COMMON BREASTFEEDING PROBLEMS

Mrs BY had a baby 3 weeks ago, she was said to have developed a high grade fever with chills and rigor. She said she cannot go for outings due to her cultural belief which forbids new mum with babies who are less than 6 weeks from going out. She then called the hospital she delivered who recommended antimalarial and paracetamol for her. She did not get better and decides to see a doctor in a clinic close to her house. She was examined by the doctor, the temp was 39 degree centigrade, the two breasts were swollen, tender and an area of redness (inflammation) was seen. The doctor explained saying that this is a breastfeeding problem and not malaria but mastitis. She was treated with antibiotics and analgesics and got well. She was also reassured that she can continue with her medications and breastfeeding.

Worldwide, breastfeeding is recognized as the best way to feed an infant because it protects mother and infant from a variety of health problems. Even so, many women who start out breastfeeding stop before the recommended minimum of exclusive breastfeeding for six months. Often women stop because common problems (listed below) interfere with their ability to breastfeed. With sound guidance and appropriate medical treatment, most women can overcome these obstacles and continue breastfeeding for longer periods.

BREAST ENGORGEMENT

Engorgement is a medical condition that can be experienced by breastfeeding mothers. The breast milk will come in around 24 to 72 hours after birth. A degree of fullness may be experienced in the breasts at this time. After a feed at least one breast should feel soft and light (well drained). Engorgement is caused by a build-up of blood, milk and other fluids in the breast. It will occur if the baby is not feeding and attaching well and the breasts aren’t drained well during a feed. Less commonly it may occur if the body is making more milk than the baby needs. 

Signs and symptoms: Engorgement results in very full and often painful breasts.

Treatment of engorgement: Ensure your baby is attached well when breastfeeding. Feed the baby frequently at least 8 to 12 times every 24 hours. Do not limit the baby’s time at the breast. Express a small amount of milk before you feed to soften your breast and help the baby to attach. Use cool towel or clothe from the refrigerator (not freezer) for comfort.

BLOCKED MILK DUCTS

A blocked duct causes tender or painful lumps as a result of milk building up in the breast behind a duct. Milk ducts are small tubes inside the breast that carry milk through to the nipples.

Signs and symptoms: A painful red lump or swollen spot on the breast. One may also see a white spot on the nipple which is another sign that a duct may be blocked. Blocked or plugged ducts are areas of the breast where the flow of milk is blocked. They can stretch the nearby breast tissue and cause a painful breast lump.

Management of blocked ducts: Feed frequently from the affected side first. Gently stroke the breast towards the nipple during the feed. This may assist the let-down reflex. For comfort and to reduce swelling from excess fluid apply a cold cloth or towel. Express after feeding. If there is a white spot on the nipple – soak the nipple with a warm moist cloth and the health worker rub or scratch off the spot with a sterile needle to allow the duct to open and the milk to flow again. Use paracetamol or anti-inflammatory tablets according to directions.

Prevention: Ensure correct positioning and attachment. Frequent drainage of the breast. Alter your position during breast feeds to include underarm position, cradle position or lying on your side. Check for a white ‘spot’ on the nipple as this may be blocking the milk duct. Avoid sudden long gaps between breastfeeds or expressing for your baby, tight or restrictive clothing such as a bra, pressing or holding one area of the breast too tightly, especially close to the nipple.

MASTITIS

Mastitis occurs when there is a blockage of milk in the milk duct. Some milk may leak out of the duct into the surrounding tissues causing inflammation and infection. Milk ducts are small tubes inside the breast that carry milk through to the nipples

Signs and symptoms: the breast has a red, painful area, An aching flu-like feeling such as a fever, feeling shivery and generally unwell. Seek medical help if fever lasts more than 6 hours.

Treatment of mastitis Drain the breast frequently. Attach the baby to the affected side first. You may need antibiotics for 10 to 14 days. Keep the breast drained by expressing the affected breast after each feed. Cool cloths from refrigerator (not freezer) can relieve discomfort and pain. Anti-inflammatory medication such as ibuprofen will reduce the inflammation and pain. Paracetamol may be taken to ease discomfort.

