Slide 12/1: Breast and nipple size and shape Slide 12/2: Full breast
Slide 12/3: Engorgement Slide 12/4: Mastitis
Slides12/5 and12/6: sore nipples
Breastfeed Observation Aid - a copy for each person.
List of Communication Skills from Session 2 - a copy for each person. Copy of the stories – one story for each group of 4-6 participants.
In Additional Information section
Slides 12/7: Syringe method for an inverted nipple Slides 12/8 and12/9: Candida on nipples
Slide 12/10: Tongue-tie
Syringe and a sharp blade to cut it.
Further reading for facilitators:
1. Examination of the mother's breasts and nipples 5 minutes
• The earlier session on promoting breastfeeding during pregnancy mentioned that antenatal nipple preparation was generally not helpful. During antenatal checks, a woman can be reassured that most women’s breasts produce milk well regardless of size or shape. • After the baby is born, health workers do not need to physically examine every
breastfeeding woman's breasts and nipples. They only need to do so if the mother has pain or a difficulty.
• Always observe the condition of the mother’s breasts when you observe a breastfeed. In most cases this is all that you need to do, as you can see most important things when she is putting the baby onto the breast, or as the baby finished a feed.
• If you physically examine a women’s breasts: - Explain what you want to do.
- Ensure privacy to help the mother feel comfortable and consider customs of modesty.
- Ask permission before breasts are exposed or touched.
- Talk with the mother and look at the breasts without touching. - If you need to touch the breasts do so gently.
• Ask what has she noticed about her breasts – is there anything that worries her? If so ask her to show you.
• Talk to the mother about what you have found. Highlight the positive signs you see. Do not sound critical about her breasts. Build her confidence in her ability to breastfeed.
Nipple size and shape
- Show slide 12/1:Breast and nipple size and shape
• There are many different shapes and sizes of breast and nipple. Babies can breastfeed from almost all of them.
• Nipples can change shape during pregnancy and become more protractile or “stretchy”. There is no need to ‘diagnose’ or treat a nipple that looks flat or inverted during
pregnancy51.
• Inverted nipples do not always present a problem. Babies attach to the breast, not to the nipple. If you think her nipples may be inverted, the best way to help is to build her confidence and provide good support from birth52.
• Long or big nipples may also cause difficulties because the baby does not take the breast far enough back in his or her mouth. Help the mother to position and attach the baby so that there is a large amount of breast tissue in the mouth, not just the nipple.
• If the baby gags repeatedly because of a large nipple, ask the mother to express the milk and cup feed the baby for some days. Babies grow quickly and their mouths soon become bigger.
51 Wearing of breast shells or special exercises during pregnancy to help the nipples protrude are no longer recommended as they may be painful and can give a woman the impression that her breasts are not right for breastfeeding. Build her confidence and provide good support from birth.
52 Supportive practices such as skin to skin contact, encouraging the baby to find his/her own way to the breast, help with positioning and attachment and avoiding artificial teats and pacifiers, assist breastfeeding to be established. These practices were discussed in earlier sessions.
2. Engorgement, blocked ducts and mastitis 20 minutes
One of the mothers in our story, Fatima, has heard that breastfeeding mothers can have sore breasts. She is worried this might happen to her, as her breasts seem to be getting swollen.
Ask: What can you explain to a mother about normal breast changes during breastfeeding and changes that may indicate a difficulty?
Wait for a few responses. Engorgement
What is engorgement?
- Slide 12/2:Picture of full breast
• Normal breast fullness: When the milk is "coming in,” there is more blood supply to the breast as well as more milk. The breasts may feel warm, full, and heavy. This is normal. To relieve fullness, feed the baby frequently and use cool compresses between feeds. In a few days, the breasts will adjust milk production to the baby’s needs.
- Slide 12/3:Picture of engorgement
• Engorgement: If the milk is not removed, the milk, blood and lymph become congested and stop flowing well, which results in swelling and oedema. The breasts will become hot, hard and painful, and look tight and shiny. The nipple may be stretched tight and flat, which makes it difficult for the baby to attach and which can result in sore nipples. • If engorgement continues, the feedback inhibitor of lactation reduces milk production. • Causes of breast engorgement include:
- Delay in starting to breastfeed soon after baby’s birth. - Poor attachment, so that milk is not removed effectively.
- Infrequent feeding, not feeding at night or short duration of feeds.
Do your practices help to avoid engorgement?
• If much engorgement is seen in a maternity facility, the pattern of care for mothers should be reassessed. Implementation of the Ten Steps to Successful Breastfeeding prevents most painful engorgement. If you can answer “yes” to all of the following questions, there should be very little engorgement in your facility.
