Chapter 16 Breast feeding

Vitamin D recommendations for an infant

a supplement of 400IU/day, beginning shortly after birth for all infants, including those exclusively breastfeed.

suckling

helps establish/maintain lactation "demand and supply" - stimulates the hypothalamus to decrease prolactin-inhibiting factor and permits release of prolactin by the anterior pituitary - prolactin levels are directly proportional to the level of suckling by the infant

protein content of human milk

- 0.9% of human milk content - 60% to 70% whey -30% to 40% casein

Oxytocin - "letdown reflex"

-Oxytocin reacts with receptors in the myoepithelial cells of the milk ducts to initiate a contracting action that forces milk down the ducts. -This action increases milk pressure called the let-down reflex or milk ejection reflex . - Oxytocin also aids in maternal uterine involution, a mechanism protective of the new mother's life by reducing blood loss after birth.

Cradle position/ Cross-cradle position

Cradle position/ Cross-cradle position -mother sitting upright with her feet on the floor or stool or her legs crossed in front - infant held or supported with pillows - mouth at nipple height, - mother and infant are in a tummy-to-tummy arrangement

Breastfeeding discharge planning

Discharge planning -Review positioning/latch-on Review signs of progress/adequate nutrition -Arrange daily follow-up for 2-3 days -Phone contact for concerns -Breastfeeding resources

Medications for Breastfeeding Mothers

Drugs normally safe for infants Avoid long-acting forms of drugs Feedings when drug levels lowest Observe infant for changes in feeding, fussiness, other symptoms Select drugs with lowest levels in breastmilk Avoid drugs that inhibit prolactin release Cautious use of herbal preparations

Mammogenesis

Mammogenesis - final stages in pregnancy - Estrogen, progesterone, placental lactogen, and prolactin all play a role. - by approximately 20 weeks, the breast is capable of milk production - actual production of breast milk is triggered by the fall in progesterone concentration after birth of the baby and delivery of the placenta.

Special considerations for breastfeeding

Significant maternal/infant illness Documented history of milk supply problems Invasive breast surgery (maternal) >Donor milk available

stages of milk production

colostrum, transitional milk, mature milk

Breastfeeding combined with foods for at least ____________.

first year

positions for breastfeeding

lay back hold, football or clutch hold, cross-cuddle hold

-Collection/storage of breast milk

Cleaning pump Store in small amounts Up to 8 days in refrigerator/cooler for 24 hours Up to 3 months if frozen Room temp: 4 hrs Refrigerator: 5-7 days Deep freezer: 6-7 months (thaw milk by submerging in warm water)

mothers returning to work

Continue to breastfeed Access to private space to pump Breaks/lunchtime for pumping (need 30 minutes) Supportive colleagues/supervisors Maximum of 8 hours of work/day

Breastfeeding problems: Flat/inverted nipples

Description/epidemiology - nipple that pulls in or everts with compression Differential diagnosis - dimpled, fissured, unusually shaped Management Prenatal - breast shells in 3rd trimester Postpartum - breast shells, manipulation of nipple Complications - frustration, inadequate nutrition, engorgement, stopping breastfeeding

Economic benefits of breastfeeding

Free/plentiful Decreased medical costs

The primary care pediatric nurse practitioner is counseling the mother of a newborn about breastfeeding her infant. Which supplements will the nurse practitioner recommend? a. Fat-soluble vitamins b. Iron c. Multivitamins with iron d. Vitamin D

ANS: D The level of vitamin D in breast milk may not be adequate for breastfed infants, so it should be given as a supplement. Human milk has more than adequate amounts of other vitamins. Iron is not present, but this is generally added at 6 months of age, when solid foods are added to the diet.

