CLC ALL SECTIONS MW

Concern: Worried About Milk Supply: Baby Wants to Feed More Often Than Expected

-baby's feeding frequency is interpreted by family as sign of inadequate milk volume or poor milk supply *Ask yourself: -could this by normal baby behavior of first months of BF? -could this by normal baby behavior consistent w/ long-term nursing (change due to changes in baby distraction, playfulness, or sleep patterns)? -baby wt gain & output appropriate? -baby appear dehydrated, jaundiced, malnourished? *What to do about it: -if there are no indications of milk supply &/or intake problem, discuss normal baby behaviors appropriate for age of baby; observe feeding -if hx of problem & baby's wt gain, indicate possible milk supply or intake problem; take following steps: obtain prefeeding wt, observe a feed, conduct post feed wt; calculate milk transfer; calculate baby's daily approx needs -suggest other changes to feeding process indicated by observation -schedule follow up & referrals *Expected resolution: -when concern about milk supply is not confirmed by problems w/ baby's growth, the family's fears may diminish w/ empathetic counseling & teaching -when potential milk supply/intake problems are confirmed by poor growth in baby, resolution varies w/ nature of underlying problem -in rare cases it may not be possible to produce a full milk supply; frequent follow up is indicated *What else to consider: -comprehensive pediatric eval, teething, ear infections, & other issues can drive baby to seek breast for comfort more frequently -maternal physical eval, including hormonal levels; physical problems like retained placental fragments, thyroid & other hormone imbalances, PCOS, & hx of breast surgery & trauma have been associated w/ inadequate milk production

Diet & Milk Supply

-balanced diet is not needed to make "good" milk or "enough" milk -in cases of starvation and famine, milk is virtually identical to that of a well nourished woman -well nourished women who BF play with their babies more and BF exclusively for longer -fewer than 500 additional calories a day is all that is needed while BF -vegans may need additional B12

To Develop a Relationship w/ Procedural Knowers

-be prepared to back up statements with evidence -be knowledgeable about multiple sources of reference -limit personal stories -understand that options & change are part of the process

Receivers of Knowledge

-believe all authorities tell the truth -like to learn the right answer & repeat it to the teacher -can not tolerate ambiguity -submit to the command of authority- not inner voice -sense of self is embedded in external definitions & roles -live at the behest of those around them -believe that authorities tell the truth

Subjective Knowing

-believes knowing is personal, private and based on intuition &/or feeling states.. rather than on thought & articulated ideas that are defended w/ evidence -sense of self is embedded one external definitions & roles -sense of authority arises primarily from the power of the group -trust their own intuition -inner voice helps guide them -distrust male authority figures -"experts don't know what they are talking about" -trust other women w/ similar experiences (mom groups) -find female support groups helpful -attracted to natural things like BF -want to be helped by someone who has BF -interested in BF from her own point of view

S2S 9 Distinct Behaviors in Prep for Feeding

-birth cry -relaxation -awakening -activity -rest -crawling/sliding -familiarization -suckling -sleeping

Bleb Treatment

-blebs may exit when treated as clogs -sometimes blebs may need to be lanced by HCP

Anatomical Problems Causing Nipple Damage

-bottom lip turned in or tongue tie (lingual) damage -visible lingual frenulum is not the same as "tongue tie" -no study was able to report that frenotomy led to long term successful BF -the evidence for routine upper lip tie release is poor for improvements in BF

Resources For Making BF Friendly Workplaces

-break time for nursing mothers from US Dept of Labor -business case for BF from hers.gov for employers and employees -investing in workplace BF programs & policies (businessgrouphealth.org) -only 13% of workers in US have access to any paid leave, according to Bureau of Labor Statistics. 40% of US households w/ kids under 18, meanwhile, rely heavily on a mother's income (protections vary from state to state)

Concern: Worried About Milk Supply: Breasts Feel Empty

-breasts are described as feeling soft & empty *Ask yourself: -could this be normal breast changes of the first month of BF? -could these changes be consistent w/ long-term nursing (the change of milk production from "fill & store milk" to "milk production on demand")? -baby wt gain & output appropriate? -baby appear dehydrated, jaundiced, malnourished? *What to do about it: -if there are no indication of milk supply &/or intake problem, discuss normal breast changes; observe a feed -if hx of problem & baby's wt gain indicate possible milk supply or intake problem take the following steps: --obtain pre feeding wt --observe a feed --get post feeding wt; calculate milk transfer; calculate baby's approx daily needs & compare -suggest other changes to feeding process indicated by feeding observation -schedule follow up & referrals *Expected resolution: -when concern about milk supply is not confirmed by problems w/ baby's growth, the family's fears may diminish w/ empathetic counseling -when potential milk supply/intake problems are confirmed by poor growth in baby, resolution varies w/ nature of underlying problem; in rare cases it may not be possible to produce a full milk supply; frequent follow up is indicated *What else to consider: -comprehensive pediatric eval, teething, ear infection & other issues can drive the baby to seek breast for comfort -maternal physical eval, including hormonal levels; physical problems such as retained placental fragments, thyroid & other hormone problems, PCOS, & hx of breast surgery & trauma have been associated w/ inadequate milk production

Concern: Nipple/Breast Pain While BF & Continuing After & B/w Feedings: Candida Albicans, Yeast or Thrush

-burning pain during & after BF; shiny, flaky skin is visible on nipple & areola in many cases; in addition, white patches are seen in baby's mouth inside the cheeks & on the tongue; baby's diaper area may also have a yeast rash *Ask yourself: -has the baby had antibiotic tx that would predispose them to C. albicans overgrowth? -are the positioning & latch optimal? *Watch out for: -overdiagnosis of yeast as the cause of sore nipples w/o consideration of other possibility -thinking there is yeast inside the breast; researches have found no C. albicans in the milk of women w/ deep breast pain & suggest that it does not migrate into the breast *What to do about it: -both members of dyad & any vectors must be tx; vectors can include breast pump parts, pacifiers, bottle nipples, & any other object that can harbor yeast; in some cases, another family member may harbor yeast; tx is only effective when vector has also been eliminated -a variety of tx are available to be prescribed for both members of dyad; the oral suspension nystatin may be carefully applied inside baby's mouth, being sure to coat all surfaces; Nystatin may also be applied to nipple, areola, & baby's mouth; Fluconazole, an oral medication used to treat yeast may be prescribed for dyad -in addition, breast pump parts, washable breast pads, bras, & other possible vectors should be carefully cleaned; washing w/ hot soapy water is important; for fabrics, washing in hot water & drying in a hot dryer is recommended; some also recommend adding vinegar to the wash or final rinse; some vectors such as pacifiers, have to much biofilm that can't be removed easily & probably should be discarded *Expected resolution: -if the tx is effective & vectors are effectively cleaned, relief should be felt in 1 or 2 days, although it may take 5-14 days to finish prescriptions *What else to consider: -deep radiating breast pain is more likely to be related to bacterial that fungal infection -research indicates that breast discomfort may be reaction to contact w/ the yeast in baby's mouth, not a yeast "infection"; careful use of antihistamine has proven to be effective in this case -there is a concern about yeast in stored/frozen milk; freezing does not kill yeast; this is less of a concern for older, healthy babies than it is for premature, fragile, or ill babies *OVERALL: -we have seen many cases at the Center for BF w/ complaint of "persistent" cases of breast & nipple "yeast" w/o symptoms in the baby; the problem in virtually every one of these cases was actually suboptimal latch & positioning ; yeast tx has been instituted w/o careful eval of latch & positioning; yeast tx were thought to be ineffective or the yeast was "drug resistant" b/c the soreness did not lessen; always assess latch-on & positioning, even in cases where visible yeast is present in baby's mouth

Caffeine

-caffeine habit does not relate directly to amount of caffeine in milk -caffeine may accumulate in premature & very newborn infants -caffeine consumption during pregnancy & while nursing has no consequence on infant sleep -coffee consumption is not associated w/ duration of EBF

Candida albicans / Yeast / Thrush

-can be seen in mouth of baby (white on tongue that cannot be wiped off) -newer research is disproving the idea that "yeast" is a problem on the breast unless they both have symptoms -is thought to cause pain for mom &/or baby (pain is described as burning & itching pain) -may be visible or not -mom will have itchy, flaky, shiny skin

Company Sponsored Lactation Programs

-can enable parents to provide BM for their infants as long as they wish, even those who are the least likely to choose BF -programs often include a class on benefits of BF & services of a CLC -private room in workplace w/ equipment for pumping -57% provided exclusive BM or EBF at 6 mos

Skin-to-Skin & Feeding Cues

-can help babies w/ motor-state maturation -baby showing subtle feeding cues should be held S2S b/w feedings -if feeding cues are not observed after careful observation an urgent comprehensive pediatric exam should be done

MRSA (methicillin-resistant Staphylococcus aureus) On Breast

-can look like mastitis -is a newly recognized issue -often feel deathly ill (cannot even get off couch to make phone call)

Hemorrhage

-can result in anemia & Sheehan's syndrome -w/ Sheehan's the pituitary has been deprived of blood & its functions are impaired (can happen even if pp hemorrhage is well managed) -other symptoms include low blood pressure, anemia, fatigue, profound hair loss, dry dull hair, etc. (some symptoms may take more than 30 years to develop) -may be possible to have low grade or transient Sheehan-like symptoms that resolve fully or partially

Concern: Baby Has A Birth Defect: Cardiac Problem OVERALL

-cardiac defects are among the most common birth defects occurring in 1 in 100 births -BF or feeding expressed BM in the event that feeding at the breast is not possible can be a wonderful contribution to the health of the baby dealing w/ a heart problem

Concern: Baby Won't Latch: Baby Sporadically Refuses to Feed

*Ask yourself: -baby's wt gain & output appropriate? -what factors are associated w/ baby's refusal? -is refusal associated w/ change in milk flow, volume increasing during early weeks or during feed when milk flow increases? -is refusal associated w/ times that breasts are harder, fuller, & baby struggles w/ forming a teat? -what is diff about those feeds in which baby refuses breast? *Watch out for: -body lang of each member of dyad *What to do about it: -ask about conditions in which baby is refusing breast (time of day, portion of feed, baby's hunger level, how decisions are made about when to feed; presence of external stressors (noise level, activity in house, before or after separation from baby); use of bottles, pacifiers, or meds for each member of dyad) -probe for anything that is diff about the days and times that baby refuses to feed -observe a feed -if baby refuses to latch during observation, ask for baby to be S2S until feeding cues observed; encourage bringing baby to breast when feeding cues are observed -suggest trying alternate positions; encourage using hand expression to release few drops to offer baby; use alternate massage to increase flow if baby becomes fidgety -if problem seems to be that baby pulls away when milk flow increases, try less dependent & more upright position; be sure no pressure on back of head; if position change does not resolve inability to cope w/ changes in flow, a swallow study may be warranted -if observation & positioning guidance do not resolve refusal, comprehensive pediatric eval is indicated; medical problems must be ruled out (stuffy nose, infection, trauma); PCP may recommend supplementation; work to maintain/build supply thru milk expression; use expressed BM over formula & consider use of at breast supplementer -suggest other changes to feeding process indicated by feeding observation -schedule follow up & appropriate referrals *Expected resolution: -when reasons for refusal are IDed, problem should gradually resolve; nursing dyad learns how to accommodate one another gradually over early weeks of BF *What else to consider: -might the baby be in pain when held in certain positions?; comprehensive pediatric eval of baby is indicated; babies w/ birth trauma, torticollis, ear infection, teething pain, etc may refuse feeds -babies w/ neuromuscular conditions, experienced painful procedures to the head, & those who have been forced to the breast may refuse to feed -if supplementation is prescribed: use expressed milk preferentially; encourage S2S as much as possible to assist baby in developing comfort being held to breast; consider at breast supplementation; assist in ensuring expression is adequate to maintain abundant milk supply -ask nursing parent is any of the following are occurring: menstruation; fuller/harder breasts; change to higher milk volume in early days; baby response to milk volume increase during let-down; new use of perfumed lotion, soap, detergent, etc; starting or sporadically taking any new or strongly flavored meds, herbs, or nutritional supplements

Concern: Baby Has A Birth Injury: Fractured Clavicle, Bracial Plexus Injury, Etc.

*Ask yourself: -does abby cry or seem unable to feed when held in certain positions? -does holding or supporting the baby differently change the baby's ability to BF? *Watch out for: -people labeling the baby as spoiled or hard to please -family feeling inadequate -defining the situation as a "BF" problem & not seeking a medical eval -aspiration pneumonia *What to do about it: -investigate what the family has been told about the condition -determine feeding hx, how baby is fed, how baby is responding to feeding & so on -observe a feed -if baby is uncomfortable, try diff positions to attempt to take pressure off the injured area; babies w/ these conditions may feed best when they have less wt on the affected part of the body; this may require the use of pillows or other props to achieve comfort for the nurser -feeding study will determine if baby is aspirating milk; milk aspiration can lead to chemical pneumonia, which can be life threatening *Expected resolution: -often these conditions heal w/ time; however PT & other developmental interventions may be needed; babies w/ brachial plexus injuries often have problems starting solid foods as well *What else to consider: -comprehensive pediatric eval & OT &/or PT for the baby -swallow study

Concern: New Pregnancy While BF

*Ask: -hx of premature delivery, miscarriage, or threatened premature delivery? if so, the oxytocin mediated uterine contractions associated w/ BF may be a concern. in absence of this hx there is no research that says low risk women need to wean. -sore nipples? sometimes desire to continue BF thru pregnancy is stated by nipple pain is so uncomfortable that BF can't continue -is baby less than 1 year old, will baby be less than 1 year when pregnancy is 4-5 mos along? it's common that milk volume decreases as mature milk becomes colosseum in mid pregnancy. nutritional assessment of baby's intake will be needed to determine if baby will need formula supplementation *Watch out for: -appropriate nutrition for nurser & nursling -some babies get loose stools when milk becomes colostrum (colostrum is powerful laxative) -many worry that new baby will get less colostrum bc older baby takes it all during pregnancy. this is not found to be a problem as hormones of pregnancy trigger continued synthesis of colostrum until complete delivery of placenta *What to do about it: -offer support the family in either choice, to continue BF or wean -ensure adequate nutrition for nurser, nursling, and new baby *Expected Resolution: -sometimes family will wean when new pregnancy is discovered -sometimes family continues to BF -sometimes family decided to nurse both babies together (tandem nursing) --new baby should be fed first and often --important to find time for non-BF interactions w/ older baby *What else to consider: -sometimes it's decided to nurse and try tandem feeding, but older baby loses interest when volume decreases as milk changes mid pregnancy -may be asked whether a weaned older baby should be offered an opportunity to BF after the new baby is born. advise families to think carefully about ramifications of this offer before making it. many formerly BF children may have forgotten how to release milk from breast, but possible that weaned child does recall how to trigger milk flow & wants to return to BF -help family explore if they want that outcome

Risks of Delayed BF In Hours After Birth

*Mother: -decrease number of prolactin receptors activated -decrease amount of oxytocin/uterine contractions -decrease milk volume -decrease opportunities to practice w/ colostrum -decrease confidence -increase risk of supplementation *Infant: -increase risk of jaundice, sleepiness & lethargy -increase risk of hypoglycemia -decrease opportunities to practice w/ colostrum -increase risk of supplementation -increase pH & opportunistic microorganisms in gut

Normal Fullness vs Engorgement

*normal: -breast soft to touch -body temp normal -mom feels well -breast may be hot -baby can grasp nipple -rounder, fuller, firmer, heavier is normal (when you get past this it is engorgement) *engorgement: -breast hard -temp normal + -mom feels discomfort -breast hot, shiny -nipple difficult to grasp, baby can't latch

Galactosemia

-

AAP Response to BF-Associated Hypernatremia

-"ensure formal eval & documentation of BF by trained caregivers (including position, latch, milk transfer, examination) at least for each nursing shift" -"All BF newborn infants should be sen by pid at 3-5 days of age which is within 48-72 hours after discharge from hospital" -evaluate hydration (elimination patterns) -evaluate body wt gain (body wt no more than 7% from birth and no further wt loss by day 5; assess feeding & consider more frequent follow up) -discuss maternal/infant issues -observe feeding -*majority of peds are not able to observe all of these things*

To Support EBF In the Community

-"interventions to be delivered in a combination of settings by involving health systems, home & family & the community environment concurrently" (phone calls, classes, meetings) -systematic review indicates that programs that support moms in the pp period, in their homes, & extend over a relatively long period are the most successful in increasing EBF rates -skilled assessment & comprehensive intervention when BF is not working well -available, affordable, culturally competent lactation care & services for all families -community ownership of the need for support throughout the BF experience (task forces & coalitions) -trying to support BF by telling the family prenatally about problems could decrease the desire to try BF -we need to focus on ongoing support that is crucial to BF duration & exclusivity -BF support works best when we reach out to families rather than waiting for them to contact us -anticipatory guidance - timely (pro active) interventions to help moms tune into baby ages & stages (social support groups of moms w/ diff aged babies) -reactive support in which families are expected to initiate the contact, is unlikely to be effective -face to face support strategies are more likely to succeed -mothers rate social support more important than health care system support of BF -ideally this can happen in informal settings

What if Mother is Undernourished?

-"no significant differences in growth of babies b/w the supplemented and unsupplemented mother groups. But... infants of undernourished mothers may not receive the extra care and stimulation needed..." and the duration of exclusive BF was higher in the increased energy group"

Myth - Not Getting Enough Fluids

-"there is not enough evidence to support increasing fluid intake beyond what BF mothers are likely to require to meet their physiologic needs" -drinking more water does not necessarily increase milk supply in BF -only thing that increases milk production is feeding baby more frequently

10 Steps to Successful BF (2018)

-**1-2 Critical Management Procedures -1. (a.) Comply w/ International Code of Marketing of Breast-milk Substitutes & relevant World Health Assembly resolutions -1. (b.) Have written baby feeding policy that is routinely communicated to staff & parents -1. (c.) Establish ongoing monitoring & data management systems -2. Ensure that staff have sufficient knowledge, competence, & skills to support BF -**3-10 Key Clinical Practices -3. Discuss importance & management of BF w/ pregnant women & families 4. Facilitate immediate & uninterrupted skin-to-skin & support moms to initiate BF ASAP after birth -5. Support moms to initiate & maintain BF & manage common difficulties -6. Do no provide BF newborn any food or fluids other than BM, unless medically indicated -7. Enable moms & infants to remain together & practice rooming in 24 hrs a day -8. Support moms to recognize & respond to infant's cues for feeding -9. Counsel moms on the use & risks of feeding bottles, teats, & pacis -10. Coordinate discharge so that parents and infants have timely access to ongoing support & care

Making Milk

--Messages from the breast travel through the nervous system to the brain. Then, hormones travel to the breast through the blood stream. -ALVEOLAR CELLS (MILK IS WITHIN THESE CELLS) ARE SURROUNDED BY THE MYOEPITHELIAL CELLS (SMOOTH MUSCLE CELLS). THE THIRD LAYER IS THE CAPILLARY NETWORK (VERY RICH BLOOD SUPPLY THAT CAN OFTEN BEEN SEEN AS INCREASED VEINS ON BREATS DURING PREGNANCY) --DUCTS ARE UNEVENLY SPACED -FAT IS MIXED INTO THE BREAST, NOT ONLY BEHIND EVERYTHING -THERE IS NO LACTIFEROUS SINUS -There are two separate hormone pathways....the pituitary gland is important to both -Prolactin levels go down in between nursings and rise during nursing. -But infrequent nursing leads to lower levels and less rise even with the same amount of nipple contact (AS FREQUENCY DECREASES, PROLACTIN LEVELS GO DOWN) -In post-partum women, prolactin is much more responsive. -Bout is when nipple is stimulated - prolactin levels go up -Inter-bout interval when nipple is not stimulated - message to make milk recedes —lengthening the interbout interval is weaning

PCOS (Polycystic Ovarian Syndrome)

-1 in 10 women may have it -excess insulin increase production of androgens. High androgens can cause acne, excessive hair growth, weight gain, problems w/ ovulation & lactation -some women have no visible symptoms -some case studies suggest tx w/ metformin during lactation may increase milk volume others do not

Original 10 Steps to Successful BF (WHO/UNICEF 1989)

-1. Have written BF policy that is communicated to all health care staff routinely. -2. Train healthcare staff in skills necessary to implement the policy -3. Inform pregnant women about benefits & management of BF -4. Help moms initiate BF within 30 min of birth -5. Show moms hwo to BF & how to maintain lactation, even if they are separated from baby -6. Give newborn no food or drink other than BM, unless medically indicated -7. Practice rooming in (24 hrs a day) -8. Encourage BF on demand -9. No pacifiers or artificial nipples to BF babies -10. Foster establishment of BF support groups & refer moms to them on discharge

Concern: Baby Has A Birth Injury: Cephalohematoma or Caput Succedaneum

-cephalohematoma: lump on the skull caused by bleeding beneath the bones of the skull; the lump arises within hours of birth -caput succedaneum: swelling of soft tissues of baby's scalp that develops as the baby travels thru birth canal; this may occur when vacuum extraction is used to assist in birth *Ask yourself: -does baby cry or seem unable to feed when held in certain positions? -does holding or supporting the baby differently change the baby's ability to BF? -how is baby's head being supported? w/ this type of birth injury, there should be as little pressure on the head as possible *Watch out for: -people labeling the baby as hard to please or fussy -family feeling inadequate -jaundice arising from resolving cephlohematoma (the baby's body reabsorbs the blood, increasing the amount of bilirubin in circulation) *What to do about it: -investigate what the family has been told about the condition -determine the feeding hx, how baby has been fed, how baby is responding to feeding & so on -observe a feed -if baby is uncomfortable, try different feeding positions to attempt to take pressure off the injured area *Expected resolution: -often these conditions heal w/ time, however physical therapy & other developmental interventions may be needed; babies w/ racial plexus injuries often have problems starting solid foods as well *What else to consider: -comprehensive pediatric eval & OT &/or PT for baby -swallow study

Parent Led

-choose least favorite nursing -substitute something equally good in the eyes of the child -watch for reactions: physical & emotional -wait & repeat

10 Steps to Successful BF

-1. have a written BF policy that is routinely communicated to all health care staff --needs to be in support of the rest of the 10 steps & available in a format/language that the staff can access -2. train all health care staff in skills necessary ti implement this policy --need to know what S2S is, how to implement it, how to help moms express milk & how to help change the baby's position when feeding if baby/mom is uncomfortable; help them learn what they need to know to get thru the first weeks of BF & help them find their local resources -3. inform all pregnant women about the benefits & management of BF --why we should consider BF, what EBF means, how to get off to a good start w/ BF; know why these are important: S2S, rooming in, cue based feed, help them learn what they need to know to get rhubarb the first weeks of BF & help them find local resources -4. help mothers initiate BF within 1 hour of birth --key ideas: immediate S2S, uninterrupted & continuing until the completion of the first feeding --if family is not planning to BF, this S2S should still occur --of the 140 million live births in 2015, 77 million newborns had to wait too long to be put to the breast; only 45% of newborns were put to breast within first hour --16% of neonatal deaths could be prevented of all infants were BF from day 1 --S2S & Safe Sleep suggestions to improve safety have been developed by the AAP -5. show moms how to BF & how to maintain lactation, even if they are separated from their infants --feeding should be assessed at least once. a day while in hospital by CLC; if baby is in NICU work w/ mom & teach how to collect milk & get it to the NICU; if mom is in ICU, work w/ mom -6.give newborn infants no food or drink other than BM unless medically indicated (and follow "the Code") --if parent is not BF then they obviously can have formula, but this basically means that all BF infants should not be given formula "just because"; the WHO gives us a list of what "medical indications" & what are common medical indication for supplementation -7. practice "rooming in" allow moms & infants to remain together 24 hours a day -8. encourage responsive feeding --the four parenting dimension of responsive parenting are feeding, soothing, sleep, & physical activity -9. give no pacifiers or artificial nipples to BF infants --this doesn't pertain to NICU babies b/c NICU babies having pacifiers can be beneficial; pacifier can be given for procedures like circumcision; if parents bring in pacifier and decide to use it they should be educated & then if they choose to use it, that is fine -10. foster the establishment of BF support groups & refer moms to them on discharge from hospital or clinic --also providing support of BF/pumping employees

Guiding Principles of Milk Production

-1. milk removal is needed in order to make milk -2. infant requires nourishment to remove milk -3. above all, the infant cannot be compromised

Domperidone (Galactogogue)

-cochrane review: did not show improvement in longer term outcomes of BF -improvement of BF practices seems to be more effective & safer than use of off-label tx -it is not currently a legally marketed drug or approved for sale in the US -rare, but serious risks

Concern: Worried About Milk Supply: Baby Wants to Feed More Often Than Expected OVERALL

-common for parents to experience persistent concern about milk supply if they don't understand the easy digestibility of BM, responsive feeding, feeding cues, & satiety cues -acknowledging, normalizing, & exploring this concern is indicated -this concern should be taken seriously regardless of baby's growth

Immature Babies

-commonly less alert, have less amino, & have greater difficulty w/ latching, sucking vigorously & transferring milk -state: from deep sleep to crying -very subtle feeding cues -may have no suck or suck w/ no swallow -may be unable to sustain a feed

BF Protection from Diarrhea

-1. pH of gut (gut of BF baby is more acidic while formula guts are more neutral/basic) -gut microbiome of mixed fed babies are similar to exclusively formula fed babies (just given a bit of formula in the hospital will change the acidity/basicness of a baby's gut for 6 weeks) -2. low iron in guy (relatively low iron in BM) -3. presence of bifidus factor in milk promotes intestinal presence of lactobacillus bifidus that maintain low pH and crowd our pathogenic organisms -formula fed have increased number of species w/ overrepresentation of clostridium difficile (C-diff) which can cause excruciating pain -4. presence of hormones (hormone like factors and growth factors that stimulate grown and development of GI tract & GI motility such as GI hormones, prolactin, EGF (epidermal growth factor), prostaglandins) -5. antibodies such and SIgA (secretory IGA) bind to microbiomes in baby's intestinal tract and prevent them from being absorbed into rest of the body (mom's IgA can protect from development of necrotizing enterocolitis (NEC) in preterm infants) -maternal IgA shapes the host-microbiota relationship of preterm neonates & that IgA in BM is a critical and necessary factor for prevention of NEC -6. white blood cells -7.cell wall disrupters kill microbes by destroying cell walls. these include fatty acids and lysozymes -8. B12 binding factor reduces amount go B12 in intestines available to microbes -9. lactoferrin - deprives bacteria of iron, disrupts integrity of outer membrane of bacteria, assists in intestinal maturation & in recovery of intestine from injury & other mechanisms -10. antimicrobial activity boosted such as fiber pectin & gamma interferon -11. mucosal wall protectors such as muffins and oligosaccharides (which also function as food for beneficial bacteria) adhere to microbes binding them so they they can't attach to the gut wall -12. microbes from mother's skin and bacteria in mom's BM seed the infant gut underscoring the importance of BF in the development of the infant gut microbiome. There is translocation of organisms from mom's intestine into her milk -13. absence of exposure to contaminants (bottles, teats, water) & formula ingredients -14a. when mom is exposed to organisms her immune system makes antibodies & secretes them in her milk -14b. cells from baby's mouth go into the breast... antibodies are made in the breast (baby is exposed to something & tells the breast that while BF and the antibodies are made in the breast) -15. synergistic effect of all of these mechanisms and other yet to be discovered (dynamic nature of BM stem cells may hold great promise for both the lactation field and regenerative medicine)

Normal Newborn Expectation

-10-12 feeds per 24 hour time period -several bowel movements each day from day 2 through the first 6 weeks (and beyond for most babies) 4 on 4 -several wet diapers daily -urinations does not equal wet diapers (sometimes there are 2-3 urinations in a diaper before it is changed)

Laws for BF/Pumping at Work

-2010 US Health Care Reform Bill -amendment to Section 7 of Fair Labor Standards Act -employers of more than 50 employees -provide "reasonable break time for employee to express BM for 1 year after child's birth each time such employee has the need to express milk" -provide private place other than a bathroom

Complimentary Food Amount By Age:

-2x day for 6-8 mos -3x day for 9-24 mos -Additional snacks may be offered 1-3x daily

According to IFPS (About Workplace & BF)

-35% of pregnant women said their workplace was very supportive of BF but.... --52% of pp women said their workplace was very supportive --only about half of working women in US are covered by FMLA -what about staying home w/ new baby? --paid maternity leave could improve EBF rates at 6 mos --fewer than 10% of Americans surveyed disagreed that the US should have paid maternity leave

Global Strategy for Infant & Young Child Feeding: Operational Targets

-4 from Innocenti Declaration & 5 additional targets -1. Appoint national BF coordinator & establish multisectoral BF committee w/ representatives from relevant govt depts, non-govt orgs, & health professional associations -2. Ensure all facilities providing maternity services follow the "Ten steps to successful BF" by the WHO/UNICEF -3. Give effect to principles & aim of the International Code of Marketing of BM Substitutes & subsequent relevant Health Assembly resolutions in their entirety -4. Enact imaginative legislation protecting BF rights of working women & establish means for its enforcement -5. Develop, implement, monitor, & evaluate comprehensive policy on infant & YC feeding, in context of national policy & programs for nutrition, child & reproductive health, & poverty reduction -6. Ensure health & other relevant sectors protect, promote, & support exclusive BF for 6 mos & continued BF up to 2 years of age or beyond, while providing women access to support needed in the family, community, & workplace to achieve this goal -7. Promote timely, adequate, safe, & appropriate complementary feeding w/ continued BFs -8. Provide guidance on feeding infants & YC in exceptionally difficult circumstances, & on related support required by moms, families, & caregivers -9. Consider new legislation & other suitable measures may be required as part of comprehensive policy for infant & YC feeding, to give effect to principles & aim of the Code & subsequent relevant Health Assembly resolutions

FDA Findings about Formula

-77% of formula feeding moms so not receive instruction on formula prep & 73% did not receive storage instruction from a health professional -no consistent pattern of maternal characteristics (age, education, income, etc.) was associated w/ unsafe practices -FDA announced on June 9, 2014 that its finalizing a rule that sets standards for manufacturers of infant formula; standards include: --current good manufacturing practices specifically designed for infant formula, including required testing for the harmful pathogens Salmonella & Cronobacter --requirement that manufacturers demonstrate that the infant formulas they produce support normal physical growth --requirement that infant formulas be tested for nutrient content in the final product stage, before entering the market, & at the end of the product's shelf life

Postpartum Adjustment Disorder (PPAD)

-85% of women experience mood changes associated w/ hormonal changes, lack of support & many life changes -PPADs are not related to feeding choice -women w/ hx of PMS & prior dysphoric disorder have higher risk of PPAD -among women w/ BF difficulties, women who had negative experience w/ BF support had significantly higher risk of pp depression -Postpartum Post Traumatic Stress Disorder (PP-PTSD) --up to 9% of pp women met the DSM-IV criteria for PTSD after childbirth --two conditions significantly increases offs of PP-PSTD (depressive symptom scores & total number of physical symptoms experienced since the birth)

BF Promotion, Protection & Support

-A variety of community expertise is needed to Promote, Protect & Support Breastfeeding There are international models for integrating breastfeeding promotion, protection and support as well as balancing technical information, programs and protocols....

Breast Problems Etc

-ANY suspicious area or appearance of breast, nipple, areola should be referred at once to HCP b/s it could be MRSA or Herpes - deadly for babies so no BF or breast milk -careful assessment is needed when baby slips off breast, tires easily, repeatedly latches & sucks only a few times before letting go of the breast --many reasons for this: wrong state, poor positioning, not hungry, premature, dehydration/malnutrition, oral/facial anatomy, cardiac anomaly, neuro inadequacy, neonatal abstinence syndrome, meds, undiagnosed breast cancer, low milk supply, low milk volume, full stomach (i.e. cesarean surgery or fast delivery); womb positions (esp w/ torticollis), birth injuries, trauma (vacuum, forceps), maternal discomfort, oral aversive behaviors (from mouth exams, vents, suctioning, etc - use pen light to look for blisters in baby's mouth) -any recurrent feeding problem needs evaluation or referral

Hormones of Lactation Emotional/Behavioral Function

-Aggression (make us aggressive in terms of protection, feeling of I don't want anyone to harm my baby and I would protect my baby physically if I needed to) -Protection (hard for mothers to leave young babies and go back to work or even go out do dinner) -Bonding & Trust

Women who do not breastfeed are at greater risk for myocardial infarction and aspects of metabolic syndrome.

