BE 03 Flashcards
(138 cards)
1
Q
In order to properly BF w/ good latch, mother must be competent in which two things?
A
Positioning
Understanding baby’s “feed me” cues
2
Q
BREAST ANATOMY:
What is the BF function of the normal, pendulous form of the lactating breast?
A
Facilitates positioning of baby in arms, easy latching of infant cradled beneath breast.
3
Q
BREAST ANATOMY:
What is the BF function of the secretions of the Montgomery follicles on areola?
A
Guide baby to breast and stimulate suckling behavior
4
Q
BREAST ANATOMY:
What is the BF function of the darker skin color of nipple and areola during pregnancy (in some women)?
A
May act as a visual guide for baby
5
Q
BREAST ANATOMY:
What is the BF function of using a wide gap and deep latch by baby?
A
Infant will form teat from nipple & much of areola, which reaches back of mouth. Flexible and elastic breast tissue facilitates optimal, comfortable lengthening of breast & nipple to facilitate this.
6
Q
BREAST ANATOMY:
What is the BF function of the thinner layer of subcutaneous fat around areola?
A
Permits suckling to more easily stimulate 4th intercostal nerve, initiating milk ejection. Meanwhile, the easily compressible ducts can respond to the positive and negative pressures exerted during suckling.
7
Q
BREAST ANATOMY:
What is the BF function of milk ducts branching close to base of nipple and temporarily increasing in diameter?
A
To accommodate increase in milk volume at milk ejection.
8
Q
See BE03 p. 4
A
Anatomy of the lactating breast
9
Q
Infant skull is composed of which 3 components?
How many bones total?
A
Cranium
Facial Skeleton
Mandible (bottom jaw)
22 bones total.
10
Q
See BE03 p. 6
A
The bones of the infant cranium
11
Q
BONES OF INFANT CRANIUM: What is the function of the sutures and fontanelles in infant skull?
A
Allow movement and overlapping of bones during passage through birth canal.
12
Q
BONES OF INFANT CRANIUM: List.
A
2 frontal bones (fuse after birth) - joined by frontal suture
2 parietal bones - joined to frontal bones by coronal suture, joined to each other at sagittal suture.
2 temporals
occipital bone
ethmoid bone & sphenoid bone
13
Q
INFANT FACIAL BONES: Maxillae
- size
- areas of skull it forms (5)
A
Largest bone of face
Forms upper jaw, hard palate, floor of nose, part of orbits (eye sockets), tooth sockets for upper teeth
14
Q
INFANT FACIAL BONES: Palatine and nasal bones form….
A
Form hard plate and nose
15
Q
INFANT FACIAL BONES: inferior nasal conchae and lacrimal bones
A
Remember this.
16
Q
INFANT FACIAL BONES: zygomatic bones form….
A
form cheek promonences
17
Q
INFANT FACIAL BONES: the vomer does…
A
separates nasal cavity into left and right sides.
18
Q
INFANT FACIAL BONES: Describe location of mandible
A
hinged to temporal bones at temporo-mandibular joints
19
Q
INFANT FACIAL BONES: Describe function and location of hyoid bone. Discuss cartilage vs bone of hyoid. Why is hyoid so important in BF?
A
Hyoid cartilage provides attachment to tongue above, larynx below, epiglottis and pharynx behind.
Located in neck at level of base of mandible and above thyroid cartilage.
Develops from cartilage to bone during childhood.
Important in BF because extension of head will slide hyoid and tongue forward, while flexion of head will slide the backward.
20
Q
As a result of moulding (movement and overriding of the cranial bones at sutures and fontanelles) during birth & in utero, how can the bones be moved back into position after birth? Why is this important to BF?
A
By yawning, sucking and crying. Importatnt because the cranial nerves involved in BF (6/12) follow the sutures.
21
Q
How many cranial nerves?
How many of these involved in infant feeding?
A
12 total
6 BF
22
Q
Where do the cranial nerves originate, how do they reach their destination?
A
Originate in brainstem; exit through base of brain; follow sutures.
23
Q
What is the general function of the cranial nerves?
A
Involved in coordination of suckling, swallowing and breathing. They provide motor and sensory functions.
24
Q
CRANIAL NERVES: CN V: Trigeminal
- motor/sensory
- what does it supply
- how does it transmit function
- mandibular branches
A
- motor & sensory
- supplies eyes, mandible, maxilla
- maxilla carries sensory impulses fr mucous membrane of nose, skin of cheek, side of forehead, upper lip and teeth
- mandibular branches: sensory impulses fr side of head, chin, mucous membranes of mouth, lower teeth & anterior 2/3 of tongue
25
CRANIAL NERVES: CN VII: Facial
- motor/sensory
- what does it supply
- how does it transmit function
- irritation of this nerve can cause....