NIPPLE PAIN, SORES AND CRACKS

Another common reason mother’s stop breastfeeding early is nipple pain. The causes of nipple pain includes: Nipple injury (caused by the baby or a breast pump), Sore nipples are one of the most common complaints by new mothers. If the nipples are cracked or raw, one can put expressed breastmilk or a nipple cream, petroleum jelly, ointment on them, and cover them with a nonstick pad. This will keep the injured part of the nipple from sticking to the bra Nipple vasoconstriction, which means the blood vessels in the nipple tighten and do not let enough blood through. To determine the cause of your pain, your healthcare provider will examine you and your baby, and watch you breastfeed.

Are you having issues with establishing breastfeeding? Talk to a lactation expert today (doctors, gynaecologists, paediatricians, nurses and other health workers who are highly skilled in breastfeeding issues). There are foods and medications called galactagogue that can help to increase breastmilk supply, this works best when a mother has low prolactin levels (i.e when there is a genuine, not a perceived, low milk supply issue), and after a mother has received support and education to improve her breastfeeding or expressing technique.

HEPATITIS B AND C MANAGEMENT IN NIGERIA

Hepatitis. Prevention, Diagnosis and Management

I read the pathetic story of a concerned citizen entitled, Hepatitis management in Nigeria: A red alert, published in the newspaper.
The writer said, “I find it compelling to call attention to the dangerous state of medical knowledge in Nigeria, as experienced in the last three years of my battling a chronic disease called Hepatitis B. Without prejudice to my respect for professionals in Nigeria, I owe it a duty as a concerned Nigerian to raise a red flag on this.”
The patient raised many issues: how the medical experts were unable to help him out of his dilemma; how he was able to join an hepatitis online community group abroad where he got the up-to-date information about the management of hepatitis; how he has been able to stay alive several years after the diagnosis; and how he lost a friend to the complications of hepatitis B Virus due to inadequate management.
There is also the issue of not knowing what to do, where to go for treatment and who to see when it comes to hepatitis.
While working at a National Paediatric Hospital, I had several encounters with many young men who are willing to donate blood to save the life of sick children, but most of them failed to meet the requirements, as they were infected with either Hepatitis B or C.
Also, women attending antenatal clinics were screened, and a few of them had the virus. Such women were counseled on the risk to the pregnancy, the possible effects on the unborn babies as well as on their partners.
Hepatitis is an inflammation/infection of the liver and can result in liver cell damage and destruction. Many people mistakenly think that hepatitis means viral hepatitis, and that all forms of hepatitis are contagious. Actually, the word ‘hepatitis’ just refers to any inflammation of the liver; or the irritation or swelling of liver cells from any cause.
Causes of hepatitis
Toxic hepatitis: This form can occur if someone drinks a lot of alcohol, takes certain illegal drugs or medications, or is exposed to poisons.
Viral hepatitis: There are lots of hepatitis viruses: from Hepatitis A virus to Hepatitis G virus. Though the viruses differ, they have one thing in common: They cause infection and inflammation that are harmful to liver cells.
Non viral infective hepatitis: Malaria Hepatitis and also autoimmune liver disease
The biggest obstacle confronting hepatitis treatment in Nigeria is not necessarily the deadly nature of the virus or even the spread of the disease, but a lack of awareness among Nigerians about the importance of discovering their hepatitis status.
Hepatitis B affects people of all ages. Most adults who become infected with Hepatitis B get rid of the virus within six months. This type of short infection is known as an acute case of Hepatitis B. About 10 per cent of adults infected with the Hepatitis B virus develop a chronic, life-long infection.
People with chronic infection may or may not have symptoms. Those who do not develop symptoms are referred to as carriers. Hepatitis B is acquired through contact with infected blood and body fluids. These viruses are usually transmitted by contaminated needles (in the case of intravenous drug users). Having unprotected sex with someone who is infected can also pass on the Hepatitis B virus. Having chronic Hepatitis B may lead to permanent liver damage, including liver cirrhosis and cancer.
The diagnosis of hepatitis B Virus is a major issue, as it has an impact on every part of life for the person who receives the diagnosis. It is a potentially chronic and life-limiting illness, associated with considerable social stigma, effects on quality of life, and consequences for decisions about work, relationships and having children.
