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CLINICIAN’S BREASTFEEDING TRIAGE TOOL
CLINICIAN’S BREASTFEEDING TRIAGE TOOL
ASSESSMENT
TREATMENT
ASSESSMENT
TREATMENT
INSUFFICIENT MILK TRANSFER
1) Refer to IBCLC* for milk transfer and latch
INSUFFICIENT MILK TRANSFER
1) Refer to IBCLC* for milk transfer and latch
assessment, and strategies to increase milk
assessment, and strategies to increase milk
Output
Output
production prn
production prn
• < 3 stools each 24h period after first 24h • < 3 stools each 24h period after first 24h 2) Increase breastfeeding frequency (at least 8-12x/24h), 2) Increase breastfeeding frequency (at least 8-12x/24h), 3) Maintain milk production by pumping w/ hospital 3) Maintain milk production by pumping w/ hospital • Voids: < 3-5 per day by Days 3-5; < 4-6 per day • Voids: < 3-5 per day by Days 3-5; < 4-6 per day grade breast pump after feedings or q2-3h grade breast pump after feedings or q2-3h 4) R/O infant and maternal anatomic, physiologic, 4) R/O infant and maternal anatomic, physiologic, Weight
neurologic, pulmonary, cardiac, infectious, metabolic, Weight
neurologic, pulmonary, cardiac, infectious, metabolic, 5) Weight loss ≥7%: monitor and assess; weight loss 5) Weight loss ≥7%: monitor and assess; weight loss • Birth weight not regained by Day 10 ≥10%: supplement prn w/ expressed milk, donor milk, • Birth weight not regained by Day 10 ≥10%: supplement prn w/ expressed milk, donor milk, • Day 5–3 mo: < 20 gm (0.7 oz) per day or 140 gm • Day 5–3 mo: < 20 gm (0.7 oz) per day or 140 gm Note: After 3 mo, weight gain slows
Note: After 3 mo, weight gain slows
JAUNDICE (
1) Refer to IBCLC* for milk transfer & latch assessment
≥ 35 weeks gestation)
JAUNDICE (
1) Refer to IBCLC* for milk transfer & latch assessment
≥ 35 weeks gestation)
ANT (birth - 3 months)
2) Treat w/ therapies that maximize breastfeeding oppor- ANT (birth - 3 months)
2) Treat w/ therapies that maximize breastfeeding oppor- • Abnormal total serum bilirubin (TSB) for age tunity (eg, biliblanket, feeding under portable bililight) • Abnormal total serum bilirubin (TSB) for age tunity (eg, biliblanket, feeding under portable bililight) 3) When possible, continue breastfeeding, increase fre- 3) When possible, continue breastfeeding, increase fre- Note:
Note:
quency (at least 8-12x/24h), waking baby to feed q2-3h quency (at least 8-12x/24h), waking baby to feed q2-3h G Visual estimates of jaundice degree may be G Visual estimates of jaundice degree may be 4) All jaundice types, including “breastmilk jaundice”:
4) All jaundice types, including “breastmilk jaundice”:
inaccurate, especially in dark pigmentation inaccurate, especially in dark pigmentation If inadequate intake, excessive weight loss, or dehydration, If inadequate intake, excessive weight loss, or dehydration, G Supplementation w/ water or glucose
G Supplementation w/ water or glucose
supplement w/ expressed milk, donor milk, or formula supplement w/ expressed milk, donor milk, or formula water does not reduce serum bilirubin
water does not reduce serum bilirubin
5) R/O ABO/RH incompatibility, G6PD deficiency, anatomic 5) R/O ABO/RH incompatibility, G6PD deficiency, anatomic G Supplement w/ expressed milk when possible G Supplement w/ expressed milk when possible abnormalities, cardiopulmonary or neurologic dysfunction abnormalities, cardiopulmonary or neurologic dysfunction BREAST ENGORGEMENT
1) Refer to IBCLC* for strategies to resolve
BREAST ENGORGEMENT
1) Refer to IBCLC* for strategies to resolve