• Ask yourself:
- Is skin-to-skin care practiced at birth? (Step 4).
- Is breastfeeding initiated within one hour after birth? (Step 4).
- Do staff offer help early and make sure that every mother knows how to attach her baby at the breast? (Step 5).
- If the baby is not breastfeeding, is the mother encouraged and shown how to express milk from her breasts frequently? (Step 5).
- Are babies and mothers kept together 24 hours a day? (Step 7).
- Is every mother encouraged to breastfeed whenever and for as long as her baby is interested, day and night (at least eight to twelve feeds in 24 hours)? (Step 8). - Are babies given no pacifiers, artificial teats, or bottles that would replace suckling
Help mothers to relieve engorgement
• To treat engorgement, it is necessary to remove the milk from the breast. This will: - Relieve the mother’s discomfort.
- Prevent further complications such as mastitis and abscess formation. - Help to ensure continued production of milk.
- Enable the baby to receive breast milk. • How to help a mother to relieve engorgement:
- Check attachment: Is baby able to attach well at the breast? If not:
- Help the mother to attach her baby at the breast well enough to remove the milk.
- Suggest that she gently express milk54 from her breasts herself before a feed to soften the areola and make it easier for the baby to attach.
- If breastfeeding alone does not reduce the engorgement, advise the mother to express milk between feeds a few times until she is comfortable.
- Encourage frequent feeds: if feeds have been limited, encourage the mother to breastfeed whenever and for as long as her baby is willing.
- A warm shower or bath may help the milk to flow.
- Massage of the back and neck or other forms of relaxation may also help the milk to flow.
- Help the mother to be comfortable. She may need to support her breasts if they are large.
- Provide a supportive atmosphere; build the mother’s confidence by explaining that soon the engorgement will be resolved.
- Cold compresses may lessen pain between feeds.
Blocked milk ducts and mastitis (breast inflammation)
• Milk sometimes seems to get stuck in one part of the breast. This is a blocked duct. • If milk remains in a part of the breast, it can cause inflammation of the breast tissue or
non-infective mastitis. Initially there is no infection, however the breast can become infected with bacteria and is then infective mastitis.
• Blocked ducts and mastitis can be caused by:
- Infrequent breastfeeding – maybe because the baby wakes infrequently, hunger signs are missed, or the mother is very busy.
- Inadequate removal of milk from one area of the breast.
- Local pressure on one area of the breast, from tight clothing, lying on the breast, pressure of the mother’s fingers on the breast, or trauma to the breast.
• A woman with a blocked duct may tell you that she can feel a lump, and the skin over it may be red. The lump may be tender. The mother usually has no fever and feels well.
• A woman with mastitis may report some or all of the following signs and symptoms: - pain and redness of the area;
- fever, chills;
- tiredness or nausea, headache and general aches and pains.
• The symptoms of mastitis are the same for non-infective and infective mastitis.
- Show slide 12/4:Picture of mastitis. Note that an area is red and there is swelling. This is
severe. Participants and mothers need to learn to recognise blocked ducts and mastitis in an earlier stage so that it does not progress to this severity.
53 Relieving engorgement when a mother is not breastfeeding is discussed in the Additional Information section for this session. 54 See Session 11 for details of how to express milk.
Assessment of a mother with a blocked duct or mastitis
• The important part of treatment is to improve the drainage of milk from the affected part of the breast.
- Observe a breastfeed. Notice where the mother puts her fingers and if she presses inwards, perhaps blocking the milk flow.
- Notice if her breasts are very heavy. If the blocked duct or mastitis is in the lower area, lifting the breast while feeding the baby may help that part of the breast to drain better.
- Ask about frequency of feeds and if the baby is allowed to feed for as long as the baby wants.
- Ask about pressure from tight clothes, especially a bra worn at night, or trauma to the breast.
Treatment of mastitis
• Explain to the mother that she MUST:
- Remove the milk frequently (if not removed, an abscess may form). - The best way to do this is to continue breastfeeding her baby frequently. - Check that her baby is well attached.
- Offer her baby the affected breast first (if not too painful). - Help the milk to flow.
- Gently massage the blocked duct or tender area down towards the nipple before and during the feed.
- Check that her clothing, especially her bra, does not have a tight fit.
- Rest with the baby so that the baby can feed often. The mother should drink plenty of fluids. The employed mother should take sick leave if possible.
Rest the mother, not the breast!
• If the mother or baby is unwilling to feed frequently, it is necessary to express the milk55. Give this milk to the baby. If the milk is not removed, milk production can cease and the breast becomes more painful, possibly resulting in an abscess.