Approach to the Problem
Assessing a nursing infant requires careful attention to the mother and the child during each clinical encounter. Effective diagnosis and treatment of breastfeeding problems cannot be accomplished without the clinician’s observation of the infant at the mother’s breast.
Unlike most other pediatric encounters, the mother becomes an important subject of a focused history and physical examination. In the mother’s medical and social history, critical findings can help the clinician easily identify treatable conditions or more difficult challenges to successful breastfeeding. Similarly, examination of the mother’s breast can reveal tell-tale signs of underlying problems. First-time mothers will usually feel their milk “come in” by 72 hours after delivery. Infrequent or inadequate drainage of the breasts in the first days of life can result in greater pain from engorgement and ultimately affect the volume of milk produced.
While the infant is breastfeeding or attempting to breastfeed, the clinician can observe critical features—including infant feeding cues, position, and latch—that can help diagnose common problems or determine the need for further assistance from a lactation consultant.
The clinician’s goals should be three-fold: (1) to encourage breastfeeding for all mothers and infants; (2) to assess and treat breastfeeding-related problems early; and (3) to provide a positive, nonjudgmental environment for promoting infant nutrition and growth.
Key Points in the History
Mother
• Delivery Complications. C-section incisions are often associated with increased pain during breastfeeding.
• Medications. Sedatives, antihistamines, diuretics, or exogenous estrogen (oral contraceptives) contribute to low milk synthesis. Even a single dose of barbiturates during labor (often given for a C-section delivery for failure to progress) has been shown to impede the milk intake of infants in the first days of life.
• Medical History. Hypothyroidism, peripartum infection, or retained placenta may impair breastfeeding success. Mothers who were overweight or obese (Body Mass Index >24) prior to pregnancy are less likely to initiate breastfeeding or to continue breastfeeding through 6 months. Preexisting or pregnancy-related back pain or hemorrhoids may also complicate the pain associated with certain breastfeeding positions.
• Surgical History. Breast reduction surgery may lead to a significant reduction in milk production. By contrast, most mothers who have breast implants can successfully nurse.
• Tobacco Use. Smoking has been shown to interfere with the milk let-down reflex. There is a direct relationship between the amount a woman smokes and decreased milk production.
• Maternal Support. Traditionally, women have relied on their spouses, mothers, and grandmothers for support and instruction. If these support figures are not available, mothers are more likely to benefit from thorough lactation instruction and support.
• Depressive Symptoms. Peripartum depression is common, often undiagnosed, and a significant contributor to other common maternal stressors in the first months of an infant’s life. Depression and anxiety may impede milk production and successful infant latch.
Infant
• Gestational Age. Preterm and near-term (<37 weeks’ gestation) infants are at higher risk for breastfeeding difficulty because of problems with latch and coordinated suckling.
• Apgar Scores. A 5-minute Apgar score less than 6 has been associated with decreased rates of successful breastfeeding initiation.
• Medical History. Significant metabolic, renal, or cardiac disorders may increase infant losses or metabolic demand. In addition to impairing adequate weight gain, these conditions may make breastfeeding more difficult for the infant or require supplementation with high-calorie formulas. Infants with Trisomy 21 syndrome often exhibit impaired oromotor skills that may make breastfeeding more challenging.
• Feeding Pattern. Infrequent feedings because of mother–infant separation, pacifier use, or supplementation with water, teas, or juices will interfere with milk production. Diaphoresis or tiring with feedings may be a sign of an undiagnosed cardiac or metabolic disease.
• Use of Infant Formula. Use of infant formula in the newborn nursery is a predictor of early discontinuation of breastfeeding and considered a red flag for insufficient milk production.
Key Points in the Physical Examination
Mother
• Nipple. Cracks or fissures of the nipple may indicate problems (see below). Nipple inversion is a common problem that may be corrected with the use of a nipple shield.
• Maternal Mood. Fatigue and stress are the most common causes of inadequate milk supply. Maternal–infant emotional attachment is crucial for the breastfeeding dyad to succeed. The mother’s ability to identify and respond to her infant’s feeding cues will ensure frequent and timely feeds. This, in turn, promotes continued milk production.
Nursing Process
• Infant Feeding Cues. Common infant feeding cues include wriggling with eyes wide open, hands to mouth or face, rooting with an open mouth, and smacking lips. Assess the mother’s facility in identifying and acting on these cues.
• Infant Feeding Position. Four common positions (cradle hold, football hold, cross-cradle hold, and lying) are illustrated in Figures 1-1 to 1-4. Assess the mother’s comfort and confidence in trying at least two different positions to accommodate her and her infant.
• Infant Latch. Nipple cracks, fissures, and pain may be caused by superficial latches that do not reach the infant’s soft palate, where the infant’s lower lip is curled inward, where mother is taking the infant off the breast without breaking suction or leading with the baby’s nose instead of the chin. Appropriate infant latch should include the following:
• Wide-open mouth immediately prior to bringing the baby to breast
• The baby’s lips should be flanged, “fish-like”
• The mother holds her breast with her thumb on top and four fingers beneath (“C” hold)
• Audible or visible swallowing, with about two to three sucks per swallow
• Maternal Comfort. During effective breastfeeding, the mother may experience tingling within the breast, but she should not experience sharp pains. After nursing, her breasts should feel softer without any soreness. Pain during breastfeeding is one of the most common causes of poor milk production and discontinuation of breastfeeding.