-Also greater risk for stroke if you do not BF -Metabolic syndrome is risk factors that occur together and increase risk of coronary artery disease, stroke, and type 2 diabetes -Nursing a baby for a year or more decreases by 10-15% the risk of developing hypertension, diabetes, hyperlipidemia and cardiovascular disease when postmenopausal compared to those who had been pregnant but never breastfed. Cardiovascular findings confirmed these results including among those who were premenopausal -Women who do not breastfeed are at greater risk of breast, endometrial and ovarian cancer -BF more than 6 mos causes decrease in breast cancer mortality

Concern: Birth Control (OVERALL)

-BC options are not thoroughly discussed in relation to BF plans, so families may thing that BF is not compatible w/ BC or that BF provides complete BC (both of which are not true)

Results of Cooper Findings (Severely Undernourished BF Babies)

-BF class was inadequate -inadequate post party follow up in the community -early discharge was NOT a factor -prenatal classes were NOT preventative -urinary output was NOT reliable measure of intake (count stools instead --should see meconium on first couple days, but if baby still has meconium on day 4 they may not be getting enough fluids --expect to see approx an oz of weight gain daily in early months but more may be needed for babies w/ metabolic or respiratory distress, LGA, SGA, etc. -babies were not IDed before 10% wt loss -a "contented" (sleepy) baby is not a well fed baby (calorically deprived babies are sleepy)

Confidence & BF

-BF discontinuation at 2 weeks was associated w/ lack of confidence in ability to BF on day 1 & 2 -achievement of exclusive BF may depend on her confidence to do so

Baby-Led Weaning

-BF goes to an "on request only" system & follows philosophy "never offer but never refuse" -only for babies 1 year and older -idea is that baby gets so involved in busy life that BF takes a more and more minor role

Weight Gain Expectations

-BF infants will be looked at by Dr/healthcare provider 48-72 hours after leaving facility

BF & Obesity

-BF is a significant protective factor against obesity in children -gut microbiota may play a part in childhood obesity, BF babies have a unique profile -recent study in Pennsylvania showed that as the amount of BF went up in a county, the % of kids diagnosed as obsessive went down (% of BF families in each county was found to be positively related to the # of CLCs in the county) -inverse relationship b/w BF & obesity is partially diminished when BM is fed from bottle because parents often want baby to finish whole bottle unlike when BF a baby stops when they want -BF is one of the CDC's strategies for obesity prevention plan for childhood along with: diet rich in fruits and veggies; increased physical activity -2010 White House Task Force on Childhood Obesity Report: support exclusive BF for 6mos & continuation of BF in conjunction w/ complementary foods for 1 year or more

WHO/UNICEF 3 Strategies for Increasing BF Initiation & Duration in Every Country

-BF promotion -BF protection -BF support

Implants (birth control)

-BF: nexplanon should be inserted after 4 wks pp; woman should be advised to use barrier method until 7 days after insertion; if intercourse has already occurred, pregnancy should be excluded -no difference in 24 month BF rates in one study comparing rods implanted in the immediate pp vs general population -IUDs (some have hormones) can be placed in the pp w/o affecting BF outcomes

BF & Environmental Contaminants

-BM can be studied to understand population exposure to environmental contaminants because it is easily accessible & rich in fats -scary headlines arise from reports of new findings -there may be specific populations at risk (generally agricultural or occupational) -toxic exposure to infant occurs largely in utero & minimally thru milk -BF should be universally encouraged & the environment should be cleaned up -environmental contaminants are minimal in milk compared to uterine exposure

Handling & Storing BM (GENERAL)

-BM is raw food -everything that comes into contact w/ it should be clean & dry -premature/fragile babies might need special containers or containers that are sterilized, might need to be frozen right away or never frozen -milk should be stored in containers in the amount baby is going to be offered at one feeding, not in the amount that was expressed -BM is a valuable commodity that deserves careful handling

Breastfeeding: A Public Health Priority

-Breastfeeding has been recognized as a public health priority in tropical climates since the 1930's - but not until the 1990's in the US -3M kids die from malnutrition every year, 25% of kids are stunted due to malnutrition, 100% of this is preventable!

Monitoring Breastfeeding Trends

-Breastfeeding has been the way to nurture babies since the dawn of human history. • However, in the last 150 years or so breastfeeding rates declined as the rate of commercial baby milk sales have increased.

What is a CLC?

-CLC is a nationally recognized designation awarded by ALPP* to those who are exam eligible and then pass the exam. The exam is based on a job task analysis. -CLCs have had their competency verified. The Certified Lactation Counselor certification program is based on the ISO/IEC 17024 Standard (for Personnel Certification). -No credential in lactation expands practice parameters beyond job description -All lactation credentials are certificates of added knowledge. Only ALPP's CLC, ANLC and ALC designations are competency verified -Both CLCs and IBCLCs are considered "health professionals who provide lactation support" by the CDC and may qualify to demonstrate competency for the ANLC or ALC credential.

What contributes to low rates of exclusive breastfeeding globally?

-Caregiver and societal beliefs favoring mixed feeding -Hospital and health-care practices and policies that are not supportive of breastfeeding -Lack of adequate skilled support -Aggressive promotion of infant formula and other breast milk substitutes -Inadequate maternity and paternity leave legislation and other workplace policies -Lack of knowledge about the dangers of not exclusively breastfeeding and of proper breastfeeding techniques

Complimentary Feeding

-Child id 6-23 mos old & Is getting human milk & solid or semisolid food.

Why BF is Stopped

-Concerns about milk quality/quantity -Feeding problems during 1st week -Problems w/ infant latching or sucking -Lack of appropriate info & support

Prolactin

-Dependent on nipple stretching (baby stimulating T3, T4, & T5 - thoracic intercostal nerves) -Not decreased by stress -Triggers production os lactose in mammary cells --presence of lactose draws water, which forms fluid milk --lactose is essential for milk production because it provides the driving osmotic force behind the fluid formation of milk

"Goals for the Nation"

-Developed in the 1970s for the US to complete by the 1990s; 75% initiation, 35% continuing to 6 months -New goals developed for year 2000; 75% initiation, 50% continuing at 6 months, 25% at 1 year -New goals in 2005; exclusive BF at 3 mos 40%, exclusive BF at 6 mos 17% -Trends in the 90s showed progress, but not to the levels anticipated -CDC Is no collecting comprehensive infant feeding statistics

Innocenti Declaration Call For Action, All Parties:

-Enpower women in own right & as moms/providers of BF support & info to women -Support BF as norm for feeding infants & YC -Highlight risks of artificial feeding & implication for health & development thru life course -Ensure health & nutritional status of women thru all stages of life -Protect BF in emergencies, including supporting uninterrupted BF & appropriate complementary feeding & avoiding general distribution of BM substitutes -Implement HIV & Feeding: Framework for Priority Action, inclusion protecting, promoting, & supporting BF for the general population while providing counseling & support for HIV positive women

Innocenti Declaration Call For Action, All Manufacturers & Distributors of Products within the scope of the International Code:

-Ensure full compliance w/ all provisions of the Code & subsequent relevant World Health Assembly resolutions in all countries, independently of any other measures taken to implement the Code -Ensure all processed foods for infants & YC meet applicable Codex Alimentarius standards

Innocenti Declaration Call For Action, All Govts:

-Establish or strengthen national infant & YC feeding & BF authorities, coordinating committees & oversight groups that are free from commercial influence & other conflicts of interest -Revitalize the BFHI, maintaining global criteria as the min requirement for all facilities, expanding the BFHI's application to include maternity, neonatal, & child health services, & community-based support for lactating women & caregivers of YC -Implement all provisions of the International Code of Marketing of BM Substitutes & subsequent World Health Assembly resolutions in their entirety as a min requirement & establish sustainable enforcement mechanism to prevent &/or address noncompliance -Adopt maternity protection legislation & other measures that facilitate 6 mos of exclusive BF for women employed in all sectors, w/ urgent attention to the nonformal sector -Ensure appropriate guidelines & skill acquisition regarding infant & YC feeding are included in both preservice & inservice training of all healthcare staff, to enable them to implement infant & YC feeding policies, & to provide a high standard of BF management & counseling to support moms toward optimal BF & complementary feeding -Ensure all moms are aware if their rights & have access to support, info, & counseling in BF & complementary feeding from health workers & peer groups -Establish sustainable systems for monitoring infant & YC feeding patterns & trends & use this info for advocacy & programming -Encourage media to provide positive images of optimal infant & YC feeding, support BF as the norm, & participate in social activities such as World BF Week -Take measures to protect population, esp pregnant & BF moms, from environmental contaminates & chemical residues -ID & allocate sufficient resources to fully implement actions called for in the Global Strategy for Infant & YC Feeding -Monitor progress in appropriate infant & YC feeding practives & report periodically, including as provided in the Convention on the Rights of the Child

Doctor Checkup 48-72 Hours After Leaving Facility

-Eval of hydration status & elimination patterns -Observe a feeding -Eval of weight gain/loss, (babies should lose no more than 7% of birth weight after 5th-6th day; if they do then close & careful follow up is needed) -Weight gain should be seen after 5th or 6th day -If baby is not gaining appropriately, explore possible issues w/ maternal milk supply and milk transfer related to daily BM requirements -Discuss other maternal & infant issues

Healthy People 2020 Goals

-Ever BF: 81.9% -BF at 6 mos: 60.6% -Exclusively BF to 3 mos: 46.2% -Exclusively BF to 6 mos: 25.5%

The First 1,000 days campaign is worldwide and includes breastfeeding!

-First 1000 days is conception up to 2 years -Pregnancy first 270 days; infancy 0-6 mos (180 days); toddler years 7-24mos (550 days) -Suboptimal breastfeeding accounts for more than 3,340 maternal and child deaths a year, of which 80% are maternal -For every 597 women who breastfeed optimally, one maternal or child death is prevented

BF Promotion

-Focuses on advantages of breastfeeding on a personal, community, country or global level

BF Protection

-Focuses on government, manufacturer and social responsibility to assure breastfeeding's ability to compete with commercial interests -Breastfeeding Protection Includes addressing improper marketing practices as described in "The International Code" -The American Academy of Pediatrics..... "... advises pediatricians not to provide formula, company gift bags, coupons, and industry-authored handouts to the parents of newborns and infants in office and clinic settings." -BF Protection In the US, state and local BF legislation addresses BF in public, employment issues, jury duty, family law, mothers in prison etc.

BF Support

-Focuses on the interaction of "helpers" with family as well as program development & implementation

Insulin Dysregularion (Prediabetes)

-GDM (gestational diabetes) & diabetes during pregnancy.. glucose intolerance but higher lactation intensity & longer duration are associated with lower DM odds after GDM -percent of women w/ GD who developed pp diabetes: did not BF 9.4%, did BF 4.2%, BF duration of 4-12 weeks made a difference

Contraindications to BF*

-Galactosemia (the ONLY ABSOLUTE contraindication to BF; must get special formula) -PKU (phenylketonuria) (must get special formula, amount of BF allowed will be determined by monitoring infants blood lvls. Other rare metabolic blood disds impact infant's needs) -Premature infants may need additional minerals, calories, & vitamins -Some professionals rec 400IU of vitamin D daily for BF infants -Other medical or nutritional. conditions may require additions to infants diet

Innocenti Declaration Call For Action, Public Interest Non-Govt Organizations:

-Give greater priority to protecting, promoting, & supporting optimal feeding practices, including relevant training of health & community workers & increase effectiveness thru cooperation & mutual support -Draw attention to activities that are incompatible w/ the Code's principles & aims so that violations can be effectively addressed in accordance w/ national legislation, regulations, or w/ other suitable measures

BF Goals for the US (Appendix R)

-Healthy People Goalsprovide objectives w/ 10 year targets designed to guide national health promotion & disease prevention efforts to improve the health of all people in the US

BF Goals for the USA (Appendix R)

-Healthy People goals give objectives w/ 10 year targets that guide national health promotion and disease prevention efforts to improve health of everyone in USA -Healthy People 2030 is the 5th generation of this initiative -Inception in late 1970s for the year 1990 the goals have included BF targets -Goals include increasing % of babies ever breastfed, BF at 6 mos, BF at 12 mos, exclusive BF at 3 mos, exclusive BF at 6 mos, workplace lactation support, decrease use of formula in first two days of life, increase births in Baby-Friendly facilities.

Evidence Based Practice

-Highest Level of Evidence Meta-analysis and systematic reviews (such as the Cochrane Collaboration and the Joanna Briggs Institute for Evidence) -Then..... Well done randomized experimental designed studies (RCTs) and On down the hierarchy of evidence through published case studies

How to support exclusive BF

-Increase hospital and health system capacity including revitalizing, expanding and institutionalizing the Baby-Friendly Hospital Initiative in health systems. -Provide community-based strategies including communication campaigns tailored to the local context. -Strengthen the monitoring, enforcement and legislation related to "the Code" and subsequent resolutions. -Enact at least 6 months' paid maternity leave. -Invest in training and capacity building in breastfeeding protection, promotion and support

Global Nutrition Target #5

-Increase the rate of exclusive BF in the first six months up to at least 50%

Breastfeeding

-Infant is receiving human milk as well s any other foods or fluids (formula)

Predominant Feeding

-Infant is receiving mother's milk as well as water, water based drinks, ritual foods (such as teas), & oral rehydration solutions, vitamins, minerals & oral meds. (not receiving other foods or drinks like formula or cow milk)

Exclusive BF

-Infant is receiving only breastmilk as its food source (babies may also be receiving oral rehydration solution, vitamins, minerals, or other oral meds)

Oxytocin

-Influenced by nipple stretching among other stimuli (hand motion & conditioned response) -Temporarily affected by stress- adrenaline

Global Strategy for Infant & Young Child Feeding (WHO) (Appendix U)

-Initiative of WHO & UNICEF to build upon previous initiative including Baby-Friendly Hospital Initiative & Innocenti Declaration -Includes the needs of all children including living in diff circumstances such as infants of moms w/ HIV, low birth weight infants, & infants in emergency situations

International Code of Marketing of BM Substitutes (Appendix T)

-Intended to protect & promote BF through provision of adequate info on appropriate infant feeding & regulation of marketing BM substitutes, bottles, & teats. -Major principles: no promotion of BM substitutes, bottles, or teats to general public; no promotion of these items from health care facilities/professionals to families; restriction of interaction of employees to companies that make, sell, or distribute these items w/ the general public, healthcare facilities, systems, professionals, and childbearing families -As of April 2020, 136 (70%) of WHO member countries have adopted some of the Code as legislation or other legal measures. 25 had measures very aligned w/ the Code, 42 had moderately aligned measures, 69 included some Code provisions; 58 countries (including USA) had no Code related legal or legislative measures in place.

The World BF Trends Initiative (WBTi)

-Intended to track, assess, & monitor the implementation of the "Global Strategy" at the country and sub country level

The International Code of Marketing of Breastmilk Substitutes (the Code)

-Is an international health policy framework to regulate the marketing of breastmilk substitutes in order to protect breastfeeding. It was published by the World Health Organization in 1981, and is an internationally agreed voluntary code of practice. -It was written in response to the marketing activities of the infant feeding industry which were promoting formula feeding over breastfeeding, which in turn was leading to dramatic increases in maternal and infant morbidity and mortality. -Subsequent clarifying and extending resolutions have been passed by the World Health Assembly.

Counseling Process

-LISTEN gather info using q's that can't be answered with a single word (what has been going on?) -LISTEN verify what you've heard (I hear you saying xy&z, but ____, is this right?) -LISTEN offer individualized info (not advice) -LISTEN work together to develop a plan (ask mom to verbalize their plan in their own words, make sure that you are clear so they understand) -LISTEN review & fine turn the plan -LISTEN establish a follow up plan & make needed referrals -SUMMARIZE, LISTEN, & DOCUMENT -avoid loaded & judging words -more info is not better, limit the number of topics discussed at any one session -communication that is centered on mother's concerns, not bio-medical convos, enhances info gathering & relation building

Stages of Milk Production

-Lactogenesis I (Secretory Differentiation) -Lactogenesis II (Secretory Activation) -Lactogenesis III (Lactation, Galactopoesus)

Mechanisms that Release Oxytocin

-Mechanism #1:Conditioned response- Conditioned Milk Ejection (Let Down) Reflex probably was given too much importance in the years we didn't understand the other mechanisms. is conditioned over time and lasts a lifetime. Is faster for women who already have one from previous breastfeeding. To condition the response... smell, touch, hear the stimulus. -Oxytocin release mechanism #2: Nipple Stretching Happens with a proper latch -For Prolactin, only nipple stroking is needed, but for oxytocin, nipple stretching is needed -Oxytocin release mechanism #3: Baby hand massage (each hand movement releases oxytocin)

Milk Composition is Unique

-Milk is species specific -Mammals w/ high fat/protein and low water content milk have infrequent feeds -Mammals w/ higher water cotent milk have more frequent feeds -All mammal milk contains lactose

2 Different Care Patterns of Mammal Mothers

-Nest/Cache (puppies/kittens, deer/rabbit) -Carry/Follow/Hibernate (monkey, opossum, giraffe, bison, bears, groundhogs) -composition of milk of a mammal species and the species feeding frequency are relates -humans should be in the "Carry" group, but we wish to be nesters (our milk composition tells us we should be carriers but society tells us we should be nesters -humans should be in the continuous feeding pattern and the "carry" group -human milk is one of the highest in lactose od all mammal milks, high in water, low in protein & fat, a very dilute mammal milk -most rapidly developing organ in human newborns is the brain, human milk is the ideal fuel for brain growth -the nursing pattern should be frequent to accommodate this composition -human milk changes continually, this makes it impossible to obtain a single representative sample of milk

Elimination Patterns

-Newborn baby should have 4 stools (some yellow) daily by day 4 (4 on 4) and for the 1st month -Should have at least 6 wet diapers w/ light colored urine -**Stools are most important sign that newborn is getting enough milk** -Baby should be back to birth weight by 12-14 days (if not then intensive in-person eval of BF, milk supply, & milk transfer w/ corrective interventions is initiated) -In early days we expect at minimum weight gain of approx. 1oz per day (although most healthy BF babies gain more than this)

Milk Prodution

-Ongoing Milk Production Is positively associated with suckling within the first 2 hours after birth -Infants who suckled within the first two hours ingested significantly more milk on day four than those who did not. -For mothers of premies - initiation of milk expression before 1 hour resulted in significantly more milk when measured on Days 7 & 42. -More than one mechanism can trigger oxytocin. -Progesterone leaves and prolactin increases with suckling, if it is not set within the first hours of birth then there isn't enough receptor sites & can cause issues with ongoing milk production

OARS: Steps to Motivational Interviewing from Bershad

-Open ended questions: show interest in what is on client's mind today; ask q's that can't be answered w/ single word; how, who, what, when, where, tell me about...; instead of saying "why did you start formula w/ your BF baby" you can say "tell me more about what led to supplementing w/ formula" -Affirmation: builds empathy & connection b/w client & counselor ; listen for and call attention to examples of good actions/ decisions to affirm; strive for genuine & specific recognition, not a generic response -Reflective listening: listen for deeper understanding of the situation, hearing not only the words, but open to possible underlying meanings & beliefs; rephrase or paraphrase statements, or reflect on the meaning of what you heard or assure understanding -Summarize & teach back: summarize strengths shared by client & action steps planned; teach back & ask client to demonstrate back a skill or learning

S2S Promotes BF

-compared w/ moms w/ no early S2S contact, elf was higher in moms who experiences longer S2S contact -women who reported depressive symptoms in pregnancy (EPDS>13): --if they did not accomplish the first BF session within 2 hours after birth --had an almost 4 fold increase in NOT EBF at 6 wks pp --counseling implication: women reporting depressive symptoms during pregnancy seem to be vulnerable to the effects of postponed first BF on exclusive BF; women who have experienced depressive symptoms may benefit from targeted BF support during the first hours after birth

Innocenti Declaration on Infant & Young Child Feeding (Appendix V)

-Originally adopted in 1990 -Inappropriate feeding practices, suboptimal or no BF & inadequate complementary feeding are the greatest threat to child health & survival globally -Improved BF can save lives of >3500 children daily (more than any other preventative measure) -Vision is excusive BF for first 6 mos, then appropriate complementary feeding & continuation of BF for up to 2 years and beyond -Achieving this vision requires skilled practical support to arrive at highest attainable standard of health & development for infants & YC, which is the universal right of every child -Challenges include: poverty, HIV pandemic, natural & human-made emergencies, globalization, environmental contamination, health systems investing in curative rather than preventative services, gender inequalities, women's increasing rates of employment outside the home. (these must be addressed to achieve the Millennium Development Goals & the aims of the Millennium Declaration, & for vision set out above to become reality for all children)

Concern: Baby Has A Birth Defect: Phenylketonuria (PKU) OVERALL

-PKU is uncommon disorder, occurring in 1 in every 15,000 births in the US

Types of Jaundice

-Pathological Jaundice - occurs within the first 24 hours of birth; usually due to sepsis, blood incompatibility -Early Onset - peaks b/w 72-96 hours (often called "physiological" or "starvation" or "lack of BF" jaundice); frequently related to underfeeding -jaundice may be an early indicator of poor milk transfer &/or weight loss -tx for jaundice should not prevent moms from BF, but jaundiced babies are sleepy, lethargic, & have difficulty sustaining a feed -Late Onset - (often called "breast milk" jaundice); may actually be related to metabolic or other issues w/ the infant (i.e. G6PD, Gilbert Syndrome, UTI); benign, prolonged UCB associated w/ BF; presents in second week & can persist for 12 weeks; current research does not support discontinuation of BF... instead a thoughtful investigation...& monitor until total falls below recommended level for phototherapy

Step 9. Counsel moms on the use & risks of feeding bottles, teats, & pacis

-Purpose: ensure BF babies are not deterred from learning how to suckle at the breast & thereby from maximizing milk production -Global Standards: at least 80% of BF moms of preterm & term infants report they have been taught about risks of using feeding bottles, teats, and pacis

Step 2. Ensure that staff have sufficient knowledge, competence, & skills to support BF

-Purpose: ensure all staff have training necessary to develop effective skill in supporting BF families providing consistent messages & implement facility policies -Global Standards: at least 80% of clinical staff providing antenatal, delivery, or newborn care report they have received pre-service or in-service training on BF on the previous 2 years; at least 80% of clinical staff providing antenatal, delivery, or newborn care report receiving competency assessments in BF in previous 2 years; at least 80% of clinical staff providing antenatal, delivery, or newborn care are able to correctly answer 3/4 q's on BF knowledge & skills to support BF

Step 4. Facilitate immediate & uninterrupted skin-to-skin & support moms to initiate BF ASAP after birth

-Purpose: ensure early initiation of skin-to-skin for all infants (whether BF or not) & support early initiation of BF when intended -Global Standards: at least 80% of moms of term infants report skin-to-skin happened immediately or within 5 min of birth & lasted 1 hour or more, unless documented medically justifiable reasons for delayed contact; at least 80% of moms of term infants report babies were put to breast within 1 hour of birth unless documented medically justifiable reasons.

Step 1. (b.) Have written baby feeding policy that is routinely communicated to staff & parents

-Purpose: ensure existence of evidence-based policy promoting BF & delineates standards of care -Global Standards: health facility has written infant feeding policy addressing implementation of all 8 key clinical practices of the Ten Steps, Code implementation, & regular competency assessment; observations in facility confirm that a summary of the policy is visible to pregnant women, mothers, and families; review of clinical protocols/standards related to BF & infant feeding used by maternity services indicates they are in line w/ BFHI standards & current EB practices; at least 80% of clinical staff providing antenatal, delivery, or newborn care can explain at least 2 elements of infant feeding policy that influence their role in facility.

Step 7. Enable moms & infants to remain together & practice rooming in 24 hrs a day

-Purpose: ensure healthy moms & infants have ample opportunities for skin-to-skin contact & ensure moms achieve early learning of the baby's feeding cues -Global Standards: at least 80% of moms of term infants report their babies stayed w/ them since birth, w/o separation lasting no more than 1 hour; observations in the pp wards & well-baby observation areas confirm at least 80% of moms & infants are together or if not have medically justified reasons for being separated; at least 80% of moms of preterm infants confirm they were encouraged to stay close to their infants day & night

Step 3. Discuss importance & management of BF w/ pregnant women & families

-Purpose: ensure integration of messages about BF in prenatal education interchanges -Global Standards: protocol for antenatal discussion of BF includes: importance of BF, global recommendations on exclusive Bf for first 6 mos, risks of giving formula or other substitutes, & fact that BF continues to be important after 6 mos; importance of immediated & sustained skin-to-skin; importance of early initiation of BF; importance of rooming in; basics of good positioning & attachment; recognition of feeding cues. At least 80% of moms who receive prenatal care at facility report having receives prenatal counseling on BF and they are able to adequately describe what was discussed about 2 of the topics listed above.

Step 8. Support moms to recognize & respond to infant's cues for feeding

-Purpose: ensure moms are encouraged to feed babies in response to baby's signs of feeding readiness -Global Standards: at least 80% of BF moms of term infants can describe at least 2 feeding cues; at least 80% of BF moms of term infants report they have been advised to feed their babies as often & for as long as infant wants

Step 10. Coordinate discharge so that parents and infants have timely access to ongoing support & care

-Purpose: ensure moms are linked to ongoing BF support resources -Global Standards: at least 80% of preterm and term infants report a staff member informed them where they can access BF support in their community; facility can demonstrate that it coordinates w/ community services that provide BF/infant feeding support including clinical management & mother-to-mother support

Step 5. Support moms to initiate & maintain BF & manage common difficulties

-Purpose: ensure ongoing BF support, assessment, & eval during maternity stay for term, preterm, and sick newborns -Global Standards: at least 80% of BF moms of term infants report someone on staff offered help w/ BF within 6 hours of birth; at least 80% of moms of preterm or sick infants report having been helped to express milk within 1-2 hours of birth; at least 80% of BF moms of term infants are able to demonstrate how to position baby for BF and baby can suckle and transfer milk; at least 80% of BF moms of term infants can describe at least 2 indicators of whether a BF baby consumes adequate milk; at least 80% of moms of BF preterm & term infants can correctly demonstrate or describe how to express BM.

Step 6. Do no provide BF newborn any food or fluids other than BM, unless medically indicated

-Purpose: ensure that healthy BF babies are not routinely supplemented w/ any food or drink unless medical indications exist for supplementation -Global Standards: at least 80% of infants (pretem & term) receive only BM (from mom or donated) throughout stay at facility; at least 80% of moms who do not BF report that staff discussed w/ them various feeding options & helped them decide what was suitable for their situation; at least 80% of moms who don't BF report staff discussed w/ them the safe preparation, feeding, & storage of BM substitutes; at least 80% of term BF infants who received supplemental feeds have documented medical indication for supplementation in medical record; at least 80% of preterm infants and other vulnerable newborns cannot be fed mom's own milk are fed w/ donor milk; at least 80% of moms w/ babies in special care report they have been offered help to start lactogenesis II (beginning plentiful milk secretion) & to keep up the supply, within 1-2 hours after baby's birth

Step 1. (c.) Establish ongoing monitoring & data management systems

-Purpose: ensure the implementation of clinical practices supporting BF & related maternity care practices is tracked & monitored routinely -Global Standards: global guidance IDs specific indicators for each of the key clinical practices (steps 3-10) including indicator definitions, targets, & data sources; facility has protocol for ongoing monitoring & data management system to comply w/ the 8 key clinical practices; clinical staff at facility meet at least every 6 mos to review implementation of the system

Step 1. (a.) Comply w/ International Code of Marketing of Breast-milk Substitutes & Relevant World Health Assembly Resolutions

-Purpose: protect families from influence of formula companies -Background: the "Code" was adopted by World Health Assembly in 1981 to be implemented internationally; however is it not in force in all nations; it requires implementation of those aspects of the Code that fall within the facility's purview -Global Standards: all infant feeding bottles use in facility have been purchased thru normal channels and not received for free or subsidized supplies; facility has no display of products covered under the Code or items w/ logos of formula companies, or names of formula products; facility has policy describing how it abides by Code, including getting BM substitutes, not accepting support/gifts from producers or distributors by products covered by the Code & not giving sample of BM substitutes, feeding bottles, or teats; at least 80% of health professionals in antenatal, delivery, or newborn care can explain at least 2 elements of the Code.

Side Lying Vs Laid Back (C-Section)

-RCT of side lying vs laid back for moms who had a C section indicated no difference in BF outcomes -there was greater satisfaction w/ comfort, ease of positioning, & BF for long periods in the side lying group compared w/ the laid back group

Why is BF so Difficult that Moms need help?

-Reason #1 Unrealistic expectations -Lack of preparation for what the newborn period would be like In other words, unrealistic expectations! -Reason #2: Lack of timely interventions --Mother's problems at 3 to 7 days posed the greatest risk to stopping. -The fastest drop-off is in the 10 days following discharge from the hospital

Innocenti Declaration Call For Action, Multilateral, bilateral & International Financial Institutions:

-Recognize optimal BF & complementary feeding are essential to achieving the long-term physical, intellectual, & emotional health of all populations, & therefore the attainment of the Millennium Development Goals & other development initiative, & that inappropriate feeding practices & their consequences are major obstacles to poverty reduction & sustainable socioeconomic development -ID & budget for sufficient financial resources & expertise to support govts in formulating, implementing, monitoring, & evaluating their policies & programs on optimal infant & YC feeding, including the BFHI -Increase technical guidance & support for national capacity building in all target areas set forth in Global Strategy for Infant & YC Feeding -Support operational research to fill info gaps & improve programming -Encourage inclusion of programs to improve BF & complementary feeding in poverty-reduction strategies & health sector development plans

The Code

-Regulates the marketing of breastmilk substitutes which includes infant formulas, follow-on formulas and any other food or drink, together with feeding bottles and teats, intended for babies and young children. -Sets standards for the labelling and quality of products and for how the law should be implemented and monitored within countries. -Restricting marketing does not mean that the products cannot be sold, or that factual and scientific information about them cannot be made available. Neither does it restrict parent's choice. It simply aims to make sure that their choices are made based on full, impartial information, rather than misleading, inaccurate or biased marketing claims.

Concern: Baby Has Hypoglycemia OVERALL

-S2S holding & feedings of colostrum are often underrated as first interventions for babies to prevent & treat hypoglycemia in an otherwise healthy baby -15 min of S2S before retesting may increase baby's blood glucose to an acceptable level

Calculating Baby's Approx Daily Needs

-Standard gain, baby is gaining weight well (baby weight x 2.5) -Catch up on weight, not gaining well (baby weight x 2.7-3.0) -Tells you total # of oz needed in a day, can take total number and divide by # of feedings to find out how many oz (on average) baby needs each feeding

Thoracic Intercostal Nerves

-T3 & T5 innervate the sides of breast -T4 innervates the nipple

The Basis of the Baby Friendly Hospital Initiative

-The 10 steps to successful BF

According To WHO, Complimentary Feeding Should Be:

-Timely (starting foods in addition to BF from 6 mos) - Adequate (nutritional value) -Safely stored, prepared & served -Appropriate in texture & sufficient quantity

Why are we concerned about jaundice? *Kernicterus*

-UCB is fat soluble & crosses the blood brain barrier easily -therefore if the amount of UCB is too high it has the potential to cause damage to the brain, spinal cord, & nerve cells -warning signs include: jaundice advancing from upper body to lower body; fussiness; lethargy; feeding difficulties; fewer than 4 wet or dirty diapers/ 24 hours -any jaundiced baby has the potential for kernicterus & should be closely monitored -Kernicterus = bilirubin encephalopathy which may result in cerebral palsy & hearing loss, also visual impairments, dental problems, occasionally intellectual & developmental disabilities, & very rarely death -who is at risk? any jaundiced baby has the potential for kernicterus & should be closely monitored -black babies account for 25% of kernicterus cases in the US despite being 14% of the population; this is a largely overlooked health disparity

Altering Diet to Prevent Allergies in Babies

-US National institute of Allergies & Infectious Disease recommends not restricting the diet during pregnancy or when BF as a way to prevent food allergy from developing in the child -most important modifiable risk factors for child allergy are: maternal smoking, type of infant feeding, c-section -consumption of allergenic foods in pregnancy may actually reduce allergies & asthma in children

Recommendations for Preparing Powdered Infant Formula (PIF)

-WHO & CDC: mix PIF w/ water heated to temp of at least 70C (158F) to Enterobacter sakazakii -formula made w/ hot water needs to be cooled quickly to body temp if it is being fed to baby immediately -if formula is not being fed immediately, put in fridge right away & keep in fridge until feeding

Growth Chart

-WHO growth curve should be used for all babies under 24 mos

Achieving a Healthy Inter-Pregnancy Interval

-WHO recommends after a live birth, to wait at least 2 mos in order to reduce the risk of adverse maternal, perinatal, & infant outcomes -which child spacing methods are appropriate for BF? --contraceptive counseling during BF extends beyond issues of efficacy, b/c the selected method must be appropriate for a woman's BF expectations -lactation amenorrhea method (LAM) asked 3 questions: is baby younger than 6 months, is there food or suckling except at the breast, has menses returned? --if no to all of these then you can rely on LAM to prevent pregnancy --return of menstruation: difficult to predict timing, ovulation first?, decreased supply?

