148 Essential Pediatrics

Fig. 9.23: Different postures of feeding

Step one

Step two
Insert piston
from cut end
Step threee
Mother gently
puls the piston

Fig. 9.25: Syringe treatment forinvertediflat nipple

mother would be able to feed the baby despite sore nipple,

Fig. 9.24: Good attachment if the baby is attached properly. Hindmilk should be
applied to the nipple after a feed and the nipple should
Effective Suckling be aired and allowed to heal in between feeds. She should
be advised not to wash nipple each time before/after
Baby suckles slowly and pauses in between to Swallow feeding. She can clean breast and nipple once daily at time
(suck, suck, suck.. and swallow). One may see throat of bathing. There is no need te apply any cream or
cartilage and muscles moving and hear the gulping
sounds of milk being swallowed. ointment tothesore nipples.
Baby's cheeks are full and not hollow or retracting Breast engorgement: The milk production increasesbythe
second and third day after
delivery. Iffeeding is delayed
during sucking.
or infrequent, or the baby is not well positioned at the
Problems in Breastfeeding Km breast, the milk accumulates in the alveoli. As milk
Inverted nipples: Flat or short nipples which become promi- production increases, the amount of milk in thebreast
nent easily on pulling out do not pose difficulty in breast exceedsthecapacity of the alveolitostore it comfortably.
feeding. However, truly inverted or retracted nipples make Such a breastbecomes swollen, hard, warm and painful
latching difficult. As the baby is not able to take nipple and is termed as an 'engorged breast' (Fig. 9.26).
and areola in the mouth properly, sucking on the nipples
makes them sore and excoriated. Treatment is started after
birth of the baby. The nipple is manually everted, stretched
and rolled out several times a day. A plastic syringe is
used to draw out to correct the problem (Fig. 9.25).
Sore nipple: Nipples become sore when baby suckles on
the nipple rather than areola because of incorrect
attachment. As the baby is unable to express milk, he sucks
vigorously in frustration and bites the nipple causing
soreness. Frequent washing with soap and water and
pulling the baby off the breast while he is still sucking
may also result in sore nipple. Treatment consists of correct Fig. 9.26: Engorged breast. Note tense and shiny skin; nipple
positioning and latching of the baby to the breast. A shows excoriation
 149
Newborn Infants

Breast engorgement can be

prevented by early and
frequent feeds and correct attachment of the baby to the
breast. Treatment consists of local warm water
breast massage and analgesics to relieve the pain.packs,
Milk
shouldbe gently expressed to soften the breast.
Breast abscess: If a congested engorged breast, cracked
nipple, blocked duct or mastitis are not treated in the early
stages, breast abscess formation can occur. The mother
has high grade fever and a raised blood count. She must
be treated with analgesics and Step 2
antibiotics. The abscess may Step
require incision and drainage. Breastfeeding must be
Continued.
(Notenough milk: First make sure that the perception of
not enough milk" is correct. If baby is satisfied and
sleeping for 2-3 hours after breastfeeding, passing urine
at least6-8 times in 24 hours and gaining weight,bethea
mother is producing enough milk. There could
numberof reasons for insufficient milk such as incorrect
method of breastfeeding, supplementary orbottle-feeding
no nightbreastfeeding,engorgementofbreast,anyillness, Step 3
painfulcondition, maternal stress or insufficient sleep. Try
toidentify the possible reason and take appropriate
actions. Advise mother to take sufficient rest and drink
adequate fluids. Feed the baby on demand. Let the baby
feed as long possible on each breast. Advise the mother
as
to keep the baby with her.

Expressed Breast Milk (EBM)

If a position to feed her baby (e.g. ill
mother is not in a

mother, preterm baby, working mother, etc.), she should Step 4

a clean wide-mouthed container and
express her milk in expression. Step 1: Massage
this milk should be fed to her baby. EBM can be stored at Fig.9.27: Four steps of breast milk Step 2: Place the thumb
in a refrigerator for the breasts gently toward the nipples;
room temperature for 6-8 hours, the dark circle
each other just outside
-20°C for 3 months. and index finger opposite then
24 hours and a freezer at back toward the chest,
around the nipple; Step 3: Press
release milk; Step 4: Repeat step
3 in different
Method of Milk Expression gently squeeze to
positions around the areola
with soap
Ask the mother to wash her hands thoroughly
She should make herself gestation) or due to intrauterine growth restriction (TUGR)
and water before she expresses.
Hold
comfortable. Gently massage the breast (Fig. 9.27). or both.
thurmb and may be present in
areola. Place her IUGR is similar to malnutrition
the container under her nipple and Neonates affected by IUGR
least 4 from the tip of the nipple both term and preterm infants.
on top of the breastat
cm

the undersurface of the breast and have loose skin folds on

undernourished
and the first finger on are usualy absence of
and release the breast the face and in the guteal region (Fig. 9.28),
opposite the thumb. Compress Problems faced by
thumb a few times. subcutaneous fat and peeling of skin.
tissue between her fingers and the
she should reposition her a preterm and 1UGR
neonate are different, although
If the milk does not appear, to both (Table 9.8).
and compress and management principles are common
thumb and finger closer to the nipple the
and release all the IUGR results when the fetus does not grow as per
release the breast as before. Compress
from both breasts. Fetal growth restriction
breast. Express milk normal fetal growth trajectory.
way around the mother should express adverse factors that affect the
To maintain adequate lactation, results from one or more

hours. normal growth pattern of the fetuses. There are two types
milk at least 8 to 10 times in 24
of IUGR babies:
om.
CARE OF LOW BIRTH WEIGHT BABIESCa s Summetric itiGR When insult on the fetal growth occurs
birth less than 2500 8)
weight early. The size of the head, body weight and length are
Low birth weight (LBW; LBW results equally reduced. Causes include genetic and
babies have higher morbidity and mortality, chromosomal disorders or TORCH infections.
from either preterm birth (before
37 completed weeks of