2) Increase milk removal (breastfeed frequently and/or 2) Increase milk removal (breastfeed frequently and/or • Significant, continual breast fullness/edema • Significant, continual breast fullness/edema 3) If difficulty latching, use Reverse Pressure Softening 3) If difficulty latching, use Reverse Pressure Softening • Flattened nipple (causing difficulty to latch) technique (sustained finger pressure beginning at • Flattened nipple (causing difficulty to latch) technique (sustained finger pressure beginning at nipple base, pushing edema away from nipple) before nipple base, pushing edema away from nipple) before Note: Normal breast fullness typically peaks
Note: Normal breast fullness typically peaks
Days 4-5, resolving without treatment; severe Days 4-5, resolving without treatment; severe 4) Apply cold packs (eg, crushed ice, frozen peas, etc) to 4) Apply cold packs (eg, crushed ice, frozen peas, etc) to engorgement may indicate insufficient milk removal engorgement may indicate insufficient milk removal 5) Consider anti-inflammatory (eg, ibuprofen) 5) Consider anti-inflammatory (eg, ibuprofen) OVERPRODUCTION
1) Refer to IBCLC* for strategies to resolve
OVERPRODUCTION
1) Refer to IBCLC* for strategies to resolve
• Significant, continual breast fullness > 3wks pp 2) Until production down-regulates, use one breast per • Significant, continual breast fullness > 3wks pp 2) Until production down-regulates, use one breast per feeding – if baby desires to breastfeed again within feeding – if baby desires to breastfeed again within Possible Infant Signs
Possible Infant Signs
3) If unused breast is uncomfortable, hand express or 3) If unused breast is uncomfortable, hand express or • Chokes, coughs, sputters, arches while • Chokes, coughs, sputters, arches while pump just enough to be comfortable (pumping too pump just enough to be comfortable (pumping too • Gassy, irritable, restless, frequent crying • Gassy, irritable, restless, frequent crying 4) Lean back or lie flat while feeding to reduce force of 4) Lean back or lie flat while feeding to reduce force of 5) Latch w/ baby’s chin pressed into breast and nose 5) Latch w/ baby’s chin pressed into breast and nose Note: Many symptoms are similar to reflux
Note: Many symptoms are similar to reflux
NIPPLE PAIN
1) Refer to IBCLC* for milk transfer & latch assessment
NIPPLE PAIN
1) Refer to IBCLC* for milk transfer & latch assessment
2) Assess latch (see Insufficient Milk Transfer above) 2) Assess latch (see Insufficient Milk Transfer above) 3) Erythema/abrasion: R/O dermal bacterial infection 3) Erythema/abrasion: R/O dermal bacterial infection 4) Blanching: see Vasospasm (Side 2) 4) Blanching: see Vasospasm (Side 2) • Nipple compressed when baby unlatches • Nipple compressed when baby unlatches 5) R/O plugged nipple duct or bleb (Side 2) 5) R/O plugged nipple duct or bleb (Side 2) • Possible blanching after or between feedings 6) R/O eczema, contact dermatitis (usually only affects • Possible blanching after or between feedings 6) R/O eczema, contact dermatitis (usually only affects areola); if dx, small amount steroid ointment after areola); if dx, small amount steroid ointment after Note: Tenderness w/o trauma is normal the first
feeding (absorbs fully, no need to remove before Note: Tenderness w/o trauma is normal the first
feeding (absorbs fully, no need to remove before week; significant pain after latch is NOT normal week; significant pain after latch is NOT normal Breastfeeding Priorities: 1) Feed the baby —> 2) Protect the milk production —> 3) Fix the problem
Breastfeeding Priorities: 1) Feed the baby —> 2) Protect the milk production —> 3) Fix the problem
T H I S T O O L I S N O T I N T E N D E D T O R E P L A C E M E D I C A L E V A L U A T I O N O R J U D G M E N T
T H I S T O O L I S N O T I N T E N D E D T O R E P L A C E M E D I C A L E V A L U A T I O N O R J U D G M E N T
* International Board Certified Lactation Consultant
* International Board Certified Lactation Consultant