US Breastfeeding Trends

-Why is there such a disparity? "Black mothers are less likely than white to breast-feed their babies, and here's one possible reason why: Hospitals in neighborhoods with many black residents do less to promote nursing than those in areas with more white residents" according to the CDC -U.S. Exclusive BF Rates 1965- 2001 did not increase in proportion to initiation rates. -Healthy People 2020 Added BREASTFEEDING TARGETS -Increase the proportion of employers with worksite lactation programs to 38% [2006 baseline: 25%] -Reduce the percentage of breastfed infants who receive formula before 2 days of age to 14.2% [2006 baseline: 25.6%] -Increase the proportion of live births that occur in facilities that provide recommended care for lactating mothers and babies to 8.1% [2007 baseline: 2.9%] -Policies and reports have also been developed to promote, protect and support breastfeeding -The US report card on how we are doing on the objectives of the Innocenti Declaration is prepared by the Healthy Children Project

Concern: Baby Won't Sleep Through The Night OVERALL

-a discrepancy b/w parental sleep expectations & reality is one of the most difficult problems for sleep-deprived family to solve -encourage families to adopt a proximate sleep environment, in the same room, in a safe sleep environment -ideally in the first weeks, if possible, encourage adults to nap during the day when their babies sleep

Kangaroo Mother Care (KMC)

-a special kind of S2S holding for premature & fragile babies that has been shown to decrease mortality by 36% as well as sepsis, hypoglycemia, hypothermia, & hospital admission -adult stays in upright position -may last for hours, even 24 -premies who have KMC or S2S: --have better long term physiologic organization & cognitive control --have improved cerebral blood flow --have improved circulation --have improved weight gain --may have nostrils decolonized that have been colonized by MRSA/MRSE organisms --have sleep patterns that are more mature -KMC promotes earlier initiation of BF compared to conventional care -very low birth wt (VLBW) babies (under 1500g at birth) have longer BF duration if they have been cared for S2S -small study of S2S w/ preterm twins found that each breast increases temperature separately for the closest baby -even VLBW babies were significantly warmer in their mother's arms -babies burned fewer calories while being held than in incubator

Soy Formula

-about 25% of formula sold; continuing concerns about estrogen exposure -can expose babies to estrogen they might not otherwise be exposed to, can increase breast bud growth in newborns

Concern: Worried About Milk Supply: Baby Seems Unsatisfied After Feedings

-after BF, baby is unsettled & fretful *Ask yourself: -baby's wt gain & output appropriate? -baby appear dehydrated, jaundiced, malnourished? -is baby's behavior appropriately interactive? -does baby only get attention & skin contact during feeds? *Watch out for: -family's knowledge of & response to baby's cues *What to do about it: -obtain pre feeding wt -observe feed -watch for baby's interest in feeding; if feeding is attempted when baby is not indicating feeding readiness, encourage S2S allowing baby to self attach or begin collaborative feeding when feeding cues are seen -when baby is attached to breast, observe for sucking & swallowing ratio to confirm feeding is nutritive; observe for complete seal of mouth to breast; suboptimal seal means milk is not transferring optimally & baby may be swallowing air during feed -conduct post feeding wt check; calculate milk transfer; calculate baby's approx daily needs & compare -suggest other changes to feeding process indicated by feeding observation -schedule follow up & referrals if needed *Expected resolution: -when baby is in receptive feeding state & able to transfer adequate milk, this problem should resolve -encourage parents to provide lots of snuggling & interaction w/ baby to meet baby's contact needs b/w feeds *What else to consider: -comprehensive pediatric eval, teething, ear infections, other issues can drive baby to seek breast for comfort w/o adequate milk transferring

Expected Wt Gain in BF Baby

-after initial wt loss of 7% or less, adequately nourished babies should have no more body wt loss after day 5 -after, BF babies should gain 1 oz or more a day -at 6 mos, BF babies should begin eating solid foods -during second half of first year, BF babies (even if well fed) gain more slowly than formula fed babies -WHO growth curve should be used to monitor growth of all children under 24 mos regardless of feeding method

Alcohol

-alcohol (beer esp) will not increase milk production -alcohol decreases oxytocin levels, but can increase prolactin levels (breasts may feel fuller, but moms are sleepier & end up giving babies less milk) -in another study, alcohol completely blocked release of oxytocin -babies may not like the taste (babies take less milk) -alcohol is water soluble; it passes in & out of the milk as her blood alcohol increases then decreases it is NOT trapped in milk (pumping & dumping will not remove alcohol) -we often get q's about "going out"; we need to get mom's definition of "going out", does it mean having a margarita at dinner or going to the club & doing a lot of shots? -another counseling issue is about safety of baby if parents are inebriated or incapacitated (most important thing is who is going to take care of baby)

When looking to increase milk supply we should assess:

-all aspects of the Comprehensive Risk Assessment Tool -how often the baby is being fed & what is being fed -whether there is milk expression -how effective feeding/expressing is -how much milk is being transferred at breast (pre and post wt checks) -how much milk the baby needs vs how much it is getting -need for comprehensive pediatric & maternal medical evaluation

Sleep Wake Cycles in First Hours

-all babies had at least a one hour awake time after birth -after the first hour wakefulness varies -in order to get in enough feedings on the 1st day, observe REM during sleep & quiet alert states

Inverted Nipples Classification

-all of these are red flags for additional assessment and follow up -Grade 1: easily pulled out w/ breast pump or infant nursing -Grade 2: can be pulled out but do not maintain their projection -Grade 3: difficult or impossible to pull out -classification is about function during feeding - not about how inverted or flat the nipple looks at rest -grade 1 and 2 (2 would invert rapidly) -grade 3 (before & after look the same) -having grade 3 on both breasts in really not very common -women w/ uncorrected (meaning they couldn't project w/ stimulation - possibly Grade 3) inverted nipples had lower prolactin levels and less milk

BF-Associated Hypernatremia (B-AH)

-almost 2% of 3718 consecutive term & near term neonates were hospitalized in Pittsburg for B-AH - median weight loss was 13.7% -"hypernatremia is a common complication of inadequate milk transfer during BF in the US"... "A completely preventable complication that seems to be relatively common" -weight loss difference: 1.6% in healthy infants, 16.2% in hypernatremic admitted infants -frequency of BF per day? 10.2 feedings per day for healthy infants, 7.6 feedings per day in the NHD (neonatal hypernatremia) admitted infants

Oversupply: Expected Resolution & What Else To Consider

-although there may be some residual pain for a day or so if nipple has been damaged, the pain level should diminish w/ the baby in control of the flow rather than feeding against it; nipple should not be distorted after nursing -hand expression or pumping to get rid of "extra" milk may compound the problem by relieving the compression on the cells; as a result the milk supply continues to increase; a water bath is preferred choice is compression is painful

Milk Expression by Hand

-always available -higher fat content -promotes continued BF -cleanest way to collect milk -simple process

Breast Pumps

-always be used and cleaned according to manufacturers instructions -combining hand expression w/ pumping can maximize milk yield -add breast pumping only after there is a considerable amount of milk to collect -no pump is right for every mother & every situation -any pump can cause damage when used incorrectly -might be manual breast pump, electric, battery (might be able to pump 1 breast as a time or both at a time) -do not use parts from one company on another company's pumps unless manufacturer specifically allows it

Contraindications to BF (GENERAL)

-always refer to the CDC website for updates lists -physicians should make case by case assessments to determine whether a woman's environmental exposure, her own medical condition, or medical condition of infant warrants her to interrupt, stop, or never stop BF

Thawing & Warming BM

-always thaw frozen BM in container in which it was frozen -fridge is great place to defrost milk -fridge or frozen milk can be warmed in container of lukewarm water or under lukewarm running tap water -never use microwave to thaw or warm BM (hot spots can burn baby & components can be damaged) -thawed BM should be kept cold until just before being fed to baby -thawed previously frozen BM should be in fridge and used within 24 hours of being defrosted -thawed BM should not be refrozen

Concern: Baby Has Hypoglycemia

-amount of blood glucose (sugar) in the blood is lower than normal or desirable *Ask yourself: -is this baby at higher risk for hypoglycemia (>4000g at birth or <2500g at birth; large for gestational age, small for gestational age, or intrauterine growth restriction; babies of diabetic moms; <37 or >42 weeks gestation at birth; suspected neonatal sepsis or maternal chorioamnionitis; Apgar score <7 at 5 min; newborns who required resuscitation; discordant twin (smaller); limited or no prenatal care; cold stress or hypothermia; respiratory distress) *Watch out for: -symptoms of hypoglycemia including temperature instability, irritability or jitteriness, seizure activity, convulsions, exaggerated Moro reflex, high pitched or weak cry, respiratory distress, irregular respiration, apnea, cyanosis, hypotonia, bradycardia, poor feeding, & lethargy -the baby w/ hypoglycemia can be very lethargic & sleepy at the breast & may not exhibit obvious feeding cues *What to do about it: -encourage as much S2S contact as possible -take feeding hx; discover how baby has been doing w/ BF, whether he/she has received supplementary feedings & if so, what has been given -observe a feed -assess adequacy of milk transfer *Expected resolution- hypoglycemia in the newborn is typically a short-term situation; baby w/o underlying medical complications should be able to normalize blood sugar within a few hours of birth -ongoing S2S contact & small amounts of colostrum obtained by licking & suckling at the breast typically assist baby in normalizing blood sugar within hours of birth *What else to consider: -comprehensive pediatric eval if problems w/ hypoglycemia are not resolved by skin contact & feeding &/or if signs of sever hypoglycemia are noted

Allergy & Anaphylaxis (formula)

-anaphylaxis related to cow milk based formula is a rare but important event -sensitization to cows milk & food allergy including cows milk allergy & anaphylaxis are primarily preventable by avoiding cow milk formula supplementation for at least the first 3 days after birth -of 143 infants in age from 1-8mos w/ cow milk allergy, 9 exhibited anaphylactic shock -"feeding w/ soy formula should not be recommended for prevention of allergy or food intolerance in infants at high risk of allergy or food intolerance" -feeding w/ cow milk formula may also provoke allergy in those at risk allergy can be provoked also after diarrhea -published estimates of formula intolerance range from 2-15% -however 33-50% of infants undergo formula change during first 6mos of life -this raises concerns that formula switching can have detrimental effects on parent/child dynamic -instead of switching formula when there is no medical indication, focus on helping families build skill in coping w/ uncomfortable babies

Suboptimal Breast Anatomy

-anatomical concerns (unusual looking breasts) -absence of breast changes in pregnancy or early days postpartum (red flag) -no postpartum breast fullness or signs of abundant milk production (red flag) -hypoplastic breasts (floppy looking w/ minimal breast tissue) -discrepant breast size (unilateral underdeveloped breast) -any abnormality, breast surgery, and or breast injury may impact BF -flat or inverted nipples

Counseling Implications When Fears About Milk Supply

-approx 40% of US BF moms have fears about milk sufficiency -avoid giving inappropriate reassurance (gather facts instead & refer as needed depending on your scope) -undertake complete eval including hx & feeding assessment before coming to conclusions since low milk supply rarely has one cause -provide adequate pp support to distinguish b/w "real" and "perceived" cases of insufficient milk -establish a community wide system eliminating the "zone of professional unavailability" especially days 3-7

Assessing Expression w/ Pump

-are both sides being pumped at same time (this is optimal) -is pump missing parts or not working properly -is flange too tight or too large

Process of Engorgement

-as pressure in the breast increases, milk production decreases, this is nature's early lactation dry-up method -failure to effectively resolve prolonged symptomatic engorgement may have a negative impact on continued adequate milk supply -nature's way to "dry up supply" -putting breast pump on engorged breast is generally not best idea, engorgement can become so much that it puts pressure on capillaries & can cause some blood streaked milk -can use container of comfortable temp water, dip breasts in, and milk will very quickly start spurting out; you don't want a lot of milk to come out, but enough so baby can latch

Collaborative BF

-as the baby seeks the breast the parent gently assists

Counseling Implications for Inverted Nipples

-ask if & when nipple everts -look over shoulder just after feeding for nipple eversion & compare to pre-feeding nipple to figure out what grade it is -if not seen - intensive follow up -consider expression (hand expression, pumping, etc) -assure adequate nutrition of infant -postpartum eversion techniques (shells, everters, shields, and pumps) have not been studied in prospective experimental controlled studies -check that gadgets are FDA approved & have safety & efficacy studies

BF Shouldn't Hurt

-assess for proper latch, good seal, baby's tongue, swallowing sounds & reteach as needed -prefeeding behaviors & more optimal latching process are related to less pain -correcting the latch process is best way to decrease pain; lanolin vs no commercial product had same result when still correcting latch using LAT -hand on back of baby's head & shaping breast to interfere w/ baby's internal fx by restricting mvmt of cranio-cervical spine & nuchal alignment were most related to nipple trauma -if there is pain, find out what the mom has already tried (their "cure" could be related to secondary problems such as reaction to a cream?)

Iron Deficiency Anemia

-associated w/ milk supply problems; may be: -physiologic (poor oxygen to milk making cells) -due to exhaustion or depression altering parent's coping behavior -combo of above -more than 20% of pp US women have this

Counseling Moms About Suboptimal Breast Anatomy

-assure privacy -ask about surgery "improvements/enhancements" or injury -determine innervation/sensation -ask: are ducts patents?; are nipple pores patent?; signs of hormonal connection?; concerns about weight gain of baby?; adequate pediatric supervision

Concern: Birth Control

-avoiding pregnancy while BF *Ask: -what are plans for future pregnancies? -religious beliefs, health concerns, or lifestyle preferences affect choices for family planning? -what choices are more or less appropriate while BF? *Watch out for: -misunderstanding the relationship b/w BF & fertility. some believe you can't get pregnant while BF (not true) -hormonal birth control containing estrogen are not recommended in early lactation -starting progesterone only birth control too early (most recommend at 6 weeks postpartum in BF women) *What to do about it: -progestin only BC are options while BF after early weeks (pills, injections, & implants) -barrier methods (cervical caps, condoms, diaphragms, foam, etc.) are acceptable while BF. (BF may result in vaginal dryness & intercourse may be comfortable w/ additional lubrication) -carefully explore options including lactational amenorrhea method (LAM) *Expected resolution: -method of BC or child spacing will meet the needs described & be compatible w/ BF *What else to consider: -learn about availability of books, classes for parents on other methods of child spacing (e.g. Natural Family Planning), a combination of calendar rhythm, basal body temperature, & other techniques

The Optimal Start

-babies born during the night & early morning (10pm-9am) had double the odds of supplementation compared to babies born during the day -frequency of exclusive BF as well as behaviors that promote BF were significantly higher in group who had doula -Intrapartum Synthetic Oxytocin (Pitocin): --oxytocin (Pitocin) infusion during labor decreased the amount of own oxytocin released from suckling on day 2 --pitocin is an independent risk factor for supplementation of formula in BFH --pitocin is independent risk factor for Apgar scores of less than 7 at 5 min & unexpected admission to NICU lasting more than 24 hours for full term infants --higher relative risks of mother receiving documented depressive or anxiety disorder diagnosis or antidepressant/anxiolytic prescription within 1st year pp than women w/o Pitocin exposure

Physical Objects (& Negative Impact on BF) [Bottles of Water & Formula]

-babies don't need manufactured formula don't need extra water until receiving solid food -even BF babies in hot, dry climates don't need extra water -babies are driven to feed by thirst (not hunger) so if we give baby water, that fixes the thirst, but provides no calories, so they're going to feel like they have been fed, but given no calories -babies who receive water supplementation are significantly more likely to get formula at 4 & 16 weeks -also higher risk for water intoxication -early introduction of supplemental bottles of formula is associated w/ decrease in the amount of human milk the infant receives as well as w/ early weaning -among women intending to exclusively BF in hospital formula supplementation was associated w/ a nearly 2X greater risk of not fully BF on days 30-60 & a nearly 3X risk of stopping BF on day 30 -why did one oz of formula per day lead to giving up BF? (they did not call for help- they gave bottle instead; they lacked confidence in milk supply, baby getting enough, BF in general)

Prenatal & Postnatal Flavor Learning by Infants

-babies nurse longer on garlic flavored milk -many anthropologists believe that flavors of the culture are conveyed to the child thru milk while lactating -children are acculturated to the taste of their native foods thru BM -longer duration of BF is associated w/ higher food variety at 3 years -foods that do not taste familiar are more likely to be refused

Baby Led

-babies older than 12 months -stop "offering" to nurse and change to on-request only

SIDS

-babies should be placed in a safe environments & on the back for sleep -BF has a protective effect against SIDS beginning at 2 mos and increasing over time -EBF at 1 month of age halved the risk of SIDS -the longer baby is BF the lower their risk of SIDS -gut microbiome in babies who died from SIDS offers one explanation (Cl. Difficile in guts of 27% of babies who died of SIDS vs 7% in healthy controls)

Concern: Baby Has A Birth Injury: Fractured Clavicle, Bracial Plexus Injury, Etc. OVERALL

-babies w/ these injuries are often seen as problem breastfeeders & are changes to bottle feeding -in this event, use expressed BM preferentially in the bottle -feeding problems may reemerge when solid foods are introduced & the baby chokes & gags

Concern: Baby Latches but Doesn't Stay Attached OVERALL

-babies who do not maintain seal are telling us one of several things: either they cannot maintain seal due to issues such as undernourishment, attachment problem, or intramural structural or neuromuscular problems, or they do not want to maintain a seal (perhaps bc of rate of milk flow is too fast or bc of discomfort associated w/ feeding)

Concern: Baby Was Born Early

-baby born before 37 weeks of gestation *Ask yourself: -how is milk supply being supported? -what is required regarding collection & storage of milk? -what are the possibilities for S2S holding & practice BF? *Watch out for: -parents perceiving baby as very fragile -family feeding inadequate -difficulty regulating baby's heart rate, oxygenation, temperature, & breathing when BF -concerns about adequacy of milk supply *What to do about it: -investigate when family knows about prematurity & baby's ability to feed -determine if baby has been stable enough to have S2S contact w/ parents -determine feeding hx, how baby has been fed, how baby is responding to feeding, if baby is receiving human milk, of feeding is fortified, etc. -explore milk expression plan & fine tune as needed; for optimal results, milk expression should begin within 1 hour of birth & continue a minimum of 8x in 24 hours to sustain adequate milk production when baby is not yet ready to feed at the breast; hand expression in early days is preferable to expression w/ a pump -when baby is deemed ready for feeding at breast, work w/ parents to establish reasonable expectations for the first feedings (i.e. baby will lick or nuzzle at breast rather than latching on and suckling vigorously); there is no specific age at which babies are "ready" for the breast; coordination of the suck, swallow, breathe, & gag reflexes is important for safe oral feeding; baby's ability to regulate cardiorespiratory stability should be the indicator that determines readiness for feeding at the breast -observe a feed; a special BF assessment tool is available for use w/ preterm babies -establish appropriate follow up plans *Expected resolutions: -preterm babies grow in their feeding abilities w/ practice & the number of opportunities to try; more time spent w/ baby in S2S contact & having practice BF, the faster the baby will become adept at feeding *What else to consider: -pediatric evaluation & referral to OT &/or PT for the baby

Starting Solids

-complementary feeding, refers to anything other than BM & infant formula, both solids & liquids, that are needed when milk feeds alone are no longer sufficient to meet the nutritional needs of infants -anticipatory guidance about complementary feeding has been shown to increase practices that are protective against obesity -overall 40.4% of all US mothers introduced solid foods before age 4 mos in spite of the "around 6 mos recommendation" --24.3% for BF moms --BF moms said "my baby was nursing too much (was hungry)"; "I didn't have enough milk"; "it would help my baby sleep thru the night" (starting solids before 6 mos is not a quick fix for sleeping thru the night) -starting complementary feeding at around 6mos is not like starting solids w/ a younger baby since they are developmentally ready to use their hands --RCT found that babies whose caregivers followed a self-feeding approach did not have a significant different in the number of choking/gagging incidents compared to babies who began w/ purees

Role of CLC Regarding Tongue/Lip Ties

-complete feeding assessment & suggest ways to optimize latch -refer onward for dx -provide ongoing support

Medications and Mother's Milk Book

-comprehensive reference on impact of currently used meds on BF dyads -updated biannually it is an way to use lactation risk rating system

Concern: Baby Has A Birth Defect: Craniofacial Anomalies (Cleft Lip/Palate, Pierre Robin Sequence, etc.)

-baby diagnosed w/ craniofacial anomaly *Ask yourself: -what is the extent of the impact of baby's condition on BF?; watch baby at breast, to assess baby's ability to make a seal on breast, keep breast in mouth, make & sustain a vacuum, & transfer milk *Watch out for: -problems coordinating treating & feeding -signs of respiratory distress, stridor (high pitched noise when baby inhales) -circumoral cyanosis during feeds *What to do about it: -determine feeding hx, how the baby has been fed, how baby is responding to feeding, & so on -observe a feed -if possible get pre and post feeding wt checks to quantify milk transfer -w/ cleft lip, angling the breast so that the soft tissue fills the void in the lip may be a good solution; alternatively the lip area may be held closed w/ fingers during the feed -when dealing w/ unilateral cleft palate, suggest angling the breast in the baby's mouth in such a way that soft tissue of breast fills the client area & nipple extends into the intact side of the mouth -w/ Pierre Robin sequence, upright feeding posture may assist baby in achieving deep latch *Expected resolution: -babies w/ clefts & Pierre Robin sequence have varying degrees of success in feeding at the breast *What else to consider: -many who nurse babies w/ these challenges will need to express milk after the feed to maintain & increase their milk supply -if baby does not transfer milk well during feeds, consider use of alternate massage &/or at breast supplementation w/ expressed BM -special feeding devices that rely only on positive pressure to create milk flow have been used to feed babies who cannot transfer milk at the breast even when using an at-breast supplemental device

Concern: Baby Has A Birth Defect: Galactosemia

-baby diagnosed w/ galactosemia *Ask yourself: -has baby been screened for galactosemia? -is baby showing any signs of galactosemia prior to parents being notified about results of a screening test? -is there family hx of galactosemia? *Watch out for: -jaundice, vomiting, poor feeding, poor wt gain, irritability, lethargy, convulsions, opacity in lenses of eyes as these are all signs of galactosemia *What to do about it: -determine which form of galactosemia has been diagnoses (classic or Duarte) -classic galactosemia is the sole pediatric contraindication to BF -babies w/ Duarte galactosemia may be able to BF *Expected resolution: -BF is not recommended except in individual cases of babies w/ Duarte galactosemia -individuals w/ classic galactosemia must avoid all foods containing galactose (which occurs naturally in all mammalian milks, including human milk as well as cow's milk based formula, including those w/ reduced lactose); consuming galactose will cause irreversible organ damage in the individual w/ classic galactosemia; a special formula is indicated *What else to consider: -support family in decreasing milk production

Breast Surgery

-concern centers on damage to nerves and/or damage to ducts -peri-areolar incision can extend all around areola, look for defined margin where the color changes from areola to breast -free nipple graft -pedicle -chest masculinization "top" surgery -just bc someone w/ breast surgery sees colostrum this doesn't mean they'll be able to BF (colostrum is produced from progesterone from placenta, mature milk is produced from hormones in brain from nipple stimulation, there is no promise when baby is put to breast that brain will sense that as "nipple stimulation" & start producing milk)

Breast Implants

-concern centers on storage capacity reduction (less room for milk cells when implants are taking up room) -significantly greater incidence of lactation insufficiency w/ implants w/ no implants in controlled study -less likely to establish BF esp exclusive BF -does not matter if implant is behind muscle or not, milk glands will have less room to expand

Concern: Worried About Milk Supply: Baby Falls Asleep After Just Few Min of Feeding

-baby falls asleep after just a few min of feeding -family may have been told that feeding baby will take certain amount of time; this can lead to concerns about milk supply when baby nurses for shorter time & falls asleep *Ask yourself: -baby's wt gain & output appropriate? -does baby appear dehydrated, jaundiced, malnourished? -baby's behavior appropriately interactive *Watch out for: -family's knowledge of & response to baby's cues -misreading of quiet-alert stage w/ eyes closed as "sleeping" (active feeding can occur during baby states that look inactive to adult observers) *What do to about it: -obtain pre feeding wt -observe a feed -watch closely for baby's interest in feeding; if feeding is attempted when baby is not indicating feeding readiness, reteach cues & appropriate responses; if baby not in receptive state, encourage S2S until feeding cues are seen -when baby is attached, observe for sucking & swallowing -if baby stops suckling & appear to go to sleep, suggest alternate massage to change rate of flow of milk; observe for sucking & swallowing; does baby get more wakeful & suckle more actively? or does baby break suction? -conduct post feeding wt check; calculate milk transfer; calculate baby's approx daily needs -suggest other changes to feeding process indicated by feeding observation -schedule follow up & appropriate referrals *Expected Resolution: -when reasons for sleepiness are IDed & addressed, problem should gradually resolve; dyad learns how to accommodate one another gradually over early weeks of BF -What else to consider: -if baby is newborn, consider near-term or prematurity, labor anesthesia, infection, hypoglycemia as possible contributing factors -ensure comprehensive pediatric eval

Concern: Baby Has A Birth Defect: Phenylketonuria (PKU)

-baby has been diagnosed w/ PKU *Ask yourself: -has baby been screened for PKU? *Watch out for: -newborns do not have symptoms of PKU -symptoms occurring in the first months may include eczema, jerking movements of arms & legs, rocking, tremors, seizures, hyperactivity, microcephaly, vomiting, & musty odor in child's breath, skin, or urine caused by too much phenylalanine in the body *What to do about it: -discuss feeding plan w/ PCP & family -babies w/ PKU can be partially BF & are also fed a formula that has been manufactured to not have phenylalanine, an amino acid that individuals w/ this disorder cannot metabolize safely -volume of human milk consumed may have to be carefully monitored to ensure that levels of phenylalanine consumed are within safe limits -baby will need some small amount of phenylalanine in the diet, which could come from BF *Expected resolution: -outcome for babies w/ PKU is good, provided that levels of phenylalanine consumed can be kept low; if baby's diet is not followed carefully, irreversible brain damage may result *What else to consider: -team approach is best, team should include as a minimum the CLC, PCP, & dietician to monitor baby's progress

Concern: Baby Has A Birth Defect: Cardiac Problem

-baby is diagnosed w/ cardiac problem *Ask yourself: -what is the extent of the impact of the baby's condition on BF?; watch the baby at the breast to assess baby's ability to seek the breast, latch, & transfer milk *Watch out for: -babies w/ cardiac defects may fatigue easily at breast, so they will need to be fed frequently -observe for signs of cardiac problems, such as circumoral cyanosis (blue, grey, or white coloration around the lips) during feeds *What to do about it: -determine feeding hx; how baby has been fed, how baby is responding to feeding & so on -observe a feed -if possible, collect pre and post feeding wt check to quantify milk transfer *Expected resolution: -cardiac defects have difference degrees of impact on the ability to feed well in each baby affected; many babies w/ cardiac problems can BF well, however they should be followed closely to ensure appropriate growth *What else to consider: -for those nursing babies w/ diagnosed cardiac problems, milk expression after feeding is often needed to enhance milk removal (& milk supply) -if baby does not transfer milk well during feeds, consider use of alternate massage &/or at breast supplementation w/ expressed milk

Concern: Baby Has A Birth Defect: Down Syndrome

-baby is diagnosed w/ down syndrome (DS) *Ask yourself: -what is the extent of the impact on the baby's condition on BF?; watch the baby at the beast to assess baby's ability to seek the breast, latch, & transfer milk *Watch out for: -babies w/ DS may fatigue easily at the breast, so they will need to be fed frequently -babies w/ DS may have low muscle tone that affects ability to create suction & draw milk from the breast, thus decreasing milk transfer, which can negatively affect milk supply -observe for signs of cardiac problems, such as circumoral cyanosis during feeding; babies w/ DS may also have heart or kidney problems *What to do about it: -determine feeding hx; how the baby has been fed, how baby is responding to feeding & so on -observe a feed -if possible, collect pre and post feeding wt checks to quantify milk transfer *Expected resolution: -DS has a different degree of impact on the ability to feed well in each baby it affects; many babies w/ diagnosis of DS can BF well; however they should be followed closely to ensure appropriate growth -babies w/ DS become more proficient at BF w/ practice *What else to consider: -for those nursing babies w/ DS, milk expression after feeding is often needed to enhance milk removal & milk supply -if baby does not transfer milk well during feeds, consider use of alternate massage &/or at breast supplementer w/ expressed milk

Concern: Baby Not Comfortable at Breast: Baby Expresses Distress During Feeding By Pulling Away & Crying

-baby is expressing distress during feeds by pulling away & crying; this may happen before or during feed *Ask: -baby's wt gain & output appropriate? -could baby be in pain? -are feeding cues being misread? -are feeds being delayed? *Watch out for: -appropriate response to feeding cues -position of dyad before & after crying starts *What to do about it: -observe a feed -watch closely for baby's interest in feed; if attempting feed when baby is not indicating feeding readiness, reteach feeding cues & appropriate responses; if baby is not in receptive state, encourage S2S, allowing baby to self attach or being collaborative feeding when cues are observed -when attached to breast, if baby begins to cry, encourage moving baby into S2S until feeding cues are seen again; then watch process closely to see if there is a difference in positions before & after fretting begins -look for restriction of baby's head, position of baby's arms & legs, & so on -if crying continues try diff positions -suggest alternate massage to change rate of flow of milk observe for sucking & swallowing; does baby begin to cry when milk flow is rapid or when it is not flowing; when baby pulls away is there spray of milk, if so then maybe flow is too strong & baby is dealing w/ change in flow by pulling away & crying -suggest other changes to feeding process indicated by feeding observation -schedule follow up & appropriate referrals *Expected resolution: -behavior should resolve when problem is IDed & addressed; if change requires diff way of holding baby, may take time for dyad to finesse new position -encourage return for follow up observation to fine tune the positioning *What else to consider: -if problem can't be resolved, comprehensive pediatric eval is indicated; problems such as stuffy nose, teething, injuries (fractured clavicle or brachial plexus injury), & other anomalies have been associated w/ this behavior

Concern: Baby Not Comfortable at Breast: Baby Expresses Distress During Feeding By Fretting at the Breast

-baby is expressing distress during feeds thru sounds and body language; fussing, fretting at the breast or not wanting to stay at the breast; may include pushing away from breast, batting at the breast, etc. *Ask yourself: -is baby exhibiting expected familiarization behaviors that are being interpreted as discomfort? (i.e. newborn attaches several times w/ small degree of mouth opening before settling into a deeper latch w/ rhythmic sucking) -wt gain and output appropriate? -does family demonstrate understanding of feeding cues & respond appropriately? -could baby be having trouble breathing? -could babe be having trouble coordinating sucking, swallowing, & breathing? -could either member of dyad be in pain? *Watch out for: -changes in baby's body position or way baby is supported during feed -changes in baby's lip & facial skin color during feed (i.e. becoming pale, gray, dusky, blue); these may indicate undiagnosed physical problem for baby, comprehensive pediatric eval is urgently required before attempting another oral feed -fretting or pulling away that appears to be necessary for baby to breathe; consider swallowing, coordination, or respiratory problem; comprehensive pediatric eval urgently required before attempting another oral feed *What to do about it: -observe a feed -watch closely for baby's interest in feed; If baby is not indicating feeding readiness, reteach feeding cues & appropriate responses; if baby is not in receptive state, encourage S2S, allow baby to self attach or begin collaborative feeding when cues are seen -when attached to breast, if baby begins to fret, encourage moving baby to S2S until feeding cues are seen again; then watch process closely to see if there is diff in positions before & after the fretting begins -if fretting continues, try diff positions -suggest use of alternate massage to change rate of flow of milk; observe for sucking & swallowing; does baby begin to fret when milk is flowing rapidly or slowly; listen to suck-to-swallow ratio -suggest other changes to feeding process indicated by feeding observation -schedule follow up & appropriate referrals *Expected resolution: -behavior should resolve when problem is IDed & addressed; if change requires new way of holding baby, it may take some time for dyad to finesse the new position -encourage follow up observation to fine tune positioning *What else to consider: -if problem can't be resolved, baby requires comprehensive pediatric eval; in some cases, stuffy nose as well as more serious problems, such as submucosal clefts & other anomalies, have been associated w/ this behavior

Baby Position At Breast For Maximal Milk Transfer

-baby is near breast -baby's shoulders are supported at base of the neck -no pressure on back of baby's head, baby must be able to tilt head -baby's body rotated toward parent's chest (tummy to mummy) -baby moved towards breast, lining up nose at nipple -breast is not moved to baby; breast should lie in natural position & baby be brought to breast -start feed w/ nose opposite nipple assists baby to orient to breast via well-developed sense of smell & aligns mouth at breast when baby's head tilts back -as baby chin comes closer to breast, he will gape, opening mouth very wide as head tilts back (if baby fails to gape, repeat this maneuver) -consider additional S2S to improve baby's motor state organization for baby who fails to gape or nurse -do not push nipple into baby's mouth, doing this can result in optimal positioning of nipple or appropriate compression & release of breast & nipple tissue (can cause pain, damage, & slow flow of milk) -head tilt allows lower lip to seal to breast first followed by upper lip -baby's mouth will appear off-center when compared w/ areola, baby's lower lip will be against breast much father from nipple than upper lip (asymmetric latch) -baby seals to breast & begins to suck rapidly (could be 8 or more sucks to 1 swallow), then shifts into pattern of 2 sucks to 1 swallow or 1 suck to 1 swallow -2:1 or 1:1 suck to swallow is a time of greater milk transfer; these are interspersed w/ more rapid sucking sequences & occasional rest periods -after colostral stage, baby can transfer several oz of milk in very few minutes when appropriately latched & hungry -there is no right length of feed to ensure adequate milk transfer, however babies with consistently short (<5 min) or long (>20 min) feeds should be assessed to ensure adequate milk transfer

Side Lying Posture

-baby is placed on his/her back, laying tummy to tummy -an arm or a rolled blanket can be used to support the baby's back; there should be no pressure on the back of the baby's head

Cradle or Madonna Posture

-baby lies on the lap, on his/her side tummy to tummy, hips flexed -forearm of the arm next to eh breast that is being used supports the side of the baby's head -hand & arm support the baby's neck & shoulders in such a way that the baby can tilt his/her head

At Breast Feeding

-baby receives additional milk while at the breast thru tube attached to reservoir -baby's suckling action signals milk making cells to make more milk -hospitals often use syringes w/ feeding tubes attached