Diagnosis of hepatitis B Virus is the first step in an effective treatment pathway for those with HBV. After diagnosis is treatment, but most of those infected stop at this first step partly due to reassurance by the health workers that there is no imminent danger, thereby postponing the evil day.
Chronic hepatitis B Virus happens if the hepatitis test (HBsAg) is repeated in six months from the time the test was first done and it came out as positive. It is said to be chronic HBV.
Hepatitis profile/viral markers :There are six parameters used in the management of HBV.
HBsAg — This is a marker of current infection or recent vaccine. Positive result means that the person is either infected or recently immunised. This is the first test and the beginning of the management. Every patient with positive result must be tested for the remaining HBV markers.
Anti-HBs — This is the marker of immunity from resolved infection or vaccine. Any patient with this is fully immunized either from the Hepatitis B vaccine or from total recovery from virus. This category of people don’t require treatment
Anti-HBc — This is a marker of current or past infection .It will show those that are recently infected (acute HBV) or those infected in the past (chronic carrier).
HBeAg — This is a marker of viral replication and infectivity. Any patient with a positive result is highly infected and may need adequate treatment.
Anti-HBe — This is a marker of the immune control in chronic hepatitis B
HBV DNA — This is a marker of viral replication commonly called viral load. Any patient with high viral load result is highly infected and will need adequate treatment. It is also used to monitor the progress with treatment.
ALT — This is a marker of liver inflammation, not a viral marker but a liver function test. When it is high, it shows the liver is undergoing inflammation.
Treatment
The treatments for acute and chronic infection are considered separately. The majority of hepatitis B Virus encountered in Nigeria is due to chronic infections. Treatment of acute hepatitis B Virus is supportive in most cases, consisting of bed rest, nutritional support and symptomatic management such as simple analgesia and anti-nausea medications.
The treatment of chronic HBV can be life-long and it is explained below:
General (lifestyle modification): Alcohol consumption should be ceased, cigarette smokers should be advised to quit, weight reduction with sound nutritional advice is ideal. Eat plenty of vegetables, legumes and fruits. Eat plenty of cereals, preferably whole grain, lean meat, fish, poultry, milk, yoghurt, cheese and regularly drinking water. AVOID SPOILT GROUNDNUTS/PEANUTS! Poorly preserved groundnuts contain toxins (aflatoxin)that are poisonous to the liver.
Vaccination: The diagnosis of hepatitis B is also an opportunity to prevent its spread through vaccination. The standard regime is at three doses at between zero and six months respectively. Post-vaccine laboratory test is required to be sure the person is fully immune.
For the person who has already acquired hepatitis B, it is too late to vaccinate against HBV, but further liver injury by another virus — hepatitis A — can be prevented.
Hepatitis B immune globulin is indicated as a post exposure prophylaxis for people at risk of developing hepatitis B because they have been recently exposed to body fluids of individuals who have hepatitis B.
Newborn treatment: Up to 90 per cent of infants born to HBeAg-positive mothers acquire the infection if untreated. The concurrent administration of two injectables Hepatitis B immunoglobulin and the Hepatitis B vaccine to the newborn immediately after birth is effective in preventing vertical transmission of the virus.
If the neonate has taken the two injectables, the mother with HBV infection can breastfeed the neonate safely because there is no increased risk of transmission. Children born to HBV-positive mothers should be assessed for their hepatitis B status after the completion of the course of vaccination.
Sexual partners of HBV positive persons should be counselled to protect themselves from sexual exposure to infectious body fluids such as semen and vaginal secretions, by using condoms; or by receiving full immunisation against hepatitis B virus.
Medication: The treatment may be appropriate in some patients. It is very rare that anti-viral drug treatment will lead to a cure for HBV infection.i.e.it is treatable but not curable. The long-term aim of treatment is to arrest or reverse the progression of liver damage, with the ultimate goal of preventing cirrhosis, cancer of the liver and liver failure.

Dr Adesanya has several certifications on Hepatitis management from western Australian government sponsored e-learning programme.

VIRAL HEPATITIS IS PREVENTABLE

A reader of this column sent this, “I am 35 years; I just found out I have hepatitis B virus. I never used drugs and I don’t drink. I’m so afraid right now, and I can’t stop crying. I don’t have a clue as to how I contracted it. The different tests listed by my doctor scare me. Dear doctor, kindly advise me’’.

My response as an expert goes to everyone that has tested positive to hepatitis B or C virus. They should be optimistic, as some people have been able to flush out the virus from their system within six months.

