Tanner Staging

What is Tanner Staging?

● is an objective classification system

● that providers use to document and track
● the development and sequence of secondary sex characteristics of children during puberty.
● Aka Sexual Maturity Rating (SMR)

It was developed by Marshall and Tanner while conducting a longitudinal study during the 1940s to the
1960s in England.
Based on observational data, they developed separate scales for:
I. the development of external genitalia: phallus, scrotum, and testes volume in males;
II. Breasts in females
III. Pubic hair in both males and females.
 Function

● utilized in pediatric and adolescent practice to counsel patients:

- about the timing of anticipated body changes

- perform appropriate medical screenings

- monitor for deviations in normal timing and sequence of physical signs of puberty that may represent physiologic
problems.

● Abnormalities may be caused by:

- idiopathic conditions

- nutritional deficiencies,

- HPG axis variations,

- or neoplastic and genetic disorders.

 Tanner staging of breast development in females

Stage Breast development Breast description

s
I
Prepubertal, with no palpable breast tissue.

II
Development of a breast bud, with elevation of the
papilla and enlargement of the areolar diameter.

III
Enlargement of the breast, without separation of
areolar contour from the breast

IV
The areola and papilla project above the breast,
forming a secondary mound.

V
Recession of the areola to match the contour of
the breast; the papilla projects beyond the contour
of the areola and breast.
Breastfeeding Policy
 CWMH Policy

CWM Hospital is firmly committed to “ensure that all women

are supported and encouraged to exclusively breastfeed their
children for the first 6 months of life and to continue
breastfeeding together with complementary food into the 2nd
year of life.”

To support its commitment the hospital sets down the following

policies to protect, promote and support breastfeeding within the
hospital premises, maternity unit, paediatric facilities & child
health clinics.
 
1. Step 1

The policy is routinely communicated to all staff.

A summary of policy that addresses the 10 steps with the

inclusion of components such as Code compliance, HIV/AIDS,
mother friendly care and support for non breastfeeding mothers is
displayed in all appropriate area in language that staff and
mothers can understand.
2. Step 2

Training for all clinical staff includes:

® Breastfeeding and lactation management- 20hrs minimum for

covering all essential topics including at least 3 hours of
clinical practice.
® Feeding the infant who isn't breastfed
® The role of the facility and its staff in upholding the
International code of marketing and subsequent WHA
resolutions.
® New staff are trained within 6 months of appointment
3. Step 3

All pregnant mothers are informed of:

® Basic breastfeeding management & care practice

® Risk of giving supplements to their babies during first 6 months
4. Step 4

All mothers and babies receive:

® Skin to skin contact immediately after birth for at least 60

minutes
® Encouragement to look for signs that their babies are ready to
breastfed and offer help if needed
5. Step 5

All breastfeeding mothers are offered further help with

breastfeeding within 6 hours of birth.
® All breastfeeding mothers are taught positioning & attachment
® All mothers are taught hand expression.

Mothers who decided not to breastfeed:

® Informed about risk & management of various feeding options
& assisted in deciding the suitable feeding option according to
their available resources and facilities.
® Taught to prepare the choice of feed & asked to demonstrate
what they learnt
® Given information on the risk & benefits of various options &
how to care for their babies if their not planning to breastfeed.
Mothers of babies in special care units are:

® Offered help to initiate lactation, offered help to start their breast

milk coming & to keep up the supply within 6 hrs. of their babies
birth
® Shown how to express their breast milk by hand and told to
breast feed or express at least 6 – 8 times in 24hrs to keep their
supply.
® Given information on risk & benefit of various feeding options
& how to care for their breast if they not planning to breastfeed
6. Step 6

Supplements/ replacement feeds are given to babies only:

® If medically indicated
® If mother has a fully formed choice after fully formed choice
receiving counseling on various options and risk & benefits of
each.
® Reasons for supplemental and replacement feeds are
documented
7. Step 7

All mothers and babies are room in together at all times:

®Separation is only allowed with justifiable and medical reasons.