- motor & sensory
- motor fibers supply muscles of facial expression
- sensory fibers convey impulses fr taste buds of anterior 2/3 of tongue, also supply submaxillary, sublingual and lacrimal glands for secretion
- irritation can produce Bell's Palsy (a type of paralysis). Paralysis is unilateral, resulting in distortion of facial expression, inability to close mouth on one side, and difficulty closing eye on affected side.
26
CRANIAL NERVES: CN IX: Glosopharyngeal
- motor/sensory
- what does it do
- motor: stimulates muscles of pharynx, soft palate, posterior 1/3 of tongue; responsible for swallowing reflex
- sensory: conveys sense of taste fr posterior 1/3 of tongue
27
CRANIAL NERVES: CN X: Vagus
- motor/sensory
- what does it supply
- how does it transmit function
- Extensive distribution to neck and down to thorax & abdomen
- Motor fibers: supply pharynx, larynx, trachea, esophagus, stomach, etc. Involved in swallowing, peristalsis and secretions from glands of stomach and pancreas and ultimately speech
- Sensory fibers: Provide input fr mucous membranes of larynx, trachea, esophagus, stomach - functions include coughing, sneezing, hunger
28
CRANIAL NERVES: CN XI: Spinal Accessory
- motor/sensory
- what does it supply
- how does it transmit function
- Motor fibers: control trapezius & sternoleidomastoid muscles (involved in stabilizing head and maintaining airway patency, and raising shoulders)
29
CRANIAL NERVES: CN XII: Hypoglossal
- motor/sensory
- what does it supply
- how does it transmit function
- motor fibers only
| - supply muscles of tongue and muscles surrounding hyoid bone; responsible for mvmt of tongue
30
What 5 muscles are involved in feeding?
- orbicularis oris (forms lips)
- mentalis (muscle of chin; lifts lower lip)
- buccinator (cheek muscle)
- masseter (one of muscles of mastication, closes jaw)
- temporalis (another muscle of mastication, elevates mandible)
31
The tongue:
| - what muscles involved & their function
- Genioglossus - main muscle, pulling tongue down and out
| - Palatoglossus, longitudinal, transverse and vertical muscles create mvmts of grooving, elevation, and lateralization.
32
See BE03 p. 9
Can't blow up images of tongue anatomy - find online. Note source.
33
One study found that XX% of women with BF issues had incorrect ____ & _____
94% had incorrect positioning and latch
34
Describe components of oral cavity of infant
- small
- tongue fills entire oral cavity at rest
- taste buds primarily on tip of tongue; increased suckling occurs in response to sweet stimuli
- lingual frenulum is fold of mucous membrane extending from floor of mouth to midline of under surface of tongue
- lower jaw (mandible) is small and slightly receding
- cheeks defined by buccinator and masseter muscles; buccal fat pads in cheeks help provide lateral stability for suckling pattern
- labial frenum is membrane attaching upper lip to gum ridge
- lips include orbicularis oris muscle
- roof of mouth formed anteriorly by boney hard palate, and poseteriorly by mobile soft palate.
35
Describe changes in oral cavity by 6-8 months of age.
- enlarges
- buccal fat pads resorb, creating cavity for mastication
- in infant, larynx sits high in neck @ C1-C3 vertebrae - functionally separates respiratory and digestive tracts. This allows infant to breathe and suckle safely. By 2-3 years, larynx descends, with common channel in oral portion of pharynx for respiration and swallowing.
36
Role of hard and soft palate
- rugae
- hard palate
- soft palate
- rugae of hard palate assist w positioning and stability of teat
- hard palate provides resistance against which tongue compresses teat
- stimulation of hard palate necessary to elicit sucking reflex
- soft palate joins hard palate to appx. epiglottis until it descends at 3-4 mos. (This, plus size of tongue in oral cavity, is why infants are mostly nose-breathers.)
- muscles of soft palate cause it to elevate during swallow, closing nasal cavity and allowing milk to enter oro-pharynx
- hard & soft palate combined separate oral fr nasal cavity, allowing sealed compartment and creation of negative pressure during suckling.
37
What tools can be used to teach proper latch technique
- flexible doll (for you and, if mother still pregnant, for her too)
- otherwise, mom holds her own baby
38
Teaching tools to demonstrate to mom how it feels when infant is in various positions:
- positioning of head (water)
- latch depth (suck thumb)
- photo
- have mom swallow water when head turned to side, or w/ chin to chest. Helps understand why baby's head needs to be in line with body or slightly extended.
- Have mom suck her thumb, put it midway, then back of mouth and such - compare effort required in each position. Remember: proper latch prevents nipple damage
- have photo of well-latched baby to show mom how wide and deep latch is, and a baby who is poorly latched (discuss differences)
39
Mother can optimize success of BF by (6/10 steps)
- cuddling skin to skin after birth for 2+ hours (& as often as possible when baby is imprinting)
- give priority to BF & establishing milk supply; baby bathing and visitors not important
- delay first bath for a few days.
