References For The Clinician - S Breastfeeding Triage Tool PDF

References for the Clinician's Breastfeeding Triage Tool, Rev 3: 03/2014
Produced by the International Lactation Consultant Association
ASSESSMENT TREATMENT EVIDENCE

INSUFFICIENT MILK TRANSFER
Chantry CJ, Nommsen-Rivers LA, Peerson JM, Cohen RJ, Dewey KG. Excess Weight Loss in First-Born
Breastfed Newborns Relates to Maternal Intrapartum Fluid Balance. Pediatrics 2011, 127: 1.
Continued weight loss after 96h
(4 days) Noel-Weiss J, Woodend AK, Peterson WE, Gibb W, and Groll DL. An observational study of
associations among maternal fluids during parturition, neonatal output, and breastfed newborn
weight loss. International Breastfeeding Journal 2011, 6:9.
Below birth weight after 336h Chantry CJ, Nommsen-Rivers LA, Peerson JM, Cohen RJ, Dewey KG. Excess Weight Loss in First-Born
(10-14 days) Breastfed Newborns Relates to Maternal Intrapartum Fluid Balance. Pediatrics 2011, 127: 1.
Weight
Dewey, K., et al. Growth of breast-fed infants deviates from current reference data: A pooled
analysis of US, Canadian, and European data sets. J Pediatr 1995; 96(3):495-503.
Dewey, K., et al. Breastfed infants are leaner than formula-fed infants at one year of age: The
Day 5–3 months: < 20 gm (0.7
DARLING study. Am J Clin Nutr 1993; 57:140-45.
oz) per day or
140 gm (5 oz) per week (note: Dewey, K., Heinig, M., Nommsen, L., et al. Growth of breast-fed and formula-fed infants from 0 to
>3 mo, gain slows) 18 months: the DARLING Study. J Pediatr 1992 Jun; 89(6 Pt 1):1035-41.
Dewey K., et al. Adequacy of energy intake among breastfed infants in the DARLING study:
Relationships to growth velocity, morbidity, and activity levels. J Pediatr 1991; 119:538-47.
Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol# 3: hospital

guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised
2009. Breastfeeding Medicine 2009;4(3).
<3 stools each 24hs after 72h (3 Metaj, M., Laroia, N., Lawrence, R., Ryan, R. Comparison of breast- and formula-fed normal
days), Dark green/brown stools newborns in time to first stool and urine. J Perinato l 2003; 23(8):624-8.
Output
after 120h (5 days), Dark, strong

Nyhan, W. Stool frequency of normal infants in the first week of life. J Pediatr 1952; 10:415.
smelling urine after 48h (2
days), Uric acid crystals after Nommsen-Rivers, L . A., Heinig, M. J., Cohen, R. J., & Dewey, K. G. Newborn wet and soiled diaper
72h (3 days) counts and timing of onset of lactation as indicators of breastfeeding inadequacy. J Hum Lact 2008;
24(1), 27-33.
Shrago, L., Reifsnider, E., Insel, K. The neonatal bowel output study: indicators of adequate breast
milk intake in neonates. Pediatr Nurs 2006; 32(3):195-201.
Page 1 of 19