Infant
• Normal weight gain is a good sign of successful breastfeeding. Weight loss of greater than 10% from birth weight or other signs of failure to thrive merit further investigation, including increased attention to the breastfeeding history and examination of the nursing process.
• Moist mucous membranes, flat anterior fontanelle, and adequate peripheral perfusion are good signs of adequate oral hydration.
• Cleft lip or palate, high-arched palate, tight lingual frenulum, or micrognathia may impair a successful latch. Absence of a strong suck reflex may indicate poor oromotor development or an underlying neurologic abnormality that would impair breastfeeding.
• Abnormal motor tone or reflexes may indicate an underlying neurologic abnormality that may also impair oromotor development and, therefore, breastfeeding.
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PHOTOGRAPHS OF SELECTED DIAGNOSES |
Figure 1-1 Cradle hold. (Courtesy of Lourdes Forster, MD, FAAP.)
Figure 1-2 Football hold. (Courtesy of Lourdes Forster, MD, FAAP.)
Figure 1-3 Cross-cradle hold. (Courtesy of Lourdes Forster, MD, FAAP.)
Figure 1-4 Lying position. (Drawing by Satyen Tripathi, MA.)
Figure 1-5 Feeding cue (hand in mouth). (Courtesy of Lourdes Forster, MD, FAAP.)
Figure 1-6 Nipple fissure. Note fissure from the 2 o’clock to 8 o’clock position. Such a fissure indicates an improper latch (i.e., “nipple latch”). (Courtesy of Lourdes Forster, MD, FAAP.)
Figure 1-7 Nipple fissure. Note fissure from the 11 o’clock to 5 o’clock position. Such a fissure indicates an improper latch (i.e., “nipple latch”). (Courtesy of Lourdes Forster, MD, FAAP.)
Figure 1-8 Infant nursing on a retracted nipple covered with a nursing shield. (Courtesy of Lourdes Forster, MD, FAAP.)
Figure 1-9 Breast engorgement. Signs of breast engorgement include a flat nipple. (Courtesy of Lourdes Forster, MD, FAAP.)
Figure 1-10 Breast reduction. Note scars from breast reduction surgery. (Courtesy of Lourdes Forster, MD, FAAP.)
Figure 1-11 Cross section of infant latch. Note two critical features of a successful latch: the nipple protrudes to make contact with the infant’s soft palate, and the infant’s lower lip is folded outward. (Drawing by Satyen Tripathi, MA.)
Figure 1-12 Milk supply, over time. (Drawing by Satyen Tripathi, MA.)
Figure 1-13 Ankyloglossia. Note the notched or heart-shaped tongue visible on protrusion. (Courtesy of Michael Lemper, DDS.)
DIFFERENTIAL DIAGNOSIS
Other Diagnoses to Consider
Maternal Causes of Poor Milk Supply
• Peripartum depression
• Retained placenta
• Postpartum hemorrhage
• Eating disorder
• Primary mammary glandular insufficiency
• Polycystic ovary syndrome
• Systemic lupus erythematosus
• Autoimmune disease or connective tissue disorder
• Other chronic illness
Infant Diagnoses That May Impair Breastfeeding
• Viremia/Viral syndrome
• Serious bacterial illness, including urinary tract infection, pneumonia, enteritis, sepsis, and meningitis
• Gastroesophageal reflux
• Prematurity
• Cleft lip or palate
• Ankyloglossia
• Gastroesophageal malformations
• Metabolic disorder
• Renal disease
• Hypocalcemia
• Hypothyroidism
• Oral–motor dysfunction
• Central nervous system abnormality
When to Consider Further Evaluation or Treatment
Failure to thrive is the most important indication for further evaluation by the pediatrician in partnership with a lactation consultant. Concerns for failure to thrive would include the following:
• Weight loss of greater than 10% in the first week of life
• Failure to regain birth weight by day 14
• Average daily weight gain of less than 20 g/day
• Infrequent stools, less than four stools per day, by the end of the first week
• Concentrated urine, less than six wet diapers per day, by the end of the first week
SUGGESTED READINGS
Ahluwalia IB, Morrow B, Hsia J. Why do women stop breastfeeding? Findings from the Pregnancy Risk Assessment and Monitoring System. Pediatrics. 2005;116:1408–1412.
Ballard JL, Aver CE, Khoury JC. Ankyloglossia: Assessment, incidence, and effect of frenuloplasty on breastfeeding dyad. Pediatrics. 2002;110:e63.
Brent N, Rudy SJ, Redd B, et al. Sore nipples in breast-feeding women. Arch Pediatric Adolesc Med. 1998;152:1077–1082.
Centers for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Atlanta: U.S. Department of Health and Human Services; 2013. http://www.cdc.gov/breastfeeding/pdf/BF-Guide-508.PDF. Accessed December 15, 2013.
Ip S, Chung M, Raman G, et al. Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries. Evidence Report/Technology Assessment No. 153 (Prepared by Tufts-New England Medical Center Evidence-based Practice Center, under Contract No. 290–02–0022). AHRQ Publication No. 07-E007. Rockville, MD: Agency for Healthcare Research and Quality; 2007.
Lawrence RA and Lawrence RL. Breastfeeding—A Guide for the Medical Profession. 7th ed. Philadelphia, PA: Elsevier Mosby; 2011.
Riordan J. Breastfeeding and Human Lactation. 4th ed. Sudbury: Jones and Bartlett; 2009.