gradually to dampen response.

 

If mum has large nipples or there is suspected frenulum tie – i.e. nipping from baby address this issue, this may be evident as baby losing milk out of corner of mouth as unable to create seal and vacuum.

 

Kay explained that with a breast wound and suspected infections or mastitis important to remember that the yellow pus from this wound is not necessarily the infection but the leukocytes starting the healing process and stressed that if a mother is in pain, to use appropriate pain medications whilst breastfeeding to reduce the discomfort. Other strategies to reduce pain –

  • Reduce duration of feed (hand express into babies mouth)
  • Use breast shells
  • Pump exclusively until the damage heals

 

There are many treatment options and often no consistency with the research

  • Hand express and add Expressed milk to nipple
  • Warm compresses
  • Salt soaks (Epsom salts)
  • Lanolin (purified) – thin coat on face of nipple
  • Gel pads (hydrogel or glycerine gel) have been associated with increased risk of mastitis as source of infection so ensure washing between use, however others have found these to be extremely helpful
  • Cotton, breathable clothing
  • Air drying nipples – avoiding retraction in those with inverted nipples (dimpled nipple ring – Velcro, which holds nipple out whilst allowing it to air dry
  • Warm soap/water destroys the biofilm – soap has a drying effect therefore wash daily if not twice daily
  • Sometimes needs to advise the mum to stop what she has currently been doing – ointments, treatments etc
  • Antifungal preparations to be added topically – nystatin and hydrocortisone cream. Ensure systemically and topically treat to reduce poor outcomes

 

If believed to be an infection best treatment course is wash with warm soapy water, advise culture from primary care provider and find out source and treat accordingly.

 

Severe mastitis = might not present with temperatures look at breasts singularly and together – patterns in infection – MRSA, step and Staph

 

If suspected fungal infection check babies cheeks not tongue, and often the mothers nipple has  a “shiny complexion”

 

Impetigo – highly contagious – use topical +/- oral treatment, wash regularly and ask if too painful to feed and draw up treatment plan accordingly, some mothers can feed fine and others need to express until healed.

 

There is some research to suggest silver caps are more effective than breastmilk for nipple damage

 

Kay finished off by highlighting the importance of not dismissing nipple pain as it was in the top 2 reasons why mothers end breastfeeding before they had planned

  • perceived low supply
  • Sore nipples
  • Baby wouldn’t latch

Jennifer Ashcroft October 2019.

Jennifer received a bursary of €50 from ALCI to attend the 2019 ALCI Conference.

ALCI At The Aras 2019

ALCI Council and members recently represented ALCI as part of a special reception in Áras an Uachtaráin in celebration of National Breastfeeding Week. This year two ALCI members Mairead Murphy IBCLC and Danielle Sullivan IBCLC (and Danielle’s baby) attended along with ALCI Council members Sue Jameson IBCLC, Lorraine O’Hagan IBCLC, Aine  O’Leary IBCLC and Fiona Rea IBCLC.

 

 

The reception, which was hosted by Sabina Higgins, included a  ‘Latching on’ morning and involved representatives, mothers and babies from ALCI, Cuidiú, La Leche League, Friends of Breastfeeding and  Association for Improvement in the Maternity Services Ireland (AIMS),

 

 

 

 

 

Breastfeeding Multiples by Kay Hoover Reviewed by Barbara Noonan Sexton

 

Kay Hoover MEd and IBCLC was the keynote speaker at the recent ALCI Conference. Kay’s final session was about breastfeeding multiples.

Kay highlighted that sometimes people can frighten mothers of multiples by saying things like “Better you than me”, “Were you on fertility drugs?” or “Do Twins run in your family?”

Kay would say to these Mothers “You will have double or triple the amount of hugs. ” Focus on positive comments not on the negative ones.

(Photo:  ALCI delegates enjoying the Conference recently.)

Infertility treatments have increased the numbers of multiples from 1991 to 2016 the twinning rate per 1,000 births went from 12% to 19%. In 2016 in Ireland there were 2,363 sets of twins and 79 sets of higher order multiples.

 

Kay highlighted that there are many Pregnancy, birth and post- partum concerns

  • Kay stated that there is maternal, physical and emotional strain.
  • Increased risk of durgical delivery ( caesarean section ) and pre term labour,
  • Pregnancy induced hypertension increases with each baby
  • Risk of gestational diabetes increases with each baby

 

There are Risks with Multiples

  • Neo – natal Mortality
  • Birth – defects
  • SIDS
  • Child – abuse
  • Developmental – disabilities

 

Kay stated that there can be growth restrictions that affect breastfeeding

  • Intrauterine growth restriction and prematurity
  • Increased Incidence of congenital anomalies
  • Infant death is five times higher than for single infants.

 

Kay highlighted the importance of mothers not being afraid to ask for help from family. In one case, Kay encouraged one mother to ask her parents to stay with her for a month so that while she was breastfeeding the babies, the parents were making the meals and doing the households jobs.

