Fundamentals of Midwifery: A Textbook for Students (96 page)

poor positioning and attachment of the baby

infrequent feeding and ineffective milk removal

poor breastfeeding management

nipple tissue damage, or

a combination of all the above.It is important mothers receive support from midwives, lactation consultants, peer support- ers, health visitors, and GPs, ensuring early recognition and appropriate management if com- plications occur. As part of assessment, the midwife should take a lactation history and observe a breastfeed before planning the care (Pollard 2012). Some of the common conditions include; breast engorgement, mastitis (non-effective or infective), sore nipples, and thrush (
Candida albicans
).
Breast engorgement
This is an accumulation of milk, congestion and increased vascularity in the breast (Lawrence and Lawrence 2011). It usually presents with both breasts feeling hot and painful, hard and full of milk, with difficulty in attachment. The aim is for the mother to achieve effective attachment and avoid increase in FIL by encouraging drainage of the breasts regularly. The feeding may be mother-led rather than baby-led to ensure the milk is removed from the breast; the mother may need to express for comfort (UNICEF 2008). Hand expression prior to the feed is helpful to soften the breast, prior to the baby attaching. The mother will need to be advised on appropriate analgesia if required.
Mastitis
Mastitis can develop if engorgement remains untreated. It is an inflammatory condition of the breast in response to breastmilk leaking into the tissue (Noonan 2010); it is usually unilateralaffecting one or more lobes or segments, but can be seen in both breasts (Pollard 2012). The mastitis may be either non-infected or infected. Mastitis presents as a blocked lactiferous duct/s, with evidence of localised inflammation and breast pain experienced by the mother. Flu-like symptoms present in the mother with body aches and pyrexia due to the inflammatory response. The aim is to achieve effective attachment of the baby using different positions to ensure drain- age of the breast, ensuring baby’s lower jaw is on the same side as the area of mastitis. Avoid increase in FIL by encouraging drainage of the breasts regularly, expressing after feeds if neces- sary, particularly from the affected breast for the mother to feel comfortable. Kent (2007) indicates that not all milk available is consumed at every breastfeed. The breast should feel softer and lighter after a feed, including the areas affected (UNICEF 2008). Expressing after feeds to ensure optimal breast drainage may encourage higher milk yield, but by gradually reducing the express- ing once the inflammation has subsided, the supply will return to normal (UNICEF 2008).‌UNICEF (2008) highlight it is difficult to determine whether infection is present, but recom- mend that if measures to drain the milk do not quickly relieve the mother’s symptoms within 24 hours, infection should be suspected. The mother will require urgent referral to the GP for antibiotic, anti-inflammatory and analgesic medications and should be encouraged to rest, increase fluid intake, and be supported to ensure there is effective removal of the milk from the breasts. Warm compresses prior to feeding and cold compresses after the feed may help to relieve the discomfort (Pollard 2012). Untreated mastitis can lead to breast abscesses and puer- peral sepsis (CMACE 2011).
Candida albicans
Candida albicans
is a commensal organism that causes oral thrush (Lawrence and Lawrence 2011). Infection may be precipitated by the mother or baby taking antibiotics, and/or the use of dummies, teats and nipple shields. In the mother, the condition usually presents in both breasts, as a sudden onset of shooting pain in the breast during and after feeds, which may develop following days or weeks of pain-free breastfeeding. The nipple/areola complex may suddenly become more sensitive and itchy with a delay in healing of sore nipples (Breastfeeding Network 2009). There is usually no inflammation of the breast and no maternal pyrexia. The mother will need to be referred to the GP for antifungal treatment and appropriate analgesia. Regular handwashing and appropriate sterilisation of any feeding equipment should be reiter- ated to the mother. The baby may present with white patches on the tongue or inside the cheeks, with nappy rash and may be unsettled. The baby will also need to be referred to the GP to be simultaneously treated with the mother. It is important that both mother and baby are treated, even if only one of them has signs and symptoms, otherwise the infection is likely to pass from one to the other.
Further reading activityAccess the Breastfeeding Network website for further information on managing commonbreastfeeding problems [Available online] http://www.breastfeedingnetwork.org.uk/
When breastfeeding is not recommended
Certain blood-borne viruses, such as human immunodeficiency virus (HIV) are passed throughthe breastmilk and may infect the child. In such cases, breastfeeding is not recommended (WHO 2010), wherereplacementfeedingisacceptable, feasible, affordable, sustainableandsafe. Certain medications the mother is taking may be contraindicated due to their effects on the baby (Hale 2012) (see Chapter 15: ‘Pharmacology and medicines management’, for further information).
229230Babies with the metabolic disorder phenylketonuria (PKU) can be prescribed supplementary phenylalanine (PHE)-free formula and have breastfeeds. The lactation consultant and paediatri- cian would work closely together to manage the feeding plan for the baby with PKU. It is recom- mended that the PHE-free formula is given prior to the breastfeeds (Page-Goertz and Riordan 2010).
Supporting mothers to formula feed
Although breastfeeding is promoted as the best form of nutrition for infants, most babies
receive some formula milk in the first year of life. The most recent UK infant feeding survey in 2010 showed 76% of mothers who initially breastfed had used formula milks, either in combina- tion with breastmilk or alone, by the time their infant was aged 4–6 months (McAndrew et al. 2012). Research has shown that many mothers receive little information on formula feeding and mistakes in preparation of feeds are common (Lakshman et al. 2009). Mothers choosing to formula feed their babies need support to ensure they are confident with sterilising equipment, preparing and storing feeds, and feeding the baby. Inadequate information, support for mothers and partners with formula feeding can lead to health complications for the baby. Prior to pre- paring formula feeds, handwashing should be undertaken. The Department of Health (2013) and the Food Standards Agency have reiterated the advice on safe preparation of formula feeding. Some of the key elements being restated include the following:

Make up powdered infant formula using water at a temperature of 70°C or above to ensure any pathogens in the milk powder are destroyed.

The advice is to boil at least 1 litre (1.7 pints) of fresh tap water and then allow it to cool in thekettle for no more than 30 minutes, so that it will have reached a temperature of at least 70°C.

Follow the manufacturer’s instructions to make up the feed correctly; the water is alwaysadded to the bottle first, before adding the powdered infant formula (UNICEF 2012c).

Once the feed is prepared, it is important to cool the formula appropriately so that it is nottoo hot for the baby to drink. The bottle can be cooled by holding the bottom half of the bottle under cold running water or placing the bottle in a cold water bath (UNICEF 2012c). Readers are encouraged to read the DH and UNICEF guidelines on safe preparation of infant formula, outlined in the Further Reading Activity below.

Feeding the baby away from home, or using ready-to-feed liquid formula which is sterile, canhelp to reduce the risk of infections (UNICEF 2012c). Information can also be accessed from reading the UNICEF guidelines.

Parents may need to be reminded that formula feeds should never be heated up in a micro-

wave, due to risk of creating hot spots and scalding the baby’s mouth.

Further reading activity

Access and read the guidelines from Department of Health (2011, 2013) and UNICEF (2010a; 2010b;

2012c) onsafepreparationofformulamilk[Availableonline] http://www.unicef.or

g.uk/babyfriendly/ and https://www.gov.uk/government/publications/start4life-updated-guide-to-bottle-feeding

Activity 10.5

Find out what resources are available on postnatal wards, to teach mothers about sterilising

feeding equipment and safe preparation of formula feeds.