INSUFFICIENT
INSUFFICIENT MILK MILK TRANSFER
TRANSFER continued
Increase breastfeeding
frequency (at least 8-12x/24h),
waking baby to feed, including
during the night
Reilly, S., Reid, J., Skeat, J. and The Academy of Breastfeeding Medicine. ABM clinical protocol #17:
guidelines for breastfeeding infants with cleft lip, cleft palate, or cleft lip and palate. Breastfeeding
Medicine 2007;2(4):243-248.
Amir, L., James, J., Beatly, J. Review of tongue-tie release at a tertiary maternity hospital. J Paediatr:
Child Health 2005; 41:243-45.
Bahr, D. Oral Motor Assessment and Treatment: Ages and Stages . Needham Heights, MA: Allyn and
Bacon, 2001.
Ballard, J., Auer, C., Khoury, J. Ankyloglossia: assessment, incidence, and effect of frenuloplasty on
the breastfeeding dyad. Pediatrics 2002 Nov; 110(5):e63.
Behrman, R., Kliegman, R. Nelson Essentials of Pediatrics (4th edition). Philadelphia: W.B.Saunders
Company, 2002, pp. 351-533.
Behrman, R., Kliegman, R., Jenson, H. Nelson. Textbook of Pediatrics (16th edition). Philadelphia:
Rule out infant and maternal W.B.Saunders Company, 2000, pp. 1271-1272.
anatomic, physiologic, Combs, V. and Marino, S. A comparison of growth patterns in breast and bottle-fed infants with
neurologic, pulmonary, cardiac, congenital heart disease. J Pediatr Nurs 1993; 19(2):175-79.
infectious, metabolic, and/or Coryllos, E., Genna, C., Salloum, A. Congenital Tongue-Tie and its Impact on Breastfeeding. AAP
other anomaly Section on Breastfeeding Newsletter ; Summer 2004.
Geddes, D. et al. Frenulotomy for breastfeeding infants with ankyloglossia: Effect on milk removal
and sucking mechanism as imaged by ultrasound. Pediatrics 2008; 122:e188-e194
Genna, C.W., LeVan Fram, J., and Sandora, L. Neurological issues and breastfeeding in Genna, C.W.,
ed. Supporting Sucking Skills in Breastfeeding Infants , 2nd. edition. Boston: Jones and Bartlett,
2013, pp. 305-358.
Hazelbaker A. The Assessment Tool for Lingual Frenulum Function (ATLFF): Use in a Lactation
Consultant Private Practice . Master’s Thesis. Pacific Oaks College, 1993.
Hoekelman, R (editor-in-chief). Primary Pediatric Care . Philadelphia: Mosby, 2001, pp. 1268-1269,
1307.
Hogan, M., Westcott, C., Griffiths, M. Randomized, controlled trial of division of tongue-tie in
infants with feeding problems. J Paediatr: Child Health 2005; 41:246-50.
Page 2 of 19

INSUFFICIENT
INSUFFICIENT MILK MILK TRANSFER
TRANSFER continued
Marino, B., O'Brien, P., LoRe, H. Oxygen saturations during breast and bottle feedings in infants
with congenital heart disease. J Pediatr Nurs 1995 Dec;10(6):360-4.
McMillan, J., DeAngelis, C., Feigin, R., Warshaw, J. Oski’s Pediatrics (3rd edition). Philadelphia:
Lippincott Williams & Wilkins, 1999, pp. 1232-1233.
Messner, A., Lalakea, M., Aby, J. et al. Ankyloglossia: incidence and associated feeding difficulties.
Arch Otolaryngol Head Neck Surg 2000 Jan; 126(1):36-9.
Miller, J. The Controversial Issue of Breasfeeding Cleft-Affected Infants . Innisfail, Alberta:Infomed
Publications, 1998.
Srinivasan, A., Dobrich, C., Mitnick, H., Feldman, P. Ankyloglossia in breastfeeding infants: the effect
of frenotomy on maternal nipple pain and latch. J Breastfeeding Med 1(4):216-224, 2006.
Wolf, L. and Glass, R. Feeding and Swallowing Disorders in Infancy . San Antonio, Texas: Therapy
Skill Builders 1992:233, 240, 426-35.
Zitelli, B., Davis, H. Atlas of Pediatric Physical Diagnosis (4th edition). Philadelphia: Mosby, 2002, pp.
543-545, 862-863.
Noel-Weiss J, Woodend AK, Peterson WE, Gibb W, and Groll DL. An observational study of
In first 36h consider diuresis
from intrapartum fluids
Maintain milk production by
expressing with multi-user
breast pump after feedings or
every 2-3h
Morton J, Hall JY, Wong RJ, Thairu L, Benitz WE, Rhine WD. Combining hand techniques with electric
Use breast compressions while
pumping increases milk production in mothers of preterm infants. J Perinatol 2009 29:11.
feeding/pumping, hand
expression after pumping to Morton J, Wong RJ, Hall JY, Pang WW, Lai CT, Lui J, et al. Combining hand techniques with electric
maximize milk removal pumping increases the caloric content of milk in mothers of preterm infants. J Perinatol 2012, 32:
791–796.
Supplement first with expressed
or donor milk, or
hydrolyzed protein formula if
human milk unavailable
Page 3 of 19