- room in 24 hrs/day
- avoid having visitors handle baby - limit handling by other family members
- create quiet, calm atmosphere in room
40
What does skin to skin (SSC) contact do?
- triggers babys innate response (pre-programmed neurobehavior) which guides him to provide for own needs, eg seeking breast
- prone position of baby on mom's chest ensures positional stability, allowing baby to use arms to lift upper body and extend neck, before placing chin on breast prior to latching.
- allows for sensory stimulation of smell, touch, warmth - cause oxytocin surges in mom which heats chest skin temp, triggers nipple erection and decreases maternal anxiety.
41
Effects of SSC on baby (list of 7)
- thermoregulation
- optimal oxygenation; stabilizes heart rate
- lowers serum cortisol
- reduced crying
- stabilizes blood glucose
- stimulates self-latching
- stimulates coordinated suckling
42
Effects of SSC on mom (list of 7)
- temp regulation
- increased oxytocin
- adequate milk volume
- stimulates right brain intuition
- promotes bonding
- fewer BF problems
- heightens confidence
43
What is the "sensitive period"
The period of transition from in-utero to adaptation to life outside uterus
44
What system triggers pre-programmed sequences of reflexes of baby in mom's presence?
Limbic system
45
SSC should be considered at times of BF difficulty, including (5)...
- difficulty latching, or not latching
- low milk supply
- breast refusal
- relactation
- induced lactation
46
List 6 states of arousal
- sleep
- drowsy
- quiet alert
- active alert
- fussy
- crying
47
After an unmedicated birth, a health newborn in the first 90 minutes, will transition between ____ and ____ states - perfect to BF!
From quiet and active alert states
48
Which state of arousal is the best time to learn and process sensory information?
Quiet alert state
49
When is the best time to feed infant?
When he first exhibits cues that he is ready to feed - do not wait for hunger!
50
Why to respond to early feeding cues and not wait for hunger.
If early cues ignored, infant's behavior will become more agitated until crying, making latching difficult. If feed is further delayed, infant may tire quickly and feed poorly.
51
List early feeding cues (5)
- subtle body mvmts, wiggling
- hand-to-mouth movements with or without sucking on hand
- mouthing and non-nutritive sucking - infant moves mouth in searching or sucking manner
- rooting when face touched
- pecking, head bobbing or thrusting when in arms of mother
52
Facilitating feeding: What 2 sensory inputs stimulate feeding?
1. Firm contact against mom's body - allows to orient and focus.
2. If needed a drop of milk can be expressed and wiped on mom's nipple & areola.
53
Facilitating feeding: What 3 positional aspects stimulate feeding?
*Baby needs EXTERNALLY CONTROLLED positional stability to control head movements.
* Babies more calm when chest and tummy touching/supported (no startle reflex in this position).
1. Stable base - provided for head by shoulder girdle.
2. Proximal stability - head & neck in alignment & supported.
3. Midline symmetry - optimal function in neck, head and mouth depends on equal muscle mvmts on both sides of body.
54
What two inputs are necessary for baby to assume the "instinctive position" to feed?
- sensory input
| - positional stability
55
Describe the "instinctive position" for a feed.
Baby tilts head back and leads with jaw and mouth to breast where mouth opens wide, tongue down and over bottom gum line, ready to take breast into mouth.
56
What does a proper latch from the "instinctive position" look like?
- a lot of areola/breast tissue beneath nipple taken into mouth, followed by nipple
- neck slightly extended, chin indenting breast
- nose free to breathe
- oro-pharynx wide open to allow unhindered swallowing
57
Describe the biological nurturing position and why it is important.
Mom semi-reclines with baby prone in close frontal contact w body.
This position promotes highest release of primitive neonatal reflexes (PNR) for pre-feeding response.
58
Positioning: While Sitting
| describe position
- semi-recline in chair with feet up on a stool or something (reduce lower back strain)
- baby's head at height of natural fall of breast (beware of pillows lifting baby higher)
- snuggle baby to chest, under breasts with baby's chest in contact with lower, inside portion of breast [sensory impact]
- mother supports baby across back, between shoulders, usually with palm of hand [stable base]
- mom's wrist or forearm supports baby's head and neck using arm on same side as breast suckled (ie cradle hold); or cup formed between thumb and forefinger supports neck (cross cradle hold) [proximal stability]
- baby's head, neck, spine aligned (ie head not flex forward not twists in spine at neck or waist); one arm on either side of breast [midline symmetry]
59
Positioning: Cradle Hold & Cross-Cradle Hold
| How positioned?