®All reasons for separation is documented.
8. Step 8

Mothers are taught how to recognize baby's sign of hunger &

satisfaction

®No restriction placed on the frequency and duration of

breastfeeds.
®Mothers are encouraged to breastfeed babies on demand.
9. Step 9

Breastfeeding babies are not fed using bottles & teats:

®Mothers are taught about the risk of using feeding bottles.

®Mothers are also taught how to cup feed
®Breastfeeding babies are not given pacifiers and dummies.
10. Step 10

®Verbal and written information is provided to mothers on where

to access help and support with breastfeeding / infant feeding after
returning.
®The hospital works to foster or coordinate with mother’s support
groups &/or other community services that provide infant feeding
support.
LACTATIONAL MASTITIS AND
BREAST ENGORGEMENT

A00071202
Sarah Sharon Narayan
 BREAST ENGORGEMENT

• Engorgement — occurs either from interstitial edema with the onset of lactation after birth, or at other times
during lactation with accumulation of excess milk.
Etiology
• Primary: the engorgement occurs with the onset of copious milk production (ie, lactogenesis stage II), usually
between days three to five after delivery. It is due to interstitial edema of the breast prompted by the decrease in
progesterone levels after the placenta is delivered. (Transition from colostrum to mature milk)
• Secondary: typically occurs later when there is a mismatch between milk production and extraction as the
mother's milk supply exceeds the amount of milk removed by her infant. This may occur from excessive
stimulation of milk production via pumping, taking medications that increase milk supply, or decreased milk
extraction resulting in insufficient removal of breast milk (e.g., due to infrequent feeds, poor attachment,
ineffective suckling, abrupt cessation of breastfeeding).

• Medications such as antipsychotics, metoclopramide and domeperidone ( galactagogues) increase milk

production.
 CLINICAL FEATURES AND
MANAGEMENT

• Breast firmness and fullness • Some mothers may find use of a breast pump or hand
expression to be helpful. However, this use should be
• Pain and tenderness
limited to immediately before a feeding to soften the breast
How do we manage? because overuse will stimulate milk production and could
• Effective management hinges on adequate removal increase the engorgement.
of the milk. For primary engorgement, it is • For others, applying pressure toward the chest wall softens
important to ensure implementation of good feeding the edema and facilitates the latch.
techniques with a satisfactory latch and optimal
nursing positioning.
• If the areola is involved, manual expression of
small amounts of milk before the feeding will
soften the areola and facilitate latching
• Applying warm compresses or a warm shower enhances let-down and may facilitate milk removal either by hand
expression or with suckling
• After or between feedings, cold compresses may decrease the swelling and discomfort
• Analgesics such as ibuprofen and acetaminophen may decrease the discomfort
• Topical application of cool green cabbage leaves is soothing, inexpensive, and unlikely to be harmful
• Engorgement usually resolves over time.
• Complication of engorgement: mastitis
 LACTATIONAL MASTITIS (MILK
FEVER)

• Lactational mastitis-breast becomes painful, swollen, and red ( inflammation of the breast parenchyma)
• it is most common in the first three months of breastfeeding. (4-6 weeks postpartum) in approximately 10% of
nursing mothers.
• tends to occur in the setting of breastfeeding problems that result in prolonged engorgement or poor drainage,
including partial blockage of milk duct, inefficient milk removal or infrequent feedings, oversupply of milk,
nipple trauma, and pressure on the breast
• Initially, engorgement occurs because of poor milk drainage, probably related to nipple trauma with
resultant swelling and compression of one or more milk ducts.
• If symptoms persist beyond 12 to 24 hours, the condition of infective lactational mastitis develops (since breast
milk contains bacteria); this is characterized by pain, redness, fever, and malaise
 ETIOLOGY

• Partial blockage of milk duct; reduced drainage results in stagnant milk distal to the
obstruction
• Oversupply of milk
• Infrequent feedings
• Nipple excoriation or cracking
• Rapid weaning
• Illness in mother or baby
• Maternal stress or excessive fatigue
• Maternal malnutrition
 PATHOPHYSIOLOGY

• Nipple fissures facilitate the entry of bacteria located in the nostril and throat of the infant or on the skin of the mother
into the milk ducts during breastfeeding.
• Prolonged breast engorgement (due to overproduction of milk ) or insufficient drainage of milk (e.g., due to infrequent
feeding, quick weaning, illness in either the baby or mother) result in milk stasis, which creates favorable conditions
for bacterial growth within the lactiferous ducts.