Concern: Baby Won't Take A Bottle/Cup

-baby refuse alternate feeding methods *Ask yourself: -who has attempted to feed this baby? (parents, daycare, other family members?) -what has been offered to baby? (expressed milk, formula, other beverages?) -where has feeding been attempted? (in presence or absence of nursing parent?) -when has feeding been attempted? (explore cue state of baby) -why has alternate feeding been attempted? (separation due to work or school, occasional relief feeding?) -how has fluid been offered? (what devices have been used - bottles, teats, cups, spoons, etc.?) *Watch out for: -cue state of baby at time of attempted feed -parental response to cue state of baby -manner in which baby is held for feed *What to do about it: -interview about attempts that have been made to feed baby w/ bottle or cup -observe attempted feed; encourage bottle/cup or other method to be offered when baby is in quiet/alert stage & not exhibiting signs of overt hunger -encourage that feeding be preceded by some gentle, pleasurable interaction w/ individual who will feed baby (often easier for baby to accept alternate feeding device from someone other than nursing parent; babies may be confused by sensory cues they receive when in that parent's presence & may not be able to focus on learning new way of feeding; some babies even refuse to accept alternate feeding method when they can see, hear, smell, or otherwise sense nursing parent's presence in the home) -encourage person who is feeding baby to begin by gently massaging around baby's lips w/ clean fingers; the purpose of this is to draw the baby's attention to the mouth in a pleasurable way -once baby shows interest in massage (i.e. turning head toward stimulus, opening mouth), θ bottle or cup should be raised to baby's lips --if using bottle, try one w/ large dome around nipple to stimulate the "wide-open" mouth position of baby feeding at breast; hold the bottle in a position that is parallel to the floor so baby is not in a dependent position --if using cup, use appropriate cup-feeding technique; coach parents to raise cup just so fluid touches baby's mouth rather than pouring fluid into baby's mouth -let baby pace the feed; baby should be allowed to rest as needed during feed & allowed to stop when ready; baby's eyes may be closed during part or all of the feed *Expected resolution: -may take time for baby to learn to accept new feeding method; babies typically come to accept alternate feeding devices after some exposure to them *What else to consider: -consider other methods of supplementation; baby who will not accept bottle may be happy w/ cup feeding; other babies prefer fluid from spoon or sip-type cup; if alternate feeding device is being used to supplement baby who is not receiving enough milk at the breast & is able to feed at the breast, consider at-breast supplementation -comprehensive pediatric eval is needed if refusal is strong or consistent; rarely a suck/swallow or other intramural problem has been discovered in these cases

Concern: Baby Won't Latch: Baby Refuses One Breast But Not Other

-baby refuses one breast, but not the other *Ask yourself: -has weight gain and output been appropriate? -is there something diff about how baby is held on one breast vs the other? -is one breast or nipple substantially diff from the other? -what is baby's body language when positioned on each breast? *Watch out for: -consistency of one-sider refusal; does baby always refuse same breast or different breasts at diff feeds? (maybe baby finishes first breast & second b/c one side is sufficient at this time) *What to do about it: -observe a feed -if baby consistently refuses the same breast: --suggest offering baby preferred breast; when baby releases breast, move baby to other breast w/o shifting baby's body position --if position switch does not result in latching on less-favored breast, then suggest trying other positions --if unable to help w/ latching, refer both for medical eval; rarely refusal has indicated abnormal process in breast or parent's body (cancer, lupus) or in baby's body (torticollis, head or brachial plexus injury) -if baby prefers only one breast per feeding, but does not always refuse same breast: --collect prefeeding weight if possible --listen for sounds of swallowing, rhythm of sucks to swallow, & any milk escaping from baby's mouth during feed --it's possible that baby is receiving adequate milk at one breast & cannot handle volume from both breasts; this is normal & reflects adequate or even abundant milk supply; inquire if any discomfort associated w/ over fullness on the unbuckled breast (& suggest hand expression to ease fullness w/o removing much milk) --conduct post feeding wt & calculate milk transfer; calculate baby's approx daily needs & divide that figure by the number of reported feeds in 24 hours; how does the amount arrived at compare w/ the amount of milk transferred during this feed -suggest other changes to feeding process indicated by feeding observation -schedule follow up and appropriate referrals *Expected resolution: -if reason for one-sided is IDed, problem should resolve quickly; adequate milk supply is possible even if baby only suckles on one breast; milk expression for comfort or to build supply may be needed should supplementation be prescribed *What else to consider: -other medical problems for either member of dyad

Concern: Baby Won't Latch: Feeding Refusal That is Continuous

-baby refuses to feed from breast; baby won't latch, or will & immediately pull off & cry *Ask yourself: -have baby's weight gain & output been appropriate? -does baby look dehydrated, jaundice, or malnourished? does baby seem alert & active or lethargic? -are breasts so full & hard that baby is unable to form teat? -has baby been forced to breast w/ pressure on back of head? -what is family's response to baby's refusal? -if onset is sudden & refusal is continuous, what has changed recently, (i.e. has milk volume increased, change in family routine, nursing parent taking new meds, nutritional supplements, etc) *Watch out for: -presence of feeding cues prior to feeding -process used to bring baby to breast -visible signs of pain for either members of dyad *What to do about it: -if breasts are hard & full, sufficient softening should be done before attempting to feed -is aggressive latch techniques are used, or pressure on back of baby's head do S2S & allow baby to self-attach -baby has trouble w/ increased volume or milk flow, make sure baby is able to move head away from breast & let milk spray -observe feed using feeding observation checklist -is baby refuses to latch, ask that baby be held S2S until feeding cues are observed & baby moves toward breast -encourage bringing baby close to breast immediately upon observation of feeding cues, & allow baby to find breast and self attach (babies need to familiarize before latching as they learn sounds & smells & tastes of feeding at breast) -suggest alternate positions, encourage hand expression to release few drops to offer baby to smell and lap; if baby latches can use alternate massage / breast compression to increase flow if baby becomes fidgety -suggest other changes to feeding process indicated by feeding observation -persist in trying to uncover underlying reason for difficulty in coming to breast; babies should show desire; not doing so raises a concern; continuing demonstration of lack of desire warrants comprehensive pediatric exam -schedule follow up & ensure appropriate referrals *Expected resolution: -comfortable & effective feeding postures & positions will be found -is baby can't be helped to BF & PCP has prescribed supplementation, frequent S2S is encourages in order to assist baby in developing comfort when being held to breast -consider at breast supplementation if supplementation is prescribed -work to ensure adequate milk expression in order to build &/or maintain abundant milk supply *What else to consider: -if observation & positioning guidance do not resolve refusal, referral for immediate broader eval is required; stuffy nose, respiratory problems, ear or other infections, trauma (fractured collar bone, torticollis) need to be ruled out -babies w/ neuromuscular problems, experienced painful procedures to the head (suctioning, intubation, repeated examination) & those who have been forced to breast may refuse to feed -if supplementation is ordered, suggest maintaining &/or building milk supply & consider use of at breast supplementer -consider family situation as well; if milk supply is low or flow is slow, the baby who has been exposed to a bottle nipple may "refuse" breast; fine tuning the latch & positioning & using alternate breast massage or at breast supplementer may assist in keeping baby at breast; both members of dyad should be examinaed by healthcare provider; breast refusal may indicate there is abnormal process occurring in breast or body (i.e. cancer, Goldsmith's, lupus) this is rare, but should always be considered a possibility if other reasons for refusal are nor found

Proof of Success of BF Baby

-baby who is responsive & interactive -growing well (about an oz a day after 5th day) -producing at least 6 wet and 4 dirty diapers starting on day 4 and continuing into the early weeks

Nursing Strike

-baby younger than 12 mos who is stopping -sudden -there is milk -not the end of BF but may be thought to be the end -reason for strike may be obscure but there is something wrong in the baby's life (stuffy nose, teething; ear infection; prefers bottle; biting & yelling; maybe mom was bit and yelped; reaction to being left unattended to "cry it out"; family stress; separation) -to end a nursing strike: (ID & resolve problem; lots of support; lots of S2S; don't force it; avoid bottle; offer breast to sleeping baby; try "peer pressure")

Concern: Baby Won't Wake Up Enough To Nurse Well OVERALL

-baby's ability to rouse easily from deep sleep can be lifesaving in event of apnea -parents are justified in their concern about babies who have long periods of deep sleep

Concern: Smoking & BF

-concerned about choosing to BF if smoking cigs *Ask: -is family aware of need to protect baby from secondhand smoke? -smoking during pregnancy (if so, BF is encouraged - BF may mitigate adverse effects on child's cognitive development of smoking during pregnancy) -cutting back on # of cigs can result in better weight gain -is there motivation to stop or cut back? -if wanting to quit a prescriber may suggest nicotine patches during BF *Watch our for: -fussiness -smokers tend to nurse for fewer months -smokers may make less milk possibly due to lower prolactin levels *What to do about it: -tobacco components can be found in milk, but greater exposure occurs w/ smoking during pregnancy and when exposed to secondhand smoke -cigs are very addictive, may not be realistic to expect person to give them up in order to BF -smoking cessation programs can be helpful -benefits of getting BM even from a smoker outweigh any negatives -emphasize importance of protecting baby from secondhand smoke -suggest options for reducing or quitting -ensure frequent nursing & other good BF practices -know local tobacco cessation resources and make appropriate referrals -ensure frequent wt checks -help family w/ baby fussiness if it is an issue *Expected Resolution: -smokers should be encouraged to BF if they want -protect baby from secondhand smoke no matter how they are fed

Potential Concerns Related to BM Mix-Ups

-concerns about potential exposure to HIV: (women who are HIV positive are advised NOT to BF infants; however if baby is exposed once to a single bottle the risk of transmission is very low) -concerns about potential exposure to Hep B & Hep C: (can't be spread unless exposure to blood, so very unlikely baby would have exposure; most infants have already received 1st dose of Hep B vaccine after birth, 2nd dose at 1-2 mos, 3rd dose at 6-18 mos; no evidence that BF spread Hep C) -concerns about potential exposure to medications: (most have little to no effect on infant well being, few are contraindicated, & a single exposure thru BM is low)

Concern: Tongue & Lip Tie

-concerns about whether or not baby w/ tongue or lip tie can BF -concerns about whether BF problems like nipple pain & fissures, mastitis, poor growth, etc can be explained by lingual or labial restrictions (tongue/lip ties) *Ask: -has a detailed, individualized BF assessment been completed & corrective interventions implemented *Watch out for: -thinking that releasing the restriction of the tongue and/or lip tie is most expedient solution for BF problems *What to do about it: -suggest options for improving BF latch & feeding; especially top lip rolling in, mouth not opening more than 140 degrees, and latch not being asymmetrical -refer as needed if dx and tx are not within scope of practice as a CLC -ensure baby had time release vitamin K injection after birth if decision has been made to revise the tongue or lip anatomy (BF babies of not reach adult levels of vitamin K until about 6 mos of age if they don't have that injection after birth) this makes them vulnerable to uncontrolled bleeding; even young babies who have had vitamin K have been hospitalized bc bleeding couldn't be stopped after tongue revision *Expected resolution: -according to research, dyads w/ BF problems attributed to tongue & lip restrictions should first get complete BF assessment, then suggested corrective interventions should be implemented

Colic

-condition of infancy described by classic rule of 3: bouts of high-pitches crying lasting more than 3 hours a day, for more than 3 days a week, & more more than 3 weeks in a well-nourished, otherwise healthy baby -typically started after 2 weeks of age & resolves by 4 months

Intervention: Positive Experiences Through Knowledgeable Peers

-confidence & empowerment increased w/ group based peer counseling -videos alone are ineffective -peer counselors provide support, information, & social learning -women's decision to BF was found to be significantly associated w/ WIC peer counselor contacts -La Leche League provides support, information, & social learning through mother-to-mother support -Mom2Mom Global provides support info & social learning thru mother to mother support for US military families around the world; it's dedicated to building BF friendly military communities

Concern: Mother is Ill & BF (OVERALL)

-contact info for state health dept, CDC< & other health authorities are important resources to have at your fingertips -when q's arise about possible contraindications, families & members of healthcare team need immediate, reliable answers

What About Creams?

-continued questions of effectiveness -fears of ingestion by baby

Dietary Choices while BF

-convey flavors of the culture to baby by flavoring BM -spicy/gassy foods should be excluded on a case by case basis, not a general rule -babies prefer flavored milk -babies get used to flavors when swallowing amniotic fluid -chocolate, coffee, tea, and sodas w/ caffeine can be enjoyed in moderation -CDC says to avoid alcohol, but no harm in having 1 drink per day and waiting 2 hours to nurse -colicky BF babies may be reacting to cow milk in mom's diet (may take 10-14 days of eliminating cow milk before BM is free of it) -some other foods may cause reactions (eczema, proctocolitis) in baby such as cow milk, soy, eggs, wheat, or fish

Concern: Weaning

-could be parent-led weaning, baby-led weaning, or society-led weaning *Ask: -what does "wean" mean to this family? (could mean beginning to stop BF, could mean stopping altogether, could me continuing to BF while adding complementary foods) clarify so you are on same page as family -is the idea to stop BF altogether? how fast does family want this to happen? rapid weaning can have negative consequence for breasts (discomfort, mastitis, abscess) and for child (longing for nursing or no longer being potty trained). faster the weaning the more watchful everyone needs to be *Watch out for: -choice of BM substitute (for babies under 1 formula is appropriate substitute), how does baby react to substitute, any physical reactions? -choice of BF substitute, substitute for the closeness of BF has to be equally good in the eyes of the child -speed of weaning (depending on stage of lactation, milk may need to continue to be removed & milk supply gradually decreased to prevent engorgement, mastitis, and/or abscess) -emotional responses (w/ baby led the baby is less interested in continuing and parent may feel sad about loss of special time together; w/ parent led the baby may feel rejected or ignored and shut down or become demanding) *What to do about it: -sometimes those who did not need help to BF are surprised at how much help & support they need when weaning -sometimes BF is ended & baby cannot tolerate the substitute *Expected resolution: -BF time & weaning time will be remembered w/ joy, irrespective of duration *What else to consider: -do not confuse weaning w/ nursing strike -sometimes weaning begins & then parent changes mind, milk supply can be built back up if needed -some people think only reason to nurse baby more than 6 mos is because they don't know how to wean

Factors The Discourage BF

-coupons, bags, other free gifts from manufactures of BM substitutes -BM substitutes advertised on social media, in print media, & on tv as cultural norm while BF is discouraged in public -care providers, family members, & peers who may discourage BF -fear of pain & embarrassment -fears about adequacy of milk supply -fears of inadequacy of breast size or appearance

What About Other Foods Eaten When BF?

-cows milk whey is the only substance consistently shown to bother some babies w/ "colic" symptoms -not all babies show symptoms & those that are bothered do so on very different amounts of liquid cows milk from 4mLs (<1tsp) to 400mLs (1.7 cups) -recommendation is to stop drinking/using liquid cows milk temporarily (up to 10-14 days) if BF baby has colic

Breastfeeding Positions

-cradle or madonna posture -cross cradle posture -football or clutch posture -semi-reclining (laid back) posture -side lying posture -australian posture

To Develop a Relationship w/ Subjective Knowers

-create time for them to talk about themselves & what they think about BF (otherwise they can take over classes or group sessions) -offer help w/ possible misconceptions about BF -offer to make contacts and referrals (they want to be with people that are more like them or have problems that are more like their problems)

Concern: Baby Won't Stop Crying OVERALL

-crying babies deserve comfort; crying does not exercise the lungs or serve any helpful purpose for the baby -in young or ill baby, excessive crying can be detrimental to growth, as it increases stress & burns calories

Cup Feeding

-cups are inexpensive, available, & easy to clean -growing body of research indicated the safety & efficacy for both term & preterm infants -baby sets their own pace -when cup feeding, sit baby upright -do not pour milk into baby's mouth -tip the cup slightly so that milk is at the edge of the cup -rest the cup gently on baby's lower lip -baby may sip, slurp, or lap milk from cup

Helpful Corrective Interventions for Positioning Babies w/ Difficulty Sustaining a Feed

-dancer technique: base of breast is held in your hand, & your thumb & pointer finger are free & are holding the baby's jaw & cheek; so baby is in an upright position -individualize positions: hold baby to assure maximize tone -provide sensory input to the mouth & muscle toning exercise if appropriate -individualize hand hold to connect the baby & breast

The Joint Commission created Perinatal Care Core Measure Set for implementation which includes:

-decrease elective delicery -decrease c sections -increase antenatal steroids -decrease health care-associated bloodstream infections in newborns -increase EBF *this quality measure: anticipates that hospitals will implement strict definition of acceptable criteria for supplementation & work toward 100% EBF

S2S Promotes

-decreased rate of primary pp hemorrhage -faster expulsion of placenta -correct suckling -less crying -S2S babies are warmer & mother's breasts are warmer too (decreases incidence of hypothermia for first 48 hours; they are actually cooler when they are placed on the warmers vs on mom's chest) -less separation (less likely to be put baby in nursery)

Infant States After First Hour

-deep sleep (don't attempt feeding) -light sleep state (REM) happens about every 27-30 min during sleep (great time to start BF) -quiet alert (still body, fixed eye focus) (also good time to start BF) -active alert (growing restlessness w/ hand to mouth activities; open eyed w/ rooting) -crying (change in state is needed before attempting feeding

Delay in Newborn Bath

-delay in bath in BFH from 2 hours to 12 hours in the mother's room rather than the nurser w/ the parents participating & w/ S2S following: -increased odds of EBF by 39% & 59% greater for near exclusive -the odds of BF initiation were 166% greater w/ delayed bath

Insulin Dependent Diabetes Mellitus (IDDM)

-diagnosis of this may be related to abundant milk supply (lactogenesis 2) coming days later than in those w/o it

Concern: Baby Won't Latch: Baby Refuses One Breast But Not Other OVERALL

-differences in rate of milk flow may describe majority of one-sided feeding that is not restricted to same breast at each feed -must be vigilant for those cases that do not fall into this category, particularly the case where breast refused is always the same side -pre- and post feed wt checks are useful tool that can be overused; they should be used only when there is genuine need to evaluate milk supply; overuse may be disempowering & suggest that the focus should be on the quantity of milk rather than quality of feeds

Grade 3 Inverted Nipples

-difficult or impossible to pull out; some think that this is because there are internal breast anomalies such as short ducts

Mothers w/ High EPDS (>12) More Likely to:

-discontinue BF by 4-12 weeks -be unsatisfied w/ infant feeding method -experience significant BF problems -report lower levels of BF self efficacy (confidence)

4-6 Months

-distractible -may need to move to quieter place -regular naps? (sometimes, all babies are diff) -separation anxiety (normal & temporary) -night feeds? -teething --sore nipples can happen when baby's saliva changes & gets new enzymes around the same age as teething --babies may nurse more of much less --offer cold "teethers" before nursing to "numb" mouth --if baby is nursing less & milk is causing compression, maintain milk supply by relieving the fullness --babies may also have runny noses & difficulty breathing at this time

Timing BF Sessions

-do not give rules about how long a feeding should last based on the idea of fore and hind milk -do not need to time feeds, do not need to nurse 10-15 min on each side -babies on average across the world nurse 140 min each day

Injections (Depo-Provera)

-does not prevent breast from producing milk, so nursing moms can use it; however, it is better for bay that for first few weeks after birth, mom's milk has no traces of any meds -your doctor may advise that you wait until at least 6 wks pp before you start using Depo -is baby is exposed to Depo in breast milk, no harmful effects have been seen in babies & children

Grade 1 Inverted Nipples

-easily pulled out by suckling or breast pump

Grade 2 Inverted Nipples

-easily pulled out by suckling or breast pump but don't maintain the projection once the baby's mouth leaves the nipple or pump flange is removed

PP Community Support for BF Families Should Include:

-ensuring that families are aware of & connected w/ BF support resources in their community -both formal & informal sources of BF support, education, & follow up -assessment of an entire BF, including prefeeding behaviors, & support to address any uncomfortable or ineffective aspects -reinforcing importance of cue-based feeding as strategy for optimizing self regulation of intake & potentially decreasing obesity rates -prompt referral to primary healthcare provider as needed

Concern: Nipple & Breast Pain After BF: Raynaud's Phenomenon Of Nipple

-excruciating nipple & breast pain after nursing & at other times when nipple is cold or wet; always accompanied by nipple color change (waxy white, quickly transient to cyanotic blue or grey, & then to raspberry pink or white to pink); often areola changes shape at the same time -pain is worse after nursing/pumping/hand expression -although the greatest amount of pain is described to be near the nipple, pain may radiate throughout the breast -pain also occurs when nipples are cold &/or wet (i.e. when getting out of shower) -pain is excruciating & may be described as burning or stabbing -consider that what is being described may indicate nipple vasospasm or Raynaud's phenomenon of the nipple *Ask yourself: -does nipple change colors from being lighter to pinker & more blue or grey?; the skin may even look white & waxy; do the color changes happen along w/ pain seconds to minutes after baby comes off breast, after pumping, after showering, when cold/wet? -is pain related to nipple changing from being warm to being cold? -does drying/warming nipple & breast decrease the pain? *Watch out for: -confusing this w/ yeast problems; nipples do not show the multiple color change if the problem is yeast, & white patches would be seen in the baby's mouth; also if the problem is yeast, the pain is usually described as burning both during & after the feed -confusing Raynaud's w/ appearance of white or grey stripes or areas on the nipple that are visible immediately after feed caused by compression of nipple that has not been properly placed in baby's mouth during feed; while pain is experienced in this case as well, it is typically present throughout the feed as well; in the case of whitening/greying caused by compression, improving the latch will stop the compression & thus alleviate this problem *What else to do about it: -ensure optimal positioning -eliminate any other causes of painful nipples that can contribute to nipple pain; sometimes it works to keep warmed cloths nearby to warm the nipple after feed so that the nipple cools more slowly -Nifedipine has been prescribed for nursing moms w/ Raynaud's symptoms w/ good results *Expected resolution: -some report a marked reduction in pain once triggering factor for nipple vasospasm has been addressed, but nifedipine may also be considered by the HCP; w/ nifedipine it may take several days of tx for the pain to resolve completely & the color changes may persist even when pain has subsided *What else to consider: -Raynaud's could have been an issue before pregnancy & BF bit it can happen after suboptimal positioning, high mouth pressure during suck, nipple infection, eczema, & other breast & nipple conditions; each possibility should be considered *OVERALL: -we have seen cases where Raynaud's began in early teens; often there is family hx of Raynaud's; we were told about one situation where Raynaud's wasn't dx until BF; the mother told us she was surprised that anyone liked to swim b/c she assumed that everyone had the same painful nipples that she did after swimming; we have also seen the development of Raynaud's after long course of painful & infected nipples

Oxytocin

-exit - helps milk come out of breasts -squeezes my-epithelial cells & helping milk exit the breasts

How Much Milk Do We Make?

-expectation is 750-1000mls per day -mother of twins could make 2355-4170mls

Weight Gain Expectations & Infant Elimination Patterns (Appendix I)

-expected that newborn will have evaluation w/ pediatric care provider within 48-72 hours after leaving birthing facility (around 3-5 days of age) -key BF components of this visit are: -eval of hydration status & elimination patterns -observe a feeding -eval of wt gain/loss; baby should lose no more than 7% of birth wt after 5th or 6th day; if baby lost 7% or more careful assessment and follow up are needed -after 5th or 6th day, wt gain should be seen -if baby had not gained wt appropriately, explore possible maternal reasons for inadequate milk supply as well as milk transfer related to estimated daily BM requirements -discuss other maternal & infant issues -we expect baby to have 4 stools (some yellow) daily by day 4 (4on4) & continuing for the first month along w/ at least 6 wet diapers w/ light colored urine -stools are most important sign that newborn is getting enough milk -baby back to birth weight by 12-14 days of age (if not an intensive, in-person eval of BF, milk supply, & milk transfer w/ corrective interventions is initiated) -in early months expect wt gain of 1oz per day (most healthy BF babies gain more than this)

Cannabis

-exposure of infant to any kind of passive smoke is a concern -there is no safe threshold limit for cannabis use in pregnancy -among pregnancy women, cannabis use was significantly associated with an increased risk of preterm birth & low birth weight -unfortunately specific recommendations on ingestion during lactation are difficult because of the lack of definitive human studies -high fat solubility of cannabinoids make them difficult to analyze in BM. -THC is still measurable in milk ~6 days after maternal marijuana use -colorado dept of health is good place to get info -opinions vary which makes policy making difficult -pregnant & lactating women should be advised to avoid cannabis use -at this time although the data re not strong enough to recommend not to BF w/ any marijuana use, we urge caution, moms should be cautious -there are insufficient data to evaluate the effects of marijuana use on infant during lactation & BF. in he absence of such data, marijuana use is discouraged -clinician should counsel the mother carefully regarding use of marijuana in lactation & the significant lack of safety data at this time -AVOID exposing baby to secondhand smoke, seems to be fair to tell a mom that marijuana use is unlikely to benefit her infant, but based on current evidence we honestly & unfortunately do not know whether it will do harm

Working & BF Options (most to least prevalent)

-express and save milk to be fed later (longer BF duration) -keep baby at work and nurse during day (longer BF duration) -neither pump nor feed during day (shortest duration of BF) -go to baby to nurse during day -have baby brought to work to feed during day -express and discard milk collected

1. Milk Removal Is Needed In Order To Make Milk

-expression within 1 hour of birth for the highest milk volume had most milk (thru wk 8) -hand expression increases milk volume -research indicates that participants (babies <31 wks gestation) who hand expressed on days 1-3 >5x a day & continuing w/ pumping & hand expression had the most milk (thru wk 8) -hand expression is more effective b/c oxytocin is responsive to conditioned response, nipple stretching & hand massage on breast -hand expressed milk was highest in calories compared to pumped milk -early hand expression w/ later addition of pump expression yielded milk that exceeded norms for fat & energy -using a pump or hand expression to build the milk supply (can nurse on one side & pump on the other side) --ongoing support person & professional oversight --express in proximity to the infant (particularly during KMC) for higher milk volume --double stimulation --collecting milk on one breast when nursing on the other is an effective strategy --guided imagery has been shown to increase the amount collected via breast pump - in a study women doing guided imagery pumped 35mL more milk --power pumping for a day or two may also help to increase volume (adequate frequency of stimulation plus try 5 min, pause, 5 min, pause, 5 min, pause)

Indications for Immediate Medical Attention: For the Infant

-extreme lethargy; unable to wake or rouse baby; extreme irritability; doesn't calm even w/ cuddles; sudden change in baby's muscle tone (extremely floppy or stiff) or repetitive jerking movements (seizure ax); sudden decreased ax; sudden disinterest in feeding; sudden cessation of mvmt of legs or arms; meconium after 5 days of life; fewer than 3 stools in BF newborn after first 2 days of life; no urine in 6 hours; brick dust urine after 2 days of life; dark color urine; fewer than 4 urines daily in BF baby after day 5; fewer than 4 bowl mvmts on day 4 for BF baby; no yellow bowel mvmts on day 4 for BF baby; sunken fontanelles; baby below birthweight at 10-14 days of age; weight loss after 5 days of age; cessation of wt gain; fever higher than 100F when younger than 3 mos old; fever above 101F when older than 3 mos old; circumoral cyanosis while feeding or crying

Premature Baby Labels

-extremely preterm: less than 28 weeks -very preterm: 28-32 weeks -moderate to late preterm: 32-37 weeks -early term: 37 weeks - 38 6/7 weeks -full term: 39 0/7 weeks - 40 6/7 weeks -late term: 41 0/7 weeks - 41 6/7 weeks -post term: 42 0/7 weeks and beyond

Preventing Milk Mix-Ups

-facilities should review & update policies & practices for storing, handling BM -train all staff in safe storage & handling of BM -clearly labeling expressed BM w/ child's name -some places put colored rubber bands for diff infants & use separate bins for each infant's bottle of milk

Common Mastitis (Breast Inflammation)

-factors associated w/ mastitis: blocked ducts (i.e. from engorgement, hurried feeds, use of nipple shield); attachment difficulties; tight bra; use of breast shell; nipple pain; anemia in mother; tongue tie in baby -systemic - fever, ill feeling, redness, pain, one inflamed breast -if infective it may be staph -problem is generally not in the milk, but in the tissues of the breast

Concern: BF Multiple Babies (Twins, Triplets, & More)

-families are concerned if BF is possible; it is possible to make enough milk for many babies, but situation is often complicated by prematurity & concerns about milk supply *Ask: -were babies premature? -was there bed rest at end of pregnancy? could be muscle atrophy & fatigue (these things don't affect milk supply, but may influence ability to cope w/ stress of multiple, often premature babies) -are babies able to transfer milk? -what resources, physical & emotional are available to the family? *Watch out for: -lethargy, decrease in urine/stools, change in BF behavior, problems w/ feeding *What to do about it: -nursing babies simultaneously is helpful for building milk supply but may be difficult to manage at first; offer help w/ positioning -at first, switch babies from one breast to the other; as they get older they may prefer nursing on one side or the other -many families have found it helpful at first to write down "who" nursed "when" to be sure each baby gets enough -undertake a feeding assessment *Expected resolution: -no way to know ahead of time how much milk is possible to make; frequent wt checks of babies are needed to assess growth in early weeks *What else to consider: -encourage family to keep open mind about babies feeding plan; sometimes plan to pump & feed bottles is found to be more work & take more time than feeding only at breast

When Babies are in Close Proximity

-families can observe for feeding cues -baby can be held S2S -babies can smell the milk -babies can be fed at their best time -learning happens together -mom's whose babies roomed in, slept slightly longer & reported a higher quality of sleep than mothers whose babies were in the nursery

What do we know about why families choose not to BF?

-families think formula feeding is "easier" -may be more comfortable w/ idea of formula feeding, so it make sense that BF is discouraged during pregnancy when we make BF seem hard or "schoolish" or focus on the advantages to the baby

BF Counseling Goals

-family concerns are heard and valued (listen to what is going on and listen to what is being said; just because the concern is the same that 10 other patients have had doesn't mean the reasons for having the concern are the same) -baby feels heard & valued (if you need to feed/care for baby during this meeting, please do) -counselor elicits "the whole story" before offering feedback or intervention (don't just get concerns from chart or referral, get into it with them) -adults, baby & counselor are fully involved in problem solving -safety is always the primary focus (even over BF) (if someone is very depressed that is first priority - "hey lets find you a counselor to help you with xy&z and we can address feeding tomorrow") -technology & gadgets are used very carefully (don't just use tools and gadgets to solve the problems

When to BF: Feeding Frequency

-feed "responsively" -more opportunities baby has to practice BF the more skill he will have -calorically deprived babies are sleepy and apathetic feeders -baby's stomach capacity varies and increases over time -BM is perfect for baby, very easy to digest, so BM needs to be fed more often than formula -crying babies may shut down and look asleep when they have actually given up -newborn BF babies need to nurse 10-12x day -crying is very late feeding cue, by this time they are disorganized and do not feed well

Concern: Baby Won't Latch: Feeding Refusal That is Continuous OVERALL

-feeding refusal must be taken seriously; babies can dehydrate quickly -best to err on side of caution, esp when baby is newborn -sometimes family/friends advise that the baby should be allowed to become hungry suggesting that when baby is hungry enough he/she will accept the breast; this is dangerous strategy that may be detrimental to baby's health -occasionally refusal is caused by misunderstanding of when to feed baby; perhaps baby is being held to a schedule rather than being fed when showing early feeding cues, or baby is expected to cries a hunger signal before being fed -sometimes family is concerned that responding to feeding cues will "spoil" the baby; we do not believe it is possible to spoil a baby by responsive caregiving

Pregnancy & Lactation Are Not The Same

-fetal calcium demand is met by increased intestinal absorption during pregnancy -regardless of the amount of calcium in the diet, BM calcium is met by renal calcium conservation & loss of bone (which is recovered post-lactation) -there is a 3%-9% decrease in bone density during lactation -BF moms (even on high calcium diets) lost 3.9% BMD (bone mineral density) in lumbar spine but gained 5.5% after weaning -pregnancy w/ BF in adolescence did not negatively affect BMD at later age -Why is the bone protected? why are the calcium levels laid down? --b/c estrogen levels increase during weaning (a good time for our body to stash calcium away in our bones) - the way bone mineralization increases in adolescent girls as estrogen levels increase --this is another example of the body adapting physiologically & positively to lactation

To Develop a Relationship w/ Women in Silence

-few words (don't overwhelm them) -familiar words -short, easy, comfortable -nothing to remember -you may need to be an advocate

BF Adequacy in Early Weeks

-fewer than 4 soiled diapers on day 4 when used in conjunction w/ delayed onset of lactation may indicate BF inadequacy -four on four and each day after!