INSUFFICIENT
JAUNDICE ( > 35MILK
weeksTRANSFER
gestation)
Abnormal total serum bilirubin for age Academy of Breastfeeding Medicine Clinical Protocol Committee. ABM clinical protocol #22:
as guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35
determined from bilirubin nomogram weeks’ gestation. Breastfeeding Medicine 2010; 5(2).
Martinez JC, Maisels MJ, Otheguy L. et al. Hyperbilirubinemia in the breast-fed newborn: a
Visual estimates of jaundice degree controlled trial of four interventions. Pediatrics 1993;91:470-473
may be inaccurate, especially in dark
pigmentation Holland, L., & Blick, K. (2009). Implementing and validating transcutaneous bilirubinometry for
neonates. American Journal of Clinical Pathology , 132(4), 555-561.
Supplement with expressed or

donor milk when possible, Academy of Breastfeeding Medicine Clinical Protocol Committee. ABM clinical protocol #22:
avoiding water and glucose guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35
water because they do not weeks’ gestation. Breastfeeding Medicine 2010; 5(2).
reduce serum bilirubin
Use therapies that maximize

Academy of Breastfeeding Medicine Clinical Protocol Committee. ABM clinical protocol #22:
breastfeeding opportunity
guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35
(e.g., phototherapy blanket,
weeks’ gestation. Breastfeeding Medicine 2010; 5(2).
feeding under portable lights)

If breastfeeding must be Academy of Breastfeeding Medicine Clinical Protocol Committee. ABM clinical protocol #22:
interrupted (very rare), express guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35
milk every 2-3h until weeks’ gestation. Breastfeeding Medicine 2010; 5(2).
breastfeeding resumes to American Academy of Pediatrics. Management of Hyperbilirubinemia in the Newborn Infant 35 or
maintain milk production; use More Weeks of Gestation. Pediatrics 2004 Jul; 114(1): 297-316.
only hydrolyzed protein formula
KJ Barrington, K Sankaran; Canadian Paediatric Society, Fetus and Newborn Committee. Guidelines
for detection, management and prevention of hyperbilirubinemia in term and late preterm
newborn infants. Paediatr Child Health 2007;12(Suppl B):1B-12B.
Gartner, L. and Herschel, M. Jaundice and breastfeeding. Pediatr Clin North Am 2001 Apr; 48(2):389-
99.
Page 4 of 19

INSUFFICIENT
JAUNDICE MILK
( > 35 weeks TRANSFER
gestation) continued
Gourley GR, Kreamer B, Arend R. The effect of diet on feces and jaundice during the ﬁrst 3 weeks of
life. Gastroenterology 1992;103:660–667.
Maisels MJ, Bhutani VK, Bogen D, et al. Hyperbilirubinemia in the newborn infant>or¼35 weeks’
gestation: an update with clariﬁcations. Pediatrics 2009;124:1193–1198.
Nicoll, A., Ginsburg, R., Tripp, J. Supplementary feeding and jaundice in newborns. Acta Paediatr
Scand 1982 Sep;71(5):759-61.
Rennie, Janet, Shona Burman-Roy, and M. Stephen Murphy. "GUIDELINES: Neonatal jaundice:
summary of NICE guidance." BMJ: British Medical Journal (2010): 1190-1192.
Symon, Brian, and Michael Bammann. "Feeding in the first year of life: emerging benefits of
introducing complementary solids from 4 months." Australian family physician 41.4 (2012): 226.
Torres-Torres, M., Tayaba, R., Weintraub, A., Holzman, I. New perspectives on neonatal
hyperbilirubinemia. Mt Sinai J Med 1994 Oct; 61(5):424-8.
Academy of Breastfeeding Medicine Clinical Protocol Committee. ABM clinical protocol #22:
guidelines for management of jaundice in the breastfeeding infant equal to or greater than 35
weeks’ gestation. Breastfeeding Medicine 2010; 5(2).
Page 5 of 19