Human milk vitamin and mineral content

- more than adequate in A, E, K, C, B1, B2, B6. - Low in vitamin D, iron

Frequency/duration of feedings

-8-12 feedings per day after the first 24 hours - 20-45 minutes/feeding -Pumping - if separation more than 1 or 2 feedings > unnecessary for mothers available q2-4hr for feeding. > if the mother is separated for more than one or two feedings, pumping should be done as soon as possible

Early feedings

-As soon as possible after birth (30-60 minutes) -Awareness of sleep/alert cycles -Practice latch-on/suckling

Principles of correct breastfeeding positioning

-Mother/baby comfortable -"Face on" at nipple ( so that no head-turning or tilting is required) -Infant on the side, not back, with good alignment ( belly to belly with the mother) - The infant's body should be in good alignment, with a straight line from ear to the shoulder to the hips. -Top and bottom lips flanged out -The tongue extends forward over the lower gum line and cups around the nipple and areola -Quiet feedings - no "click" or "pop" sounds should be heard from the infant -Audible swallowing, such as "glug" or air blowing out the baby's nose, should be heard

Benefits of breastfeeding to mother

-Rapid return to nonpregnancy state -Establishment of the strong bond -Decreased risk for breast and ovarian cancer -Decreased metabolic syndrome, type 2 diabetes, postpartum depression

Benefits of breastfeeding

-Vitamins, minerals, macronutrients, antibodies, specific for humans -Ideal support for the growth of infant -Properties change as the infant grows -Short- and long-term benefits Lower risk of gastroenteritis, NEC(necrotizing enterocolitis), AOM in early childhood), lower respiratory tract infections, asthma, atopy, diabetes, SIDS, leukemia

Baby Friendly Hospital Initiative

-Written breastfeeding policy/staff training 10 point criteria -Teach benefits/management of breastfeeding -Initiate breastfeeding within 30 minutes - 1 hour of birth -Breastfeed/maintain lactation if separated from infant -No food or drink for infants other than breast milk -Rooming-in practices -No pacifiers -Breastfeeding support groups

Transitional milk

-appears between 32 and 96 hours after birth - the drop in placental hormones and increased prolactin levels triggers the transition milk. -More lactose, calories, fat/less total protein -Breastmilk produced between colostrum and mature milk, during the first 4-10 days postpartum.

Colostrum milk

-begins at about 16 weeks of gestation Fewer calories, lower fat than mature milk Rich in immunoglobulins/antibodies Facilitates passage of meconium Meets all needs of term newborn in first few days -thin, yellowish, "immature" milk, may appear at any time from late pregnancy to early postpartum -rich in protein, minerals, and vitamin A - higher in Na, K, Cl, protein -fewer carbs and calories -contains antibodies and immune system cells -encourages the growth of good bacteria in the large intestine -natural laxative

Lipid content of mature milk

-most variable - during/between feedings, and over time -

Contraindications to breastfeeding

1) HIV 2) galactosemia in baby 3) HSV if lesions on breast- herpetic lesions on mothers nipples, areolas,or breast) - expressed breastmilk can be fed to infant 4) HBV until neonate has received HBV vaccine 5) Acute maternal disease if absent in infant (e.g., tuberculosis , sepsis) 6) Breast cancer receiving tx/ dx of cancer with treatment 7) Substance abuse 8) Mother with diagnosis of untreated brucellosis (an infectious disease caused by a type of bacteria called Brucella. The bacteria can spread from animals to humans) 9) Maternal dx of human T-cell lymphotropic virus type 1 or 2 10) Maternal use of cocaine, PCP and cannabis

Breastfeeding exclusively for first ___________.

6 months

Healthy People 2020 breast feeding goals

81.9% of mothers initiating breastfeeding 60.6% breastfeeding by 6 months 34.1% breastfeeding by 1 year 56.2% breastfeeding exclusively for 3 months Removal of barriers for working mothers Efforts to support breastfeeding

What percentage of breastmilk is water?

90%/can meet all hydration needs

Breast milk jaundice

>Description/epidemiology - elevated bilirubin on 7th-10th day >Clinical findings : -Healthy, thriving infant -Adequate stooling/voiding/weight gain -Elevated bilirubin levels; peaks around day 10 to 15 >Diagnostic tests - serum bilirubin; cultures as needed to rule out infection >Differential diagnosis - pathologic jaundice >Management - continue breastfeeding/reassurance

Breastfeeding problems: Sore Nipples

>Description/epidemiology - irritation, trauma - -Improper latch-on/positioning -Inappropriate suction release -Nipple cream sensitivity -Incorrect use of supplies (pumps, shells, shields) -Thrush Incorrect air-drying of leaking nipples >Clinical findings - tenderness, bruising, raw/cracked/bleeding nipples >Differential diagnosis -Mild tenderness in early stages -Trauma from another cause -Mastitis/abscess -Milk plugs at nipple pores >Management: Assess and prevent earl, Colostrum onto nipple; Expose to air; Use breast shells to prevent friction; Short, frequent feedings from least sore side first; Pump if needed Mild analgesia