VISIT ILCA.ORG FOR REFERENCES, TO FIND AN IBCLC IN YOUR AREA, AND TO DOWNLOAD THE
VISIT ILCA.ORG FOR REFERENCES, TO FIND AN IBCLC IN YOUR AREA, AND TO DOWNLOAD THE
CLINICAL GUIDELINES FOR THE ESTABLISHMENT OF EXCLUSIVE BREASTFEEDING
CLINICAL GUIDELINES FOR THE ESTABLISHMENT OF EXCLUSIVE BREASTFEEDING
CLINICIAN’S BREASTFEEDING TRIAGE TOOL
CLINICIAN’S BREASTFEEDING TRIAGE TOOL
ASSESSMENT
TREATMENT
ASSESSMENT
TREATMENT
NIPPLE BACTERIAL INFECTION
1) Refer to IBCLC* for latch assessment
NIPPLE BACTERIAL INFECTION
1) Refer to IBCLC* for latch assessment
2) Apply smal amount mupirocin ointment/cream to nipples 2) Apply smal amount mupirocin ointment/cream to nipples after feed x 10d; may also apply steroid ointment/ cream after feed x 10d; may also apply steroid ointment/ cream after feed to speed healing (no need to remove either after feed to speed healing (no need to remove either med before next feeding unless baby refuses) med before next feeding unless baby refuses) VASOSPASM
1) Refer to IBCLC* for latch assessment
VASOSPASM
1) Refer to IBCLC* for latch assessment
2) Have mother gently squeeze blood down into nipple to 2) Have mother gently squeeze blood down into nipple to • Blanching nipple after or between feedings • Blanching nipple after or between feedings • Deep shooting, burning, or stinging breast pain • Deep shooting, burning, or stinging breast pain 4) Consider nifedipine SR 10mg po 3x/d x14d 4) Consider nifedipine SR 10mg po 3x/d x14d If not painful: No treatment necessary
If not painful: No treatment necessary
If painful:
If painful:
• If bleb rises when pressure applied to nipple 1) Rub gently with warm, damp cloth until opened or soak in • If bleb rises when pressure applied to nipple 1) Rub gently with warm, damp cloth until opened or soak in base, may correspond to plugged duct in breast warm water to soften bleb and open with sterile needle base, may correspond to plugged duct in breast warm water to soften bleb and open with sterile needle 2) Breastfeed or pump frequently to remove thickened milk 2) Breastfeed or pump frequently to remove thickened milk Note: Small hardened milk strands or crystals
3) Apply small amount OTC antibiotic ointment on wound Note: Small hardened milk strands or crystals
3) Apply small amount OTC antibiotic ointment on wound released after bleb is opened are normal after breastfeeding until healed (avoid neomycin) released after bleb is opened are normal after breastfeeding until healed (avoid neomycin) PLUGGED DUCT
1) Refer to IBCLC* for milk transfer and latch
PLUGGED DUCT
1) Refer to IBCLC* for milk transfer and latch
assessment, screening for pressure from bra,
assessment, screening for pressure from bra,
MOTHER • Localized breast pain, usually unilateral
sleep position, etc
MOTHER • Localized breast pain, usually unilateral
sleep position, etc
• Possible erythema and/or tender lump/area 2) Breastfeed frequently beginning on affected breast • Possible erythema and/or tender lump/area 2) Breastfeed frequently beginning on affected breast 3) Position baby w/ chin pointing toward painful area 3) Position baby w/ chin pointing toward painful area • Typically more painful before breastfeeding • Typically more painful before breastfeeding 4) Massage gently w/ edible oil during breastfeeding 4) Massage gently w/ edible oil during breastfeeding • Usually afebrile or below 38.5°C (101.3°F) or pumping: Start at areola edge, massaging toward • Usually afebrile or below 38.5°C (101.3°F) or pumping: Start at areola edge, massaging toward nipple, repeat slightly higher until reaching leading nipple, repeat slightly higher until reaching leading • Milk production may temporarily decrease • Milk production may temporarily decrease MASTITIS