BREAST ENGORGEMENT
Significant, continual breast Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol # 20: engorgement.
fullness/edema Breastfeeding Medicine 2009; 4(2)
Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol # 20: engorgement.
Breast pain
Breastfeeding Medicine 2009; 4(2)
Flattened nipple (causing difficulty to Breastfeeding Medicine 2009; 4(2)
latch) Cotterman, K. J. Reverse pressure softening: a simple tool to prepare areola for easier latching
during engorgement. J Hum Lact , 2004; 20(2), 227-237.
Afebrile, no myalgia or erythema
Severe edema often secondary to
large IV fluid load during labor; Chantry CJ, Nommsen-Rivers LA, Peerson JM, Cohen RJ, Dewey KG. Excess Weight Loss in First-Born
history of breast/nipple surgery Breastfed Newborns Relates to Maternal Intrapartum Fluid Balance. Pediatrics 2011, 127: 1.
increases risk and severity; normal
Chapman, D.J. Evaluating the evidence: Is there an effective treatment for breast engorgement? J
breast fullness typically peaks 96h-
Hum Lact 2011; 27(1):82-83.
120h (4-5 days), and resolves without
Cotterman, K. J. Reverse pressure softening: a simple tool to prepare areola for easier latching
treatment; later severe engorgement
during engorgement. J Hum Lact , 2004; 20(2), 227-237.
may indicate insufficient milk removal
Noel-Weiss J, Woodend AK, Peterson WE, Gibb W, and Groll DL. An observational study of
or overproduction
Evans, K., Evans, R., Simmer, K. Effect of the method of breast feeding on breast engorgement,
mastitis and infantile colic. Acta Paediat r 1995 Aug; 84(8):849-52.
Mangesi, Lindeka, and Therese Dowswell. "Treatments for breast engorgement during lactation."
Cochrane Database Syst Rev 9 (2010).
Increase milk removal Moon, J., Humenick, S. Breast engorgement: contributing variables and variables amenable to
(breastfeed frequently and/or nursing intervention. J Obstet Gynecol Neonatal Nurs 1989 Jul-Aug; 18(4):309-15.
express after feeding to Snowden, H. M., Mary J. Renfrew, and M. W. Woolridge. Treatments for breast engorgement during
comfort) lactation. The Cochrane Library (2001).
Hill, P. and Humenick, S. The occurrence of breast engorgement. J Hum Lact 10(2):79-86, 1994.
Hill, P. and Humenick, S. Breast engorgement: patterns and selected outcomes. J Hum Lact 10(2):87-
93, 1994.
Page 6 of 19

INSUFFICIENT
BREAST MILK TRANSFER
ENGORGEMENT continued
Ahn S, Kim J, Cho J. Effects of breast massage on breast pain, breast-milk sodium, and newborn
Lie flat and massage breasts
suckling in early postpartum mothers]. J Korean Acad Nurs . 2011 Aug; 41(4):451-9.
toward armpits to improve
lymphatic drainage and venous
Bolman, Maya, Linda Saju, Karine Oganesyan, Tatiana Kondrashova, and Ann M. Witt. "Recapturing
congestion
the Art of Therapeutic Breast Massage during Breastfeeding." J Hum Lact 29, no. 3 (2013): 328-331.
If difficulty latching, use Reverse

Pressure Softening technique
(sustained finger pressure Cotterman, K. Reverse pressure softening: a simple tool to prepare areola for easier latching during
beginning at base of nipple, engorgement. J Hum Lact 2004 May; 20(2):227-37.
pushing edema away from
nipple) before feeding
Arora S, Vatsa M, Dadhwal V. Cabbage leaves vs hot and cold compresses in the treatment of breast
engorgement. Nurs J India . 2009 Mar;100(3):52-4.
Lawrence, R, Lawrence, R. Breastfeeding: A Guide for the Medical Professional ,7th ed. Elsevier,
Apply cold packs (crushed ice, Mosby. 2011.
frozen peas, etc.) or
Mangesi L, Dowswell T. Treatments for breast engorgement during lactation. Cochrane Database
raw cabbage leaves to reduce
Syst Rev . 2010 Sep 8;(9):CD006946.
swelling and facilitate
latching Nikodem, V., Danziger, D., Gebka, N., et al. Do cabbage leaves prevent breast engorgement? A
randomized, controlled study. Birth 1993 Jun; 20(2):61-4.
Roberts, K. A comparison of chilled cabbage leaves and chilled gelpaks in reducing breast
engorgement. J Hum Lact 1995 Mar; 11(1):17-20.
Roberts, K., Reiter, M., Schuster, D. A comparison of chilled and room temperature cabbage leaves
in treating breast engorgement. J Hum Lact 1995 Sep; 11(3):191-4.
Oral anti-inflammatory (eg, Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol # 20: engorgement.
NSAID) Breastfeeding Medicine 2009; 4(2)
Page 7 of 19