• Staph aureus is the most common pathogen

• Streptococcus and E.coli (rarely)
• The risk of recurrence of mastitis in women with prior history of lactational mastitis is higher than in women with no
prior history.
 CLINICAL
FEATURES

• Tender, firm, swollen,

erythematous breast
(generally unilateral)
• Pain during breastfeeding
• Reduced milk secretion
• Flu-like symptoms, malaise,
fever, and chills
• In some cases, reactive
lymphadenopathy

It is a clinical diagnosis. Breast milk cultures can be done if mother is unresponsive to treatment, infection is severe or if it
keeps recurring. If mom shows signs of sepsis/ systemic infection, blood cultures can be performed.
 TREATMENT

• In nursing mothers, breastfeeding with alternate breasts is recommended every 2–3 hours. ( no need to stop breastfeeding)
• Analgesics (e.g., ibuprofen)
• Cold compresses
• Antibiotic treatment- Oral penicillinase-resistant penicillin or cephalosporin (e.g., dicloxacillin or cephalexin)
• In the case of methicillin-resistant Staphylococcus aureus (MRSA): clindamycin (risk of Clostridioides difficile colitis) or
trimethoprim-sulfamethoxazole (septrin not for <1 month old) or vancomycin (systemic illness)
• Tx for 5-7 days or 10-14 days
• In the case of inadequate response to initial treatment:
Initiate treatment according to breast milk culture results.
• Consider an underlying breast abscess, which requires surgical drainage.
Prevention
• Anticipatory lactational counseling
• To prevent recurrence: oral Lactobacillus probiotic
 BREAST
PROBLEMS
BREAST ABSCESS
CANDIDA MASTITIS
BREAST ABSCESS
– It is a painful build-up of pus in the breast caused by infection.
– Breast infections are divided into: Lactational and Non-lactational or Puerperal and Non-
puerperal.
– Breast abscesses are more common in lactating women.
– Clinical manifestation:
 History of breast pain, erythema, warmth, and possibly edema.
 Complain of fever, nausea, and vomiting, purulent drainage from the nipple, or the site
of erythema.
– Etiology of breast abscess:
 Lactational breast abscess: Staphylococcus aureus and Streptococcal species including
methicillin-resistant S. aureus.
 Non-lactational breast abscess: Result of mixed flora with S. aureus, Streptococcus, and
anaerobic bacteria.
CANDIDA MASTITIS – BREAST AND NIPPLE THRUST
– Thrush is a fungal infection caused by the organism Candida albicans, which can occur in the
nipples or breast tissue.
– Nipple pain that doesn’t go away even upon adjustment of breastfeeding attachment, may
indicate a breast problem.
– Breast and nipple thrush may be linked to a history of vaginal thrush, recent use of antibiotics or
nipple damage.
BREAST PROBLEMS
NIPPLE PAIN
Etiology:
Nipple injury:
Fissured nipple
●Normal nipple sensitivity
●Nipple injury- poor position or latch on, harsh breast
cleaning, infant biting, use of irritating products
● Areolar dermatitis
●Breast engorgement
Areolar dermatitis:
●Plugged ducts During an acute presentation,
vesicles, crusting, and erosions
●Nipple and breast infections are seen in the affected
areas (panel A),
●Excessive milk supply whereas in the chronic state, the
areas are generally dry,
erythematous and scaling (panel
B).
CARE OF TRAUMATIZED NIPPLES

• Assess infant positioning and technique

with nursing on the unaffected side

• If cracked or abraded, antibiotic ointments

can be applied

• Cool/ warm compresses to the nipple or

mild analgesics
Flat or inverted nipple