Sesi 12 Breast and nipple conditions

Health talk for breast feeding

1. SESSION 12
BREAST AND NIPPLE
CONDITIONS
BREASTFEEDING PROMOTION AND SUPPORT
A TRAINING COURSE FOR HEALTH PROFESSIONALS
ADAPTED FROM THE BABY FRIENDLY HOSPITAL INITIATIVE:
REVISED, UPDATED AND EXPANDED FOR INTEGRATED CARE (SECTION 3)
WHO/UNICEF 2009

2. 1. Examination of mother’s
breasts and nipples

3. Examination of mother’s breasts & nipples
•Reassure mothers that most breast
produce breast milk well regardless
of size and shape.
•No need to physically examine
women’s breasts and nipples
except if she has pain or difficulty.
•In most cases , observation is all you
need to do

5. Examination of breasts and nipples
Explain what you want to do
Ensure privacy
Ask permission
If touching the breasts is
necessary, do gently
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6. Examination of mother’s breasts and
nipples
•Look for:
— engorgement/lumps/swelling/redness
— evidence of past surgery
Highlight positive sign
Do not sound critical about her
breasts.
Build her confidence in her ability to BF
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7. Nipple size and shape

8. Flat Nipples and Protractility
Nipples become protractile /stretchy during pregnancy
No need to diagnose or treat flat/inverted nipple during
pregnancy
wearing shells / exercise may cause pain
Makes woman feel that her breasts are not right for BF
No longer recommended
Protractility improves during pregnancy and after delivery
May look flat but baby is able to suckle
Build her confidence and provide support.
Attachment and avoiding artificial teats and pacifiers
assist BF to establish.

9. Inverted Nipples
Not always a problem as babies attach to breast
and not to nipple.
Build mothers’ confidence and provide support.
Supportive practices include : Skin to skin contact,
encourage baby to find own way to breast ,
correct positioning.
Help mothers to attach properly
Can breastfeed successfully with
help
Really difficult nipples are rare.
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10. 2. Management of Nipple
Problems

11. Management of Flat and Inverted Nipples
•Antenatal treatment
—Probably not helpful
•Soon after delivery
—Build mother’s confidence
—Explain baby sucks from BREAST not nipple
—Let baby explore breast, skin-to-skin
—Help mother to position her baby
—Try different positions
—Help her to make nipple stand out more - Use syringe, pump,
massage
•For first week or two if baby not suckle effectively
—Express breastmilk
—feed with cup
—Express into baby’s mouth

12. Syringe method for inverted nipples

13. Long or Big Nipples
May cause difficulties
baby does not take breast far enough back into
mouth
likely to suck only nipple and not taking breast
with the lactiferous sinuses into mouth.
Be ready to help mother with BF technique
help mother to position and attach correctly

14. Long Nipples

15. Helping Mother With Long and Big Nipples
•Re-assure mother:
Baby’s mouth will grow and
lengthen.
Her nipples will not grow !!
•Express breastmilk and feed
with cup.
•Express breastmilk into
baby’s mouth.

16. Management of Nipple Fissure
(Cracked Nipple)
Commonly caused by incorrect positioning
and poor attachment.
Baby pulls on nipple as he sucks and
causing pain
Repeated suckling >> damage nipple skin
>>> fissure.
Help mother for correct positioning.

17. UNICEF/WHO Breastfeeding Promotion and Support in a Baby-Friendly Hospital – 20 hour Course 2006
Sore Nipple
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18. Sore Nipples
Breastfeeding shouldn’t hurt
Some find nipples slightly tender at
beginning of feed for few days but usu.
disappears in a few days
•Most causes of nipple soreness are
simple and avoidable
•Ensure all maternity staff know how to
help mothers get babies attached to
breasts
If babies are well attached
Most mothers do not get sore nipples
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19. Observation and history taking
for sore nipples
Causes of sore nipple:
•Poor attachment
•Baby is pulled off breast to end feed
•Breast pump ( cause stretching of
nipple)
•Candida (from baby’s mouth) infection
of nipple
•Infant’s tongue tie causing friction on
nipple.