Clogs or Plugs or Cakes Treatment

-find out cause, especially if recurring (i.e. bra) -massage, warmth, double nursing may help (point chin toward clog) -see HCP is systemic symptoms appear or if clog does not move in 24-48 hours

Concern: Nipple Pain That Radiates Thru Breast & Even To The Back: Bleb

-firm, small white spot of accumulated milk solids visible on the nipple face; sometimes nipple itself may be distended, esp if there are multiple blocked nipple pores; occasionally, nipple skin "grows over" the bleb & prevents the bleb's removal w/o lacing; nipple pain is experiences while baby is latched on & actively nursing as well as in b/w feeds; pain usually also increases when anything (such as clothes) touches the breast, & radiates from nipple tip toward the spine *Ask yourself: -can baby extract retained milk w/ more effective feeding? -is this a milk blister from friction?; if so a BF assessment may determine if a change in latch can reduce friction, which is the cause of the blister -does baby has a blister on lip (which may also indicate that this is a milk blister due to friction, not a bleb)? *Watch out for: -reoccurrence if the underlying problem is not addressed -development of systemic symptoms (fever, malaise) that may indicate onset of mastitis *What to do about it: -work to achieve a more effective position -will soaking the breast in warm water prior to nursing or hand expression help to "loosen" the bleb? -will gentle hand expression & finger manipulation expel the bleb? -has skin (or clear layer of tissue) accumulated over the bleb? Is that the reason the bleb is not moving out of the nipple? in some cases, lancing followed by expression of retained milk is the only way to solve the problem; milk behind the bleb is usually thick (consistency of soft cream cheese); a few drops of blood are not unusual after lancing -why did bleb form? is part of the breast draining poorly? tight bra? underwire? binding? other constriction on milk flow? bruise? was there a plugged duct further up in breast prior to bleb forming? *Expected resolution: -once the bleb & milk behind it are removed, the pain should decrease markedly *What else to consider: -plugged ducts; mastitis (will have systemic symptoms) *OVERALL: -no one really understands why blebs happen; there are reports of repetitive cases of plugged ducts or blebs being decreased in incidence w/ an increase in the amount of lecithin in the diet; we have known cases where this has worked

Latch (LAT)

-first line up nose to the nipple -then move baby back an inch or two -baby should gape, repeat as needed -as baby is moved toward breast, the head tilts back -a hand should not be on back of head in order to allow for head to tilt -bottom lip & chin reach the breast first -nipple will then align w/ upper half of the mouth; when baby is latched optimally, there is more of the lower peer of the breast drawn in -nose & chin should be close to breast -angle at corner of mouth should be at least 140 degrees; baby's tongue takes up half of the mouth, so a wide angle is needed for room for the nipple to stretch in the top half of the mouth -both lip should optimally seal (both lips need to be flanged out to where the seal of the lips is the wet part on the breast) -the cheek line should optimally be a rounded cheek line (not ideal if cheeks go in while baby is sucking - dimpling; if baby doesn't have rounded cheek line they might not have a good top lip seal) -not broken cheek line -not dimpled cheek (during feed the cheek stays round and full) -bursts of 1:1 or 2:1 in an irregular pattern indicate a nutritive suck (after first few days we don't want to see sucks of more than 6:1, as they get older then 4:1 is probably the maximum) -baby looks off center, this is the asymmetric latch; more of the lower part of breast goes in baby's mouth -rocker motion is optimal (goes back & forth, rocks back towards the ear & then back to the breast) -piston motion is not optimal (more like a chewing motion, up & down) -the baby should end the feeding w/ hands relaxed

Greater BF Support Needed For:

-first time parents -mothers of late preterm infants (born 34-37wks) -women w/ family or financial problems -women experiencing postpartum adjustment disorder

NOT Related to Decreased Milk Production

-fluid intake (encourage drinking to thirst, drinking beyond that won't make more milk) -physical labor -stress -fatigue (being tired w/o underlying problem like anemia, thyroid issues, does not affect milk supply) -diet (malnourished does not affect milk supply)

Relactation

-follows pregnancy (not necessarily BF) -variables include ability to produce milk, baby's willingness to nurse, & length of time it will take to produce milk -good strategy for emergencies

BM & The VLBW Baby (<1500 g)

-for every 10ml/kg/day increase in breast milk ingested there was an increase in the Bayley Mental Development Index, the Bayley Psychomotor Dev Index & the Behavior Rating Scale; there was a 6% decrease in re-hospitalization

Can BM Improve NICU Outcomes?

-for every increase in BM of 10ml/kg/day, the odds of sepsis decreases by 19% -for a 2lb baby that translates to 9ml or 1.8tsp of BM/day -for a 4lb baby that translates to 18ml or 3.6tsp of BM/day -NICU costs were lowest in the VLBW babies who receives the highest average daily dose of BM days 1-28

Strategies for Supporting BM when Separation due to Work or School

-get BF off to best possible start in first week after birth -explore parent's options w/ nursing or pumping at work -assure community support available for families -save tips for appropriate time (2-3 wks before return to work or school) -become familiar w/ available resources for employers and employees

Calculating Baby's Approx Daily Needs

-get pre-feed wt check -observe a feed -conduct post feeding wt & calculate milk transfer; calculate baby's approx daily needs & divide that figure by the number of reported feeds in 24 hours; how does the amount arrived at compare w/ the amount of milk transferred during this feed --if milk transfer estimate is much lower than estimated need, follow protocol for poor milk supply & milk transfer --if transfer estimate is higher than estimated need, follow protocol for oversupply --if transfer estimate is roughly the same as estimated need, schedule follow up contact to ensure that the problem is resolving --any single feed does not necessarily indicate typical milk intake; it's helpful to observe several feeds over a period of time to get better estimate of average transfer

Peri-Areola Incision (Breast Surgery)

-goes around the areola either part way or all of the way -this kind of incision Is the MOST significantly related to milk insufficiency; chances are some of the nerves or ducts have been damaged -if you see someone w/ VERY round areola, might want to ask if they have implants because nipples are naturally more oval shaped and nipples may have been altered -if you see line/scar going down the middle of breast under nipple is also a sign that augmentation probably happened

Lactogenesis I (Secretory Differentiation)

-happens during pregnancy -you produce colostrum

Concern: Breast Lumps: Plugged Duct

-hard (often) painful area of breast, swollen (clogged) w/ milk b/c of temporarily poor milk drainage but w/ not systemic symptoms *Ask yourself: -how can positioning & milk transfer be improved? *Watch out for: -are there any systemic symptoms (fever, malaise)? if so, consider this could be mastitis -is the skin over the hard, painful area reddened? consider it could be mastitis *What to do about it: -solicit an accurate description of the plug's location; (i.e. right breast, 11 o clock, 4 finger widths from base of nipple); that way it can be documented how the lump has moved -encourage starting on the side w/ the plug to maximize flow when baby's suckling is the most efficient -change posture (& baby's body position); changing position at breast may allow the plug to exit the breast; there are many reports that changing position so that baby's chin points in another direction at the breast was helpful -light massage during BF on affected side may increase milk flow *Expected resolution: -plug should move toward nipple w/ each feeding & disappear within 24-48 hours -tenderness in area of the lump may be reported for several days after lump has moved -lump may come out as stringy milk or a hardened blob of milk; this is not harmful for the baby to consume -if lump does not move in 24-48 hours, a referral to HCP must be assured -occasionally, dried milk solids lodge in the nipple as blebs *What else to consider: -lumps in breast can have many other causes; if plugs do not move out in 24-48 hours, a physical exam by qualified HCP is required *OVERALL: -blocked ducts tend to happen when breast is not draining as well as it should; careful assessment of feed & examination of possible items such as bras, seat belts, baby carriers, bags, which can create compression on breast, can help determine the underlying reasons for development of plug, & correction may serve to prevent or minimize future plugs

Indications for Immediate Medical Attention: Other Symptoms in Pregnancy & First Year PP

-headache that won't go away or worsens over time; dizziness or fainting; changes in vision; fever of 100.4F or higher; extreme swelling of hands or face; throughts of harming self or baby; trouble breathing; chest pain or fast heartbeat; severe nausea & vomiting; severe belly pain that doesn't go away; baby's mvmt stops or slows during pregnancy; vaginal bleeding or discharge after pregnancy (heavy bleeding - soaking thru 1 or more pads in an hour; passing clots larger than chicken egg, &/or vaginal discharge that smells bad); severe swelling, redness, or pain of leg or arm during pregnancy or up to 6 weeks pp; overwhelming sadness or tiredness; seizures; incision that is not healing

Infected Nipple

-heal best w/ antibiotics (systemic or topical) -lanolin users had 62% infection rate, non lanolin users only 18%

Issues to Consider When Using Bottles

-healthy babies fed at breast only are most likely to be BF at 6 mos -BF support should be offered in NICU before using bottles -babies who are bottle fed babies (with either formula or expressed milk) are 2X more likely to empty the cup or bottle in late infancy than those who are fed only directly at the breast -bottle feeding may alter self regulation of intake contributing to later obesity, higher weight gain velocity, & BMI -bottle size may be modifiable risk factor cup feeding for premies

Self-Attached BF

-healthy baby should be dried after birth & placed on chest for prolonged S2S -dyad covers w/ warm blanket -mom & newborn assessment, eye care, & other procedures are done w/ baby in S2S -babies warm better in S2S compared to electric warmers (breasts will increase and decrease in temp according to baby's needs) -allow newborn baby to find breast & self attach. This may take more than 2 hours when labor analgesia has been used; do not force baby to breast, doing so may stress baby, decrease willingness, & cause baby to place tongue on roof of mouth

Neonatal Hypoglycemia

-healthy term newborns who are BF on demand & are asymptomatic do not need blood glucose routinely checked -AAP guidance current evidence does not support a specific concentration of glucose that separates normal from abnormal -however "a reasonable (although arbitrary) cutoff for tx symptomatic infants is 40 mg/dL" -NH occurs most commonly in infants who are SGA, LGA, both to moms who've diabetes & late-preterm infants; greatest attention should be paid to neurologic signs in these babies -symptoms include: jitteriness, cyanosis, apnea, hypothermia, poor body tone, poor feeding/lethargy, seizures -S2S & BF should be initiated immediately after birth for best outcomes -BF (compared to formula) was associated w. reduced requirement for repeat gel tx -adding dextrose gel into protocol of BFHI designated hospital had no significant impact on NICU admissions or EBF at discharge

What To Do About Oversupply?

-help mom achieve posture where baby is able to move head freely when flow of milk is too great or too fast to handle; reclining or semi reclining & baby's body is supported on tummy to tummy; down under posture is good too -more aggressive tx may include nursing on only one breast each feed to allow a small amount of breast compression in order to tamp back the supply; a firm bra may also help to put little compression on milk cells in order to cause milk compression; warn about not allowing too much pressure b/c this can foster mastitis;(i.e. wearing bra that is so tight that it leaves track marks on breast should be avoided; check for red or swollen areas and signs of clogs) -in some cases it's necessary to nurse on one side for two or more feeds in a row to decrease milk production; encourage monitoring unsuckled breast closely for any signs of redness or swelling -we have had good success w/ encouraging expressing until breasts are soft before starting block feeding; this should only be done once, as continued expression will perpetuate the overproduction of milk -instead of decreasing milk supply using compression, some prefer to collect extra milk & donate to milk bank

How Women Know (5 Categories)

-helps us understand how women learn & gives us insight into how to teach -do not seem to be related to age, IQ, social or ethnic group or race (rather related to life circumstances, wha the woman feels is her place in the world, & relationships w/ others) -women in silence -recievers of knowledge -subjective knowing -procedural knowing -constructed knowing

Society Led

-historical way of weaning described by anthropologists & historians as usually from 2-3 to 7 years -same as everyone in society -everyone knows & expects -ritual & celebration

Alternate Milk Options for Babies

-homemade formulas, animal milk or plant milks are not appropriate for human babies -babies fed goat milk may suffer from electrolyte imbalances, metabolic acidosis, folate deficiency & specific & non specific antigenicity -scurvy is a new & severe complication of improper use of almond drinks in the first year

Fore & Hind Milk

-how and when there is the most fat and calories in milk is a lot more complex than originally thought -originally thought fore milk was watery to quench baby's thirst and hind milk was the fatty milk -foremilk does not mean "low fat" and hind milk is not always highest in fat, sometimes they have equal amounts of fat

Separation Due to Work or School

-how to support parents? --get tuned into reality for this family --re-examine our individual point of view --focus on helping w/ VF in the first week after discharge --assure support 2-3 weeks before return to work or school & continuing thru adjustment --make support for parents available in the workplace or school -working plans: --expecting to work in first year after baby's birth does not significantly impact whether or not BF is initiated --planning to go to work may negatively influence the intention to EBF --timing of returning to work & ending BF are closely linked --"returning to work full time before 3 mos may reduce mother's ability to meet her intention to BF by at least 3 mos" --62% of mothers of infants are in the labor force

After 1 Year of Lactation Human Milk Changes:

-human milk expressed has significantly increased fat and energy contents compared w/ milk expressed by women who have been lactating a shorter time -around 6 mos the fat & energy content really increases, volume does not go up, composition of milk changes to hae more calories -carb content goes down slightly to 7 g per deciliter -fat grams per deciliter goes up dramatically to almost twice the fat content -protein grams per deciliter do slightly increase -energy content/calories in (kcal per deciliter) also increases

Milk Storage & Handling

-human milk storage info for home use for full term infants -milk is a raw food & should be handled with care -heat little (or not at all) to preserve immune properties & nutrients -countertop or table: 77F, freshly expressed milk can be kept for up to 4 hours; thawed milk 1-2. hours -fridge: 40F or colder; freshly expressed milk up to 4 days; thawed milk up to 24 hours -freezer: 0F or colder; freshly expressed milk within 6 mos is best up to 12 mos is acceptable; never refreeze after it has been thawed

Myth - Types/Amount of Food Eaten while Lactating

-humans have BF and are BF under conditions we cannot even imagine (concentration camps, etc) -lactation has lower energy cost for humans compared to other mammals -number of Kcal/day for lactation is much less than previously believed -body adapts w/ physiological mechanisms in favor of lactation in humans --"when infant suckles there is an outpouring of 19 different gastrointestinal hormones in both mom and infant, including cholecystokinin (CCK) which cycles to the kidneys & gastrin, which stimulates growth of baby's and mom's villi, increasing surface area and absorption of calories w/ each feeding"

Concern: Baby Not Comfortable at Breast: Baby Expresses Distress During Feeding By Fretting at the Breast OVERALL

-hungry babies often exhibit this fretting & batting at breast behavior -it can be misread as anger; but may also reflect baby's kneading behavior at breast which is associated w/ increased oxytocin & thus enhanced milk flow -baby "pulling away" may be baby pushing back against something that is restricting his ability to get the widest mouth opening which the BF baby comes to associate w/ greatest milk flow rate -one of the most helpful acts of the supportive CLC may be interpreting the baby's body language correctly to the family

Colostrum

-ideal milk for newborn -high in antibodies and other components that protect baby from pathogens -best for baby to have many opportunities to learn to BF before the time of abundant milk

Best Practice w/ Robson's Criteria

-if dyad experiences immediate, continuous, uninterrupted S2S contact for first hour or so after birth & progressed thru Widstrom's Stages & suckled they have achieved the standard of best practice -this algorithm combines Robson's criteria fro obstetric classification, parameters of best practice of S2S contact (immediate, continuous, & uninterrupted) along w/ Widstrom's 9 stages in order to evaluate the experience of moms and babies in the first hour after birth -this simple algorithm for hospitals to follow could have far reaching impact on making practice visible, auditing, & reporting practices enabling the achievement of best practice, as well as providing a consistent measure for future research

Black/White Gap in BF

-if only hospital formula introduction were eliminated, the black/white gap in BF duration could be reduced by 20% of overall difference -black mother's newborns are much more likely to be fed formula in hospital (this is a system problem, it is structural racism) -black women not only have lower rates of BF compared to white women, but they are also disproportionally affected by triple-negative breast cancer, an aggressive subtype -reducing BF disparities could decrease the incidence of aggressive breast cancers among black women -there could be a reduction in the disparity of breast cancer mortality

Concern: Mother is Ill & BF

-illness may be acute or chronic, infective or noninfective -countries have own recommendations esp for HIV poise moms or high risk for HIV -maternal health conditions may impact BF, but few are absolute contraindications to BF -BF is contraindicated if HIV positive & HTLV-I or HTLV-II positive (BF is allowed w/ acute infectious diseases such as respiratory, reproductive, or GI infections) -BF is allowed w/ active tuberculosis after 2 or more wks of tx (it is communicated via droplets, not BM, so separation from baby may be required, collected milk may be fed to baby from someone else) -hep A, BF can start as soon as gamma globulin has been administered -hep B, baby should receive hep B immune globulin & first dose of hep B vaccine within 12 hours of birth, no reason to delay BF -hep C, BF plans should not be altered, however CDC recommends if nipples are cracked or bleeding, nursing should be stopped on affected side until healing occurs -women w/ venereal warts can BF -herpes virus, for cytomegalovirus (CMV) BF full term infant is allowed, for premature freezing milk reduces but does not eliminate CMV; for herpes simplex, BF is allowed except if lesion if on breast, areola, or nipple; for chicken pox infection that developed within 5 days prior to delivery & 2 days following delivery BF is not allowed, but expressed milk can be fed; for Epstein-Barr BF is allowed -toxoplasmosis & mastitis, BF is allowed -Lyme disease BF is possible as soon as tx is initiated -untreated brucellosis, neither BF nor expressed milk is allowed -flu virus is always changing so safety of mother-baby contact and BF should be verified w/ CDC or state health dept *Ask: -are drugs prescribed for condition contraindicated? -what other support does family need to cope w/ condition? *Watch out for: -ideas that illness require maternal/baby separation bc the illness can be transmitted thru BM or BF, this is not always the case *What to do about it: consult w/ health debts, CDC, & other infectious disease authorities when there are q's about BF & illness or disease -each case must be assessed individually, contraindications to BF are rare -be prepared to ID and share w/ health care team sources of EBP up to date info about safety of BF to clinicians working w/ BF families *What else to consider: -contraindications

PP BF Management Strategies Associated w/ BF Success

-immediate, continuous, & uninterrupted S2S -early initiation of BF thru self attachment in first hours -basics of good positioning & attachment -recognizing feeding cues -feeding on cue -feeding frequency -rooming in & minimizing separation -signs of adequate milk transfer (audible swallowing beyond colostral phase, 4+ stools from day 4 & onward thru newborn period, signs of fullness, etc.) -EBF (avoiding use of BM substitutes, unless medically indicated) -avoiding use of pacifiers & artificial nipples until BF is well established

Concern: Hx of Breast Surgery/Injury: Breast Augmentation

-implants have been inserted into the breasts *Ask yourself: -is there nipple sensation? did the surgery alter sensation? -are ducts patent? -are nipple pores patent? -is there hx of changes in breast size &/or appearance during pregnancy? *Watch out for: -engorgement, breast binding, tight bras that can decrease milk supply -insufficient milk *What to do about it: -use tank tops w/ shelf bras, soft bras, or no bra for first week or two to avoid pressure against breast -consider recommending milk expression to optimize production -encourage report of the surgery to the pediatric healthcare provider *Expected resolution: -breast implants are not likely to have negative effect on BF outcome *What else to consider: -sometimes reassurance is needed about concerns that BF may harm the implants (this is not likely) -ask about breast surgery when in private; the partner & family members may not be aware of the surgery -people may not think of this procedure as "surgery"; we have come to ask about "breast improvements" as well as surgery *OVERALL: -it's important to have weekly (or more often) wt checks of baby for first months to ensure that there is adequate milk

What Can We Do To Support EBF During Hospital Stay?

-implement 10 steps to successful BF -bags containing BF supplies or no bag at all were positively associated w/ EBF at 10 wks & 6mos -weaning risk is greater when hospital practices do not support BF -positive relationship was found b/w mPINC score & in-hospital EBF, any BF & EBF at 8 wks -use quality improvement measures to ID & change unhelpful practices -use hands off technique

Core Topics IDed by Global Standards of BFHI

-importance of BF -definition of EBF & recommendation that EBF continue thru first 6 mos -risks associated w/ feeding formula & other BM substitutes -role of BF beyond first 6 mos when complementary feeding begins -the fact that BF continues to be important after 6 mos when other foods are given

During Pregnancy Families Should Learn About

-importance of EBF -risk reduction does not equal prevention --while BF reduces disease risk in the population, it does not provide 100% protection from illness for an individual --many factors contribute to disease risk, including nutrition, infant feeding choices, genetic, & environmental influences -pp community resources -frequent feeding & having enough milk -BF management such as responsive feeding, rooming in & S2S

Expression of BM (OVERALL)

-important consideration is whether the pump is personal pump (single user) or multi user pump. -up to manufacturer whether a pump is a single or multi user pump -previously used pumps from garage sale, bought online, or borrowed from friend can transmit diseases from one user to another user's baby

Concern: New Pregnancy While BF (OVERALL)

-improved nutrition during BF & pregnancy today has made BF during pregnancy & tandem nursing viable options for many

Concern: Weaning (OVERALL)

-in US, public nursing of babies 6+ mos is rare, so people may think they need to wean because they only see young babies nursed in public. -as BF becomes more cultural norm & is seen more in public, it is our hope that duration of BF will increase

Semi-Reclining (Laid Back) Posture

-in a comfortable semi-reclining posture, the baby is supported tummy to tummy in a more upright position -this position is especially useful when the milk supply is larger or there is a powerful let down because in this position the baby has increased ability to maneuver his/her head to better manage large or rapid milk flow

Weight Loss in BF Baby

-in first days after birth most babies lose weight (from normal diuresis-extra fluid they had on board) -AAP says "weight loss of >7% from birth weight indicates possible BF problem & requires more intensive evaluation of BF & possible intervention to correct problems & improve milk production & transfer" (does NOT mean supplementation!) -AAP added "evaluate body wt gain - body wt loss no more than 7% from birth an don further wt loss by day 5: assess feeding and consider more frequent follow up" -by 2 weeks at the latest, baby should be back to birth weight -supplementation rates for wt loss decreases with routine use of 24 hour wt and did not increase untoward effects during hospital stay

Getting Started w/ BF

-in first hours and days the dyad learn to BF together and move gradually from self-attached BF to collaborative BF -each dyad moves in a unique pattern: one feed may be self-attachment and the next collaborative -BF moves into more collaborative after baby is able to locate the breast -both will become more & more comfortable w/ collaborative feeding as they learn together -baby's arms should not cross over his/her body, but should embrace the breast -baby's hands knead breast while suckling, do not swaddle hands away -shouldn't be pain while nursing; after feed. nipple shouldn't be misshapen, abraded, fissured, bruised, or blanched -if there is pain, baby should be gently removed and allowed to relatch

What if despite optimal latch there is persistent nipple pain during feeding w/ poor milk transfer?

-in rare cases, babies have strong sucking vacuum as measured by pressure transducer or nipple shield -suck is so strong baby can pull nipple tissue through the holes on a nipple shield

After 2 Years

-in the US "closet" nursing (sometimes other family members don't know) -normal in other cultures -it's changing

Prevalence of Vitamin D Deficiency

-in the US, 36% of moms and 58% of babies are deficient -28% of pregnant women w/ lower serum vitamin D had a cesarean compared 14% of women who had higher vitamin D levels -lower vitamin D levels may be associated w/ gestational diabetes -according to IFPS II, how many babies wer getting the recommended amount of vitamin D? --only 5-13% of EBF infants --only 9-14% mixed fed infants --only 20-37% of exclusively formula fed infants during pregnancy vitamin D is stored, passed to fetus & if stores are adequate then too the baby via BF -sun is main source of vitamin D for humans -"reproductive women need to have enough vitamin D from conception to delivery for the best change that their neonates will enter infancy w. sufficient vitamin D" -supplementation during pregnancy & lactation may improve vitamin D status of both mother & nursling

Concern: Baby Has A Birth Defect: Craniofacial Anomalies (Cleft Lip/Palate, Pierre Robin Sequence, etc.) OVERALL

-in the event that a baby affected baby one of these challenges is unable to feed at the breast, ascertain if the parent wishes to express milk to be fed to the baby & provide support as needed -baby will benefit from receiving human milk via any feeding method -in the event of a problem such as oral clefts, which will be surgically repaired, the baby may be able to BF after the repair

Maternal Reasons for Inadequate Milk Supply

-inadequate breast stimulation (inverted nipples that do not evert, use of nipple shield) -infrequent BF (scheduled feeds, use of formula or pacis to increase time b/w feeds) -inadequate milk removal resulting in engorgement -inadequate hormone stimulation due to slow feeding by baby (longer than 20 min or so) -suboptimal hormone balance (placental fragments, hypo/hyperthyroidism, sheehan's syndrome, insulin dependent diabetes, theca lutein cyst or PCOS -smoking -use of nipplie shield -breast injury impacting nerves or ducts -injury to spine at T3-T6 (where nerves innervate the breast) -congenital breast abnormalities -discrepancy in breast size (asymmetric breasts) -breast surgery -certain drugs (pseudoephedrine, corticosteroids, hormonal birth control, high doses of B6) -new pregnancy -maternal depression

Prenatal/Antenatal Interactions w/ Expectant Parents Should:

-include both professional & lay encouragement to consider BF -acknowledge normalcy of BF -elicit & magnify reasons why individuals are attracted to BF -elicit & address individual concerns about BF -provide opportunities for family to observe & ask q's of other BF families -cover core topics for antenatal education IDed by global standards of BFHI -provide information about pp BF management strategies associated w/ BF success -provide opportunities to visualize how BF will fit into family life -provide opportunities to establish friendship ties w/ other families w/ close due dates -provide info about pp community BF support

Step 4 of the Ten Steps to Successful BF (S2S in 1st hours & encouraging early feeding) is one of most powerful steps in influencing BF:

-increases EBF -S2S is good starting point in changing practices -Widstrom found that all babies transition through the same 9 states in the first hours after birth

Moms should NOT BF or Feed Expressed Milk if:

-infant diagnosed w/ classic galactosemia (rare genetic metabolic disorder) [can be rapidly fatal if lactose is not completely removed from infant's diet]; special formula required -mother has HIV (may be different in other countries) -mother has human T-cell lymphotropic virus type I or type II (HTLV-1/2) [If test positive, ask for re-test because false positives are common] -mother is using illicit street drug (i.e. PCP, cocaine); except narcotic dependent moms enrolled in supervised methadone program & have negative screening for HIV and other illicit drugs -mother has suspected or confirmed Ebola virus

Marketing Claims & Health Claims (Formula)

-infant formula industry is adept at making marketing claims that appear to imply that formula is just as good as (or even better than) human milk -LCPUFAs (long chain poly unsaturated fatty acids) are a marketing case in point; they get added to formula and they tried to make claims that adding these made it just as good or even better than BM -according to Cochrane review: full term babies fed formula w/ LCPUFAs did not have better outcomes than were reported for full term babies fed formula w/o LCPUFAs -no better outcomes in premature babies either -potential side effects of fat enhanced formula: incidents of infants experiencing adverse reaction including diarrhea, vomiting, bloating, & GI distress have been reported -growth curves for each brain region are different depending on whether baby is fed only formula or only BM for first 3 mos

S2S

-influences the state organization & motor system modulation of the newborn & can help w/ difficulty latching & sustaining a feed, it's not just for right after birth -when BF isn't going well, S2S can help -even after weeks & months of severe latch on problems, S2S was found to shorten the time it took to resolve severe latch problems when compared to the usual technique of re-attempting the latch on process -in Australia, midwives are using co-bathing w/ S2S to augment self attachment when things have gone wrong (might be used w/ an older baby who has not been successful w/ BF)

What to do if baby is mistakenly fed another woman's expressed BM?

-inform mom whose BM was given to another child & ask: -when was BM expressed & how was it handled prior to being given to caretaker or facility? -would she be willing to share info about current medication use, recent infectious disease hx, presence of cracked or bleeding nipples during milk expression? -discuss the even w/ parent of child who was given the other mother's milk: -inform them child was given other mom's milk -inform them risk of transmission of infection diseases is small -provide family w/ info on when milk was expressed & how milk was handed prior to be being delivered to caretaker -encourage parents to notify child's pid of the situation & share and specific details known

Donor Milk Banking is NOT Same as Informal Sharing

-informal milk sharing cannot be condoned in US -"as donors need screening, we discourage the use of any milk from an anonymous donor" -US & Canadian health authorities have raised concerns -wet nursing or cross nursing *except where culturally appropriate) -borrowing or buying milk not from HMBANA member or licensed milk bank: --human milk purchased via internet exhibited high overall bacterial growth & frequent contamination w/ pathogenic bacteria --milk purchased via internet contained caffeine & cotinine in almost every sample --many contained cows milk or formula --participants underestimate the risks --donors to "peer to peer" symptoms knew they would not qualify for milk bank --all donors may be criminally liable if they know they are ineligible as milk bank donors, & sell or distribute their milk anyway

Concern: Nipple Pain While BF: Worse at Beginning of Nursing Then Subsides

-intense nipple pain that is worse at beginning, for the first minute or two, then subsides or continues at a lower level *Ask yourself: -is baby latching on sub optimally & then correcting head or body position to accommodate a better flow of milk? -does change in position or body motion coincide w/ change in pain level? *Watch out for: -baby head change, body movement, or other changes as the pain level decreases *What to do about it: -watch the baby nursing, paying close attention to the change in the baby's sucking, head position, & the BF posture the instant the pain level changes -position baby in the new (less painful) position to begin the next feeding, encourage attentiveness in positioning the baby in the pain free posture *Expected resolution: -although there may be some residual pain for a day or so if the nipple has been damaged, the pain level should markedly decrease w/ more optimal positioning from the beginning of the feed *What else to consider: -is there pressure during the feeding against the back of the baby's head? if so, this may cause the baby to pull back, stretching the nipple uncomfortably -could it be that a pillow is changing the angle of the baby's head? *OVERALL: -nipple creams & other treatments will not fix this problem; in fact, use of these commonly used preparations may discourage help seeking or working on corrective positioning interventions

Infant Risk Center

-internet and telephone resource based on Dr. Hale's work

Suboptimal or Altered Physiology

-iron deficiency anemia -hemorrhage -hormone imbalance -insulin dysregulation (prediabetes) -PCOS -some drugs can alter physiology -smoking alters physiology

Institue of Medicine Says About BF Mom's & Alcohol

-is alcohol is used, advise lactating woman to limit her intake to no more than .5g of alcohol per kg of maternal body wt per day (for 132lb woman, this is 2-2.5ox of liquor, 8oz of wine, or 2 cans of beer) -low level drinking during BF is not linked w/ shorter BF duration or adverse outcomes up to 12 mos of age -q's remain about effect on the infant when mother combines smoking & drinking, esp binge drinking -consuming alcohol in excess of two standard drinks per day during lactation was found to be independently associated w/ shorter BF duration, even after consideration of previously IDed predictors of BF duration

Baby Gaining Too Fast/Too Much

-is baby unhappy or unsettled after nursing? -issue w/ sore nipples or recurrent mastitis? -are nursing sessions difficult w/ baby pulling on & off breast? -does baby have multiple large stools a day? (blow outs) -are some stools shiny & greenish? --if answer is yes to 2 or more of these, mom could have oversupply -issue is not wt gain, it's volume of milk and speed of transit thru baby's GI system is not comfortable for baby & baby is clamping on nipples to slow flow of milk

Feeding Observation Checklist: Before The Feed

-is possible, weigh baby prior to feed on digital scale, sensitive to 2 grams; the baby need not be naked but should be weighed after the feed in the same clothes w/o diaper change -does S2S precede the feeding? -what cues trigger the parent to feed the baby? -is baby frantic, fussing, or crying? these are late cues -is baby deeply sleeping or shut down? wait until REM is seen before offering the breast -what does the preparation for the feeding look like? are diaper changing or other activities delaying when the feeding begins? -how much time lapses from observed cues until the baby is brought to the breast? -position yourself so that you can best view the feeding (i.e. standing behind or beside the dyad allows you to look at baby & feeding from best perspective)

The Strategy is intended as a guide for action:

-it identifies interventions with a proven positive impact, -it emphasizes providing mothers and families the support they need to carry out their crucial roles, -and it explicitly defines the obligations and responsibilities in this regard of governments, international organizations and other concerned parties.

Concern: Worried About Milk Supply: Baby Seems Unsatisfied After Feedings OVERALL

-it is thought that some babies if not offered cuddles & attention b/w feeds. may demand frequent feeds to meet their need for comforting touch -we cannot say enough about the importance of cuddling & skin contact to calm, sooth, & nurture babies & their parents

Concern: Worried About Milk Supply: Breasts Feel Empty OVERALL

-it's common for parents to experience persistent concerns about milk supply -acknowledging, normalizing, & exploring this concern is indicated -this concern should be taken seriously, regardless of baby's growth

Concern: Worried About Milk Supply: Baby Has Not Gained Adequate Amount of Weight OVERALL

-it's essential to explore this concern fully; too many times the advice is given to stop worrying about milk supply or to just go to bed & nurse baby to increase supply -any concerns about supply deserves our full exploration & examination -we have no way of knowing when we are dealing w/ a situation that I far from either common or normal -there is traditional saying that parents know when something is wrong; strive to honor their knowledge by fully exploring their concerns no matter how common

Concern: Baby Won't Take A Bottle/Cup OVERALL

-it's never appropriate to support common belief that babies will learn to feed in a different manner when they are "hungry enough" -although those who expose this belief do so in an attempt to reassure the parents, it may lead to the unfortunate practice of "starving the baby out" -very hungry babies have less energy & patience for learning new feeding methods -babies may also come to distrust those around them when caregivers are not responding to baby's need for food, a primal need that should never been ignored -there are pros & cons to all alternate feeding devices; be prepared to aid parents in choosing a method that protects milk production & suits their baby's abilities & their own skills & situation

Concern: Baby Has A Birth Injury: Cephalohematoma or Caput Succedaneum OVERALL

-it's not surprising that babies w/ these conditions may not enjoy feeding -they probably have severe discomfort & pain -pain relief may be prescribed for the baby who has noticeable discomfort

Concern: Baby Not Comfortable at Breast: Baby Expresses Distress During Feeding By Pulling Away & Crying OVERALL

-it's unfortunate that many caregivers equate crying w/ hunger & soothing w/ spoiling -baby who is crying is telling us something is wrong -responsive attention is needed to discern & respond to baby's need

Concern: Baby Has A Birth Defect: Down Syndrome OVERALL

-it's well worth the clinician's time to support this family in BF -the many benefits of BF can be invaluable to this baby & this family, including reduced illness, increased IQ, enhanced bonding, & so on.