The primary care pediatric nurse practitioner performs a well child assessment on a 6-month-old infant whose mother reports having less breast milk because of stressors associated with pumping and returning to work. The nurse practitioner will provide resources to promote pumping and what other intervention? a. Discussing adding other foods to the baby's diet. b. Encouraging the mother to increase her fluid intake. c. Prescribing a multivitamin containing iron. d. Suggesting offering only breast milk to the infant.

ANS: A After 6 months, infants should continue to breastfeed while taking other nutrients, at least up to 1 year of age. The mother should be encouraged to continue breastfeeding while adding other nutrients. The mother has successfully breastfed up to this point and increasing fluids is not the source of the problem.

The mother of a newborn infant asks the primary care pediatric nurse practitioner about pumping her breasts when she returns to work in 2 months. What will the nurse practitioner include in teaching this mother? a. Frozen breast milk may be stored up to 3 months in a 0° F freezer. b. Once she begins pumping the infant should drink only pumped breast milk. c. Pumped breast milk must be discarded after 3 days when stored in the refrigerator. d. Unused defrosted breast milk may be stored in the refrigerator for 48 hours.

ANS: A Frozen breast milk may be stored up to 3 months in a well-regulated freezer. It is not necessary to use only pumped breast milk once this begins. Refrigerated breast milk may be stored up to 8 days. Once frozen breast milk is thawed it should be used within 24 hours.

The primary care pediatric nurse practitioner is examining a newborn who is breastfeeding and notes the presence of an ankyloglossia. What will the nurse practitioner do next? a. Ask the mother if the infant has any feeding difficulties. b. Refer the infant for a possible frenulectomy. c. Schedule an appointment with a lactation consultant. d. Suggest that the mother feed breast milk by bottle.

ANS: A Infants with ankyloglossia may have difficulty feeding if the tongue does not extend well. The PNP should first assess feeding difficulties and then may refer for a lactation consultant or consider a frenulectomy

The mother of a 15-month-old infant tells the primary care pediatric nurse practitioner that she wishes to continue nursing her child for another year, if possible. What will the nurse practitioner recommend? a. Breastfeed only at bedtime to establish meal patterns. b. Clean the toddler's teeth after each breastfeeding. c. Offer the breast just prior to meals to maintain the milk supply. d. The toddler should continue to be breastfed "on demand."

ANS: B One drawback to breastfeeding toddlers is the effect of prolonged contact with lactose on the teeth. Mothers should be cautioned to consult with a dentist and to clean the toddler's teeth. The mother may choose when and how often to breastfeed but should not allow "on demand" feedings. The breast should be offered after meals

The primary care pediatric nurse practitioner learns that the mother of a newborn infant is being tested for tuberculosis after a positive TB skin test. What will the nurse practitioner tell the mother who states a desire to breastfeed her baby? a. Breast milk is contraindicated if the mother has tuberculosis. b. She may continue to nurse her baby since the risk of transmission is low. c. That she can express breast milk and feed that to her infant. d. To give formula until results of tuberculosis testing are known.

ANS: C A maternal diagnosis of active, untreated TB is a contraindication to nursing, but expressed breast milk may be fed to the infant. The mother may feed expressed breast milk; the milk itself is not contraindicated. Until active TB is ruled out, the mother should not breastfeed her infant. It is not necessary to feed formula if the mother can provide expressed breast milk.

The mother of a nursing infant expresses concern about whether high-cholesterol foods will increase her infant's risk of hyperlipidemia. What will the primary care pediatric nurse practitioner tell her? a. Breastfed infants have lower serum cholesterol levels than those who are not breastfed. b. Maternal cholesterol levels affect the cardiovascular risk of breastfed babies. c. Maternal dietary cholesterol intake does not affect the infant's serum cholesterol values. d. She should limit her dietary cholesterol to prevent hyperlipidemia in her infant.

ANS: C Changes in the maternal diet do not produce changes in cholesterol values in infants. Breastfed infants tend to have higher cholesterol levels than other infants, but cholesterol is necessary for brain and retinal development.

