Dr. Balaji Chinnasami and Dr. Janani Arul, draft quick practice points and treatment guides for 4 cases of issues related to breastfeeding in mother and child.

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Case 1- Breast engorgement

A 6-day-old male child born to a primi mother was brought to the paediatric OPD with a complaint not taking feeds adequately. The mother also complained that the baby is not latching on properly. On examination, there was poor weight gain and he fed 4 to 5 times in a day each lasting for 10 minutes only. The mother complained of fullness of breasts and pain even after feeding the child.

Science behind management

If the feeding is delayed or infrequent/not positioned well at breast (latching), the milk accumulates in the alveoli. Increased milk production → breast becomes swollen, hard, warm and painful known as engorged breast. Common causes → giving prelacteal feeds, delayed initial of breastfeeds, bottle feeding, early removal of baby from breasts.

If congested, engorged breasts are not treated early, it can lead to breast abscess. If breast abscess occurs → treat with analgesics and antibiotics.

Prevention

1. Correct attachment technique

• The baby's mouth should be wide open
• Most of the nipple and areola should be covered, only part of upper areola should be visible
• The baby's chin should touch the breast
• The baby's lower lip should be everted

2. Demand breastfeeding

Treatment

1. Warm fomentation and gentle massage should be advised.
2. Analgesics should be prescribed to relieve pain.
3. The mother should be told to express milk to soften areola- enabling proper attachment.
4. The mother should be advised to continue breastfeeding.
5. In case of breast abscess, the mother should be given oral antibiotics and analgesics.

Indication	Drugs & dosage	Duration
Analgesics	Tab. Paracetamol 500 mg - 0 - 500 mg	SOS
Oral antibiotics (Indicated in case of breast abscess)	Cap. Amoxyclav 625 mg - 0 - 625 mg	10-14 days

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Case 2- Sore nipple

A 21-year-old primi mother, brought her 4-day-old baby with a complaint of difficulty in breastfeeding. She had pain during breastfeeding. On examination, the baby seemed clinically well, sucking well. Maternal breast examination revealed the mother had bilateral sore nipples.

Science behind management

If the baby is not well attached to the breast; if he/she sucks only the nipple, it can lead to sore nipples. If poor attachment continues, sore nipple leads to cracked nipple, and mastitis/breast abscess. Oral thrush in the baby can also lead to sore nipples.

Prevention

• The baby should never be removed from the breast; one should always wait till the baby leaves the breast or insert one finger into the baby’s mouth to release the suction first, so as to avoid injury to the nipple
• Proper attachment and re-positioning of the baby should be followed

Treatment

1. Feeding in the correct position is the best treatment option.
2. Application of hind milk on the nipple can help in healing faster.
3. If the baby has oral thrush, it can lead to maternal fungal infections; in such cases treatment is warranted.

Indication	Drugs & dosage	Duration
Oral thrush (In baby)	Candid mouth paint 0.5 ml (1- 0 – 1)	10-14 days
Maternal fungal infection (Mother)	Tab. Fluconazole 250 mg	10-14 days

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Case 3- Fore milk diarrhoea

A 10-day-old male child was brought with complaint of loose stools over 3 days. He was breastfeeding 10 to 12 times/day for 5 minutes each time. The baby was passing loose stools 6 to 7 times per day. On examination, the baby was sucking vigorously but not having adequate weight gain; he had perianal excoriation.

Science behind management

Fore milk is thin and rich in lactose, whereas hind milk is thick - rich in fat, proteins, fat-soluble vitamins that promote satiety and also ensure body and brain growth. When the mother feeds only dilute, lactose-rich foremilk – it quenches the thirst but does not attribute to weight gain and growth. The high lactose content can cause fermentation and perianal excoriation. “Foremilk syndrome” leads to diarrhoea with perianal excoriation, failure to thrive and colicky abdominal pain.

Prevention

Counsel regarding feeding 8 to 10 times/day, for about 15 to 20 minutes per feed and ensuring emptying of hind milk.

Treatment

1. The mother should be advised to refrain from switching from one breast to another during the same feed.
2. The mother should also be advised to prolong the duration of each feed.
3. No specific treatment is required for this diarrhoea- proper feeding advice should be given.

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Case 4- Inadequate milk secretion

A 10-day-old child was brought with complaint of frequent crying. Baby was sucking well, but the mother felt that she did not have enough milk secretion. On examination- current weight was 3.1 kg (birth weight- 3 kg). In this case, the weight gain is only 10 g/day, which was inadequate.

Science behind management

1. Signs that neonate is getting adequate milk

• Baby sleeps for 2-3 hours post feeds
• Baby has 1-4 episodes of golden yellow, seedy stools
• Baby passes 6-8 times of urine/day
• Baby demands feed once every 3-4 hours

2. Adequate weight gain

• Term baby, should gain 20-30 g/day
• Preterm baby should gain 15-20 g/day

3. The weight gain starts after a permissible weight loss of less than 10% for the first 10 to 14 days of life

Treatment

1. Breastfeeding advice is the most important treatment.
2. If there is inadequate weight gain, and the mother has decreased milk secretion, advising increased intake of liquids and proper diet can increase milk secretion in the mother.
3. Tab. Lactare (1-1-1) can be given to the mother if she is not responding to diet modifications.
4. In cases of weight loss up to 10%, and lack of response to the above treatment, formula feed can be added to prevent dehydration.
5. When weight loss is more than 10%, NICU admission is warranted to prevent complications associated with dehydration.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

Dr. Balaji Chinnasami is a Professor of Paediatrics and Medicine at a reputed medical college in Chennai.

Dr. Janani Arul is an Assistant Professor of Paediatrics from Chennai.