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Unfolding Case Scenario 6-1 for Providing anticipatory guidance and supporting inclusive breastfeeding after breast surgery

Learning Objectives

  1. Describe signs of adequate breast milk production in the first 4 months postpartum
  2. Describe the normal growth pattern of breastfed infants in the first 4 months postpartum
  3. Identify clinical signs of hyperlactation based on maternal and infant presentation
  4. List the negative pediatric and maternal health consequences of hyperlactation
  5. Describe management strategies for hyperlactation

Question 1

A 41 year old G1P1 and her 3 day old newborn son have been cleared for discharge from the postpartum ward. The mother is concerned that her baby hasn’t had a wet diaper in 6 h and reports feeling exhausted from the night, which felt like one ‘marathon nursing session after the next.’ 

What is the expected number of wet diapers and stools per day in the first week of life?

Two wet diapers, one pink-tinged diaper, and three dark green, sticky stools on day of life 2.

Question 2

A 41 year old G1P1 and her 3 day old newborn son born at 39w0d have been cleared for discharge from the well-mother-baby ward. The mother is concerned that her baby hasn’t had a wet diaper in 6 h and reports feeling exhausted from the night, which felt like one ‘marathon nursing session after the next.’

You learn that the baby is 8% below birth weight and has not received any supplementation with formula and donor milk. The mother mentions that she didn’t have any medical conditions prior to pregnancy and that her pregnancy, labor, and delivery went smoothly. Which of the following is a risk factor for low milk production in this patient?

Lack of breast growth during pregnancy.

Question 3

A 41 year old G1P1 and her 3 day old newborn son born at 39w0d have been cleared for discharge from the well-mother-baby ward. The mother is concerned that her baby hasn’t had a wet diaper in 6 h and reports feeling exhausted from the night, which felt like one ‘marathon nursing session after the next.’ You learn that the baby is 8% below birth weight and has not received any supplementation with formula and donor milk. The mother mentions that she didn’t have any medical conditions prior to pregnancy and that her pregnancy, labor, and delivery went smoothly.

The mother mentions that she had breast reduction surgery nearly 20 years ago and that she has never been told by any healthcare provider that she may have difficulties with breastfeeding. She also does not remember what kind of breast reduction surgery it was.  When asked about breast changes, she said that her breasts increased in size and the areola darkened during pregnancy. What is the most common reason that a breast reduction surgery may contribute to breastfeeding difficulties?

Question 4

A 41 year old G1P1 and her 3 day old newborn son born at 39w0d have been cleared for discharge from the well-mother-baby ward. The mother is concerned that her baby hasn’t had a wet diaper in 6 h and reports feeling exhausted from the night, which felt like one ‘marathon nursing session after the next.’ You learn that the baby is 8% below birth weight and has not received any supplementation with formula and donor milk. The mother mentions that she didn’t have any medical conditions prior to pregnancy and that her pregnancy, labor, and delivery went smoothly. The mother mentions that she had breast reduction surgery nearly 20 years ago and that she has never been told by any healthcare provider that she may have difficulties with breastfeeding.

The mother is adamant that she wants to exclusively breastfeed. Many of her friends had a delay in milk coming in until day 7 or 10 postpartum, but she clearly doesn’t have that issue since she started feeling breast fullness this morning and her breast milk color now has a bluish-white tint. She grows visibly upset that you are bringing up the possibility of low milk production. What should be the focus of your conversation with the mother regarding the possibility of inclusive breastfeeding?

Question 5

A 41 year old G1P1 and her 3 day old newborn son born at 39w0d have been cleared for discharge from the well-mother-baby ward. The mother is concerned that her baby hasn’t had a wet diaper in 6 h and reports feeling exhausted from the night, which felt like one ‘marathon nursing session after the next.’ You learn that the baby is 8% below birth weight and has not received any supplementation with formula and donor milk. The mother mentions that she didn’t have any medical conditions prior to pregnancy and that her pregnancy, labor, and delivery went smoothly. The mother mentions that she had breast reduction surgery nearly 20 years ago and that she has never been told by any healthcare provider that she may have difficulties with breastfeeding. The mother is adamant that she wants to exclusively breastfeed. Many of her friends had a delay in milk coming in until day 7 or 10 postpartum, but she clearly doesn’t have that issue since she started feeling breast fullness this morning and her breast milk color now has a bluish-white tint. She grows visibly upset that you are bringing up the possibility of low milk production.

Even after you explained the reason why breast reduction surgery puts mothers at risk for low milk production, the mother is convinced that she will be able to produce sufficient milk for her infant to breastfeed exclusively. What is some information you can provide to the mother to reassure her that her infant is receiving enough milk?

“Your baby latches on well and seems satisfied after most feedings.”