Cradle: Semi-reclined, baby across chest and supported with arm on same side feeding.
Cross-cradle: Same, but baby held using opposite arm.
60
Twin or Football hold
| What types of women prefer this option?
Baby held under arm. Good for women w very large breasts.
61
Positioning: While side-lying
| Describe position
- mom lying on side w lower arm tucked under head or pillow (safer co-sleeping position)
- lay baby on bed, on side with upper shoulder facing mom [proximal stability]
- baby's lower arm cradles breast from underneath, upper arm free to move [midline symmetry]
- baby's chest and upper shoulder tuck under mom's upper (unused) breast [sensory input]
- mom supports baby across back between shoulders with free upper hand [stable base]
62
Positioning: side-lying - benefits
- mom can rest/sleep during feed
- avoid sitting on painful perineum post delivery
- avoid weight of baby on c-section wound
63
What to NEVER to in providing proximal stability.
NEVER hold back of baby's head at any time during positioning, latching and feeding
64
What 7 checks to make for proper positioning?
1. Is there adequate sensory input (chest to chest, baby held in firmly)
2. Is there a stable base (support across back between shoulder blades)
3. Is there proximal stability (neck & head supported but NOT held)
4. Is there midline symmetry (neck and head aligned w spine; one arm on either side of breast)
5. Is chin firmly applied to breast, nose free to breathe
6. Is mom relaxed and well-supported
7. Is mom's baby-supporting arm held comfortably, with relaxed wrist and fingers
65
Which cranial nerves provide the innervation for the rooting reflex? (4)
CN V
CN VII
CN XI
CN XII
66
How is rooting reflex elicited?
By touch to cheek or near mouth
67
Why is the rooting reflex so called?
Because it triggers:
- turning toward stimulation
- opening mouth (gape)
- protrusion of and dropping of tongue ready to grasp breast
68
Which cranial nerves provide the innervation for the sucking reflex? (4)
CN V
CN VII
CN IX
CN XII
69
How is the sucking reflex elicited?
What happens when adequate teat is formed?
What about an inadequate teat?
tactile or chemical stimuli on hard palate
When an adequate teat has been formed, pressure will be exerted on palate by upper surface of teat eliciting this reflex.
When inadequate teat formed, can be seen as adaptive function - eg when baby unable to form teat d/t insufficient breast tissue in mouth,, won't suck and therefore avoids nipple damage
70
What are the characteristics of a well-latched baby (5) (Positioning and interaction with breast)
- Nipple and much of areola and underlying breast structures drawn into mouth to form teat
- Tip of teat (nipple) reaches within 3-5 mm of junction of hard and soft palate (at back of mouth)
- Tip of tongue protrudes past bottom gum line
- Lateral edges of tongue form a trough-like shape, cupping breast
- Mouth will be wide open with both lips relaxed on breast and flanged outwards. Angle at corer of mouth should be at least 140 degrees.
71
Mother may need to shape breast slightly to ensure proper latch. If needed, describe technique options
- base of nipple position
- "sandwich" areola position
- Base: put pressure near base of nipple, at point where nose is pointing, causes nipple to tilt toward nose. As bottom lip firmly plants at edge of areola, the finger that is causing the tilting can then roll the nipple so it just brushes under, or folds under baby's top lip.
- Sandwich: One finger placed on either side of areola to "sandwich" breast and tile nipple to touch the top lip and offer underside of areola to baby's bottom lip.
72
Mom provides the POSITIVE PRESSURE in BF - how?
Milk ejection
73
Baby provides the NEGATIVE PRESSURE in BF - how?
Negative pressure in baby's mouth draws breast into position and maintains. Baby removes available milk when jaw and posterior tongue lowered creating further negative pressure in mouth, opening milk ducts and drawing milk into mouth. Baby's gums compress milk ducts and create slight positive pressure.
74
Where is the majority of milk stored in mammary gland?
Alveoli
75
Describe the process for initiation of the milk ejection reflex (MER) (6 steps)
MER initiated:
- physically by stimulation of nipple & areola (supplied by lower branches of 4th intercostal nerve)
- nerve impulse travels to hypothalamus
- this causes posterior pituitary gland to release oxytocin into blood stream
- oxytocin travels via bloodstream to both breasts (recall that oxytocin receptors found on myoepithelial cells)
- in response to oxytocin, myoepithelial cells surrounding alveoli contract, squeezing the alveoli, and
- forces milk into ductal system toward nipple
76
What happens to milk not removed by infant or by expressing?
Moves back up ductal system to alveoli once more.