The primary care pediatric nurse practitioner is performing an assessment on a 1-week-old newborn with a slightly elevated bilirubin who is breastfeeding well and who has gained 30 grams in the past 24 hours. The infant is stooling and voiding well. The nurse practitioner suspects breast milk jaundice. Which action is correct? a. Order home phototherapy and closely monitor bilirubin levels. b. Reassure the mother that the bilirubin level will drop in a few days. c. Recheck the serum bilirubin and infant's weight in 24 hours. d. Recommend that the mother pump her breast milk for a couple of days.

ANS: C Infants with breast milk jaundice who are gaining weight and thriving should continue to breastfeed and be monitored for the development of pathologic jaundice. It is not necessary to order phototherapy or discontinue breastfeeding unless pathologic jaundice is present. The bilirubin may remain elevated up to 3 months.

The mother of a newborn asks the primary care pediatric nurse practitioner about the benefits of breastfeeding. What will the nurse practitioner tell her? a. Breastfeeding for 9 months or longer will reduce the incidence of food allergies. b. Breast milk is an excellent source of vitamin D, iron, and other essential nutrients for the baby. c. Nursing her baby exclusively for at least 4 months will help her infant to resist infections. d. There is a decreased risk of atopic dermatitis in babies who nurse for 12 months or longer.

ANS: C There is evidence that infants who exclusively breastfeed for at least 4 months have less risk for infection than infants breastfed for less time. However, infants who breastfeed exclusively for 9 months or for longer than 12 months may have increased risks for food hypersensitivities and atopic dermatitis. Breast milk is a poor source of vitamin D and iron.

10. The mother of a 2-month-old infant tells the primary care pediatric nurse practitioner that she is afraid her breast milk is "drying up" because her baby never seems satisfied and wants to nurse all the time. Which action is correct? a. Recommend pumping her breasts after feedings. b. Refer the mother to a lactation consultant. c. Suggest supplementation with formula. d. Weigh the infant to assess for a growth spurt.

ANS: D Infants have growth spurts about every 3 to 4 weeks that increase their breast milk needs. Until the mother's milk supply catches up, the infant will act hungry and want to nurse more frequently. The PNP should evaluate for this growth spurt and then instruct the mother to feed her baby more often to increase her milk supply. Since the infant is hungry, the infant should nurse. It is not necessary to refer for a lactation consultation or to supplement with formula.

The primary care pediatric nurse practitioner sees a 3-day-old nursing infant whose newborn metabolic screen is positive for galactosemia. The nurse practitioner refers the newborn to a specialist for immediate evaluation and will tell the mother to do what? a. Continue to breastfeed her infant. b. Give the infant a cow's milk formula. c. Supplement breast milk with formula. d. Stop breastfeeding immediately.

ANS: D Infants with galactosemia cannot consume galactose, which is in both cow's milk and breast milk. Since there is a potential for a life-threatening response, the mother should be instructed to stop nursing immediately.

The primary care pediatric nurse practitioner performs an initial well-baby exam on a 1-week-old infant who is breastfeeding and who is at birth weight. The mother tells the nurse practitioner that her baby is already sleeping 5 or 6 hours at night. What will the nurse practitioner recommend? a. Consultation with a lactation specialist to assess intake b. Pumping her breast during the night to maintain milk supply c. Supplementing the last feeding of the day with formula d. Waking the infant up at least every 3 hours to nurse

ANS: D Newborn infants should nurse every 2 to 3 hours in order to establish a routine and stimulate milk supply. The infant has regained birth weight, which is expected by age 2 weeks, so weight is not a concern and a lactation consultation is not warranted. The infant should continue to nurse during the night, so there is no need for the mother to pump her breasts or to supplement with formula. Using formula from a bottle also causes nipple confusion and should be avoided.

Mature milk

The breastmilk after colostrum and transitional milk, typically beginning 2 weeks postpartum. -replaces transitional milk by the second week after birth -provides, on average, 20 kcal/oz. - ongoing milk is supported by autocrine, endocrine, and metabolic controls

The primary carbohydrate of human breast milk is____________________.

lactose; which is synthesized by the mammary gland from glucose. - Lactose supports growth of pathogen- competing microflora in the intestines and enhances the absorption of calcium- important because of low levels of calcium in human milk