Unfolding Case Scenario 6-2 for Providing anticipatory guidance and supporting inclusive breastfeeding after breast surgery

Learning Objectives

  1. Describe normal infant behavior and development during the first week of life
  2. List maternal and neonatal clinical signs associated with lactogenesis II and adequate breast milk intake when directly feeding at the breast
  3. Identify maternal risk factors for low milk production
  4. Understand when breast augmentation surgery may predispose to breastfeeding or breast milk production challenges
  5. Learn how to employ shared-decision making strategies when discussing inclusive breast milk feeding

Question 1

A 41 year old G1P1 and her 3 day old newborn son born at 39w0d have been cleared for discharge from the well-mother-baby ward. The mother wants to make sure that she knows what to expect in the coming week. She also wants to get some advice about breastfeeding as her baby spent the entire previous night attached to her breasts, with a preference for the right side.

What can you tell the mom about normal infant behavior in the first week postpartum?

“Newborns should be fed on a schedule to ensure they are taking in enough calories each day, although it is important not to feed for no more than 10 minutes per side. Letting a baby suckle at the breast longer than this will tire out the baby, burn excess calories, and put him at risk for excessive weight loss.”

Question 2

A 41 year old G1P1 and her 3 day old newborn son born at 39w0d have been cleared for discharge from the well-mother-baby ward. The mother wants to make sure that she knows what to expect in the coming week. She also wants to get some advice about breastfeeding as her baby spent the entire previous night attached to her breasts, with a preference for the right side.

The baby is 5% down from birth weight and as an appropriate number of wet and dirty diapers. The last stool has transitioned to a yellow-brown. The mother wants to know why he has a preference for the right side. She wonders if the breast milk in the left side tastes bad because of the silicone implant from her breast augmentation surgery from ten years ago. What should be your response?

Question 3

A 41 year old G1P1 and her 3 day old newborn son born at 39w0d have been cleared for discharge from the well-mother-baby ward. The mother wants to make sure that she knows what to expect in the coming week. She also wants to get some advice about breastfeeding as her baby spent the entire previous night attached to her breasts, with a preference for the right side. The baby is 5% down from birth weight and as an appropriate number of wet and dirty diapers. The last stool has transitioned to a yellow-brown. The mother wants to know why he has a preference for the right side. She wonders if the breast milk in the left side tastes bad because of the silicone implant from her breast augmentation surgery from ten years ago.

The mother tells you that her left breast was always smaller than the right. For cosmetic reasons she got breast augmentation surgery and was told by the surgeon that none of the milk ducts were severed so she won’t have any issues breastfeeding. What can you tell her about the potential risk for low milk production in the left breast?

“Because of your history of a smaller breast on the left side, you may not have enough glandular tissue to produce enough milk on that side. We will monitor your production from both breasts closely to optimize the amount of breastmilk your baby receives. It is most important that your baby is growing well, so we can discuss how to supplement with donor milk or formula.”

Question 4

A 41 year old G1P1 and her 3 day old newborn son born at 39w0d have been cleared for discharge from the well-mother-baby ward. The mother wants to make sure that she knows what to expect in the coming week. She also wants to get some advice about breastfeeding as her baby spent the entire previous night attached to her breasts, with a preference for the right side. The baby is 5% down from birth weight and as an appropriate number of wet and dirty diapers. The last stool has transitioned to a yellow-brown. The mother wants to know why he has a preference for the right side. She wonders if the breast milk in the left side tastes bad because of the silicone implant from her breast augmentation surgery from ten years ago. The mother tells you that her left breast was always smaller than the right. For cosmetic reasons she got breast augmentation surgery and was told by the surgeon that none of the milk ducts were severed so she won’t have any issues breastfeeding.

The mother wants to know how much each breast typically produces and at what point she will know whether the left has reached its full milk production potential.  What can you tell this mother regarding normal infant milk volumes during the first six weeks of life?

Feed your baby 2.5 oz of breast milk per pound of weight daily, with a maximum of 32 oz per day. By the second week of life, your milk supply will be established and you are unlikely to increase the amount of milk you produce daily. Because of this, as your baby grows, you will need to supplement with donor milk or formula.

Question 5

A 41 year old G1P1 and her 3 day old newborn son born at 39w0d have been cleared for discharge from the well-mother-baby ward. The mother wants to make sure that she knows what to expect in the coming week. She also wants to get some advice about breastfeeding as her baby spent the entire previous night attached to her breasts, with a preference for the right side. The baby is 5% down from birth weight and as an appropriate number of wet and dirty diapers. The last stool has transitioned to a yellow-brown. The mother wants to know why he has a preference for the right side. She wonders if the breast milk in the left side tastes bad because of the silicone implant from her breast augmentation surgery from ten years ago. The mother tells you that her left breast was always smaller than the right. For cosmetic reasons she got breast augmentation surgery and was told by the surgeon that none of the milk ducts were severed so she won’t have any issues breastfeeding.

After telling the mother that pumping after feeds to stimulate milk production will help, she expresses concerns about how much work that will be. She has to get back to work in 3 weeks since she is a partner at a law firm and she’s worried that this kind of feeding-pumping schedule will not be feasible. What is your response?