Concern: Baby Has Jaundice

-jaundice in BF baby *Ask yourself: -when was jaundice diagnosed? -who diagnosed it? -what was baby's age at onset? -what was gestational age of baby at birth? *Watch out for: -signs of dehydration (sunken fontanelles, decreased urination, brick dust urine, decreased stools) *What to do about it: -confer w/ PCP about feeding plan -observe a feed -assess milk transfer using pre and post feed wt checks -suggest ways to improve milk supply if needed -ensure comprehensive pediatric eval as needed -if any condition that might limit milk production is discovered, ensure that the pediatric clinician is apprised *Expected resolution: -babies w/ jaundice may be somewhat lethargic; milk expression & alternate massage during feeds may help to increase milk supply & intake -once jaundice resolves, baby's ability to feed should normalize *What else to consider: -avoid use of bottle or other feeding device w/ firm teat; at breast supplementation is ideal in this situation; if baby is supplemented away from breast, consider supplementation via cup

Concern: Lactation in Transgender Individuals

-lactation in transgender individuals who may or may not have given birth *Ask: -what are their pronouns? what temperature would they like you to use to describe their parental role? inquire respectfully -what is desired outcome for individual? (chestfeeding, BF, milk expression for feeding away from chest/breast, or reduction of milk production quickly and safely) -what support is needed to achieve the goals? how can multidisciplinary team support these goals? -has there been surgery to chest/breast? -is there desire to continue or resume hormonal protocols? (both testosterone and estrogen are incompatible w/ milk production but not w/ supplementary feeding using feeding tube device) -desire to use binder around chest? (compression reduces milk production & can cause clogged ducts and mastitis) -desire to produce milk when there has not been a pregnancy? -desire to stop lactation as quickly & safely as possible? (water baths, binding, pain/inflammation relieving med can help as milk production is reduced) *Watch out for: -assumptions about parental roles & desires based on cultural expectations *What to do about it: -remember there is little biological difference b/s male & female breast tissue in innervation, etc. -strategies used to support the initiation f milk production & to increase & decrease it are the same regardless of gender of the individual *Expected resolution: -trans individuals should be able to BF, chested, or neither depending on their desires & goals

Cup Feeding for Premies Results in:

-less increase in heart rate -better oxygenation -ability for in fact to pace own feeding -premies randomized to cup feeds (vs bottle) were significantly more likely to be fully BF on discharge home (two Cochrane reviews agree) -cup feeding is the preferred supplementation method of WHO/UNICEF -inexpensive to implement -however, regardless of method (cup or bottle) supplementation had a detrimental effect on BF duration -the number of supplements makes a difference (more supplements, less duration)

Counseling Implications After Breast Surgery

-likelihood of full BF is unknown -hormonal exposure of pregnancy & lactation may mitigate some effects of surgery -assessment and close follow up are the keys -assure adequate nutrition for the infant (need to support supplementation when it is necessary; DO NOT want to undernourish babies)

Negative Influences on Milk Production

-long spaces b/w feedings (ends up being fewer feedings per day) -long, slow feedings (faster milk is removed, the faster milk is made) -excessive pressure on the breast -breast surgery or injury -suboptimal breast anatomy -suboptimal or altered physiology -physical objects

Concern: Baby Has Jaundice OVERALL

-low levels of transient jaundice in full-term, health, BF baby appears to be normal -however, any jaundice needs to be seriously considered bc of the risk of kernicterus -high bilirubin levels may indicate that there were disturbances in early feeding & contact or the presence of underlying medical condition, such as infection, hemolysis from blood type incompatibility b/w mom & baby, or conditions such as G6PD (glucose 6 phosphate dehydrogenase deficiency) -due to fear of kernicterus, jaundice must always been appropriately IDed & treated -follow up checks are necessary since physiologic jaundice peaks of days 3-5 -human milk, fed frequently, is ideal food for all babies including those w/ jaundice

Safer Use of Infant Formula

-majority of US babies receive infant formula in the first 6 mos of life -when we start thinking about the wide use of formula we could ask "what are the issues in our society that make this happen?" -inadequate & unpaid maternity leave, unequal pay, maternal mortality & morbidity, lack of universal counseling for BF, health care inequities... -formula is frequent recalled -formula can be contaminated in the collection or manufacturing process &/or in the home -powdered formula is particularly susceptible to contamination (clostridia, spores, etc) -United Nations & WHO first raised concerns about contamination of powdered infant formula w/ Cronobacter (Enterobacter) sakazakii & other microorganisms in 2004 -recommended that caregivers, particularly for infants at high risk, should be regularly alerted that powdered infant formula is not a sterile product -other routes for contamination: water used, additives such as melamine, bottles (improper cleaning, BPA & other chemicals in plastic bottles), bottle nipples, breast pump -formula stretching can have negative consequences for infants both immediate & long term (1 in 8 low income moms water down formula) -findings show that at minimum the CO2 emissions attributable to the powder formula sold is a very very large amount which has a big environmental impact

Myth - Maternal Exercise/ Rest and Milk Supply

-maternal exercise while BF was not related to infant weight gain or growth -rest is not associated w/ increased milk production -"fatigue" may be tiredness, but may also be symptom of underlying medical problem that could affect milk supply

How is it possible for humans to make milk w/ such a small amount go energy expenditure?

-maternal plasma prolactin concentration generally increases under conditions of negative energy balance, which may serve to protect lactation -changes in maternal processes can spare energy.. this may account for a third to a half of the total costs of milk synthesis -together w/ low cost of human lactation and large fat reserves from pregnancy may account for human ability to BF infants under nutritional conditions which are often far from ideal

Hand Expression

-may be easier & faster than using pump -produces milk that is cleaner & higher in calories than pumped milk -less cleaning time & less concern about contamination & biofilm -easiest to learn if baby is nearby, being held S2S, or while nursing -expressing one breast while nursing on other helps trigger milk flow & may get better milk yield -when separation after birth (premature baby) start hand expression ASAP (within an hour after birth is best) & continue as frequently as a not separated baby would nurse each day (10-12x daily) for a few min

Fenugreek (Galactogogue)

-may cause reduced absorption of all meds -worsening of asthma, diarrhea, maple smelling urine & perspiration -cross reaction is possible if there is an allergy to chickpeas, peanuts, & other legumes -concerns about decrease in blood coagulation & decreased serum glucose -after 21 days of taking fenugreek or a placebo, there was no statistical difference in prolactin levels or milk volume

Pacifiers for Premies

-may have earlier hospital discharge -tube fed babies may gain faster w/ pacifiers & have improved physiologic & behavioral responses -reduced the time to full oral feeds -did not affect BF among premies

Discrepant Breast Size

-may indicate inadequate glandular tissue in one or both breasts (might think the larger breast will make more milk, but you don't know for sure) -one implant may indicate that there was a discrepant breast size

Less Mature/Disorganized Babies & Feeding Cues

-may pass quickly from deep sleep (no REM) to crying in a short period of time, so the subtle cues may be missed if baby is not nearby

Common Mastitis (Breast Inflammation) Treatment

-medical intervention is needed -NSAIDS are usual first step -antibiotics? (little evidence of effectiveness of antibiotics for one breast "common" mastitis) -keep milk flowing & breasts soft & comfortable to avoid abscess development -nursing w/ common mastitis is not controversial -if tx are ineffective, consider anemia, ductal or inflammatory breast cancer

Men think it's "not natural" to BF

-men worry breasts will "get ugly" -study of breast changes: mothers frequently report that size & shape of breasts have changes after childbirth, but these changes do not seem to be associated w/ BF -studies of fathers report that BF separates them & others from the woman -BF makes it hard for others to develop a relationship w/ the child -makes father feel inadequate *We must address for fathers... BF is: -normal, achievable, desirable -BF protects from specific diseases (share list) -breasts were made for BF (can talk about how body parts can have more than 1 function) -US fathers are "eager to learn"

Milk Composition is Complex & Milk Action is Redundant

-milk is more than nutrition -bioavailability of nutrients is higher in human milk than in other food or supplements (e.g. iron) -formula looks like it has more iron, but it is more bioavailable in BM; babies who drink formula will have. a lot more leftover iron in their gut than BF babies -besides water, lactose, fat, & protein, BM has hundreds of other species specific bio-active components forming a unique microbiome -less diarrhea is advantage of BF, but exclusive BF makes biggest difference in rates and severity of diarrhea -in the US, 86% of diarrhea associated infant deaths occurred among LBW (low birth weight) infants

Pain Meds During Labor

-mixed results from studies -moms who have labor meds need extra BF support -may have delayed onset of "milk coming in" *What can we do about this?: -keep baby S2S; separation in first 1-2 hours has more profound negative impact effect than meds -some drugs may have more profound effect (as amount of fentanyl increases, the change of suckling decreases) -when mom has had labor main meds her baby may need at least 2 hours of S2S for baby to self attach *Research suggests: -avoid longer durations, delay administration of epidurals -conservative use of IV fluids -close follow up & good BF support -continuous support in labor (doula) -reduce need for pharmacologic pain management thru Lamaze or other childbirth education, breathing & relaxation, hypnosis, acupuncture, acupressure, etc.

6-9 Months

-mobile -teething -regular naps? maybe -night feeds? maybe -playful -long periods of concentration -biting: need to explore why --teething? playfulness? falling asleep? --watch baby closely & take off breast before biting starts & calmly say "no" --end feeding --offer breast at next regular feeding

BF Changes Both Immune Systems

-mom and babies bodies are more similar to each other after BF -babies who BF have fewer rejections if you needed to donate a kidney or organ from mom to child -kidney function and longevity was also improved by both siblings having been BF -if two siblings are BF then had to donate kidney to the other, the kidney function was significantly higher

Concern: Baby Has Colic OVERALL

-most babies have some gastric discomfor; this does not indicate colic -some nursing parents restrict their diet severely, often w/o positive effect on baby's symptoms (this may be unnecessary as only a portion of colic cases can be alleviated by dietary changes) -if dietary trial does not alleviate symptoms, encourage resumption of normal diet & focus on helping family learn healthy coping skills for responding to baby's discomfort

Concern: Smoking & BF (OVERALL)

-most effort put on importance of protecting baby from secondhand smoke and disadvantages of formula feeding than on possible cig toxins conveyed to baby via BM

Concern: OTC or Prescription Meds & BF

-most meds prescribed while nursing should have little effect on milk supply to on infant well being, except antimetabolies & street drugs are ALWAYS contraindicated; radioactive compounds usually require temporary cessation of BF; all meds should be checked w/ reliable source (LactMed, book: Medications & Mother's Milk, Infant Risk Center, AAP) -**need to know name of med or substance, dosage, route of administration, & age of baby *Ask: - if med is not good for lactation, can a diff med be substituted by provider? -if med is "long-acting", can a "short-acting" type be substituted by provider? -if contraindicated med is prescribed, what plan can be made to keep up milk supply or help w/ weaning? & what is plan for feeding baby? *Watch out for: -recommendations that are not EBP because of mistaken belief that BF isn't possible (encourage checking each individual med, every time, w/ reliable drug safety source) -individuals not taking prescribed meds because they think they are contraindicated or taking less of the meds due to concern about effect on baby w/o checking reliable drug safety resource -assuming that drugs considered safe during pregnancy are also safe when lactating (this is not always the case) -babies who have otherwise unexplained behaviors, which may be associated w/ medication used by lactating parent *What to do about it: -ensure appropriate resources for families and providers so that EBP decisions can be made *Expected Resolution: -w/ few exceptions, BF and meds are compatible *What else to consider: -changes in milk supply (pseudoephedrine can reduce supply) -baby behavior & other effects on baby (tricyclics that accumulate over time can make baby more sleepy; fluoxetine has been associated w/ slower growth in BF babies)

BM Composition Changes In A Day

-most milk is produced at nighttime b/c prolactin levels are highest at night and in early morning hours -maximum fat levels are obtained 30 min post feed -mothers of male infants seem to produce milk that has a 25% greater energy content -men w/ high prolactin levels (due to brain tumors or drugs) make human milk (male galactorrhea)

Moms should TEMPORARILY NOT BF & NOT Feed Expressed Milk if:

-mother has untreated brucellosis -mother is taking certain meds (methotrexate, drugs for cancer & rheumatoid arthritis) -mother is undergoing diagnostic imaging w/ radiopharmaceuticals (good to know what isotope is being used in the radiopharmaceutical bc some of them take longer to leave the body & the milk) -mother has active herpes simplex virus (HSV) infection w/ lesions present on the breast (moms can BF on unaffected breast if lesions on affected breast are covered completely to avoid transmission)

Moms should TEMPORARILY NOT BF but CAN Feed Expressed Milk if:

-mother has untreated, active tuberculosis (mom may resume about treated appropriately for 2 weeks & is documented no longer contagious) [airborne & contact precautions kay require temporary separation of mother & infant during which expressed milk can be fed to infant by another care provider] -mother has active varicella (chicken pox) infection that developed within 5 days prior to delivery to the 2 days following delivery

Insufficient Milk

-need to figure out if it is an actual problem or a perceived problem -some families thing colostrum is low in quantity and not sufficient for baby and may want to start formula right away (this is perceived problem) -some think a fussy baby is hungry baby and a quiet baby is full and content. Calorically deprived babies are quiet & this behavior may reinforce parents to further decrease feeds; less feeds can lead to decrease in milk supply (so milk supply was adequate, but now it's not) -might think not enough milk because of the amount of milk expressed when pumping -often there is perception of not enough milk when there is adequate supply; assess baby's growth w/ growth chart or calculating test weights may be helpful in affirming baby's adequate growth

What Other Interventions Help Moms of Premies?

-neonatologist encouragement during prenatal meeting to feed human milk -using PIBBS observations (for practical advice & research about the progress of BF premies; not for scoring) -PIBBS Individual Aspects include (these go in phases/steps) --rooting (moving face against the breast) --areolar grasp (when baby gapes, opens mouth & comes to breast & puts lips to breast, no suckling, no attempt to move milk out) --latched on (baby is making that seal) --sucking --longest sucking burst --swallowing -use odor of BM to enable earlier transition (putting a bit of BM smell under baby's nose the entire time while they are being tube fed)

Sequence of Successful Feeding

-newborn held S2S or close to breast so feeding cues may be observed -when baby has cues, baby is brought to breast -breast should be at normal angle (not held or shaped w/ hand; if large breast put rolled up towel under breast, do not fold breast upward to see the nipple) -collaborative BF may bb initiated when baby exhibits appropriate cues: rooting, increasing alertness/REM, flexing of legs & arms, mouthing w/ little sucking motions, attempting to bring hand to mouth, sucking on fist or finger, mouthing motions of lips and tongue -crying is late feeding cue because it does not usually begin in full term babies until more subtle cues have failed to elicit the parents attention -less mature & more disorganized babies may pass quickly from deep sleep (no REM) to crying -when using collaborative BF strategy, baby is supported by the frame of the parent's body which provides support needed to keep the baby at the breast -parent finds a comfortable posture & makes breast accessible to baby -baby is allowed the freedom to achieve pain-free suckling w/ maximal milk transfer -BF sessions are best ended by the baby, when feeding ends baby is relaxed, hands are open, arms are floppy, brow is smooth, toes are curled

Sleeping Through the Night

-newborns need to feed around the clock whether BF or not -means stretch of 5-6 hours -not realistic to expect babies to sleep more than 3 hours in a row until they weigh 10lbs (or around 2 mos of age) -babies will continue to wake at night if not fed adequately during day and evening -in early weeks many babies "tank up" and increase nursing in late afternoon and early evening (in anticipation of sleeping longer stretches) -baby who is not gaining well must be fed frequently at night too (have baby sleep in close proximity to parents to help respond to subtle nighttime feeding cues) -"daytime interventions work best for nighttime problems" (babies who have lots of naps and sleepy times during day are less likely to sleep longer stretches at night -babies learn to self regulate sleeping, eating, & crying during first months -sleep training programs mail to help and may increase parental stress and baby crying -babies 6 mos and older who may be sleeping through the night may start waking again due to teething discomfort -babies may wake more at night because they are busy during the day to get in enough nursing, calories, and cuddles

Concern: Flat/Inverted Nipple: Inverted Nipple

-nipple appears drawn into surrounding tissue *Ask yourself: -is this a nipple inverted by engorgement? (is this a new appearance for the nipple?; is the area around the nipple engorged?; is there pitting edema around the nipple?) -if nipple was inverted prior to baby's birth, does nipple respond to cold or tactile stimulation by becoming more erect? -is baby able to compress areola & breast tissue & draw the nipple area into the mouth to form the teat? -what grade is the inverted nipple? (it's about function, not appearance) *Watch out for: -prenatal nipple manipulations are not effective for inverted nipples & may cause earlier cessation of BF than when prenatal nipple preparation is not suggested -confusing flat w/ inverted nipples -milk-supply problems; individuals w/ inverted nipples have been shown to have less milk & lower prolactin levels in research studies & their babies have higher risk of readmission for failure to thrive *What to do about it: -suggest asymmetric latch technique; when baby's bottom lip & jaw reach the breast first, the configuration of the nipple is less important -ask if nipple ever everts; if so, is there. technique that has been used to draw out the nipple?; can this be done prior to latching the baby? -document whether nipple has everted during BF; stand behind dyad & watch latch-off -ensure adequate nutrition for baby; some will suck happily even though nipple is not drawn out; remember calorically deprived babies often act sleepy & satisfied; listen for frequent swallowing & assess milk transfer -encourage report of this challenge to pediatrician to help assure close follow up of baby's growth *Expected resolution: -often grade 1 & 2 nipples become everted over time w/ BF, hand expression, or pumping -in this situation, milk expression is needed as an adjunct to BF -w/ grade 3 nipples, there is a very high risk of milk insufficiency & failure to thrive; frequent wt checks & diaper checks & assessment of milk transfer are necessary -provide close ongoing pediatric follow up to assess growth *What else to consider: -sometimes using hard plastic breast steel in bra b/w feeds has been reported to help to dry & evert the nipple -using nipple shield w/ inverted nipples may further reduce milk supply & put baby at increased risk for failure to thrive; if a shield is used, a milk expression plan is required to maintain milk supply -calorically deprived babies act sleepy; the baby sleeping more & acting content is an ominous sign; frequent wt checks are only way to know how baby is doing w/ BF if there is an inverted nipple *OVERALL: -inverted nipples are related to failure to thrive & readmission for hypernatremic dehydration & malnutrition in the baby; assessment of the BF, assessment of milk transfer, & frequent wt checks are necessary w/ inverted nipples but are esp. important w/ grade 3 inverted nipples

Concern: Flat/Inverted Nipple: Flat Nipple

-nipple appears level w/ surrounding tissue *Ask yourself: -does nipple evert? (milk making hormones may not be adequately released if it does not) -is it flat appearing because it is stretched & occluded by breast engorgement or edema? (is this a new appearance for the nipple?; is the area around the nipple engorged?; is there pitting edema around the nipple?) -if nipple was flat prior to baby's birth; does nipple respond to cold or tactile stimulation by becoming more evert? if so, the nipple should respond easily when stimulated during BF -is the baby able to compress the areola & breast tissue & draw the nipple area into the mouth to form the teat? *Watch out for: -misunderstanding that baby latches only to the nipple; rather the baby forms a "teat" of the nipple, areola, & some breast tissue -thinking that a nipple has to look like a bottle nipple in order to work -considering this to be a permanent situation -flat nipple "epidemics" that are a result of poor maternity BF management practices (i.e. muscle relaxants used during labor, edema from excess fluids during labor) -confusing flat w/ inverted nipples (inverted nipples are drawn back into the breast) *What to do about it: -if the report is that the nipple was flat before the baby was born, assure the use of the asymmetric latch technique; it's esp important that the baby's bottom lip & jaw reach the breast first & that the latch is asymmetric; this makes the configuration of flat nipples unimportant -document whether the nipple has everted during BF; stand behind dyad during bF & observe nipple at moment of latch-off -if nipple is flat b/c nipple is engulfed within milk filled tissue, hand expression or engorgement relief is needed so that the area is soft enough for the baby to draw into the mouth; then use asymmetric latch *Expected resolution: -often, formerly flat nipples become everted over time w/ BF -BF should not be a problem if flat nipples are managed appropriately *What else to consider: -although using a nipple shield may seem like a good solution for flat nipples, long term shield use may have negative effects on milk supply *OVERALL: -preventing engorgement, starting nose to nipple, assuring wide gape w/ bottom lip & tongue sealing first, & using asymmetric latch are the keys to managing BF w/ flat nipples

Concern: Nipple Pain While BF: Continuous Thru Nursing, Beginning After Abundant Amount of Milk: Oversupply

-nipple pain that begins after there is an abundant supply of milk & continues throughout each nursing; nipple is misshapen when baby latches off; this may be the constellation of factors called "oversupply" *Ask yourself: -is the pain worse after the first few days? -is there abundant supply of milk? -are there other signs of oversupply? *Consider: -sometimes baby can manage the slower flow of colostrum but has trouble managing the abundant & rapid flow of milk after day 3 or 4 -the pain may be related to the baby clamping down on nipple because flow of milk is too much or too rapid to handle -problem of oversupply often has constellation of findings including rapid wt gain of baby & many large explosive bowel movements, along w/ pain during feedings that usually is the reason for asking for help; baby is often unsettled after feed & may spit up or vomit a quantity of milk -considering that the baby is gaining well, the baby may still not act contented b/w feeds, giving the family the mistaken idea that there is not enough milk or that there is "something wrong" with the milk -wts taken before & after nursing that shows a rapid transfer of milk in a shorter than expected amount of time (i.e. 3 oz in 5 min in a baby under 1 month old) *What to do about it: -help w/ achieving a posture in which the baby is able to move head freely when flow of milk is too great or too fast to handle -one posture that works well is reclining or semi-reclining & baby's body is supported chest to chest; in this posture the baby no longer has to work against milk flow -more aggressive tx may include nursing on only one breast at each feed to allow a small amount of breast compression to tamp back the supply; a firm, but not overly tight bra may also help; counsel against too much pressure that could foster mastitis -massive oversupply may respond to nursing on the same breast for 2 or more feeds in a row; again, watch for plugged ducts & mastitis -instead of decreasing the milk supply using compression, some prefer to collect the extra milk & donate to milk bank *Expected resolution: -although there may be some residual pain for a day or so if nipple has been damaged, the pain level should decrease with the baby in control of the flow rather than overwhelmed by it -nipple should not be distorted after nursing *What else to consider: -excessive hand expression or pumping to get rid of the "extra" milk may compound the problem by relieving the compression on the cells; as a result, the milk supply continues to increase *OVERALL: -for many years poor BF management practices highlighted the issue of "not enough BM"; we think that the constellation of oversupply of BM is increasingly common as more & more families choose to BF, do EBF, & for longer durations; it seems to be more likely to happen w/ second or subsequent BF babies

Concern: Nipple Pain While BF: Continuous Thru Nursing, Beginning In First Few Days

-nipple pain that begins in the first few days & continues thru the nursing; nipple that is misshapen when baby latches off; a compression line may be visible; baby may spit up blood tinged milk or expressed milk is colored by small drops of blood *Ask yourself: -did the soreness start before there was an abundant supply of milk? -is the nipple misshapen after baby comes off breast? *If yes, consider: -suboptimal position of the baby at θ breast *What to do about it: -assess the next breastfeed, including the prefeeding behaviors, using the BF assessment criteria -use corrective interventions to optimize the latching process & positioning for the feeding -if blood is seen, provide reassurance that the small amount of blood will not harm the baby *Expected resolution: -although there may be some residual pain for a day or so if the nipple has been damaged, the pain level should improve dramatically with more optimal positioning -if baby has been positioned optimally, the nipple will not be misshapen after the baby latches off breast *What else to consider: -correcting position will markedly decrease pain for more than 95% of dyads -a few babies exert higher than average amounts of pressure at the breast; arrival of abundant milk flow may encourage some babies to increase pressure; breast compression or alternate massage may be used to increase milk flow & to diminish pressure -nipple shield may seem like a good solution for nipple pain, but its use may increase the change of milk insufficiency; it's best to work on assessment of the latch & suggesting corrective interventions *Research confirms that: -positioning the baby correctly is effective in diminishing pain for almost every mother

Signs of Oversupply

-nipple pain worse after first few days w/ abundant milk supply; pain is related to baby clamping down b/c flow is too abundant or too rapid for baby to handle -baby gags, chokes, &/or coughs at breast as milk is coming too fast -baby spits up & is gassy after feeds -baby pulls off breast & milk sprays -nipple is compressed or discolored at end of nursing -painful nipples, frequent plugged ducts, &/or episodes of mastitis are experienced -baby gains wt rapidly, significantly more than an oz a day -baby has many large explosive bowel movements -although baby is gaining well, baby may still not act contented b/w feeds, giving mistaken idea that there isn't enough milk or there is something wrong w/ milk -wts taken before & after nursing show rapid transfer of more than expected amounts of milk in shorter than expected amount of time

Free Nipple Graft (Breast Surgery)

-nipple removed from breast entirely, put in Petri dish & then put back on breast after reduction

Pedicle (Breast Surgery)

-nipple stays intact w/ tissue under it

Support for "International Code" is Built Into BFHI

-no advertising of BM substitutes, teats, or dummies to public or promotion of unsuitable products for babies -no contact b/w company marketing personnel & mothers/parents (no contact w/ patients) -no gifts or personal samples to health workers -no promotion of products thro health care facilities (no lanyards, posters, water bottles, placards, etc w/ formula/pacifier/baby food company name on it) -no free samples or supplies to moms

Common Newborn Attributes

-no apparent schedule to their life -night feeds -frequency days may be noted if moms have gotten off to a difficult or scheduled start or baby needs to catch up; these are not growth spurts --we cannot predict when babies have growth spurts

BM Composition Changes by the way it is taken:

-no difference in baby's net fat intake according to the number of breasts suckled per feeding or the BF frequency -the BF baby can regulate his fat intake quickly and thus mothers should be encouraged to practice "baby-led" feeding -some babies do better on one breast per feeding (infants whose moms produced higher energy milk consumed less milk volume compared to infants consuming milk w/ lower energy densities) -moms who produce high energy milk (babies drink less volume)

Milk Expressed When Pumping

-not a direct indicator of how much milk is in breast (babies are more efficient than pump) -start w/ hand expression (hand expression w/ pumping can yield more milk and can increase caloric content of milk) -can use of guided imagery increase milk amount Ilisten to audio recording of relaxation or imagining ocean or waterfall of milk) -does power pumping increase amount collected after a day or two -collect more milk with flange of a different shape -would a different pump make a difference

Professional Role in Weanign

-not a matter of when, but rather about the feelings about ending BF -focus should be on the parent's feelings about ending nursing, not the timing of the weaning -understand the difference between: --stopping trying to make BF work (gradually introducing bottles or topping off feeds w/ bottles then doing more bottles & not focusing on increasing milk supply) --a planned ending of BF --an unplanned ending of BF -acknowledge emotions & be a good listener (tell me about the sadness/emotions that you are feeling)

Tandem Nursing

-nursing two babies not from same pregnancy -milk volume increases faster but less engorgement is experiences with two nurslings -may require specific teachings to manage faster flow -help parents respond to different needs of each child -nurse newborn first & frequently -find time for non-nursing interactions w/ older babies

Feeding Observation Checklist: During The Feed

-observe the body language of nurser *. nursling while feeding; look for tension in arms, shoulders, hands, feet, & face -is motion of baby's jaw an up & down piston motion; this is associated w/ nonnutritive sucking & poor milk transfer -is baby's jaw moving in a rocker-like fashion w/ jaw driving forward into the breast; this is correlated w/ nutritive sucking & good milk transfer -how does baby handle the milk flow? -caution: does baby sputter or choke during the feed? -caution: does baby release the breast in order to take a breath? -does the baby stay a the breast or come off & on during the feed? if so, why? would breast compression or alternate massage keep the baby feeding? -caution: does baby seem to have difficulty breathing at the breast? -caution: does the skin around baby's mouth & nose appear normal during the feed? (blue or grey coloration is a sign of a medical problem; ensure immediate comprehensive pediatric exam) -count rhythm of sucks to swallows; expect bursts of one suck to one swallow or two sucks to one swallow; if swallows aren't heard easily, use a pediatric stethoscope

Lactation Counseling

-observe, explore, and coach -parents, baby, & other family members know more about their situation & resources than we do -our job to observe, collect info, & explore mature of presenting issues, & to coach families regarding feeding & nurturing their babies -as we seek to understand the nature of the presenting issues, other problems & concerns may be uncovered -in our conceptual framework, problems & symptoms are not the same thing (for example, pain w/ BF is a symptom of a different problem perhaps a poor latch) -thru BF counseling we seek to ID the true nature of the underlying problems rather than only removing the presenting symptoms -once we have gathered enough info about the nature of the problems at hand, we can formulate potential solutions & propose them to the family -it is up to the family to choose the solutions they are willing to implement & to carry them out -it's our responsibility to provide info & suggestions in an open, transparent, non-judgmental manner, IDing strategies that may be useful for the family, sharing pros & cons of IDed strategies, all in full acknowledgement that the family will make the final determination regarding what actions to take, if any, to address IDed challenges -it's our responsibility to refer families for additional clinical support or other eval as needed, if it is not available at our workplace or within our scope of practice -it's our responsibility to ensure adequate follow up for IDed BF problems

Protocol for Estimating BM Transfer

-obtain prefeeding weight in grams on accurate digital scale sensitive to 2 grams; make sure same articles of clothing are worn when post feeding weight is taken (discourage diaper changes b/w pre and post feed weight checks) -observe feed using the feeding observation checklist -observe baby's approach to breast; does baby exhibit interest in feeding? does baby seem to be conserving energy or actively feeding? when baby is attached to breast, observe for sucking & swallowing; use neonatal stethoscope to listen for swallows if they are not audible -if baby stops suckling & appears to go to sleep, suggest alternate massage to change rate of flow of milk; observe for sucking & swallowing; does baby get more wakeful & suckle more actively, or does baby break suction? -conduct post feeding weight check -calculate milk transfer by subtracting prefeeding weight from post feeding weight; 30ml = 1oz -calculate baby's approximate daily needs & divide that figure by the amount of reported feeds in 24 hours; is the amount transferred at this feeding similar to the average mount per feed just calculated? -any one feed does not necessarily indicate typical milk intake; it's helpful to observe several feeds over a period of time to get better estimate of average transfer -try diff positions to determine if there is better transfer in one or the other

Lactogenesis II (Secretory Activation)

-occurs w/ complete delivery of placenta -rapid drop in progesterone -produce transitional milk (mix of colostrum & mature milk)

Oversupply (general)

-often overlooked -babies may take on an extraordinary amount of milk in short period of time -confirm w/ weight check before/after feed w/ scale accurate to 2 grams would show rapid transfer of more than expected amounts of milk at the breast in a shorter than expected amount of time (e.g. 3oz in 5 min)

AAP & Drugs & BF

-often publishes a list of prescription & nonprescription drugs, indicating their compatibility w/ BF

Raynaud's Phenomenon of the Nipple

-often treated inappropriately for organisms such as yeast -is not the same as blanching due to poor attachment during feeding -it happens after feed, baby's warm mouth was on nipple & when baby comes off, nipple is wet & cold -involves vasospasm of nipple; recognized by triple color sign white to blue to raspberry or the bi-color sign white to raspberry -pain is extreme & spasmodic (not continuous - may go from one nipple to the next); (kind of like frost bite - excruciating); mom may report shooting pain

Preterm Baby

-on average newborns usually weigh about 8lbs; babies who are born weighing less than 5lbs 8oz are considered low birth weight (LBW) -LBW babies may be healthy but small or have serious health problems that mean spending time in the NICU even if full term -LBW babies may have difficult time staying warm & feeding at the breast right away -even if LBW baby is full term, strategies used to support BF for premature baby may be helpful

Milk from Human Milk Bank Association of North America (HMBANA)

-or state licensed milk bank -banked donor milk is: preventive (reduced long term morbidity); reduces mortality; decreases NEC, cost effective in many cases, safe -safety guaranteed by donor screening: by hx, serology, bacteriology, heat tx / pasteurization process, heat tx does not destroy all beneficial components but does destroy bacteria, HIV, herpes, CM, & other viruses -can be personalized with addition of small amount of mother's own milk -take donor BM & add bit of mom's own BM to the donor milk & after 4 hours the milk has components more similar to mom's BM than to donor's milk

Other Reasons for Nipple Soreness

-oversupply; baby trying to hold back flow by clamping down -w/ oversupply you also usually see: rapid wt gain; unsettled baby esp after feeds; recurrent plugged ducts & mastitis; painful feeds; voluminous stools often green & shiny -From CLC's perspective, green shiny stools indicates need for feeding eval: --is there deep latch w/ nipple stretching --if nipple is not stretched deeply into mouth, less oxytocin flows & less fat is in the mix; w/ less fat the milk is digested quickly, perhaps leading to not enough time for lactase to digest the lactose; w/ improved latch, more fat flows & slows down digestion, allowing time for lactose to be digested --is there overactive letdown &/or overproduction of milk? --if there is lot of milk at once the production of lactose may not keep up w/ amount of lactose (try: minimize oversupply; decrease additional stimulation/milk removal if possible; consider block feeds; try Australian posture; watch for mastitis; consider donating to milk bank) --is lactation mgmt solutions are ineffective, consult w/ HCP for medical dx for both mom & baby

Physical Objects (& Negative Impact on BF) [Pacifier]

-pacifier use may be indicator that parents need extra BF teaching; why is is being used (sore nipples, hunger, crying, sleep problems) -from AAP "consider pacifier use at nap time & bedtime, for BF infants, delay pacifier introduction until BF has been firmly established" (3-4 mos in) -meta analysis studies of pacifiers are contradictory -of you see lots of pacifiers (couple in carseat, clipped to baby) ask questions -pacifier use has other health implications (diarrhea in first 3 years, ear infections - 20% reduction in paci use led to 25% reduction in otitis media)