OVERPRODUCTION
Significant, continual breast Livingstone, V. Too much of a good thing. Maternal and infant hyperlactation syndromes. Can Fam
fullness > 3wks pp Physician 1996 Jan;42:89-99.
Very forceful milk ejection, Livingstone, V. Too much of a good thing. Maternal and infant hyperlactation syndromes. Can Fam
possibly painful Physician 1996 Jan;42:89-99.
Maternal
Nipples may be abraded from Smillie, C., Campbell, S., Iwinski, S. Hyperlactation: How left-brained “rules” for breastfeeding can
baby clamping wreak havoc with a natural process. Nwbrn Inf Nurs Rev 2005; 5(1):49-58.
Increased mastitis risk from

poor milk removal and/or nipple Mohrbacher, N. Breastfeeding Answers Made Simple . Amarillo, TX, Hale Publishing, 2010
infection
Rapid weight gain likely
Mohrbacher, N. Breastfeeding Answers Made Simple . Amarillo, TX, Hale Publishing, 2010
(>900g/2lbs/month)
Chokes, coughs, sputters, arches
Infant
at breast
Gassy, irritable, restless,
frequent crying
Green, thin, frothy stools Mohrbacher, N. Breastfeeding Answers Made Simple . Amarillo, TX, Hale Publishing, 2010
Rule out infant causes for Mohrbacher, N. Breastfeeding Answers Made Simple . Amarillo, TX, Hale Publishing, 2010
difficult feeds (e.g.,
gastroesophageal reflux [GERD],
respiratory Knox, Isabella. Tongue tie and frenotomy in the breastfeedingewborn. NeoReviews 11.9 (2010):
dysfunction, neurological e513-e519.
dysfunction, ankyloglossia)
Page 8 of 19

OVERPRODUCTION continued
Until production down-
regulates (baby feeds more
easily): * Express milk 1x /day
to thoroughly drain both
breasts, * Use same breast for
van Veldhuizen-Staas CG. Overabundant milk supply: an alternative way to intervene by full
all feeds in 3-4h blocks; switch
drainage and block feeding. Int Breastfeed J. 2007 Aug 29;2:11.
breasts after each block, limit
only 1 week, * If unused breast
is too painful, express just
enough milk to reduce pain
(about 15-30ml)
Aljazaf K, Hale TW, Ilett KF, Hartmann PE, Mitoulas LR, Kristensen JH, Hackett LP. Pseudoephedrine:
effects on milk production in women and estimation of infant exposure via breastmilk. Br J Clin
Pharmacol . 2003 Jul;56(1):18-24.
Findlay JW, Butz RF et al. Pseudoephedrine and triprolidine in plasma and breast milk of nursing
mothers. Br J Clin Pharmacol . 1984;18:901-6.
If not improved after 7d, Mitchell JL. Use of cough and cold preparations during breastfeeding. J Hum Lact . 1999
consider drug therapy Dec;15(4):347-9.
van Veldhuizen-Staas CG. Overabundant milk supply: an alternative way to intervene by full
drainage and block feeding. Int Breastfeed J . 2007 Aug 29;2:11.
Walker, Marsha. Breastfeeding Management for the Clinician: Using the Evidence . Jones & Bartlett
Learning, 2009.
Page 9 of 19

INSUFFICIENT
PLUGGEDMILK TRANSFER
DUCT
Localized breast pain or tender area,
erythema
Usually unilateral Mohrbacher, N. Breastfeeding Answers Made Simple . Amarillo, TX, Hale Publishing, 2010
Typically more painful before

breastfeeding
Usually afebrile or below 38.5°C
(101.3°F)
Milk production may temporarily
decrease
American Academy of Pediatrics and American College of Obstetricians and Gynecologists.
Breastfeeding Handbook for Physicians . 2006: 137.
Untreated, can progress to abscess Giugliani, E. [Common problems during lactation and their management] J Pediatr (Rio J) 2004 Nov;
and/or mastitis 80(5 Suppl):S147-54.
Breastfeed/express frequently
on affected breast
Position baby w/ chin pointing
toward plug/painful area Riordan, J, Wambach, K. Breastfeeding and Human Lactation . Jones & Bartlett Learning, 2010.
Before feeding or expressing,

massage gently with edible oil
from plug to armpit; during and
Bolman, Maya, Linda Saju, Karine Oganesyan, Tatiana Kondrashova, and Ann M. Witt. "Recapturing
after feeding or expressing,
the Art of Therapeutic Breast Massage during Breastfeeding." J Hum Lact 29, no. 3 (2013): 328-331.
massage from plug toward
nipple/areola; hand express to
increase drainage
Lecithin granule supplement 1
tablespoon 3-4x/day to resolve, Scott CR. Lecithin: it isn't just for plugged milk ducts and mastitis anymore. Midwifery Today Int
1 tablespoon 1x/day to prevent Midwif e. 2005 Winter;(76):26-7.
reoccurrence
Page 10 of 19