77
What factors stimulate oxytocin (5)
- hearing a baby cry
- thinking about baby
- seeing photo of baby
- prep to feed
- being usual time baby feeds
78
What factors inhibit oxytocin (4)
- pain
- embarrassment
- anxiety
- fear
79
Ways to assist mom with MER (8)
- repeat same pre-feeding/pumping activities and even thoughts each time
- sit in same chair
- look at photo of baby
- think positive thoughts about baby
- visualize milk flows, rivers, waterfalls
- listen to recording of same relaxing music
- gently massage or stimulate nipples
- ensure privacy, empathetic support, and good pain relief if necessary for all mothers.
80
How many mothers experience sensation with first MER?
| How about subsequent MER's?
First: 79%
Subsequent: rarely feel
81
How MER might be described (3)
- sharp momentary pain in breast
- fullness or tightness in breasts
- tingling sensation in breast
82
Sx associated with oxytocin release (other than MER) (2)
- involution pain (postnatal uterine contraction)
| - thirst
83
Signs MER has occurred include (3)
- drips or squirts of milk fr breast
- change in suckling pattern to nutritive
- gulping as swallows larger volume of milk transferred
84
Define sucking vs suckling
Sucking - mechanical action within oral cavity to transfer fluid or provide comfort
Suckling - normal action of suck that occurs while at breast
85
Describe order in which newborn's reflexes mature (sucking, reflexes, coordination, etc) (5)
- 15-24 weeks gestation in-utero: sucking demonstrated
- 26 weeks +: lingual and gastric lipases present
- 26-27 weeks: gag reflex present
- 28 weeks: rooting reflex present
- 28-37 weeks gestation: Coordinated and effective suck/swallow/breathe for nutritive purposes
86
Describe the 4 steps of the "suck cycle"
- Lower jaw opens, posterior tongue and soft palate descend, touching each other and creating maximum intra-oral vacuum
- At this point, milk xfer to baby, assuming MER has been elicited
- Jaw closes, posterior tongue and soft palate rise, intra-oral vacuum is decreased, and the milk bolus prepared for swallow
- milk xfer is momentarily paused awaiting next cycle
87
Describe teat/infant oral positioning during such cycle.
Tip of teat reaches w/in 5 mm of junction of hard/soft palate.
Nipple position varies by appx 1 mm during suckling.
Anterior tongue remains mainly flat during suck/swallow.
88
Types of sucking: Stimulation
- when used
- describe (4)
Stimulation is initial suck pattern used.
Describe:
-appears as short, fast sucks of up to 2 per second
- seen when infant first latches, prior to MER
- milk ejection usually stimulated within a minute
- intra-oral vacuum greater during this pattern than nutritive sucking
89
Types of sucking: Nutritive (AKA Expression)
- when used
- describe (4)
Used to obtain nutrition in presence of fluid.
Description:
- During MER when milk flow is high, sucking bursts will be long with infrequent pauses
- rate is about 1 per second
- during MER, sucks appear continuously, followed by immediate swallow
- as milk avail diminishes through feed, sucking bursts become shorter and pauses become longer
90
Types of sucking: Non-nutritive
| - describe
Spontaneous sucking in absence of anything being introduced into mouth, or sucking on something that will not produce liquid nourishment.
91
Describe process of the swallow (4)
- milk moved fr nipple, held momentarily by posterior tongue
- then passes under soft palate
- posterior tongue lifts, helping milk bolus move into oro-pharynx
- epiglottis closes to protect airway and milk may be safely moved into esophagus to complete swallow.
92
Describe baby's breathing during the swallow.
Infant CAN NOT breathe during swallow. Breathes in during suck, and in or out during pauses between sucking bursts.
93
Possible causes of poor latch (11)
- Mom not supporting baby
- Baby's neck not extended
- Baby's mouth isn't wide open to "deep" latch
- Baby's bottom lip did not contact breast first or contact point moved after contact
- Baby's nose is obstructed by breast tissue
- Baby's lips are turned under instead of flanged outwards - mom may not be able to see this
- Cheeks are sucked in or dimpled when suckling
- Mom experiences pain throughout feed
- Baby comes off breast easily, or frequently
- Baby does a few sucks then just waits (not always poor latch, but often)
- Nipple is compressed or otherwise misshapen as observed immediately after baby detatches
94
Results of poor latch for mom (5)
- pain while feeding (not always!)
- damaged nipples (not always!)
- ineffective breast damage
- reduction in milk supply
- early weaning
95
Results of poor latch for baby (5)
- inefficient milk transfer - ALWAYS!