 

Strategies for breastfeeding is very important

  • Make sure the babies can establish a milk – supply,
  • Pumping if necessary
  • Transitioning premature babies to total breastfeeding
  • Discharge planning
  1. Sometimes one baby comes home before the other,
  2. Frequently one breastfeeds better than the other at the start.

 

Kay stated that 60% of Twins are born preterm. When a mother pumps by her bedside nears the babies, she usually pumps more times and gets more milk. Donor milk is available in America until the mother has milk.

 

Kay highlighted practical tips

  • Keeping track of each baby by feeding record using different coloured paper for each baby, Individual differences in the normal range,
  • Ways to tell the babies apart
  1. Clothing
  2. Toe nail polish
  3. Bracelets

 

Kay also highlighted the importance of mothers getting out of the house

  1. Take one baby and leave one at home
  2. Strollers made for multiples
  3. Elastic waist band so she can go the toilet easier herself,
  4. Start saving weekly for the children
  5. Accept all help offered
  6. Remember it does get easier when the babies get older and the night feeds stop

 

Barbara Noonan Sexton October 2019.

Barbara received a bursary of €50 from ALCI to attend the 2019 ALCI Conference.

Tongue Tie by Alan O’Reilly reviewed by Barbara Noonan Sexton

Dr. Alan O’Reilly MB BCH BAO DCH DRCOG IBCLC facilitated two workshops entitled “Tongue Tie: Lactation Support V Frenotomy” at the recent ALCI Conference.

Dr. Alan O’Reilly is a GP who works in Camden Street in Dublin. He qualified as a Doctor in Galway, In 2013 he trained in assessing and releasing tongue ties. He qualified as an International Board Certified Lactation Consultant (IBCLC) in 2017. Margaret O’Connor IBCLC works alongside him in his Gp surgery in Dublin.

 

Objections of the Workshop

  • Normal tongue movement and function
  • Symptoms of tongue tie
  • Examination of tTongue tie
  • Lactation Support
  • Tongue Movement during breastfeeding

What is a Tongue Tie

This is a lingual frenulum that causes a restriction in tongue movement. Reduced tongue movement leads to impaired tongue function.

 

Examination of Tongue Movements

  • Extension: rub chin just below the lower –lip.
  • Lateralisation: run a finger along outside of lower gum from side to side.
  • Elevation: may be noted when infant cries.
  • Suction: allow infant to suck on the clean finger.
  • Grooving: allow the infant to suck finger and assess how well the sides of the tongue holds on to the finger.

Examination of Tongue tie

  • Insertion of Lingual frenulum on

1. Inferior surface of tongue

  1. Floor of mouth
  • Elasticity of Frenulum on elevation
  • Thickness and Fibrosity of Frenulum

 

 

Tongue tie and Frenotomy

  • Everybody seems to have a tongue tie.
  • Parents are leaving Lactation Consultations believing a Frenotomy is that sliver bullet that will solve all of their feeding problems.
  • The Focus needs to always be on lactation support and Frenotomy if indicated should be just part of the plan.

Lactation Support: First few days

Baby not Latching on

  • Hand express colostrum
  • Avoid bottle – feeding
  • Consider finger – feeding, spoon or cup feeding
  • Syringe feeding is also a good option
  • Suck training
  • Electronic pump when milk comes in

 

Single most Important factor in getting baby to latch is an abundant milk supply”   (Jack Newman).

 

Dr. O’Reilly also stated that treating nipple pain is very important.  He highlighted the importance of working on a deeper latch. Topical steroid may help reduce inflammation and take pain killers if needed. Feed expressed milk to allow nipples time to heal. Ensure to maintain an abundant milk supply.

 

Nipple shields are also useful if a baby is unable to sustain a latch or has a dysfunctional suck. Nipple shields may transfer more milk with a nipple shield that without. Useful for flat or inverted nipples. The shield is a barrier for inflamed or ulcerated nipples.

A mother protects her milk supply by pumping intermittently. Monitor weight gain. Supplement if required with feeding tools. Use for a short period if possible. Wean slowly if used for an extended  period (over 7 – 10 days).

 

  • If a baby is not gaining weight, look at history of mother: Breast surgery, PCOS and Hypothyroidism.
  • Improve latch.
  • Ensure mum recognizes effective feeding and swallowing
  • Breast Compression towards end of feed.
  • Consider galactogogues.
  • Consider additional feeds by feeding – tube: further stimulates supply.

There should be a Weight Gain of 155 grams per week. Fluid requirements: 160 mls per Kilo e.g 4 kg baby requires 640 mls per 24 hours, which equates to 80mls per feed.

Useful Handout here.

 

Barbara Noonan Sexton October 2019.

Barbara received a bursary of €50 from ALCI to attend the 2019 ALCI Conference.