5/15/17

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Breas+eedingTelephoneCare

May25,2017,Duluth,MNPamelaHeggieMD,IBCLC,FAAP,FABMSheilaHumphreyRN,IBCLCKarinKishel,RN,CLE

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Disclosure

•  WehavenofinancialorethicalconflictstodeclarerelatedtothiseducaPonalacPvity

Objec'ves

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1.Outlinegeneralprinciplesofbreas+eedingtelephonecare2.IdenPfyreferencesandresourcesavailableforprimarycareclinicstousefortelephonetriageandadvice3.Discussbreas+eedingtelephonecarecaseexamples

WhatisBreas+eeding“TeleCare”MulPpleopPonsforcommunicaPonØ Telephonecalltoclinic-OB/Peds/FPØ MyChartorsimilarEMRportalØ Hospitalpost-dischargecallbackprogramØ WarmLine,CallstoLC,WICpeercounselingcalls,LLLorothercommunityorganizaPon

LearnyourscopeofpracPceandclinicprotocols

CommonBreas+eedingTelephoneConcerns

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•  DoIhaveenoughmilk?•  CanIbreas+eedwiththismedicaPon?•  “Isitoktobreas+eedifX?”•  Crying/fussybaby•  Stoolingissues,poopcolor•  Mombacktoworkanddaycareissues•  PumpingquesPons•  Sorenipplesorbreastpain•  Sleeping(ornot)

PrinciplesofBFTelephoneCare•  Listen!!AcPveandempathiclistening•  Restatewhatyouheard•  ClarifywithopenendedquesPons,verifythe“concern”•  KeepyourobjecPvity...HaveanopenmindforallpossibiliPes•  Gathermoreinfo-learnageofbaby(andgestaPonalage),what/how

isbabyeaPng,fever,sorenipples,breastpain,eliminaPon,bealertformentalhealthissues...

•  Reviewchart-WCCrecently?,missedappts,previouscalls•  Assesscaller’slevelofconcern-whyaretheycallingnow?•  Decideifvisitisneeded–when,where,who?•  GiveImmediateBreas+eedingPps–duringtransiPonbefore

beingseen,espifnottoday•  Reviewplan-includingf/u-officevisit,phone,MyChart,email

Breastfeeding Telephone Care Heggie, Humphrey, Kishel May 25 '17

5/15/17

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ClinicReferenceBooks HospitalPost-DischargeTelephonecallbackprogram

Telephonecallbackprogram

•  Whodoescall?-skilledlactaPonstaffathospital•  Calleverybreas+eedingmother2-3daysajerdischarge,soonerifindicated

•  UseEMRtogeneratelistofdischargedmothersthatisshareablewitheveryoneresponsibleforcalling

•  Plantomake2alemptstocall.Documentoutcome•  ProvidePhoneguidanceandclearrecommendaPons•  DifferentthanptsaPsfacPon/QIcallback-differentgoals

Telephonecallbackprogram-Benefits

•  Safetynet:– catchbabiesnotpooping,notlatching,motherswithnippledamage,engorgement,milkdelay

•  Safetynet:– Latepretermandearlyterminfants

•  Preventreadmission

•  Preventsprematureweaning•  Anotherpointofcontactajerdischarge•  BigmPINCscore!!

Case1-Frontdesk:“amomhasaquesPonaboutbreas+eeding”

•  “Mybabyisveryfussy–she’scryingnon-stop-andIthinkshe’sconsPpated.Shehasn’tpoopedfor2daysandIdon’tthinkIhaveenoughmilk”– Whataretheimportantnextsteps?– WhatinformaPondoyouneedtogatherbeforemakingaplan?

InformaPontoGatherBeforespeakingtoparent

•  ReviewChart•  Checkageofbaby•  CheckGAB(gestaPonalageatbirth)•  LastofficevisitdateandinformaPon

–  Growthchart–  Providernotesregardingmedicalissues,feeding,jaundice,parentalconcerns

–  DateandPmeofnextvisit-Appointmentmadeorneeded?•  Slowdown...getreadytospeaktoparent

Breastfeeding Telephone Care Heggie, Humphrey, Kishel May 25 '17

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InformaPontoGatherSpeakingwithparent

•  Hearparent'sconcerns•  GatheraddiPonalinformaPon•  Breas+eedingquesPons:

•  Howojenisbabynursing?•  Howlongdoesbabynurse?•  Areyouabletoseesuckingandhearswallowing?•  Doyouhavesorenipplesorbreasts?

•  EliminaPon:•  Howmanypeesandpoops?

Ø  SpecialnoteofcolorofurineØ  Colorandconsistencyofstool

•  Howdoesbabyseem?•  Awake,content,crying,sleepingalot?

•  Whathaveyoudonesofar?•  Whatmadeyoucallmenow?

MakingaPlan

•  RefertoBFtriagebookorotherreference•  Useyournursingjudgment•  Speaktoprovider,ifneeded•  Ifbabyisnewbornneedstobeseeninclinicwithin24hours

–  Ifjaundiceconcernsinpastorintelephonecalltodayoranyconcernsaboutdifficultytoarouse

•  SpeaktoproviderwithinformaPongathered-chartandparent’sreport•  Whenisappointmentavailablewithprovider?