MASTITIS
Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol# 4: mastitis.
Breastfeeding Medicine 2008, 3(3): 177.
Febrile above 38.5˚C (101.3˚F)
Wambach, K. Lactation Mastitis: A Descriptive Study of the Experience. J Hum Lact Feb 2003; 19: 24
- 34.
Systemic symptoms (eg, chills, flu-like Breastfeeding Medicine 2008, 3(3): 177.
aching) Wambach, K. Lactation Mastitis: A Descriptive Study of the Experience. J Hum Lact Feb 2003; 19: 24
- 34.
Localized breast erythema and pain
- 34.
Possibly decreased milk production
- 34.
Baby can breastfeed safely
- 34.
Mother may be afebrile
- 34.
Usually unilateral
- 34.
Infection may not be present
- 34.
Page 11 of 19

INSUFFICIENT
MASTITISMILK TRANSFER
continued
Rule out overproduction and Breastfeeding Medicine 2008, 3(3): 177.
insufficient milk removal Wambach, K. Lactation Mastitis: A Descriptive Study of the Experience. J Hum Lact Feb 2003; 19: 24
- 34.
Breastfeed frequently / express Breastfeeding Medicine 2008, 3(3): 177.
on both breasts every 2-3h Wambach, K. Lactation Mastitis: A Descriptive Study of the Experience. J Hum Lact Feb 2003; 19: 24
- 34.
Consider oral anti-inflammatory Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol# 4: mastitis.
(eg, NSAID) Breastfeeding Medicine 2008, 3(3): 177.
Wash hands SCRUPULOUSLY; Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol# 4: mastitis.
shorten nails Breastfeeding Medicine 2008, 3(3): 177.
Encourage rest
If febrile or not resolved after
Livingstone, V., and Stringer, L. The treatment of Staphyloccocus aureus infected sore nipples: a
24h: consider staph sensitive
randomized comparative study. J Hum Lact 1999 Sep; 15(3):241-6.
antibiotics
If unresponsive to therapy,
culture milk to determine Osterman, K. and Rahm, V. Lactation Mastitis: Bacterial Cultivation of Breast Milk, Symptoms,
pathogen. If MRSA, treat with Treatment, and Outcome. J Hum Lact Nov 2000; 16: 297 - 302.
MRSA-effective antibiotic
3 or more recurrences: Rule American Academy of Pediatrics and American College of Obstetricians and Gynecologists.
out scar tissue, underlying Breastfeeding Handbook for Physicians . 2006: 138-40.
pathology (eg, fibroids, mass, Amir L, Harris H, Andriske L. An audit of mastitis in the emergency department. J Hum Lact 1999;
inflammatory breast cancer) 15(3):221-224.
Giugliani, E. [Common problems during lactation and their management] J Pediatr (Rio J) 2004 Nov;
80(5 Suppl):S147-54.
Page 12 of 19

INSUFFICIENT MILK
NIPPLE TRANSFER
BLEB
Huml S. Sore nipples. A new look at an old problem through the eyes of a dermatologist. Pract
Midwife 1999 Feb; 2(2):28-31.
Tiny, shiny white cyst on tip of nipple
Huml S. Sore nipples. A new look at an old problem through the eyes of a dermatologist. Pract
Midwife 1999 Feb; 2(2):28-31.
Possibly intense, focused pain
If bleb rises when pressure applied to

nipple base, may correspond to Mohrbacher, N. Breastfeeding Answers Made Simple . Amarillo, TX, Hale Publishing, 2010
plugged duct in breast
If not painful: No treatment
necessary
If painful: Soften with edible oil
or soak in warm water
Rub gently with warm, damp

cloth until opened or mother Mohrbacher, N. Breastfeeding Answers Made Simple . Amarillo, TX, Hale Publishing, 2010
open with sterile needle
Breastfeed or express
frequently to remove thickened
milk (stringy or hardened milk
strands or crystals normal)
Wash wound daily with

soap/water to prevent biofilm
Resistant bleb: apply thin coat

O’Hara, M.A. Bleb histology reveals inflammatory infiltrate that regresses with topical sterioid; a
of mid-potency corticosteroid
case series. Breastfeed Med 2012; 7(Suppl 1):S2-S17.
with occlusion for several days
Page 13 of 19