- tires quickly or may feed adequately only during MER
- failure to thrive; due to inefficient milk transfer and poor intake (may take few weeks, with baby doing well initially w milk from overabundant supply that accompanies secretory activation)
- poor sucking habits which may be difficult to correct
- premature weaning
96
Possible causes of poor/uncoordinated suck in a well, full-term infant (10)
- poor latch
- maternal drugs
- separation from mom- absence of skin to skin contact
- birth trauma
- oral insult, esp before BF established
- suck confusion
- oral infection
- infant's state (eg agitated)
- anything which interferes with baby's innate reflexes to latch and suckle (eg swaddling)
- Abnormalities of face, mouth of pharynx (see later cards)
- dysfunction in infant's musculature, or cranial or peripheral nervous system affecting suck (eg Down's, muscular dystrophy)
97
Abnormalities of face, mouth or pharynx: High arched palate or "bubble palate" - describe how this could happen
Baby could b thumb-sucking in utero or just hold tongue in high palate, or push breast up into high cavity rather than allowing normal position between hard and soft palate.
Could also result from abnormality of tongue since tongue helps shape palate in utero.
98
Abnormalities of face, mouth or pharynx: Ankyloglossia (tongue tie) - describe resulting problems
Prob: If baby cannot extend tip of tongue beyond bottom gum margin, will decrease efficiency of milk xfer and prob cause trauma to breast as he sucks.
99
Abnormalities of face, mouth or pharynx: Micrognathia (small, receding chin) - describe how to ID & resulting effect
Observed: when mouth is closed, mandible will tuck back and up under maxillae, sometimes noticeable gap is present.
Effect: affects link and forward mvmt of tongue - baby may find it hard to grasp breast and maintain fleshy teat in mouth, so pay careful attn to ensuring chin is well-anchored to breast
100
Breast Anatomy Abnormalities: Inverted Nipples
- How to ID
- Possible treatments
ID: Palpate nipple w thumb and forefinger - compress just behind base of nipple. Nipples which are severely inverted will retract and a thick core is felt under finger tips.
Tx: Everting device in late weeks of pregnancy to stretch. Nipple shield is an option, after secretory activation (colostrum does not transfer properly with nipple shield).
101
Change in nipple protractility during initial and subsequent pregnancies?
Generally increase in protractility with each pregnancy and lactation.
102
What are 2 likely causes of inhibited MER?
- surgical trauma to branches of 4th intercostal nerve, which innervates nipple & areola (eg during breast reduction or other surgery using peri-areolar incisions)
- psychological inhibition (eg anxiety, pain, embarrassment)
103
Tx options for inhibited MER (5)
- hold baby in SSC for 20+ mins before baby wants to feed
- discuss and try to alleviate psychological barriers
- 'conditioning' of reflex incorporating relaxation techniques
- some women have successfully used oxytocin nasal spray
- if only one side affected by surgery, stimulating MER on other side will cause it to function on both sides
104
3 possible factors affecting milk xfer
- insufficient milk production
- severe engorgement - milk ducts become compressed and milk flow inhibited. Baby also has difficulty achieving good latch.
- surgical trauma to lactiferous ducts, as will occur in reduction mammoplasty, etc.
105
Discuss legal informed consent requirements as they relate to consultations.
Before commencing assessment seek mother's permission. Must get informed consent before any assessment or intervention, and prior to reporting relevant info to primary care provider.
106
Wolf and Glass' 5-step consultation process: Step 1
GATHER INFO AND PLAN FOR VISIT
- review pertinent info prior to interviewing mom & infant, incl. review of charts, phone notes, referrals, etc.
- planning includes assembling items and equip expected to be use during assess, eg comfy chair for mom or infant scale
107
Wolf and Glass' 5-step consultation process: Step 2
FEEDING OBSERVATION
1. General: psych stats of and general interaction between mom & infant
2. Naturalistic: observ of portion of portion of sal BF interchange, without any assessor intervention
3. Elicited: observ of outcome of assessor-suggested modification of aspects of feeding (eg changes to position, attachment, etc)
108
Wolf and Glass' 5-step consultation process: Step 3
EXPLORATION OF STRATEGIES FOR IMPROVEMENT
- develop hypotheses for improving feeding interaction based on hx and observed phenomena
- discuss with mom hypotheses generated, incl pros and cons of various methods for improving feeding outcome
- testing of agreed strategies
109
Wolf and Glass' 5-step consultation process: Step 4
SYNTHESIS OF A PLAN
All observed data, hypotheses,, strategies are synthesized into action plan for feeding mgmt, agreed upon between assessor and mother
110
Wolf and Glass' 5-step consultation process: Step 5
COMMUNICATION OF RESULTS
- reiterate findings & action plan for mom *be aware of language using - don't blame!
- review plans with mother to be sure they are agreeable and achievable to all parties *could have mom write down in own words the important points and actions used to achieve successful latch
- document outcomes of assess & eval
- communicate findings to key healthcare providers (according to moms consent). Clearly ID and refer items needing further medical eval.