•  Iflateindayornoprovideravailableandbaby’sbehaviorisconcerning,togotoED

•  Ifbabyhasbeengrowingwell,eliminaPonisnotconcerning,baby’sbehaviorisnotconcerning,bringinfornurseweightcheck–  Providervisitmaybeneededforparentwithconcerns

Case1-FussyBabywithnostoolx2days

Doesbabyneedclinicappttoday,ER,homecare,reassurance?•  Babyneedstobeseentoday

–  Ifagelessthan2weeks-veryconcerning•  Whenamomsays“Idon’thaveenoughmilk”

–  seetoday(orsoon)forweightcheck•  Baby“fussy”...think?sickbabyandseesoon•  Ifolderbaby-greaterthan1mo-reassuranceIFrecentclinicvisitwithokgrowth

•  Don’tuseconsPpaPonguidelineforBF?sJ

Case2-PrenatalCare Ø ApregnantwomanG1P0at34weekscallsthenurse-linewithbreasBeedingconcerns

Ø Shehadbreastimplants4yearsagoandisconcernedthatshewon’tbeabletobreasBeed

Ø ShewondersifitisevenworthtryingtobreasBeed

•  Howwouldyouadviseher?

Case3–pharmacistsaidnottobreas+eed

•  Mother/paIentcallsbecauseshewasjusttoldbypharmacist“nottobreasBeed”whiletakingfluconazoleforvaginalyeastinfecIon

•  6weekoldbaby,G1P1,6wkpostpartumvisit•  FluconazoleprescribedbyMD

– CanIsIllbreasBeed?– ShouldIstopthemedicaIon?– Whatwouldyoudonext?

Lookitup!Meds&Mom’sMilkLactMed

Breastfeeding Telephone Care Heggie, Humphrey, Kishel May 25 '17

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BreasBeedingandMedicaIons

•  Lookitup!•  References

•  MedicaPonsandMother’sMilk&LactMed(NIH)

•  AskMDs...andmakesuretheylookituptoo!•  CommonmedicaPonquesPons–lookitup!

– Cough,allergymeds– AnPdepressants– Anesthesia/surgicalprocedures– CT/MRIscans

Case4–cliniccall

•  PaIent-34yoG1P1•  3monthspostpartum-callsinwithfeverof101degreesx2days,feelslikeshehastheflu.Hasmildrunnynose

•  Sheisconcernedthatshehasavirusandthatherbabywillalsogetsick.CanshekeepbreasBeeding?Hermother-in-lawthinkssheshouldstopforafewdaysandstayawayfromthebaby

•  Babyjuststartedtosleep6hoursatIme– Whatdoyouthinktheproblemmightbe?

–  Howwouldyoucounselthismother?

Case5–daycare&bolles•  Baby4mo.Momhasbeenbacktoworkfor2weeksandisconcernedthatsheislosinghermilksupply.Sheusedtobeabletopump4-6oz,nowonlygets3-4ozeachImeshepumps

•  DaycareprovidersaysbabyissIllhungryaZera4ozbo[leandwantsthree6ozbo[lesratherthan4ozbo[les/day.Suggestedusingformula

•  Babysleeping7hoursatnight,andseemssaIsfiedaZerfeedsathome.Feeds7-8/day

•  Mompumpsonceatworkfor30minutesoverherlunchhour

Case54mo-daycareandbolles

•  Isthereaproblem?•  Whatwouldyousuggesttothismother?

_________________________________•  Babyseemstobedoingfine•  Mommayhavedecreasedmilksupply•  LactaIonconsultantmaybeneeded•  InmeanIme:gathermoreinformaIon...

Case5-daycare&bollesGathermoreinfo....Reviewchart•  Birthweight8lb6oz,Babynowweighs14lbs,followinggrowthcurve,“normalgrowth”perMDnote

•  Talkwithmomaboutplan....co-createtogether– Howojenisshepumping?– Whendoesshebreas+eed?– Cansheaddmorepumpsin24hrs?– Pumpmoreatwork–forshorterPme(2-3x)– Considermini-pumpsonweekend,?nightpump– 4ozbolleisok–babydoesnotneed6ozofEBM

BreasBeedingTelephonecare:Commonissuesforage

•  NB–latch,sorenipples,jaundice,stools,engorgement

•  1mo–fussiness,bolleintro,pacifier•  2mo–“consPpaPon”normalvariaPonofbreastfedstool,

preparingforworkreturn,storingmilk

•  4mo–distractedbaby,mombacktowork,milksupply

•  6mo–solidsintro,biPng•  9mo–decreasedinterestinnursingwithmoresolids,biPng

•  12mo–weaning,cow’smilkintro

•  2yrs–weaning,tantrums,family/publicpressuretowean

Breastfeeding Telephone Care Heggie, Humphrey, Kishel May 25 '17

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Summary-“Pearls”ofBFTeleCare

•  Listenandlistenagain...•  Keepanopenmind•  Slowdown•  Don’thesitatetobringbabyandmominforvisittoday...orsoon

•  Helpbuildconfidence•  Useresources–BFtriageprotocols,Meds&Milk•  Arrangeforandencouragef/ucalls•  Listenformentalhealthissues,copingskills•  Thinkbeyondthetelephone....

Breastfeeding Telephone Care Heggie, Humphrey, Kishel May 25 '17