NIPPLE VASOSPASM
Blanching or tri-phasic coloration after Page, S. and McKenna, D. Vasospasm of the nipple presenting as painful lactation. Obstet Gyneco l
or between feedings 2006 Sep; 108(3 Pt 2):806-8.
Deep shooting, burning, or stinging Page, S. and McKenna, D. Vasospasm of the nipple presenting as painful lactation. Obstet Gynecol
breast pain 2006 Sep; 108(3 Pt 2):806-8.
Amir LH,Garland SM.Dennerstein L,Farish SL.Candida Albicans:Is it associated with nipple pain in
lactating women? Gynecol Obstet Invest .1998;46-73-74.
Amir LH. Breast pain in lactating women - mastitis or something else? Aust Fam Physician 2003
Rule out bacterial or fungal Mar;32(3):141-5.
infection
Walker, Marsha. Breastfeeding Management for the Clinician . Jones & Bartlett Publishers, 2013.
Wu M, Chason R, Wong M. Raynaud's phenomenon of the nipple. Obstet Gynecol 2012 Feb;119(2
Pt 2):447-9.
Gently squeeze blood down
into nipple to stop spasm and Wilson-Clay, B., Hoover, K. The Breastfeeding Atlas (5th ed). Manchaca:TX, Lactnews Press, 2013.
temporarily halt pain
Apply warmth routinely post-
Page SM, McKenna DS. Vasospasm of the nipple presenting as painful lactation. Obstet Gynecol
feed (back of arm, palm of
2006 Sep;108(3 Pt 2):806-8.
hand, hot pack); dress warmly
Amir, L. Breast pain in lactating women--mastitis or something else? Aust Fam Physician 2003 Mar;
32(3):141-5.
Anderson, J., Held, N., Wright, K. Raynaud's phenomenon of the nipple: a treatable cause of painful
breastfeeding. Pediatrics 2004 Apr; 113(4):e360-4.
Barrett ME, et al. Raynaud phenomenon of the nipple in breastfeeding mothers: an underdiagnosed
cause of nipple pain. JAMA Dermatol 2013 149(3):300-6
Consider calcium channel
blocker (eg, nifedipine) Coates, M. Nipple pain related to vasospasm in the nipple? J Hum Lact 1992 Sep; 8(3):153.
Garrison, C. Nipple vasospasms, Raynaud's syndrome, and nifedipine. J Hum Lact 2002 Nov;
18(4):382-5.
Lawlor-Smith L, Lawlor-Smith C. Vasospasm of the nipple - a manifestation of Raynaud's
phenomenon: case reports. Br Med J 1997 Mar 1;314(7081):644-5.
Page, S. and McKenna, D. Vasospasm of the nipple presenting as painful lactation. Obstet Gynecol
2006 Sep; 108(3 Pt 2):806-8.
Page 14 of 19

INSUFFICIENT MILK
NIPPLE TRANSFER
PAIN
Tait, P. Nipple pain in breastfeeding women: causes, treatment, and prevention strategies. J
Pain, erythema, and abrasion
Midwifery Womens Health 2000 May-Jun; 45(3):212-5.
Nipple compressed when baby Tait, P. Nipple pain in breastfeeding women: causes, treatment, and prevention strategies. J
unlatches Midwifery Womens Health 2000 May-Jun; 45(3):212-5.
Tenderness without trauma is normal
in the first week; actual pain is NOT Mohrbacher, N. Breastfeeding Answers Made Simple . Amarillo, TX, Hale Publishing, 2010
normal
Heller MM. Fullerton-Stone H, Murase JE. Caring for new mothers: diagnosis, management and
treatment of nipple dermatitis in breastfeeding mothers. International Journal of Dermatology
Rule out any latching/sucking 2012; 51: 1149-1161.
issues, ankyloglossia (anterior
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eczema, contact dermatitis
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infection Midwifery Womens Health 2000 May-Jun; 45(3):212-5.
NIPPLE BACTERIAL INFECTION
Nipple abrasion, erythema Mohrbacher, N. Breastfeeding Answers Made Simple . Amarillo, TX, Hale Publishing, 2010
Moderate to severe pain, worse when