111
Step 1: Observation & Assess: Gather Info
| - list 4 component parts
- take complete hx (medical, personal, pregnancy, labor, birth, BF)
- breast exam
- baby assess
- observ of BF
112
Step 1: Observation & Assess: Feeding Observation: General Observation
- list 3 component parts (describe = later cards)
- breast exam
- global assess of baby
- oral assess of baby
113
Step 1: Observation & Assess: Feeding Observation: General Observation: Breast Exam
- describe complete assess
Assess breast for...
- size, shape
- nipple variation - normal? large, inverted, flat? infection/damage?
- palpation of breast for appropriate stage of lactation (ie degree of fullness, presence of lumps)
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Step 1: Observation & Assess: Feeding Observation: General Observation: Global assess of baby
- describe complete assess
*Some can be done while infant in mom's arms & during hx taking. Otherwise use exam table or a pillow on your lap.
Assess....
- general muscle tone: facial and body mvmts should be symmetrical & smooth
- color & respiration: observe healthy skin color, pink mucous membranes and moist lips. respirations should not be labored or audible.
- degree of nourishment: body fat stores present in face, abdomen, arms and legs
- physical symmetry: head, neck and shoulder symmetry
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Step 1: Observation & Assess: Feeding Observation: General Observation: Oral Assess of Baby
- describe complete assess
* Baby on exam table or lap. Use clean, gloved finger to assess:
- rooting and gape response: stroke baby's face and see response. Check for symmetrical facial mvmts. Elicit gape response by stroking down midline of face, watching for gape & tongue mvmt forward to extend past bottom gum to lick finger. Observe tongue forming long trough down middle to curl up laterally.
- lips moist, pink mucous membranes. Check for infections, ulcers, and observe labial frenulum adhesion point.
- Mouth size of oral cavity: stretch cheeks slightly to observe cheek pads for oral infection; note lower jaw position closed under maxilla; check under tongue for tight/short frenulum (tongue tie); are there teeth?
- tilt baby's head back and visualize palate - should be evenly sloped & about as wide as avg nipple. Be aware of high palates, rounded only in anterior position or very narrow. Possible to see undetected cleft.
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Step 1: Observation & Assess: Feeding Observation: Natralistic Observation
- describe complete assess
- Prep: Have mom BF usual way - no intervention, positioning and support the same. Ask her to share current knowledge and talk about technique as she assists baby to latch.
- Observe: Listen to how mom talks to baby, noises baby makes. Observe baby's reflexes and how mom responds to them. How comfortable is mom in position? Where is baby's body in relation to mom's? Is latch correct - position, indent, gape, nipple resting on top lip before going in mouth, deep latch?
- Progression of BF: see next card
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Step 1: Observation & Assess: Feeding Observation: Natralistic Observation
- describe complete assess
CONTINUED
- describe progression of the BF
- Observe sucking patterns - stimulation to nutritive, w/ audible swallows? Stay in stimulation pattern, or lapse quickly into non-nutritive and fall asleep?
- Note jaw mvmts. Lower jaw should make "deep" mvmts, visible up to temporo-mandibular joint
- How long was nutritive pattern sustained (w only brief resting pauses)? Normally, after period of nutritive suckling the pauses will be come longer w occasional smaller jaw mvmts and fewer swallows will occur. Cycle may be repeated during BF w/ milk ejections
- As mom how it feels. Should be pain free, with exception of maybe 'nipple stretch pain' in very beginning - occurs as nipple and areola form into teat.
- How is feed completed? Baby should fall asleep (sated) at breast, or come off contented or wanting more milk from other breast.
- Note appearance of nipple at moment of release from baby's mouth. Should look almost same as when left baby's mouth. No ridges or 'squashed' appearance or white lines across it.
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Step 1: Observation & Assess: Feeding Observation: Elicited observation
- describe complete process of making adjustments
- describe your observations to mom
- adjustents to hers/baby's positions & re-education about correct latch can be offered immediately so BF can proceed w improvement
- further observation of BF may indicate further investigation or implementation of specific plan
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Optimal BF is NOT defined by (4)
- one breast or two during BF session
- how much time passes until infant has next feeding cue
- whether infant sleeps through night, or time between feeds. Sleepy infants usually a warning sign, not a sign of satisfaction.
- whether or not infant is "good". May not have sufficient energy to draw mom's attention if not crying, etc.
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See p. 56/68 of BE03 for table
Compares BF Assess Tools
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Which, if any, of the three tools evaluated (LATCH, MBA, IBFAT) should be used clinically?
None are sufficient for use.
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Print and use...
BE 03, p. 57 - BF Observation Aid
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Didn't make cards for Observational Tools
Use pages 57-68 of BE03, and print all out
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IBCLC must be sure these 4 things are happening with mom/baby at all times.