20. Observation and history taking
for sore nipples
•Ask mother to describe what she feels:
—Pain at start of a feed that fades when
baby lets go, is most likely related to
attachment.
—Pain that gets worse during feed and
continues after feed has finished, often
describe as burning/stabbing is more
likely caused by Candida Albicans.

21. Observation and history taking
for sore nipples
•Look at nipples and breast
—Broken skin is usually caused by poor attachment.
—Skin is red, shiny, itchy, flaky with loss
pigmentation often seen with Candida.
—Candida and trauma from poor attachment can
exists together.
—nipple can have eczema, dermatitis and other
skin condition.

22. Observation and history taking
for sore nipples
•Observe a complete breastfeeding
•Check how the baby :
—goes to breast
—Attachment
—Suckling
—Notice how mother ends feed
—Observe what nipples look like at end
of feed
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23. Management of Sore Nipples
Reassurance
sore nipples can be healed and prevented in
future
Treat cause of sore nipples
Suggest comfort measures while nipple healing
Treat Cause:
•Help mother to improve attachment and positioning
•Show mother how to feed in different feeding
position
•Treat Candida both on mother and baby
•If baby had tongue tie – refer for treatment
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24. •.
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25. Suggest comfort measures
While nipples are healing:-
•Apply expressed breast milk to nipples
after feed.
•Begin each breastfeed on least sore
nipple
•Gently remove baby if baby begin to fall
asleep at breast.
•Wash nipples only once a day.
•Avoid using soap on nipples, as it
removes natural oils.
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26. What do not help
DO NOT stop breastfeeding to rest
nipple.
DO NOT limit frequency or length of
breastfeeds.
DO NOT apply any substances to
nipple.
DO NOT use nipple shield.
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27. 3. Causes, Prevention and
Management of Common
Breast Problems
Engorged breast

28. Common Breast Problems
1. Breast engorgement
2. Block duct and mastitis
3. Breast abscess
4. Candidiasis

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Breast Engorgement
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30. Full breasts Engorged breasts
•NORMAL 48/72 hours
after birth.
• PATHOLOGICAL
• can occur any time during
breastfeeding.
• Warm, full and heavy.• Painful, Oedematous.
• Hot and hard.
• Tight and flat especially nipple
area.
• Shiny and may look red.
•Milk flowing. • Milk NOT flowing.
•Fever uncommon. • Fever may occur.
• For the next 10 to 14 days
breast fullness often
occurs BEFORE a feed.
•**FIL (Feedback Inhibitor of
Lactation) may cause decrease
in milk supply if engorgement
continues.

31. Causes and Prevention of Breast
Engorgement
CAUSES PREVENTION
•Plenty of milk.
•Delay starting to
breastfeed.
•Start breastfeeding soon
after delivery.
•Poor attachment to
breast.
• Ensure good attachment.
• Infrequent removal of
milk.
• Restriction on the
length of feeds.
• Encourage unrestricted
BF (feeding day and night with
long duration of feeds).
•Express in between feeds
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32. Management of Breast Engorgement
• If the baby able to suckle•Feed frequently, help with
positioning
•If the baby not able to
suckle
• Express milk
•Before feed
(to stimulate oxytocin
reflex)
• Warm compress or warm
shower.
• Massage neck and back.
• Light massage of breast
• Help mother to relax
• Provide supportive
atmosphere.
• After feed
(to reduce oedema)
• Cold compress on breasts.
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33. Relief of engorgement
•Removing milk from breast will relieve
engorgement.
•This will:
•Relieve mother’s discomfort.
•Prevent mastitis and abscess formation.
•Help to ensure continued production of milk.
•Enable baby to receive breastmilk.