The tests are just the beginning of treatment, be patient with your doctor so that proper diagnosis could be done after which treatment follows.

The United States Centres for Disease Control and Prevention has declared the month of May as Hepatitis Awareness Month and May 19 as Hepatitis Testing Day in some countries.

The day provides an opportunity to remind the public and health care providers about the essence of hepatitis testing. Millions of Nigerians have chronic hepatitis, most of whom do not know that they are infected.

Viral hepatitis

Hepatitis is an inflammation of the liver. It can be caused by alcohol, drugs, bacteria, viruses and other toxins.

Viral hepatitis refers to hepatitis resulting from infection of the liver by viruses. These include the hepatitis A, B, C, D and E. The most common forms of viral hepatitis are hepatitis A, hepatitis B and hepatitis C.

Hepatitis A is acute, with no long-term effects. Hepatitis can be acute or long-term (chronic). An acute infection will last only a short time. Although symptoms could be severe, most people recover from the illness within six months with no lasting effects.

Chronic hepatitis is ongoing, and can last for the rest of a patient’s lifetime. Having chronic hepatitis B may lead to permanent liver damage, including liver cirrhosis and cancer. Hepatitis C, if left untreated, can be life threatening.

Transmission

Hepatitis A

It usually spreads through food or water. Food can be tainted when it is touched by a person with hepatitis who does not wash his hands after using the bathroom. This transfers tiny amounts of infected stool to the food.

Raw shellfish, fruits, vegetables and undercooked foods are common means of hepatitis A outbreak. The virus can also spread in daycare centres if employees are not careful about hand washing after changing diapers.

Hepatitis B

It is spread by contact with the blood or body fluids of an infected person or through unprotected sex. It is also possible to get hepatitis B by sharing an infected person’s needles, razors or toothbrush. An infected mother can pass the virus to her baby during childbirth. Hepatitis B is not spread by hugging, sharing of food or coughing.

Hepatitis C: It spreads through infected blood. Sharing needles or other items used to inject drugs is the most common cause of infection. Getting a tattoo or body piercing with an infected needle is another means of exposure. A mother may pass the virus to her child at birth.

Signs and symptoms

People with chronic infection may or may not have symptoms. Those who do not develop symptoms are referred to as carriers.

Symptoms are fatigue, tiredness, unexplained weakness, flu-like symptoms, dark urine, pale stool, abdominal pain, loss of appetite, unexplained weight loss, yellow skin and eyes, which may be signs of jaundice.

Treatment

Treatment of acute hepatitis B is supportive measure in most cases. It consists of bed rest, nutritional support and symptomatic management such as simple analgesia and anti-nausea medication. The treatment of chronic HBV can be life-long. It is explained here:

General (lifestyle modification): Alcohol consumption should be ceased; cigarette smokers should be advised to quit; weight reduction with sound nutritional advice is ideal. Patients should be encouraged to eat plenty of vegetables, legumes and fruits. They should also eat plenty of cereals, preferably whole grain, lean meat, fish, poultry, milk, yoghurt, cheese and drink water regularly.

Medication: Anti-viral drug treatment is used to manage HBV infection. Some individuals have been able to achieve cure. The long-term aim of treatment is to arrest or reverse the progression of liver damage, with the ultimate goal of preventing cirrhosis, cancer of the liver and liver failure.

Newborn treatment: The concurrent administration of two injections – hepatitis B immunoglobulin and hepatitis B vaccine – to newborn immediately after birth is effective in preventing vertical transmission of the virus. If the neonate has taken the two ‘injectables’, mother with HBV infection can breastfeed safely.

Preventions

Hepatitis A and Hepatitis B can both be prevented with vaccines. Hepatitis A vaccine is recommended for all children and for adults who may be at increased risk. Hepatitis B vaccine is recommended for all infants at birth and for adults who may be at risk. For an individual that has already acquired hepatitis B, it is too late to vaccinate against HBV, but further liver injury by another virus — hepatitis A — can be prevented.

Sexual partners of HBV positive persons should be counselled to guard against exposure to infectious body fluids such as semen and vaginal secretions, by using condoms during sex. They can also receive full immunisation against hepatitis B virus.

I plan to conduct a seminar on World Hepatitis Day, which comes up on July 28. Save the date!