1. Feed baby - ensure adequate nutritional intake - could mean alt feeding methods temporarily if BF not successful
2. Ensure adequate/abundant milk supply
3. Ensure today's plan doesn't make tomorrow more difficult (avoid quick fixes)
4. Keep BF attempts calm and reinforce positive experience for mom & baby
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Possible causes of lack of rooting reflex and/or inadequate gape (8)
- prematurity
- birth trauma/asphyxia
- sick infant
- temp CNS depression from intrapartum medications
- short/tight frenulum
- holding back of baby's head to force latch
- baby's cues are absent or being missed, body not touching mom, no positional stability, nipple not @ top lip, baby not given enough time to lick
- confused baby from overstimulation of face
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Management options for lack of rooting reflex and/or inadequate gape (8)
- medical review and tx of condition as necessary
- prolonged SSC with mom
- encourage biological nurturing positions to stimulate primitive neonatal reflexes (PNR) as BF stimulants
- mom to lie in bed next to baby as he sleeps and place nipple at top lip, ready to trigger innate root response
- drip drops of expressed milk on baby's top lip while nipple is ready
- maintain nutritional status via means other than sucking
- multi-disciplinary approach and therapy as necessary
- time for recover, maturation, re-learning
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Management options for shallow latch +/- ridged/damaged nipples (5)
- instruct mom how to position baby and breast correctly
- instruct mom how to elicit rooting reflex for good gape, and encourage patience
- gentle encouragement
- gentle massage to posterior tongue, allow finger to be sucked back to correct place on palate, using breastmilk reward
- treat tongue-tie or oral thrush present
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Possible causes of gape w/o progression to latch and/or suckling (6)
- overly full or edematous breast
- nipple doesn't stimulate hard palate, therefore suck reflex (eg inverted or flat nipple)
- restrictive frenulum, tongue unable to come forward to feel breast and grasp (eg absence of cue)
- tongue up, blocking infant oral cavity
- oral hypersensitivity from aggressive suctioning
- previous sucking on bottle teat or pacifier
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Possible management options of gape w/o progression to latch and/or suckling (4)
- treat and soften breast approproately
- tease nipple out; +/- "nipple puller"; position infant in sitting position to use gravity to assist in grabbing more breast tissue; 'shape up' breast tissue and hold until sucking well established; may benefit from nipple shield, but only after good milk flow evident
- facial stimulation exercise prior to attempted BF - slowly stroke midline of face iwth emphasis on bottom lip to encourage tongue to come forward and grasp finger
- eliminate all forms of non-nutritive sucking until BF well established
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Possible causes for difficulty maintaining suction - coming off breast frequently/easily (3)
- poor positioning, esp. head turned toward shoulder, or nose blocked by breast tissue d/t flexed neck or baby's head higher than natural breast level
- weak muscle tone - non-congenital causes/underdeveloped
- unusual palate shape, ankyloglossia (tongue tie), small or receding jaw
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Possible management options for difficulty maintaining suction - coming off breast frequently/easily (4)
- instruct proper positioning techniques, esp. adequate neck extension to provide jaw indent into breast and tongue stability
- fill baby's mouth with breast tissue and assist with breast support and compressions during feed
- medical review and tx; frenulotomy for ankyloglossia
- upright (sitting) feeding positions may help; good for cleft problems
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Name the two anchor points for the lingual frenulum
floor of mouth & under tongue
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What two conditions must be met for frenulum to allow full range of mvmt of tongue?
Frenulum must be THIN and MOBILE
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Short/tight frenulums may cause the following BF concerns (6)
- inability to grasp breast
- sore/damaged nipples - often a compression line
- reduced milk transfer
- uncoordinated suck
- tired baby
- undernourished baby
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Possible management options for short/tight frenulum (2)
- frenotomy by trained health professionals...mom encouraged to BF immediately after
- young baby will adapt to the extra tongue mobility quickly. Older baby may need tongue exercises to help focus tongue mvmts
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Provide description and management option(s) for the following 3 non-productive suckling patterns (one per slide):
CHEEKS SUCKED IN
Descr: insufficient breast tissue in mouth
Mgmt: Instruct re: positioning and deep latch
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Provide description and management option(s) for the following 3 non-productive suckling patterns (one per slide):
SHALLOW SUCKS (small jaw mvmts)
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Descr: insufficient breast tissue in mouth; oversupply of BM or forceful MER; inadequate milk xfer; tongue-tie
Mgmt: instruct re: position and deep latch; mgmt of oversupply and MER, incl. sitting position to help until cause treated; ensure adequate milk supply; frenotomy and possible re-training exercises
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Provide description and management option(s) for the following 3 non-productive suckling patterns (one per slide):
ROCKER MOTION OF JAW (lg mvmt of jaw, indenting breast, but minimal audible swallowing of milk)
Descr: poor muscle tone; prematurity; malnourished
Mgmt: breast compression technique; carefully assess for adequate intake - may require test weight using precise, sensitive digital scales; commence supplemental feeding line
