Sonya, a 23 year old first time mother presents with her two week old baby girl, Jade. She is worried that she has poor milk supply and that the baby might not be growing. She reports her baby feeds very often, up to 10-12 times a day, and she does not seem to feed for long. However she does settle between feeds well. She has ~6 soaked nappies in 24 hours and one poo. She denies any nipple changes or pain.
The infants weight at birth was 3.2kg. She lost about 300 grams in the first few days which made it clear to her that breastfeeding was not enough. However she has put this back on now and is 3.3kg. Her neonatal exam is normal. She does not smoke and has no allergies. The midwife reviewed her at home 2 days ago and reported the attachment and breastfeeding technique were good. Sonya reports “Should I change to formula?”
What is your advice and management for Sonya? List 3
- Reassure her this history is normal
- Providing information on what constitutes ‘normal’ newborn feeding behaviour
- Follow up in 2 weeks
- Safety net to review earlier if concerns ( IS THIS OVERCODING OR INCLUDED?)
Case continued… Sonya continues breastfeeding and Jade continues to put on weight. However she presents again 3 weeks later with a painful and swollen left breast. On examination her temperature is 37.8, and her left breast has a localised area of erythema, tenderness and swelling.
What is your advice and management for Sonya now? List 6
- Continue breastfeeding
- Gentle massage and warm compress prior to feeding
- Using cold packs on the affected breast to relieve pain.
- Paracetamol 1g qid prn
- Minimum 5 days of flucloxacillin [or dicloxacillin] in a dose of 500 mg four times per day
- Review in 1-2 days
RACGP Feedback
In this case a 23 year old mother is presenting with her two week old baby concerned that she has poor milk supply and the baby is not growing. The case provides information to assess whether her concerns are correct to offer the appropriate advice and management at this point and in a follow up appointment when the mother presents with symptoms and findings suggestive of early mastitis.
The case was answered well with candidates giving appropriate advice in the initial presentation but in the management section many candidates gave extra responses by justifying their answers or providing the rationale. Candidates also erroneously provided lists of treatments, sometimes also providing alternatives on the same line. It is important to remember that in the exam there is one line provided for each answer requested so there there should only be one answer per line. In this part good answers included both continuing breastfeeding and the correct antibiotic alone with evidence based symptomatic management.
It is important for candidates to assess their current day to day practice and identify presentations or clinical areas they do not commonly see and ensure they review these areas as they prepare for the exam.
GPCC Feedback
The general guidelines that are usually given for weight loss and weight gain are: a baby loses 5-10% of birth weight in the first week and regains this by 2-3 weeks.