34. Blocked milk ducts and Mastitis

35. Symptoms of blocked duct and
mastitis
blocked duct milk stasis
non-infective
mastitis
infective
mastitis
•Lump
•Tender
•Localised redness
•No fever
•Feels well
•Hard area
•Feels pain
•Red area
•Fever
•Feels ill
Progresses to
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Symptoms of Blocked Duct and Mastitis

36. Causes of Blocked Duct and Mastitis
•Poor drainage of part
or all of the breast
•Stress, overwork
•Trauma to breasts
•Cracked nipples
Which is due to:
•Infrequent breastfeeds
•Ineffective suckling
•Pressure from clothes
•Pressure from fingers during
feeds
•Large breasts draining poorly
•Reduces frequency and
length of feeds
•Damages breast tissue
•Allows bacteria to enter

37. Management of Blocked Ducts, Mastitis
Assessment
•important part of treatment is to improve
drainage of milk from affected part of
breast
—Observe a breastfeed
—Notice if her breasts are very heavy
—Ask about frequency of feeds
—Ask about pressure from tight clothes
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38. Management of Blocked Ducts, Mastitis
•Explain to mother that she MUST Remove milk frequently
•Continue breastfeeding frequently
•Check that baby is well attached
•Gently massage blocked or tender area down towards
nipple before and during feeds.
•Apply warm cloth to area before feed.
•Check that her bra does not have a tight fit.
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39. Management of Blocked Ducts, Mastitis
Treatment
•Explain to mother that she MUST:
—Rest with baby so that baby can feed often
—Drink plenty of fluids
—Express milk if baby unwilling to feed
frequently
•Infrequent removal >>engorgement
>>abscess
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REST THE MOTHER,
NOT THE BREASTS

40. Drug treatment for Mastitis
•Anti-inflammatory treatment
- Ibuprofen
- Or mild analgesia
Antibiotic therapy is indicated if:
fever for 24 hours or more
evidence of possible infection eg infected
cracked nipple
symptoms do not subside within 24 hours of
frequent and effective feeding/milk expression
condition worsens
Course of 10 to 14 days to avoid relapse
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41. Breast Abscess
A collection of pus forms in part of breast.
May result fr untreated mastitis
painful swelling
Needs surgical incision ( I&D ) and antibiotic
Continue breastfeeding if
incision far from areola and does not interfere BF
mother tolerate pain
otherwise express milk from affected side
Continue BF from unaffected breast
Good management of mastitis should be
preventive
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42. Candida infection
Can make skin sore, shiny, red and itchy
Often follow antibiotic use to treat
mastitis/other infections
May be due to/cause baby’s oral thrush
Describe burning/stinging pain which
continues after feed
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43. Candida
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AreolaNipple

44. Oral Candidiasis

45. Signs and treatment for thrush
Signs Treatment
• Skin looks red, shiny and
flaky . Nipples and
areola may lose
pigmentation/ look
normal /red
• Nystatin cream 100,000
IU/g
•Apply to mother’s lesions
4x/day, after breastfeed and
continue till 7 days after
lesion healed
• Nipples remain sore
between feeds for
prolonged time despite
correct attachment.
•Nystatin suspension 100,000
1U/ml:
• Apply 1 ml by dropper to
child’s mouth 4x/day after
breastfeed.

46. SUMMARY :
Session 12 BREAST AND NIPPLE CONDITIONS
Examination of mother's breasts and
nipples
Prevention and management of :
engorgement and mastitis
sore nipple
How to assist a mother with breast or
nipple condition

47. THANK YOU

48. Question 1
To avoid sore nipples, these statements are
true except :
A.Ensure correct positioning and latch on
B.Check baby’s mouth for oral thrush
C.Do not wash breast before every feed
D.Limit breast feeding for only 5 minutes from
each breast
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49. Question 2
During routine anc check up, if a mother is found to have
inverted nipple, recommended mx include the following:
I.Tell the mother that she is unable to breast feed her baby after
birth
II.Reassure her that she is able to breast feed her baby after birth
III.Teach the mother how to manipulate her nipple and breast to
ensure she can breast feed effectively
IV.Educate mother to take good care of her health and breast
hygiene
A.I, III and IV
B.II and IV
C.I and IV
D.III only
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50. Question 3
Management of mastitis include :
I.Assessment of mother’s practice of BF
II.Apply warm cloth to the area before a BF
III.Stop BF
IV. Apply antibiotic cream to the affected area
A.All of above
B.I and II
C.III and IV
D.I, II and III
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