feeding
Purulence or yellow crusting Mohrbacher, N. Breastfeeding Answers Made Simple . Amarillo, TX, Hale Publishing, 2010
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NIPPLE MILK TRANSFER
BACTERIAL INFECTION continued
Amir L, Garland SM, Lumley. A case-control study of mastitis: nasal carriage of Staphylococcus
aurues. BMC Fam Pract . 20067:57
Eglash A et al. History, physical and laboratory findings, and clinical outcomes of lactating women
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pathogen, may progress to mastitis if Fetherston C. Management of lactational mastitis in a Western Australian cohort. Breastfeeding
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ointment/cream to nipples after randomised comparative study . J Hum Lact 1999 Sept;15(3):241-6.
feed until healed (may use Tait, P. Nipple pain in breastfeeding women: causes, treatment, and prevention strategies. J
expressed milk to wipe off Midwifery Womens Health 2000 May-Jun; 45(3):212-5.
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Edlich, R., Winters, K., Britt, L., et al. Bacterial diseases of the skin. J Long Term Eff Med Implants
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Eglash A, Plane VB, Mundt M. History, physical and laboratory findings, and clinical outcome of
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Thomassen, P., Johansson, V., Wassberg, C., et al. Breast-feeding, pain and infection. Gynecol
Obstet Invest 1998 Aug; 46(2):73-4.
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NIPPLE / AREOLAR MILKCANDIDAL
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Amir, L., Garland, S., Dennerstein, L., et al. Candida albicans: is it associated with nipple pain in
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positional change; unilateral or
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Johnstone, H. and Marcinak, J. Candidiasis in the breastfeeding mother and infant. J Obstet Gynecol
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Health 2006 Mar-Apr; 51(2):125-8.
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suspension; apply antifungal
Mohrbacher, N. Breastfeeding Answers Made Simple . Amarillo:TX, Hale Publishing, 2010.
cream to diaper/nappy area as
needed Porter, J. and Schach, B. Treating Sore, Possibly Infected Nipples. J Hum Lact May 2004; 20: 221 -
222.
MOTHER: Apply small amount Midwifery Womens Health . 2007;52(6):595-605.
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feed (no need to remove prior
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222.
Page 18 of 19

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/ INFANT CANDIDAL INFECTION continued
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Consider probiotics for both candida colonization in a PICU-a randomized controlled trial. Crit Care Med . 2013 Feb;41(2):565-72.
mother and baby
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interferon status in children with bacterial complications of acute viral infections of the respiratory
tract and their correction by high doses of bifidumbacterin forte. Antibiot Khimioter .
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Wash hand SCRUPULOUSLY,
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women. J Obstet Gynecol Neonatal Nurs 2005 Jan-Feb; 34(1):37-45.
Check mother and baby for

other sites; treat if found Mohrbacher, N. Breastfeeding Answers Made Simple . Amarillo:TX, Hale Publishing, 2010.
©2014 International Lactation Consultant Association®

Developed by Diana West, BA, IBCLC and an international clinical team.
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ASSESSMENT TREATMENT EVIDENCE

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol# 3: hospital

after 120h (5 days), Dark, strong

ASSESSMENT TREATMENT EVIDENCE

ASSESSMENT TREATMENT EVIDENCE

ASSESSMENT TREATMENT EVIDENCE

Supplement with expressed or

Use therapies that maximize

Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol# 3: hospital

ASSESSMENT TREATMENT EVIDENCE

ASSESSMENT TREATMENT EVIDENCE

ASSESSMENT TREATMENT EVIDENCE

If difficulty latching, use Reverse

ASSESSMENT TREATMENT EVIDENCE

Increased mastitis risk from

ASSESSMENT TREATMENT EVIDENCE

ASSESSMENT TREATMENT EVIDENCE

Typically more painful before

Before feeding or expressing,

ASSESSMENT TREATMENT EVIDENCE

ASSESSMENT TREATMENT EVIDENCE

ASSESSMENT TREATMENT EVIDENCE

If bleb rises when pressure applied to

Rub gently with warm, damp

Wash wound daily with

Resistant bleb: apply thin coat

ASSESSMENT TREATMENT EVIDENCE

ASSESSMENT TREATMENT EVIDENCE

Moderate to severe pain, worse when

ASSESSMENT TREATMENT EVIDENCE

ASSESSMENT TREATMENT EVIDENCE

ASSESSMENT TREATMENT EVIDENCE

ASSESSMENT TREATMENT EVIDENCE

Kumar S, Bansal A, Chakrabarti A, Singhi S. Evaluation of efficacy of probiotics in prevention of

Check mother and baby for

©2014 International Lactation Consultant Association®

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