Difficulties in Breastfeeding: Indian Academy of Pediatric Guidelines

The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Difficulties in Breastfeeding. The lead author for these guidelines on Difficulties in Breastfeeding is Dr Chandrakala BS along with co-author Dr Dipen V Patel and Dr Febi Francis. The guidelines come Under the Auspices of the IAP Action Plan 2022, and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan PT and Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan.

Nipple protractility is important than shape and size of nipple. If nipple stands prominent when pinched at base, it is a flat nipple. If nipple goes in, then it is a retracted nipple. Flat nipple does not pose any problems, as baby suckles at breast not nipple.

Following are the major recommendations of guidelines:

Breast and Nipple Problems Affecting Breastfeeding:

Postnatal Management:

Antenatal management of flat/retracted nipple is not beneficial; Management starts at delivery; Build mother's confidence that with patience and perseverance, she will succeed ; Help mother to position baby early, trying different positions. Provide skin-to-skin contact. ; Help her to make nipple stand out more; for retracted nipple, use syringing initially (Kesari method). Assure that problem will resolve gradually.

Sore Nipples Causes:

Incorrect positioning and attachment of baby, nipple sucking, frequent use of soap and water on breast, and fungal infection of nipple. Treatment; Continue breastfeeding with correct position and attachment; Expose the nipple to air between feeds and apply hind milk to the nipple after breastfeeding; Counsel mother to avoid frequent washing of breasts; If fungal infection occurs, apply medicine on the nipple and inside the baby's mouth.

Breast Engorgement:

It occurs due to milk accumulation. Breasts are swollen, hard, areola gets overstretched, and milk does not flow well.

Causes: Delayed initiation of breastfeeding, poor attachment to breasts, plenty of milk, infrequent removal of milk, and restriction of length of feeds.

Prevention: Providing supports to breastfeeding soon after delivery to all mothers, ensures good attachment, and encourage unrestricted breastfeeding. Treatment: Apply warm water packs for not >15 minutes.Paracetamol to relieve pain.

Breast Abscess: The mother may have high-grade fever, pain in breast, and overlying skin is warm and red.

Treatment: It includes incision and drainage of abscess, analgesics, and antibiotics. Breastfeeding must be continued from the other breast.

Not Enough Milk: Milk is adequate if baby passes urine at least six times a day and gains weight adequately.

Causes: Not breastfeeding frequently, poor position, poor attachment, too short or hurried breastfeeds, and breast engorgement or mastitis.

Treatment: More frequent feeds, especially at night, proper attachment to breast, care of painful condition, back massage for stimulating lactation, and build mother's confidence.

Breastfeeding in Special Circumstances:

Vaccination: All vaccines given to lactating woman are safe for women and their infants, except for smallpox and yellow fever vaccines.

Medications: Only a small proportion of medications are contraindicated in breastfeeding mothers. The reader should refer to LactMed (available freely at https://www.ncbi.nlm.nih.gov/books/ NBK501922/?report=classic) to obtain the most current data on an individual medication.

Working Mother: She should exclusively breastfeed for 6 months. She may be encouraged to carry the baby to a work place/crèche wherever such facility exists. She can express her milk in clean container which can be stored at room temperature for up to 4–6 hours, in the refrigerator for 4 days and in the freezer for about 6 months. Expressed milk can be given with spoon.

Cesarean Delivery: Start breastfeeding as early as possible and preferably within 1 hour of birth. Help mother to find a comfortable position to breastfeed. She may feed in her supine position (on first day), side-lying position (on second day), or sitting position (day three onwards).

Infant having Cleft Lip and/or Cleft Palate : Each child with this problem needs individual evaluation; Mothers and family should be counseled about likely breastfeeding success; If direct breastfeeding is unlikely then expressed breast milk can be given by cup/spoon; Semi-upright position is recommended to reduce nasal regurgitation and reflux of breast milk into the eustachian tubes.

Hypotonic Infant: Breastfeeding should be initiated as soon as the infant is stable. Encourage skin-to-skin contact, closely monitor latch, position, and suck of the baby ; Consider alternative modes of feeding such as a cup, spoon, or ghokarnam or orogastric feeding if the infant is unable to breastfeed or sustain adequate suckling; Regular follow-up for weight gain.

Contraindications to Breastfeeding: Mother using an illicit drug; Refrain from breastfeed or giving expressed milk if mother is infected with human T-cell lymphotropic virus type I or type II or Ebola virus infection, infants with classic galactosemia, maple syrup urine disease, and phenylketonuria; Temporarily avoid breastfeeding as well as her expressed milk if she is infected with untreated brucellosis and when she is on medications like anticancer or radioactive compounds ; If mother has herpes simplex virus lesions on the breast or having active untreated sputum positive tuberculosis then she should avoid direct breastfeeding, but expressed milk can be given.

Breastfeeding in Preterm and Very Low Birth Weight Neonates:

Mode of feeding should be based on maturity ; First choice of milk is mother's own milk (MoM), followed by pasteurized donor milk or preterm formula; Enteral feeding: Start minimal enteral feeding, preferably within 24 hours of life with 10–20 mL/kg/day. Fortification once reaches 100 mL/kg/day at 1 sachet of 1 g in 25 mL breast milk to improve calorie and protein intake ; Multivitamins: 1 mL/kg/day, calcium (110–220 mg/kg/day), phosphorus (55–110 mg/kg/day), and iron (4 mg/kg/day) ; Monitor the growth of the newborn regularly.

Reference:

Academy of Breastfeeding Medicine (ABM). Protocols. [online] Available from https://www.bfmed.org/ protocols. [Last accessed December, 2021].

Boostani R, Sadeghi R, Sabouri A, Ghabeli-Juibary A. Human T-lymphotropic virus type-1 and breast feeding; systematic review and meta-analysis of the literature. Iran J Neurol. 2018;17(4):174-9. Breastfeeding Promotion Network of India. Management of breast feeding. [online] Available from http://www.bpni.org/docments/Management-of-BreastFeeding.pdf. [Last accessed December, 2021]. Centers for Disease Control and Prevention. Breastfeeding and Special Circumstances. [online] Available from https://www.cdc.gov/breastfeeding/breastfeeding-special-circumstances/index.html. [Last accessed December, 2021].

Spencer J, Abrams SA, Hoppin AG. (2021). Patient education: Common breastfeeding problems (Beyond the Basics). [online] Available from https://www.uptodate.com/contents/common-breastfeedingproblems-beyond-the-basics. [Last accessed December, 2021].

Tiwari S, Bharadva K, Yadav B, Malik S, Gangal P, et al. Infant and young child feeding guidelines, 2016. Indian Pediatr. 2016;53(8):703-13.

The guidelines can be accessed on the official site of IAP :https://iapindia.org/standard-treatment-guidelines/