1) Refer to IBCLC* for milk transfer assessment
MASTITIS
1) Refer to IBCLC* for milk transfer assessment
2) R/O overproduction, insufficient milk removal 2) R/O overproduction, insufficient milk removal POSSIBLE S/S:
POSSIBLE S/S:
3) Breastfeed frequently on both breasts or pump q2-3h 3) Breastfeed frequently on both breasts or pump q2-3h 5) SCRUPULOUS hand washing, shorten nails 5) SCRUPULOUS hand washing, shorten nails 7) Febrile or s/s not resolved after 24h: dicloxacillin
7) Febrile or s/s not resolved after 24h: dicloxacillin
Note:
or flucloxacillin 500mg po 4x/d x10-14d
Note:
or flucloxacillin 500mg po 4x/d x10-14d
8) If unresponsive to therapy, culture milk to determine 8) If unresponsive to therapy, culture milk to determine 9) 3 or more recurrences: R/O scar tissue, underlying 9) 3 or more recurrences: R/O scar tissue, underlying pathology (eg, fibroids, mass or inflammatory breast CA) pathology (eg, fibroids, mass or inflammatory breast CA) CANDIDAL OVERGROWTH
1) R/O vasospasm, bacterial infection, dermatitis, and CANDIDAL OVERGROWTH
1) R/O vasospasm, bacterial infection, dermatitis, and • Bilateral nipple/areola sharp pain, itching, or • Bilateral nipple/areola sharp pain, itching, or 2) Check mother and baby for other sites; treat if found 2) Check mother and baby for other sites; treat if found 3) INFANT: Fluconazole suspension 3mg/kg po 1x/d x7d 3) INFANT: Fluconazole suspension 3mg/kg po 1x/d x7d OR apply <1% gentian violet 1x/d to mouth x3d only. OR apply <1% gentian violet 1x/d to mouth x3d only. Apply miconazole, clotrimazole, or nystatin cream to Apply miconazole, clotrimazole, or nystatin cream to • Possible infant oral thrush and/or shiny • Possible infant oral thrush and/or shiny 4) MOTHER: Apply small amount miconazole, 4) MOTHER: Apply small amount miconazole, clotrimazole, or nystatin cream to areola/ nipples after clotrimazole, or nystatin cream to areola/ nipples after Note:
feed (no need to remove prior to feed) OR apply ≤1% Note:
feed (no need to remove prior to feed) OR apply ≤1% ANT AND MOTHER G Both mother and baby must be treated if either
gentian violet 1x/d to areola/nipples x3d only. For ANT AND MOTHER G Both mother and baby must be treated if either
gentian violet 1x/d to areola/nipples x3d only. For persistent/recurrent infections: Fluconazole 200-400mg po x1d loading dose, then 100-200mg po 1x/d x14d persistent/recurrent infections: Fluconazole 200-400mg po x1d loading dose, then 100-200mg po 1x/d x14d 5) SCRUPULOUS hand washing, shorten nails 5) SCRUPULOUS hand washing, shorten nails Breastfeeding Priorities: 1) Feed the baby —> 2) Protect the milk production —> 3) Fix the problem
Breastfeeding Priorities: 1) Feed the baby —> 2) Protect the milk production —> 3) Fix the problem
T H I S T O O L I S N O T I N T E N D E D T O R E P L A C E M E D I C A L E V A L U A T I O N O R J U D G M E N T
T H I S T O O L I S N O T I N T E N D E D T O R E P L A C E M E D I C A L E V A L U A T I O N O R J U D G M E N T
* International Board Certified Lactation Consultant
* International Board Certified Lactation Consultant
VISIT ILCA.ORG FOR REFERENCES, TO FIND AN IBCLC IN YOUR AREA, AND TO DOWNLOAD THE
VISIT ILCA.ORG FOR REFERENCES, TO FIND AN IBCLC IN YOUR AREA, AND TO DOWNLOAD THE
CLINICAL GUIDELINES FOR THE ESTABLISHMENT OF EXCLUSIVE BREASTFEEDING
CLINICAL GUIDELINES FOR THE ESTABLISHMENT OF EXCLUSIVE BREASTFEEDING
Copyright 2007 International Lactation Consultant Association (Rev 2: 5/07) Copyright 2007 International Lactation Consultant Association (Rev 2: 5/07) Developed by Diana West, BA, IBCLC • Concept by Madonna Fasimpaur, LPN, IBCLC Developed by Diana West, BA, IBCLC • Concept by Madonna Fasimpaur, LPN, IBCLC

Source: http://www.ilca.org/files/Bookstore/Triage%20Tool-2007-Sample-web.pdf