Concern: Swollen, Painful Breasts: Engorgement

-painfully swollen breasts often occur b/w days 2-4 after birth, or later if the baby was born via C section; this can also happen any time in early weeks if baby is not feeding often or effectively enough *Ask yourself: -is baby feeding frequently & efficiently enough? -is baby positioned well at the breast? -is there a mild fever w/o an area of redness on breast? *Watch out for: -redness, malaise, flu-like symptoms - signs of mastitis *What to do about it: -increase frequency & efficiency of feeds -relieve pressure & pain by allowing excess milk to flow out of breast; water is wonderful aid, either the shower or bath or breast water baths may help milk flow & relieve compression -baby should be allowed to nurse until he comes off on own; if baby is not interested in taking second breast at that feed, offer that breast first the next time cues are seen -gentle expression may also relieve pressure -consider mild analgesics, esp if they are also NSAID (non steroidal anti-inflammatory) meds *Expected resolution: -improving frequency & efficiency of feeds, along w/ relief of some pressure should decrease the pain & discomfort within hours; it may take a few days for engorgement to completely resolve *What else to consider: -natural swelling in breast beginning on days 2-4 is not only b/c of accumulated milk; there is an increased amount of blood & lymph that will resolve as the days pass -suboptimal BF increases the amount of milk remaining in breast after a feed leading to engorgement; "normal fullness" w/o high levels of pain & discomfort is almost universally experienced after birth whether or not BF is planned *EBP review of literature: -does not support either warm or cold applications as the superior choice in the relief of engorgement; either may provide relief; individualize comfort measures based on personal preference & cultural belief; exposure to cold during pp period is not considered healthful in many cultures -does not support the use of cabbage leaves or cabbage salves over cool gel packs or other comfort measures for reducing pain & engorgement; the best possible method to reduce engorgement is to keep the milk flowing & baby nursing effectively *OVERALL: -we have seen rare cases where the engorgement resolves in only one breast; the other continues to be swollen w/ pitting edema; this does not seem to be an issue w/ milk but rather w/ lymph draining; techniques to promote lymph drainage (exercise, massage) have been helpful in the successful resolution of this residual swelling

Clogs or Plugs or Cakes

-palpable lumps of milk within the lumen or duct system; usually not visible -local; they move & should disappear on their own, may come out as a string or blob

Three Strategies for Ending BF

-parent led -baby led -society led

Australian Posture

-parent lies "down under" the baby -baby is supported on the chest, tummy to tummy -this position is especially useful when the milk supply is larger or there is a powerful let down because in this position the baby has increases ability to maneuver his/her head to better manage large or rapid milk flow

Concern: Baby Won't Sleep Through The Night

-parental expectation of baby's nighttime sleep pattern is not being met *Ask yourself: -how old is baby? -how long has this problem existed? -what does "sleeping through the night" mean to this family? -how many hours is the baby sleeping in a stretch at night? during the day? -when does the baby go down to sleep for the night? -when does the baby awaken for feedings? -baby wt gain & output appropriate? *Watch out for: -unreasonable expectations about baby sleep; longest stretch of sleep that can be expected in a BF baby after the newborn period is one 5-6 hour stretch per 24 hours; if baby sleeps for 5-6 hours during the day, he or she probably won't be able to repeat a sleep of that length at night & gain adequate wt -some babies wake frequently at night when they do not have adequate access to human milk during the day; this can be due to parental distraction (i.e. many demands on time may mean that early feeding cues are not noticed, babies who spend a lot of time in the car may be lulled to sleep more often during the day) or baby distraction (i.e. around 4-6 mos many babies become distracted during the day by other activities, such as creeping & crawling, & feed less often); either family or baby distraction can lead to more night feeding *What to do about it: -explore baby's sleep pattern w/ family -compare baby's daily sleep pattern w/ age appropriate expectations -ID whether there is a problem w/ baby's growth or other indications that the baby may be feeding at night to make up for lost daytime feeding opportunities -if day/night imbalance problems are discovered, encourage family to work on changing the daytime patterns first; for example if baby is sleeping 5-6 hours during the day, encourage caregiver to observe sleeping baby & pick baby up when light sleep stage (REM) is seen; baby can be easily & gently offered a feeding while baby's eyes are still closed & in REM *Expected resolution: -feeding baby more often during day will lead to less awakening at night *What else to consider: -comprehensive pediatric eval; babies who are in pain may awaken more often & seek food for comfort; pain can result from teething, ear infection, & other problems

Concern: Baby Won't Stop Crying

-parents are unable to soothe their crying baby *Ask yourself: -how long has this problem existed? -what preceded the crying? -what methods have been used to attempt to calm the baby? *Watch out for: -the truly inconsolable baby needs urgent medical eval -baby's cue state -parental response to baby's cue state -visible symptoms of pain or distress *What to do about it: -encourage S2S contact to calm the baby; calm the environment; consider sound, light, motion & so on -suggest other comfort techniques as needed (massage, rocking, singing, bathing) -encourage offering the breast when baby demonstrates feeding cues *What else to consider: -if these techniques do not calm baby's crying or any of the pediatric warning signs are seen, baby need emergent care -family of baby who cries repeatedly needs support; family members may need some "time-out" opportunities to care for themselves -could be colic

Parent-Led Weaning

-parents decide to end BF

After 15 Months

-part of self image -my blanket, my carseat, my milk -time to think up a public name (maybe not calling it booby if you won't be okay with that in public)

LactMed

-peer reviewed & referenced database of drugs to which BF parents may be exposed -include maternal and infant levels of drugs, possible effects on BF babies & on lactation & alternate drugs to consider

Goldsmith's Sign

-persistent newborn refusal to nurse on one breast is of concern but one breast refusal may also happen suddenly w/ older babies -rule out common problems like ear infection, teething, birth trauma -breast cancer is also possibility that must be medically monitored -CA may be dx as late as 5 years after Goldsmith's sign -"recognition of Goldsmith's sign" is vital & will enable early dx & improved prognosis of breast cancer

Nursing During Pregnancy

-placenta always wins & milk will revert to colostrum mid-pregnancy, extremely sore nipples -safe for women who are not at risk for premature delivery to nurse during pregnancy

BM Containers

-plastic of glass reusable hard sided containers w/ cap that fits securely; plastic bags specifically manufactured to collect & store BM -each container should be labeled w/ the date; -name should be included if going to daycare; -premature might be given labels from hospital or require specific info to include; -use waterproof/smudge proof marker

Concern: Worried About Milk Supply: Baby Has Not Gained Adequate Amount of Weight

-poor weight gain is reported (thought to be problematic or has been measured & found inadequate) *Ask yourself: -has baby's PCP IDed a problem w/ baby's wt gain pattern? -has baby's output (esp stools) been appropriate? -does baby appear dehydrated, jaundiced, malnourished? -is baby's behavior appropriately interactive? -does family report that nighttime feeds seem to go better than daytime feeds? *Watch out for: - parental knowledge of & response to baby's cues -description of daytime demands & routines that lower priority to BF at baby's best time; when nighttime feeds are better, it may be bc baby is close by & cues are more likely to be noticed -possibility of inaccuracy of measurements (i.e. wt taken on diff or inaccurate scales) -use of inappropriate growth chart to track growth of exclusively BF babies; esp after 4-6 mos (WHO growth curve should be used for all babies under 24 mos) *What to do about it: -obtain prefeeding wt if possible -observe a feed -observe baby's approach to breast; does baby exhibit interest in feeding?, does baby seem to be conserving energy or is he actively feeding? -when baby is on breast, observe for sucking & swallowing; suck:swallow ratio should be below 4:1 w/ intermittent bursts of 1:1 & 2:1; suck:swallow ratios above this indicate milk transferring at a rate too slow to be considered nutritive; if baby falls asleep and stops sucking suggest alternate massage to increase milk flow; observe for sucking & swallowing after compression; does baby get more wakeful & suckle more actively? or does baby break suction, indicating a problem in managing the flow? -get post feed wt check; calculate milk transfer; calculate baby's approx daily needs -suggest other changes to feeding process indicated by feeding observation -schedule follow up & appropriate referrals *Expected resolution: -when inadequate wt gain is confirmed, intensive pediatric follow up & BF assessment, corrective intervention, & education are indicated; in most cases, milk supply can be increased & milk transfer can be improved -if milk supply/milk transfer problem is not confirmed, additional follow up is indicated to ensure appropriate growth *What else to consider: -PCP may prescribe supplementation; in this case suggest ways to maintain/build milk supply thru expression; use expressed milk preferentially as supplement & consider use of at breast supplementer -if milk supply/transfer problem is confirmed, but not explained by pediatric eval, a comprehensive maternal medical eval is indicated; occasionally medical issues like endocrine insufficiency, PCOS, meds, superimposed pregnancy, & other conditions have been associated w/ milk production that is less than accurate

To Develop a Relationship w/ Constructed Knowers

-position of constructed knowledge involves enormous "empathetic potential"... the capacity to feel connected w/ another person despite potentially enormous differences -many women in this position nonetheless experience loneliness & discouragement largely due to difficulty in finding companionable & supportive partners

Women in Silence

-position of not knowing in which the person feels voiceless, powerless & mindless -afraid of words -see themselves as relatively powerless & dependent on others for survival -do not trust their ability to understand or remember -have little awareness of their intellectual capabilities -live at the behest of those around them

Oversupply: What to do about it?

-posture where baby is able to move head freely when flow is too much (reclining or semi reclining, Australian hold) -suggest nursing on 1 breast per feed to allow some breast compression to cut back in supply a bit; firm bra may also help; be careful not too much pressure can cause mastitis -block feeding: using 1 breast for 2 or more feeds in a row -collect excess milk and donate to milk bank

What About if Milk Never "Comes In"? (Anemia)

-pp hemorrhage Sheehan's syndrome -hormone imbalance -retained placental fragments -lactogenesis II / secretory activation (onset of abundant milk) happens only after the dramatic fall of progesterone that happens with the complete delivery of the placenta -woman w/ premature baby is pumping, only getting 5ml of milk for first 21 days, then on day 22 she hemorrhages & happened to have retained placental fragments in her; these placental fragments can put out enough progesterone to convince the body that the baby has not been born yet

Premies Do Better on Human Milk

-predominant BM feeding in the first 28 days was associated w/ greater nuclear gray matter volume at term equivalent age -28-32 wk gestation infants in NY NICU "infants fed BM have faster brainstem saturation compared w/ infants fed premie formulas" -exclusive BM feeding is associated w/ more rapid maturation in intestinal barrier function -extremely premature infants who received an exclusive human milk diet had significantly lower odds of incidence of NEC (necrotizing enterocolitis) & mortality --human milk diet of more than 98% - NEC rate of 1.3% --preterm formula - NEC rate of 11.1% ---mixed - NEC rate of 8.2%

Diabetes & BF

-pregnancy itself can increase risk for Type 2 diabetes in mother, which BF can negate -compared w/ woman who have not had children, childbearing women who do not BF have a 50% increases risk of Type 2 diabetes in later life

Early Babies

-premature babies, late preterm (34-36 6/7) & early term (37-38 6/7) infants as well as others may struggle w/ BF; they need many opportunities at the breast to develop the skill of latching & transferring milk -birthweight & length of stay are not associated w/ BF behaviors -preterm babies at the breast have better suck-swallow coordination & oxygenation including REE (resting energy expenditure after feeding) than when bottle feeding -guidelines for the initiation of BF in preterm infants should be based on cardiorespiratory stability, irrespective of current maturity, age, or wt (babies do not need to be a certain age, wt, length of time in NUCY to BF; their ability to BF should be based on cardiorespiratory stability)

Concern: Baby Was Born Early OVERALL

-preterm babies benefit greatly from receiving BM -BM is protective against necrotizing enterocolitis, a serious disorder common in preterm babies -BF also allows parents to observe baby's innate abilities -along w/ all preterm babies, late preterm infants (LPTI) require special attention -when these babies are more likely to appear to have a capability similar to full-term babies & to be cared for in the maternity unit rather than the NICU; they are often sleepier, show fewer feeding cues, & have a lower energy reserve -these factors may decrease milk production potential, down-regulate whatever milk production there is, & lead to low weight gain or even weight loss for the LPTI -we encourage CLCs to observe these babies closely to determine if they are feeding adequately & effectively.

BM Composition Changes

-preterm vs term milk -preterm milk appears to have different composition for the first 5-7 weeks after delivery independent of gestational age (milk of someone who delivered at 26wks vs 33wks is not that different) -preterm milk appears to be higher in protein, fat, & electrolytes than mature milk -if baby is small (SGA), large (LGA), or appropriate (AGA) for gestational age does not seem to make a difference in milk composition -BM composition changes over the course of lactation, within the day (diurnal variations), within a feeding, between feedings -BM compositions also changes by the way it is taken

Raynaud's Phenomenon of the Nipple Treatment

-preventing or decreasing cold exposure (put dry warm towel on nipple as soon as baby comes off) -avoiding vasoconstrictive drugs (including some hypertensive drugs) + caffeine/nicotine -pharmacologic methods especially Nifedipine (Procardia) a calcium channel blocker (not a good option for someone w/ low blood pressure)

Cow's Milk

-proctocolitis (rectal bleeding) may be seen in EBF babies -cows milk protein allergy may play a role in the pathogenesis on many cases of Proctocolitis --sometimes happens thru "hidden bottle" practices (someone has given baby formula w/o BF parent's knowledge) --standard tx for proctocolitis is exclusion of the offending protein from mother's diet (usually cows milk, or soy, corn, egg, & chocolate have been implicated); many (50%) have multiple positivity -resolution of visible rectal bleeding took place within 72-96 hours in most babies although one took a week

Prolactin

-producing milk -making more milk from receptor sites

Gastrointestinal Hormones & BF

-prolactin & oxytocin are only two of the major hormones that play w role in lactation -gastrin & cholecystokinin promote glucose induced insulin release & growth promoting effects in the gut -somatastatin (stress - on the adrenaline/flight or fight side) inhibits GI secretion, inhibits motility (stops digestive system) in the GI tract & the release of most GI hormones. Also somatostatin inhibits secretion of HGH (human growth hormone) from pituitary & inhibits cellular growth & proliferation in the gut

Lactogenesis III (Lactation, Galactopoesus)

-prolactin from frequent nipple stimulation is produced -we need frequent removal of milk at this stage because that is what decreases the pressure on the milk cells

Concern: Baby Has Colic

-prolonged & specific crying in a BF baby *Ask yourself: -what was baby's age at onset? -when did problem begin? -who has diagnosed this problem as colic? the PCP, the family? *Watch out for: -when the symptoms occur *What to do about it: -explore hx of the problem -observe a feed, looking esp for problems that may increase baby's gastric discomfort (i.e. baby crying before or during feeds may introduce extra air into digestive system; large milk supply, fast flow of milk or suboptimal seal may increase baby's gastric discomfort) -teach parents soothing methods: singing to baby, rocking, walking, S2S, massage, etc -encourage parents to take turns having "time-out" if needed from distraught child *Expected resolution: -typically begins after 2 weeks of age and resolves by 4 mos; changing nursing parent's diet may alleviate colic in some cases; major cause of colic are unexplained but it it thought to be related to the maturation of GI & nervous systems *What else to consider: -specialized GI eval -trial of removing cow-based dairy foods from parental diet may be conducted for 10-14 days to determine if colic symptoms decrease; if symptoms do not change, encourage resumption of normal diet

BFHI

-promotes, protects, & supports BF through the ten steps to successful BF for hospitals as outlined by UNICEF/WHO -only scientific & factual info can be provided by companies for health professionals -all info on artificial feeding including labels, should explain the benefits of BF & the costs & hazards of artificial feeding

PROBIT Trial (Promotion of BF Trial)

-prospective, cluster randomized trial in hospitals & polyclinics (associated clinics) in the Republic of Belarus -15 sites continues usual infant feeding practices -16 sites implement the 10 steps to successful BF --infants born at these sites were significantly: ---more likely to be BF to any degree at 12 mos ---more likely to be EBF at 3 mos & 6 mos ---less likely to have GI infections ---less likely to have atopic eczema --at age 6.5: ---the experimental group had higher means on all the Wechsler Abbreviated Scales of Intelligence measures, w/ mean differences of +7.5 for verbal IQ, +2.9 for performance IQ, & +5.9 for full scale IQ ---teachers academic ratings were significantly higher in the experimental group for both reading & writing --at 11.5 years they found a reduction in problematic eating attitudes in the areas where EBF was promoted via BFHI PROBIT intervention --at 16 they found a relationship b/w problematic eating & obesity -conclusion: implementation of the BFHI may be the "fast track" option to a foundation of enhanced public health

Drugs & Altering Physiology

-pseudoephedrine (Sudafed) a single 60mg dose decreased 24 hour milk production by 24% probably by decreasing prolactin levels -corticosteroids: temporary suppression of lactation (for 24-48 hours) after a local injection of 24mg prednisolone in a BF woman who was 6 wks pp -corticosteroids such as betamethasone (i.e. Celestone): if it was given 2 IM injections of 11.4mg were given 24 hours apart) b/w 3-9 days before delivery; there was delay in lactogenesis II & lower milk volumes during the 10 days following delivery (all of the nipple stimulation, baby latching, hand expressing, pumping can help with her supply once meds wear off)

Power Pumping

-pumping a few minutes then stopping for a few minutes then pumping again (may take longer than if you are to just pump for 15 min straight)

Pumps

-pumping along w/ lack of breast/mouth contact independently influences the milk microbiota (& baby's gut microbiota) -should be appropriate for mom's intended usage -must be used according to manufacturers instructions; get training from the rep, see cleaning guidelines on CDC website -if multi-user, must be used w/ kits specified by the manufacturer unless manufacturer says so -any pump can cause breast/nipple damage when used incorrectly (1/3rds of breast pump users reported problems with their breast pump & 15% reported an injury that was attributed to the pump -increasing vacuum & amplitude increases pain and decreases amount of milk collected -can report damage or injury from pumps to FDA -no one pump that is right for every situation -in study of hospital distribution of pumps, getting a pump was associated with decreased odds of any BF around 10 wks -distribution of free pumps was not associated w/ increased rates of exclusive BF at 1.5-3.5 mos pp -lower cost pumps & hand expression may be as effective or more effective than large electric pumps for some outcomes -common intention to use a breast pump early after delivery w/o an IDed BF problem indicates a need for increased lactation supply to reduce concerns about having an insufficient milk supply -no one flange shape is going to be best for all women -observe entire pumping sessions to assure appropriately shaped flange & tunnel size (pain in nipple or poor milk collection may be due to a tight fit; poor fit may also decrease effective emptying causing breast problems & decrease in supply)

Abscess

-pus - not milk -as many as 60% may be positive for MRSA -nursing on other breast is possible -no clear clinical consensus about nursing on breast w/ abscess before or after "drainage"

Concern: Breast Lump w/ Flu-Like Symptoms: Abscess

-pus filled lump in breast that does not move; abscess is often associated w/ continuation of mastitis symptoms after 5 days of appropriate antibiotic tx but may occur w/o hx of mastitis; the affected area of breast is usually tender *Ask yourself: -is the tender lump milk or pus?; needle aspiration is needed to confirm the diagnosis *Watch out for: -the worst solution is to stop BF/milk expression altogether or even stopping only on the affected side; suddenly stopping BF will make the problem worse; engorgement will become part of the problem -if the choice is made to "dry up" on the affected breast, it should be done slowly -pus may drain out thru the nipple; this will relieve some of the pressure but does not preclude medical tx; do not put pressure on a draining abscess -there is a possibility of MRSA infection in the abscess; this appears to be on the rise *What to do about it: -refer to the obstetric care provider who can assess need for: --eval for abscess, usually dx is confirmed by needle aspiration of pus --drainage of abscess; repeated needle aspiration is sometimes needed; drain (or drains) insertion ultrasound to guide the placement reduced the need for surgical placement of a drain; any entry into the breast should be made as far away from the nipple & areola as possible & cutting across ducts should be avoided --antibiotic therapy & non steroidal anti-inflammatory, fever reducing meds -after dx and tx: --recommend bedrest & continued BF on unaffected side --encourage continued BF on affected side if possible; if putting baby to breast is not possible, hand expression or gentle pumping should be recommended to remove milk --assess BF & ensure that any pressure on breast that might hinder milk flow is removed *Expected resolution: -abscess will be drained & if there has been an incision, the area healed -BF can definitely continue on the unaffected breast & at a minimum, milk supply should be maintained until the baby can return to the breast that had the abscess *What else to consider: -galactocele; breast cancer *OVERALL: -abscesses happen rarely, but they are usually the result of untreated or inadequately treated plugged ducts or mastitis

Leverage Points For The BFHI

-recognition of excellence -enhances the facilities status -supports the Joint Commissions Perinatal Core Measure Set -Supports a facility's community benefit strategy -cost neutral "the number of BF supportive practice a hospital has in place is not significantly associates w/ higher birth costs" -recognizes prevention as the key strategy to improve the heath of our nation

Other Issues Associated w/ Formula Feeding

-reflux -colic -allergy & anaphylaxis

Sleeping Through The Night

-regulatory problems (crying, feeding, sleeping) co-evolve, particularly in the first 4 mos -from about 4 mos of age, sleep is consolidated in the nighttime; although 94% of babies wake up to 3x a night & are awake in the day (except for 1-4 naps) --for BF families nighttime waking w/ crying is often perceived to be a problem w/ "not enough milk" -RCTs have demonstrated that "behavioral intervention programs" fail to help & may actually increase parental stress & infant crying -overly frequent or prolonged BF w/ frequent nighttime waking indicates underlying feeding problem which requires appropriate assessment & management not behavioral intervention & increasing inter bout interval -when working, "reverse cycle nursing" has been traditionally practiced (when babies get most nursing sessions at night b/c mom is separated from baby during the day b/c of work or b/c mom is limiting the feeds during the day) -parents of infants (3mos old) who were BF in the evening &/or night slept on average of 40-45 min more than parents of infants given formula & reported less sleep disturbance -w/ infants 6-9 mos, no difference in night waking or night feeds compared to formula fed infants -infants who received more milk or solid feeds during the day were less likely to feed at night; but not less likely to wake -daytime interventions for night time problems -dont assume your point of view & the family's are the same -no associations have been found b/w uninterrupted infant sleep, mental or psychomotor development or maternal mood -prolactin levels in the milk are highest in early morning & in early lactation (when you have highest levels of milk) --so babies who are fed after 2AM are getting more volume of milk & more prolactin --prolactin has been associated w/ more than 300 diff biological fx including assisting in the development of the pituitary & adrenal glands, reproductive organs, gastrointestinal & respiratory tracts & modulation of the immune system

BF Babies Who Become Dangerously Undernourished

-report by Cooper IDed significant increase in incidence of malnutrition & hypernatremia (high sodium) in BF infants. -multiple cases of babies who were 23% below birth weight on average and showed clinical signs of dehydration and hypernatremia (NA +150mmol/L) -babies were not discharged early, were nursing ever 3-4 or 4-6 hours (scheduled), both breasts 5-10 min each side, VERY SLEEPY -babies had sunken soft spot, skin was "tenting", had normal urine output, appeared content and slept most of day, all moms had attended BF class

Concern: Tongue & Lip Tie (OVERALL)

-research does not support revising tongue and lip ties as the first intervention for BF problems -comprehensive pediatric exam, BF assessment by multidisciplinary team (including oral motor specialists) should be first step, even when there is an indisputable restriction of the tongue or lip

Reglan/Metoclopramide (Galactogogue)

-research shows that it does not improve breast milk volume or duration of BF in moms pumping for premies

Effect of BFHI on Infant Abandonment

-researched the rate of infant abandonment 6 years before & 6 years after encouraging early contact, suckling & rooming as part of implementing the BFHI in St Petersburg Russia -rate of abandonment was almost halved; a similar hospital had a 32% increase of abandonment over the same time period

Colic

-review of literature of management of infantile colic concludes that it is "an easily identified childhood problem that has no clearly identified tx guidelines" -colic does not seem to be associated w/ GERD -colicky babies has more than double the abundance of proteobacteria (i.e. escherichia, salmonella, vibrio, helicobacter, yersinia) where bififobacteria and lactobacilli were increased in control infants

Feeding Cues Include:

-rooting -increasing alertness, especially REM under closed eyelids -flexing legs and arms -attempting to bring hand to mouth -sucking on fist or finger -mouthing motions of lips and tongue -crying is late cue and usually does not occur in full term infants until subtle cues have failed to elicit the parent's attention

3. Above All, The Infant Cannot be Compromised

-rule number 1 is to feed the many

Sleeping in Close Proximity

-safest when close to parents -parents will be awakened by quiet sounds and movements -BF works best when dyad is close together -"close proximity" means baby shares room with parents for at least first 6 months, this helps w/ BF and protection from SIDS -adult beds are not safe, safest place for baby is next to parental bed on back in side car, bassinet, or crib -couches, chairs, recliners are not safe to sleep with baby

Factors That Affect The Duration of BF

-scheduled, delayed, or timed feedings -inadequate number of feeds -inadequate transfer of BM to baby -inverted nipple that does not evert during suckling -concerns about perceived inadequate milk production; this is also common reason for introduction of formula & weaning foods before recommended age of around 6 mos -breast surgery that has damaged lactiferous ducts &/or breast/nipple innervation or circulation -conditions that can impact baby's ability to feed effectively, such as prematurity, cleft lip or palate, etc.

Edinburgh Postnatal Depression Scale (EPDS)

-screening tool used to identify depression during pregnancy or in the postpartum period -10 questions that can be completed in less than 5 min -to err on safety's side, a woman scoring 10 or more points or indicating any suicidal ideation (scoring 1 or higher on question #10) should be referred immediately for follow up -even if scoring a 9 or lower, if care provider feels she is suffering from depression an appropriate referral should be made

Improving Milk Transfer

-scrupulously observe for feeding cues, feed the baby at the baby's best time -try different feeding positions to determine if there is better transfer in one or the other -babies often nurse better when their hips are flexed & feet are flat against the back of a chair or another surface -ensure that the baby's arms are free & able to encircle the breast -ensure that the baby's body is in alignment; head over shoulders, shoulders over hips -ensure that baby is aligned nose to nipple to start -ensure there is no pressure on the back of baby's head from a hand, finger, arm, pillow, or anything else -ensure baby's head can tilt back to allow maximum jaw excursion & wide-open mouth -if baby stops suckling & appears to go to sleep, suggest breast compression/alternate massage to change the rate of flow of milk; observe for sucking & swallowing -continue to suggest alternate massage/breast compression to move the milk if this technique is helpful; at each pause, suck, swallow, compress breast; suck swallow compress breast -suggest a semi-upright position w/ flexed hips; in this position, the baby may be more wakeful -consider trying expressed milk in an at breast feeder -if baby is still not able to feed effectively, consider use of nipple shield, combined w/ milk expression to protect the milk supply -ensure continued monitoring of milk transfer -WARNING: seek emergent medical care is any pediatric warning signs are observed or suspected; occasionally problems w/ inadequate milk transfer reflect a pediatric medical condition.

Concern: Worried About Milk Supply: Expressed Milk Volume is Less Than Expected OVERALL

-seems common to imagine that full bottle of milk can be expressed on the very first attempt; this is very rare experience -the body needs to be tricked into "letting down" to the hand or the pump -usually takes time & practice to become adept at expressing milk -hand expression is vastly underrated skill; it is expected that it should be universally taught during hospital stay

Oversupply

-seems to be increasingly common as more families choose to EBF & for longer durations -more likely to happen w. subsequent BF babies

Normal BF

-should be enjoyable experience -shouldnt have pain or discomfort, but they are common -follow feeding cues signaled by REM, bringing fist to mouth, seeking food w/ lips tongue & head, smack lips, extend tongue -crying is late feeding cue

Weight Loss in Newborn

-should be no more than 7% from birth weight and should stop by day 5 -if BF infant lost more than 7% there should be prompt & intensive eval of BF -interventions to correct problems & improve milk production and transfer should start, w/ close follow up -if BF problems cannot be identified and promptly corrected, ensure adequate nutrition for baby w/ expressed milk, donor milk, or BM substitute as directed by ped

Exclusive BF

-should continue until about 6 mos of age -optimal duration of EBF "although infants should be managed individually.. no apparent risks in recommending as general policy, EBF for first 6 mos in both developing & developed country settings" -vitamin K should be given shortly after birth -no supplementary fluoride during first 6 months -complementary food rich in iron & zinc starting ar about 6 mos of age --supplementaion of oral iron drops before 6 mos may be needed to support iron stores --premature infants should receive both a multivitamin preparation & an oral iron supplement until they are ingesting a completely mixed diet & their growth & hematologic status are normalized -all BF infants routinely should receive an oral supplement of vitamin D (400IUs per day beginning at hospital discharge)

Feeding Cues

-signs that baby is in state that is favorable to feeding -begin during active sleep (REM that occurs every 20-30 minutes is first feeding cue) -as baby becomes hungrier and more awake feeding cues become more obvious: bring fist to mouth, seek food w/ lips, tongue, & head, smack lips or extend tongue

Lactational Amenorrhea Method (LAM)

-similar to other types of birth control -menses retuned, supplementing BF regularly, baby older than 6 months (if yes to any of these then mother's change of pregnancy is increased) -if no to those three questions then 1-2% chance of pregnancy

Concern: BF Multiple Babies (OVERALL)

-simultaneous nursing is very helpful for adequate milk supply -important to have weekly or more frequent wt checks of babies to ensure all babies are thriving, especially w/ higher-order multiples (3 or more babies) -no reason to expect enough milk cannot be made for multiples, given early & adequate stimulation, milk removal, & support

BF Myths & Illusions

-size of breast related to the amount of milk -not getting enough fluids -maternal exercise/ rest and milk production -increased worry/stress does not seem to diminish milk supply -it's about types or amount of foods eaten during lactation

Concern: Baby Won't Wake Up Enough To Nurse Well

-sleepy baby *Ask yourself: -how old is baby? -when did problem begin? -baby wt gain & output appropriate? -do parents understand & respond to feeding cues? *Watch out for: -true inability to awaken needs emergent medical eval -breathing problems in baby require urgent medical eval -inadequate urinations &/or stools in baby (calorically deprived babies seem sleepy) require urgent medical eval -diagnosed congenital anomalies & neurologic problems can result in arousal difficulties *What to do about it: -encourage observation of baby while sleeping & responsive feeding; baby should be picked up & brought to breast when signs of light sleep (REM) are seen & the hands fist -hold baby S2S b/w feedings to improve motor & state organization -explore baby's sleep environment; when babies are warmly dressed /wrapped they may sleep longer; swaddled babies may not house themselves as easily when transitioning from deep to light sleep -take a feeding hx; determine if adequate number of effective feedings is occurring in.a 24 hour time period (10-12 feeds in 24 hours for a newborn) -ensure comprehensive pediatric eval if there is any indication of recurring pattern of low frequency of feeding or difficulty rousing the baby from deep sleep *Expected resolution: -as baby gets older, he/she will learn to regulate sleep/wake & feeding patterns -family will become adept at reading & interpreting baby's language -in newborn, recovery from birth, as well as exposure to labor & delivery pain meds administered to the mother &/or analgesia or anesthesia given directly to the baby for painful procedures, may result in transient changes to normal sleep/wake cycle *What else to consider: -could baby be marginally nourished, jaundiced, or dealing w/ infection or other condition? ensure comprehensive pediatric eval of wt gain problems, development, output, & sleep patterns -explore daytime patterns in baby's environment; might there be too much environmental stimulation, such as sound or light, causing baby to shut down? -jaundice

Concern: Worried About Milk Supply: Expressed Milk Volume is Less Than Expected

-small quantity of expressed milk is reported *Ask yourself: -what has experiences w/ milk expression been? -what methods are being used to collect her milk? -baby's wt gain & output appropriate? -is this a new phenomenon? *What to do about it: *-if there are no indication of milk supply or intake problem... -acknowledge this is common experience; explain it is common to be able to express only few droplets of milk initially before becoming accustomed to milk expression -if this is change (gradual or sudden drop in milk expression volume) explore changes or additions to daily routines (i.e. new meds, supplements, herbs, decreased number of feeds or expressions, changes to pumping equipment, onset of menstruation, onset of new pregnancy) -teach or reteach milk expression techniques; encourage nipple stimulation & massage prior to expression & use of guided imagery & other tools that may enhance milk flow -if breast pump is used, check for missing parts or assembly problems; ask manufacturer how to check pressure generated by pump; observe pump session & check for appropriate technique & good fit of flange -if method of expression is currently only a breast pump, encourage considering addition of hand expression -suggest consideration of expressing the unbuckled breast using one flange of breast pump of hand expression while nursing the baby (this may increase yield) or combining hand expression w/ pumping -if hx of problem & baby's wt gain indicate a possible milk supply or intake problem undertake feeding observation -suggest other changes to feeding process indicated by observation -schedule follow up & referrals *Expected resolution: -practice is the way to become more adept & milk expression -in cases where inadequacy of milk supply is confirmed, milk expression can assist in stimulating milk production; milk expressed may be used to supplement the baby if supplementation is prescribed *What else to consider: -if milk cannot be expressed from breast or colostrum is expressed beyond first 4 days of life, comprehensive maternal medical eval is indicated -problems such as retained placental fragments & hx of breast surgery have been associated w/ phenomenon of not moving on to adequate production of milk as expected

Bleb

-small white spot on face of nipple that look like milk filled blister -one duct opening is usually covered -women describe stabbing pinpoint pain

Smoking and Altering Physiology

-smoking mothers make less milk -smoking mothers may have lower prolactin levels (after 12 hours of not smoking the prolactin rise was more similar to non-smokers) -pump dependent mothers of premies collected less milk if they smoked -women who smoke more wean earlier -smoking and nursing may result in babies who nap less -quitting smoking during pregnancy is significantly associated with reduced risk of premature birth -pregnancy is a time when many are motivated to quit smoking & providing targeted smoking cessation interventions at this time, which take into account factors predictive of quitting smoking are more likely to be successful -support to quit smoking should help to prolong BF duration especially those most at risk for not exclusively BF -nicotine patches: FDA states "women who are pregnant or BF should use these products only w/ approval from their HCP" (not something we can answer as a CLC) -Cadmium (heavy metal kind of like lead) exposure can affect the kidneys. liver, lungs, & nerves as well as other body systems (it is in cigarettes) [kiddos w/ high cadmium exposure cannot do multistep directions, must be given things step by step] -new assumption is that 22% of SIDS can be directly attributed to maternal smoking during pregnancy -BF may mitigate adverse effects of smoking during pregnancy on the child's cognitive development -apart from support to stop or diminish tobacco consumption, encourage BF & protect the baby from secondhand smoke

Storing BM

-specific recommendations will be given for premature or fragile babies -any milk left over from feeding should be thrown away after 1-2 hours -if milk is going to be frozen, it should be frozen right away -milk is good in fridge for 4 days -milk is good in freezer for 6 mos and acceptable up to 12 mos -over course of day, expressed milk can be added to milk stored in fridge -place milk in coldest part of fridge or freezer (not in door or near fan) -can be stored at room temp, but best to keep in cooler bag w/ ice

9-12 Months

-stand & walk -regular mealtimes & snack nursings -nursing before bed & naps -BF thru the first year: --supports toddler energy & growth by fostering a shared mother-infant regulation of toddler food intake --promotes a pattern of mother-child interaction during feeding that acknowledges the child's role in regulating food intake (results in less conflict at mealtimes)

Other Tips with BF

-start S2S -look for feeding cues -baby tummy to mummy, belly to belly -mom in comfortable position, not hunched over, shoulders not raised too high -baby's hands and arms around breast -let breast hang in natural environment (don't hold it up or reposition is -BF should not be painful, not for one second -if there is pain, suggest breaking the seal, remove baby & start over again -baby should come off breast on own then you can offer second breast; not all babies will take both breasts for every feed -baby's tone should be relaxed -if baby has tight fists at end of feed, probably want to look for more feeding cues & offer next breast

Babies w/ Down Syndrome

-struggle w/ BF -low tone - cues -depressed reflexes (hard to latch on) - gape (when you put nose to nipple, it may take several tries for baby to gape due to depressed reflexes) -hyptonic perioral muscles, weak suck (enough to decrease mom's milk supply) - piston, ratio (could be 8 sucks to 1 swallow), sustain (difficult time maintaining the seal & sustaining the feed) -deficiency in smooth tongue movement (can cause baby to choke & sputter) -skeletal abnormalities of mouth & skull will decrease volume of oral cavity -significant improved development in sucking behavior over time is possible -juliasway.org

Feeding Cues Info

-study of 24-48 hour old babies indicated that rooting was most common first behavior followed by hand to mouth movements -babies show more cues when they are close to the source of the milk -when cues are missed or state is not optimal infants fret or sleep at the breast (solution: S2S & reteach feeding cues) -when baby is in the optimal state for learning & feeding, the baby will have long periods of concentration, usually during REM & quiet alert -don't want to nurse baby when swaddled because their legs won't be flexed and baby won't have opportunity to put hands/arms around breast

Galactogogues

-substances believed to increase milk production -we need to remember that if there is a concern w/ milk supply, we should look for underlying medical conditions -some providers may inappropriately recommend galactagogues before emphasizing the primary means of increasing milk synthesis or evaluating other medical factors that may potentially be involved -given insufficiency of evidence, no recommendation is made for the use of herbs as galactogogues -existing studies about galactagogues cannot be considered conclusive -current research of both pharmaceutical & herbal galactagogues is still relatively inconclusive & all agents have potential adverse effects -prescribing drugs & herbal remedies is not within the scope of practice of and CLCs unless they are legally prescribers -herbs can have pharmacological properties & significant side effects; recommending herbs is prescribing -Lawrence & Lawrence gives a list of herbs that are considered safe for tea drinking -some galactagogues do increase serum prolactin levels -no direct correlation has been demonstrations b/w artificially increasing baseline serum prolactin levels & long term BF success -conclusion: "if mothers are provided education & practice techniques that support lactation physiology, galactagogues appear to have little or no added benefit"

Supplementing Pregnant or BF Mom w/ LCPUFAs

-such as "expecta" or fish oil -no significant reduction in depression in supplemented women -no effect of DHA tx during pregnancy on early childhood cognition or language scores -meta analysis: no difference in child neurodevelopment or visual acuity -cochrane: "currently there is an insufficient evidence to support or refuse the practice of giving LCPUFA supplementation to BF moms in order to improve infant growth & development"

Nutritive Flow

-suck:swallow ratio should be below 4:1 w/ intermittent bursts of 1:1 & 2:1

What increases gastrin & decreases somatostatin in babies?

-sucking: babies have cutaneous (touch) receptors in their mouths that respond to sucking starting at 27 weeks gestation -species own milk -decreased stress -wellness -adult GI hormones also impacted by suckling. when mom is suckled on her gastrin and cholecystokinin go up. This increases efficacy of insulin & increases storage of ingested nutrients

Concern: Reddened Area of Breast w/ Systemic Symptoms: Mastitis

-sudden illness w/ flu-like symptoms & a painful, hard, reddened area on one breast; mastitis always indicates inflammation in the breast & may be either infective or noninfective *Ask yourself: -could illness be caused by something besides mastitis? *Watch out for: -are both breasts reddened w/ fever & flu-like symptoms? if so, this is potential medical emergency (i.e. strep infection) for which care should be sought urgently -mastitis that is not tx promptly & effectively may result in abscess *What to do about it: -mastitis may be infective or noninfective, but always indicates an inflammatory process; NSAID meds should be considered -if improved BF practices & NSAID meds do not resolve symptoms, or if symptoms become worse in a few hours, consider a course of antibiotics if infection is suspected (i.e. if there are nipple fissures or signs of nipple damage); Staphylococcus aureus is the most likely organism cultured in cases of infective mastitis, although a variety of other organisms have been implicated -think about cause of mastitis & how to decrease change or mastitis recurring -predictive factors for mastitis may include: ineffective hurried feeds, plugged ducts, suboptimal feeds, tight bra or pressure on breast, nipple damage, anemia (esp if mastitis is recurrent), use of breast shell. inside bra b/w feeds, short lingual frenulum or tongue tied baby -help the family think about caretaking during this time; bedrest, fever reduction, NSAIDs & improving BF practices should be considered along w/ BF frequently; mastitis, even infective mastitis does not require BF suspension or cessation *Expected resolution: -symptoms should resolve in 5 days, usually before prescribed antibiotic is finished; encourage continuing antibiotic even after symptoms resolve *What else to consider: -anemia in the case of recurrent mastitis -inflammatory breast cancer *OVERALL: -mastitis is often accompanied by feeling people describe as being "run over by a truck"; prompt medical attention, rest, & appropriate changes to BF practices result in speedy recovery for most; there is no need to interrupt BF -breast cancer dx, esp dx of inflammatory breast cancer, may be delayed during BF b/c of the mistake dx of recurrent mastitis; breast cancer, including inflammatory breast cancer & Paget's disease of the breast have been dx in the population of lactating individuals; people w/ recurrent mastitis should be referred to their HCP for medical eval.

Nursing Strike

-sudden refusal of the baby to nurse even though there is plenty of milk -many reasons: stuffy nose, teething, ear infection, prefer bottle, bitten breast and gotten yelling as response which scared baby, family stress, separation -needs to be dealt w/ before baby will return to nursing -assist w/ temporary milk expression and alternate feeding method -to end strike: offer lots of S2S, never force baby to breast, avoid bottles if possible, offer breast when baby is sleepy, bring baby to meeting where there are lots of BF babies (baby may respond to peer pressure of seeing other nursing babies)

Concern: Hx of Breast Surgery/Injury: Breast Reduction

-surgery has made breasts smaller *Ask yourself: -is there sensation especially down to the nipple?; did surgery alter breast or nipple sensation? -are ducts patent? -are nipple pores patent? -was there any change in breast size &/or appearance in pregnancy? *Watch out for: -adequacy of ongoing milk supply; milk volume may increase around the third day because of the change in hormones due to the delivery of the placenta; however, the nerves that convey sensation to the pituitary & signal adequate hormone release may have been severed or altered by surgery, & mature milk & ongoing production may not be sustained at an adequate level -insufficient milk making tissue -inability of milk to exit the breast b/c of severed ducts -initial engorgement that does not resolve easily; this can be due to severed ducts & may further reduce milk production *What to do about it: -assessment & close follow up w/ frequent wt checks in the first month & beyond -consider recommending milk expression to optimize production -ensure adequate nutrition for the baby -consider at-breast supplementation if needed -encourage report of surgery to the pediatrician *Expected Resolution: -there is no way to know ahead of time how much milk will be able to be made after breast reduction surgery; frequent wt checks of the baby are mandatory throughout the first month & beyond -What else to consider: -ask about breast surgery in private; partner & other family members may not be aware of the surgery -people may not think of this procedure as "surgery"; ask about "breast improvements" as well as surgery *OVERALL: -it's important to have weekly (or more often) wt checks of baby for first months to ensure there is adequate milk

Abscess Treatment

-surgery may cut thru nerves & ducts -drainage of breast abscess w/ ultrasound-guided technique has been shown to be efficient & safe should be the first choice for both MRSA & non MRSA abscesses

Engorgement

-symptoms occur most commonly b/w days 3-5 but moms who have had IV fluids in labor & postpartum have higher levels of swelling up to day 9 -women w/ c-section births experience peak engorgement 24-48 hours later than those who deliver vaginally -more time spent BF in first 48 hours is associated w/ less engorgement

Protocol to Calculate Baby's Approx Daily Needs (Appendix F)

-take baby's weight in lbs and multiple by 2.5 for standard gain, 2.7-3.0 if baby needs to catch up on weight -this is a rough calculation of potential need and are likely to be most accurate for newborn baby -pediatrician determines which multiplier (2.5, 2.7, 3.0) to use

Good Counseling is NOT like

-talking to a friend -a teacher talking to a student -mechanical fixing of "what's wrong", "hands on increases the mother's sense of being a machine that can be turned on & off by others" (teaching with doll and crochet breast is preferred *HANDS OFF*) -giving advice that would work for you -one size fits all info (as found on the internet) -imposition of the counselor's agenda on the family (it is their decision how they want to feed this baby, it's our job to clarify misconceptions, offer viewpoints, weigh in on strategies that may or may not be good for BF, but not in judgmental way)

To Develop a Relationship w/ Receivers of Knowledge

-teacher or counselor must project authority -never be ambiguous -advantages must be concrete & appropriate for her -teaching should center on the right way & include return demonstrations (don't give examples of things done the wrong way)

Alternate Massage / Breast Compression

-technique used to increase flow of milk during a feed -hand is used to compress or massage breast when baby is not sucking -this technique is especially useful w/ a baby who sucks a fe times & then has a long pause -massage/compression is used to increase flow of milk which stimulates baby to nurse actively again -works esp well w/ premature babies, babies w/ Down syndrome, & other babies for whom the swallow stimulates a suck -when nursing a baby w/ cleft palate, a more active alternate massage is used b/c the baby usually cannot maintain a vacuum; the hand action is similar to the repetition of manual expression in that a synchronicity w/ baby's suckling is implemented, increasing flow of milk so baby can manage a greater flow

Breast Storage Capacity

-the amount of milk that can accumulate before the growing fullness signals the mammary cells to make less milk

Football or Clutch Posture

-the baby lies on his/her back or side, curled beside the breast, tummy to tummy, hips flexed -the forearm supports the baby's upper body -the hand that supports the baby's neck & shoulders does so in such a way that the baby can tilt his/her head -the baby's hips are usually automatically flexed because the feet are pressed against the chair's back

Babies Use Their Senses to Reach Breast

-the higher temperature of areola helps guide babies to breast -smell is also an important early developed sense for most newborns to attract the baby to the breast -exposure to mom's odor may facilitate infant's adaptation to the early postnatal environment -mother's areola & milk odor appear to be sufficient to attract & guide neonates to the odor source, esp after infant has been exposed to the contractions of labor; maternal breast milk odor calms newborns during painful procedures -women are rewarded when they smell babies; body odors of unfamiliar 2 day old babies elicits activation in reward-related cerebral areas of women regardless of their maternal status

Procedural Knowing

-the position at which techniques & procedures for acquiring, validating, & evaluating knowledge claims are developed & honored -invested in learning, constantly taking in new information -interested in obtaining & applying knowledge -want to understand other people's points of view -assume that every one including themselves can be wrong -will read a variety of books with different points of view -may attend several classes & change health care providers easily -may be viewed as inconsistent by others -may want very technical information about BF

Constructed Knowing

-the position at which truth is understood to be contextual, knowledge is tentative, and it is understood that the knower is part of (constructs) the known -have abandoned either/or thinking -have learned to live with conflict & have high tolerance for internal contradiction & ambiguity -believe all knowledge is constructed & the knower is an intimate part of the known -want to avoid compartmentalizing thought & feeling, home and work, self & other -want to embrace all the pieces of the self in some ultimate sense of the whole: mother-daughter-wife-artist -aspire to work that contributes to the empowerment & improvement in the quality of life of others -believe that ideas & values must be nurtured -have a unique and authentic voice

Myth - Size of Breast

-the proportion of glandular & fat tissue and the number & size of ducts are not related to milk production -a larger cup size does not mean you will produce more milk than a mom with a smaller cup size -for HCP, perceptions of who will have difficulty w/ BF may be related to breast size

Working & BF

-the separation, not the physical act of working complicates BF -choice to BF isn't based on whether or not a mom is working -expecting to work in first year after baby does not significantly impact whether BF is initiated -timing of returning to work is closely linked to ending BF -workplace support is underestimated during pregnancy -takes less than an hour distributed across a couple sessions to collect milk during typical workday -may have company sponsored lactation programs (classes on benefits of BF, service of CLC, private space w/ equipment for pumping at workplace)

Concern: OTC or Prescription Meds & BF (OVERALL)

-there are some occasions where BF is not possible due to contraindicated meds, but are quite rare -weaning unnecessarily due to inadequate knowledge about med safety is not uncommon -potential side effects of BM substitutes are rarely considered -be prepared to provide prescribers w/ current EBP info about meds and BF

Concern: Worried About Milk Supply: Baby Falls Asleep After Just Few Min of Feeding OVERALL

-there is no "right" amount of time for feed to last -concerns about feed that are too short (or too long) always warrant feeding eval -although most newborns have longer feeds as they learn how to feed effectively, experienced babies may be able to transfer significant volumes of milk in a very short amount of time (i.e. as little as 5 min)

Concern: Baby Has A Birth Defect: Galactosemia OVERALL

-these conditions are extremely rare -classic galactosemia is thought to occur in 1 in 60,000 births -Duarte galactosemia apesar to be more common in many populations -when counseling the family of a baby w/ classic galactosemia, allow space for expression of feelings about loss of the BF opportunity

Calorically Deprived Baby

-they conserve energy, cry less, have difficulty feeding, and sleep more -their suck may weaken, further diminishing stimulus required by breasts to continue producing an adequate supply of milk.

Intervention: Normalize BF

-think about potential adult benefits due to lactation (i.e. knowledge of breast cancer risk reduction may influence BF practices) -change "fewer ear infections for the baby" to "you may have fewer pediatric visits for ear infections" -interact w/ people as though exclusive BF is the expected choice: "how can I help you to BF your baby" -"women who decided not to BF are not so much embracing this method of feeding (formula) as rejecting BF"

2010 Health Care Reform (ACA) Created a Workplace BF Law

-this amendment to section 7 of Fair Labor Standards Act requires employers: --to provide "reasonable break time for an (hourly) employee to express BM for her nursing child for 1 year after the child's birth each time such employee has to the need to express the milk" --the space must be a private place other than a bathroom and "is shielded from view & free from intrusion by coworkers & the public" -only 40% of employed women w/ infants has access to both break time & a private space to express BM -employers who have less than 50 employees can claim an exemption; but they have to prove that have less than 50 employees -the law also doesn't specify rules for break time, so women may have to clock in and out every time they take a break to pump (this can impact someone's income & the amount of time spent pumping at work)

Concern: Baby Latches but Doesn't Stay Attached

-this indicated need for feeding observation as baby is unable to maintain adequate seal at breast's resulting in ineffective milk transfer -*Ask yourself: -wt gain & output been appropriate? -does baby appear well nourished? -does baby seem appropriately interactive & interested in feeding? *Watch out for: -lips not sufficiently flanged out or lips rolled in -mouth not open wide enough (140-160 degrees) -potential anomalies of baby's mouth or of breast and/or nipples -location of parent's hands during feeds -baby's body language *What to do about it: -obtain prefeeding wt -watch closely for baby's interest in feeding; if feeding attempts happen when baby is not indicating feeding readiness, reteach feeding cues & appropriate responses; if baby is not in receptive state, encourage S2S until feeding cues are seen -observe a feed; note condition of latch before baby latches off breast; was baby nursing well & then became overwhelmed by change in milk flow -when baby is attached to breast & does not maintain seal, suggest detaching baby & using hand expression to release few drops of milk for baby; observe baby attempting to latch again; suggest diff positions -conduct post feeding wt check; calculate milk transfer; calculate baby's approx daily needs & divide that figure by the number of reported feeds in 24 hours; how does the amount arrived at compare w/ the amount of milk transferred during this feed -suggest other changes to feeding process indicated by feeding observation -schedule follow up & appropriate referrals *Expected resolution: -when reasons for attachment difficulties are IDed & addressed, they should gradually resolve -nursing dyads learn how to accommodate each other gradually over early weeks of BF *What else to consider: -if observation & positioning guidance do not resolve the problem, refer baby to PCP for eval -problems like stuffy nose, respiratory issues, tongue tie, clefts, & neuromuscular or cardiac issues must be ruled out -PCP may recommend supplementation; suggest ways to maintain/build milk supply thru milk expression & encourage S2S as much as possible to assist baby in developing comfort being held to breast

Cross Cradle Posture

-this position is considered especially useful for nursing a newborn or preterm baby -the baby lies on the lap on his/her side tummy to tummy, hips flexed -the forearm of the arm opposite to the breast that is being used supports the baby's body -the hand that supports the baby's neck & shoulders is positioned in such a way that the baby can tilt his/her head

Concern: Baby Won't Latch: Baby Sporadically Refuses to Feed OVERALL

-this type of refusal typically denotes some miscoordination b/w nurser & nursling -observing & suggesting appropriate responses to baby's cues is often all that is needed to help overcome this problem

Hormone Imbalance

-thyroid imbalance (hypo & hyper) -maternal obesity & overweight -first 7 days only (delay in lactogenesis II) -increases odds of early weaning, but increased support resulted in increased BF duration & intensity

Uncommon & EMERGENT Mastitis

-tissues of both breasts are inflamed -strep is the probably organism - potentially fatal, whole body inflammation - sepsis -this is not a problem w/ the milk -someone tells you they have two red hot breasts send them to the ER ASAP

Chest Masculinization "Top" Surgery

-transmasculine individuals experiences w/ chestfeeding -not the same as mastectomy -possible they can BF -gender dysphoria is possible due to breasts swelling -restarting testosterone & binding were common concerns (bc a lot of people of off testosterone during pregnancy which can cause some more female features to come back and can cause more gender dysphoria) -care providers should communicate an understanding of gender dysphoria & trans identities in order to build trust & provide trans competent care

Candida albicans / Yeast / Thrush Treatment

-treatment includes simultaneous pharmacologic tx -nystatin ointment is typically the first round -fluconazole (diflucan) oral capsules may be used also -cleaning or replacing yeast vectors (toys, packs, pump parts, etc; may be contaminated w/ candida biofilm) -if breast tx doesn't work it may NOT be yeast -even when symptoms of severe nipple & breast pain, candida was not found in the ducts or milk -antihistamines were found to relieve symptoms when there was persistent pain thought to be yeast (mom might be having allergic reaction to yeast in baby's mouth; but antihistamines can decrease milk supply)

Concern: Breast of Dissimilar Size: Unilateral Underdeveloped Breast

-two breasts are markedly different in size &/or shape *Ask yourself: -have breasts responded to the hormones of pregnancy? -are Montgomery glands visible? -have breasts increased in size or appearance during pregnancy? *Watch out for: -adequacy of ongoing milk supply *What to do about it: -assessment & close follow up w/ frequent wt checks for the first month & beyond -ensure adequate nutrition for the baby -consider if at-breast supplementation is needed -encourage apprising pediatrician of situation *Expected resolution: -there is no way to know ahead of time how much milk can be produced; frequent wt checks are mandatory *OVERALL: -sometimes the breast development may have been affected by chest tube placement before puberty , or other surgical or traumatic changes to the chest

Fortifiers of Mom's Own Milk & Donor Milk in Premies

-two main choices: fortifier made w/ cow's milk or fortifier made w/ human donor milk; preterm formula should be the last choice according to most expert groups -reanalysis of 12 center randomized trial os VLBW infants concluded that "the available evidence points to an increase in adverse outcomes w/ the cows milk fortifier, including NEW & severe morbidity comprising NEC surgery or death" -in the US this is a cost savings of $117,239 per infant

Clefts

-typically the combination of sub-optimal seal, jaw motion, & instability to sustain the feed are problems w/ making & holding the vacuum -longer duration w/ BM lowered the incidence of otitis media in babies w/ clefts (incidence was not affected by day care, siblings, or family medical hx) -for babies w/ clefts in the lip & palate, making a seal, creating a vacuum & sustain the feed is the challenge --use alternate massage, breast compression, or sometimes a nipple shield --can try to point nipple towards the not cleft part of baby's mouth

How do we assure adequate milk supply?

-universal understanding of how BF works -early initiation and adequate BF (10-12x daily) -appropriate BF assessment -improved and early BF support to decrease "lactastrophes" -appropriate HCP and LCP (lactation care providers) follow up in the postpartum -admitting that there's no magic bullet

Cesarean Birth is Barrier to BF

-unplanned, elective, & repeat c section have negative impact on BF -first hours after birth you have short window; one the progesterone goes out w/ delivery of placenta, then we need to have prolactin available in bloodstream to pop into those receptor sites in order to start making milk; in order to change those cells over to milk making cells from colostrum making cells; if progesterone goes out & there is no prolactin to fill them, those cells are going to involute & are not going to be available to make milk until the next pregnancy -perhaps due to later initiation of BF or more separation or more supplementation or greater wt loss -better post-op pain control improves BF outcomes -baby's gut microbiome is affected by antibiotic use, mode & place of birth -babies who are born via c section can go S2S during closing -S2S after c section may increase BF initiation, reduce formula supplementation in hospital & maintain infant temperature -if mother is separated from baby, partner can do S2S -in study of fathers, "infants in the S2S group were comforted, they stopped crying, became calmer, & reached a drowsy state earlier than the infants in the cot group" -not in the first 2 hours, but maybe when mom goes to take a shower, S2S w/ dad is important too; if mom is hemorrhaging or has an emergency than dad should do S2S within that first hour time frame

Growth in BF Baby

-until Fall 2000, NCHS growth charts on babies weight gain patterns were based on growth of babies from 1929-1978 w/o reference to how they were fed -WHO study released in 2006 makes exclusively BF babies the growth standard -in 2010, the CDC recommended that the WHO growth standards be used for all children under 24mos -2012 AAP statement agrees: exclusively BF babies looked like they were dropping percentiles on the NCHS chart when they slow down their rate of growth; exclusively BF babies gain faster at first and then slow down

Physical Objects (& Negative Impact on BF) [Nipple Shield]

-use has raised concern -use w/ good caution & good follow up -uncertain effects on milk supply (they're covering the nerve endings on the nipple) -3x risk of not exclusively BF -readission for weight loss & hypernatremic -dehydration -lawsuits -fungal biofilm -weaning an infant from shield can be difficult -higher risk of early weaning -mothers perceive nipple shields as a barrier -research w/ pump dependent moms of preterm infants hint that shields may have a place in transition to the breast for preemies -this finding does NOT indicate that shields are universally appropriate -published research does not provide evidence for safety or effectiveness -training staff in BF counseling prolonged the duration of BF when women had been given a nipple shield to solve BF problems

Electronic Cigarettes

-use of e-cigs in BF moms is understudied, but the trans we of nicotine from e-cigs appears minimal and less than or equal to nicotine inhalers -some products tested by FDA, even though were advertised as not containing nicotine did indeed contain some when studied -there were also reports of substances notes to be human carcinogens found in many samples -counseling techniques really come into place here (& w/ regular cigs) it is best to encourage BF

Excessive Pressure on the Breast (Can Result From:)

-vascular, lymphatic, & third-spacing forces, especially early on -secretory activation (lactogenesis II) [if you have multiples like twins/quads, your body may ramp up milk making and can cause more engorgement] -too much milk left in breast (baby too weak to remove milk) -missed feedings -restrictive bras and clothing (storage capacity can be reduced by tight clothes and engorgement) -breast implants

Is Nursing Possible?

-very few maternal & infant conditions that preclude BF -lactation is possible for virtually everyone who gives birth

Indications for Immediate Medical Attention: For the Lactating Parent

-visible red areas on breast(s)/chest (increased concern when this occurs on both breasts simultaneously due to possibility of septicemia) -persistent bleeding from nipple b/w feeds -symptoms of infection (redness or pus at site of bleeding; 100.4F fever or higher; chills; ashiness; malaise) -Extreme breast discomfort

Teaching Hand Expression

-wash hands and scrub all surfaces at least 20 seconds -use clean container to collect milk (large, lightweight bowl for first few times) -position bowl on table if standing or on lap if sitting; aim spray into container -do gentle, light breast massage, stitch nipples to get hormones flowing -make C shape w/ hand, place thumb & index finger on breast, position hand behind nipples -pull back toward chest wall, then compress index finger and thumb gently and rhythmically (mimicking the suckling of baby - about 1 compression per second) -repeat this in same area until flow subsides or slows down -move finger and thumb to another spot & repeat -switch to other breast -proficient expressers can do both breasts at same time

Spoon Feeding

-we like to use small plastic spoons to collect drops of expressed colostrum if needed for first few days -coach parents to use spoon to dribble a drop or two of milk on baby's lips -if in right state for feeding, the baby is likely to lap or like milk from the spoon -even small amounts of colostrum or human milk delivered via the spoon are enough to spur the baby's interest & energy

To Make BF The Norm

-we need to take the first chair (we need to get there first w/ the right answers) -today, social marketing, technology, & unique campaigns are taking the first chair *research also shows: -decision to initiate BF is influenced more by embodied knowledge (kind of knowledge gained from seeing BF) than by gaining theoretical knowledge about its benefits -that the decision does not come from prenatal education -neither do behaviors such as exclusive BF result from education -providers seem to not be adequately addressing family concerns about BF

Feeding Observation Checklist: As The Baby Latches

-what does nipple look like before it enters the baby's mouth? note shape & coloration -what position has been chosen? -is baby's body turned tummy to tummy w/ the parent's? -is baby's body aligned (ears over shoulders, shoulders over hips, legs & arms flexed or midline)? -where are the hands? the baby's hands should encircle the breast -there should not be pressure on back of baby's head; look for hands, arms, pillows, etc that may limit baby's ability to tilt head -watch for altering natural shape of breast &/or tilt of the nipple -is baby's position nose to nipple to start? -when does baby open his/her mouth? is it a gape? the mouth should open wide & head tile back in the nose to nipple position -what is angle of mouth opening? -is baby able to extend head backward? -does baby reach breast w/ lower lip & tongue first, followed by upper lip sealing to breast? -does baby's mouth appear off center in relation to position of nipple -is baby's chin close into the breast? -is baby's nose near the breast? -are baby's arms up around (hugging) the breast?

Feeding Observation Checklist: After The Feed

-what triggered the end of the feed (the clock, the parent's determination that the feed is over, or the baby's self removal, etc) -what does the nipple look like just as it exits the baby's mouth? any changes in shape (other than increased length & width)? -any change in coloration of nipple?

Infants Lose More Weight in First Postpartum Days When:

-when labor pain meds are used, but perhaps not at a baby friendly hospital -when more intrapartum fluids have been given (IV fluids tend to cause babies to have mildly elevated birth weight, so they are over hydrated at birth and will release those fluids in early days) -when there was no labor prior to Cesarean (scheduled C-section w/o going into labor first)

Milk Composition (lactose, volume, fat, etc.)

-when lactose & volume were high the fat content is low; but when lactose and volume were low the fat content was SIGNIFICANTLY high -baby may be getting less mL of milk, but it is rich and high in fat which makes baby feel more full -if higher caloric content is needed for specific preterm infant, evening sample should be used (NICU babies may need low amount of milk that is high in fat) -fat provides ~49% of energy in BM -degree of breast emptying and amount of milk available & breast storage capacity influence the amount of fat transferred -longer time b/w feeds decreases the fat concentration (so more frequent feeds you get higher fat content) -faster milk removal increase fat content within diurnal rhythm (longer feeding [more than 30 min] is associated w/ lower levels of milk transfer and less fat) -

Concern: Lactation in Transgender Individuals (OVERALL)

-when sex assigned at birth & identified gender diverge, anxiety, gender dysphoria, & distress may be heightened around events of pregnancy & lactation -offering sensitive, individualized care is key (everyone deserves optimal care)

Induced Lactation

-when there has not been a prior pregnancy -possible including for transgender women -requires a lot time and work -almost never results in a full milk supply (we don't know how much of a supply is going to occur) -works best when the focus is on the experience & the relationship rather than on the amount of milk from the mother in the baby's diet

2. Infant Requires Nourishment to Remove Milk

-when thinking about a supplemental feeding device consider: --cost & availability of the device --ease of use & cleaning of the device --stress to the infant of feeding method --whether milk volume can be fed in 20-30 min --whether anticipated use of the plan is short or long term --family preference --expertise of the healthcare staff to teach/supervise plan --whether the method enhances development of BF skills --safety & efficacy of device used --consideration of parents' ability to use device safely

Society-Led Weaning

-where everyone in the society weans at the same time (usually after 2nd year) -weaning is a time for ritual & celebration

Flat or Inverted Nipples

-will hormones function optimally? -prolactin: nipple stroking -oxytocin: nipple stretching -nipple stretches one time to twice its length, then is stable in length. nipple expands in diameter into the open mouth to accommodate optimal milk flow. nipple compressed during the swallow -babies don't need a nipple to latch onto because it is their job to form the "teat" -may evert in pregnancy -may evert in postpartum -flat nipples evert during suckling -both may evert sometimes (sexual stimulation, finger manipulation, cold)

Supporting Calcium Needs

-women on milk-free diets should be referred for dietetic counseling as dairy products have nutrient value other than calcium

Birth Control

-women using combined oral contraceptives (vs progestin only) were least likely to continue BF for 4 mos -progestin oral contraceptives are effective while nursing -women using contraceptive hormones were slightly more likely to report concerns about milk supply esp around time of starting them -"barrier" and natural family planning methods are all considered okay; IUDs are considered okay -"progestin" only forms of hormonal birth control are considered okay when BF but when to start is controversial (i.e. injections, implants)

Depression

-women who are more likely to wean early are those who have experienced depression either during pregnancy or pp (may achieve BF goals w/ counseling) -early cessation of BF or not BF was associated w/ increased risk of maternal pp depression -among women w/ BF difficulties, women who had a negative experience w/ BF support had a significantly higher risk of pp depression -EPDS is excellent screening tool, easy to use and score, can be used by any provider -women w/ negative early BF experiences were more likely to have depressive symptoms at 2 mos

Myth - Increased Worry/Stress and Milk Supply

-worry/stress may alter behavior, which may alter supply -increased worry/stress does not affect the macronutrient content of milk and does not diminish supply -endogenous oxytocin from BF "may act as a buffer against the deleterious effects of stress, thereby protecting the high risk women from developing depressive symptoms & promoting more sensitive maternal interactive behavior" -BF mothers may perceive less stress -compared to formula mom's, BF moms have more positive moods, report more positive events, perceive less stress -stress + male hormones - fight or flight -stress + oxytocin + female hormones = tend and befriend

Why Such a Difference in Weight Gain Patterns?

-wt gain pattern of formula fed babies after 2 mos may be due to hyperinsulinemia -production of insulin that does not move glucose into the cells -receptor sites on cells seem to be blocked so the function of insulin to move glucose out of the blood and into the cells can't occur efficiently -excess insulin in the blood is used to make and lay down fat -cells send out repeat signals to secrete more insulin because of lack of glucose in cells

Jaundice/Hyperbilirubinemia

-yellow coloration of skin & sclera (whites of eyes) -yellow coloration is caused by unconjugaed bilirubin (UCB) -jaundice is a recycling problem -babies are born w/ fetal type red blood cells -they start producing adult type red blood cells & destroy the fetal ones; iron is saved & other components are excreted as waste; UCB is a product of this process & may accumulate -newborns livers & intestines are immature so this may take a week or so to complete -advancing jaundice requires clinical evaluation --clinical signs of jaundice are seen in 50-70% of all newborns --moderate jaundice (>12 mg/dL) occurs in 4% of formula fed infants & 14% of BF infants --severe jaundice (>15 mg/dL) occurs in 0.3% of formula fed infants & 2% of BF infants -of newborns before BFHI implementation, 20.3% were dx w/ hyper bilirubinemia; after BFHI implementation only 6.98%

Hierarchy of Infant Feeding Choices for the Term Baby

1. baby at mother's own breast 2. mother's own expressed milk 3. milk from HMBANA 4. cow milk formula 5. soy formula

Windstorm 9 States in Newborn Babies

1. birth cry: distinctive cry occurs immediately after birth as baby's lungs expand 2. relaxation: newborn exhibits no mouth movements & hands are relaxed (usually begins as soon as birth cry ends 3. awakening: small thrusts of movement in the head & shoulders (usually begins anywhere from 1-5 min after birth) 4. activity: increasing mouthing & sucking movements as the rooting reflex begins to become more obvious (begins anywhere from 4-12 min after birth); baby may root, may protrude tongue, may look at mom, may massage breast, may salivate 5. rest: baby has periods of rest b/w period of activity (interspersed with all the stages) 6. crawling/sliding: baby approaches breast w/ short periods od action that result in reaching the breast (usually begins ~35 min, anywhere from 18-54 min after birth) 7. familiarization: newborn baby becomes acquainted w/ the mom by licking the nipple & touching & massaging the breast (usually begins ~40 min, anywhere from 29-62 min after birth); baby may mouth own hand, may look at mom, may make soliciting sounds to get mom's attention, may mouth the nipple, lick nipple, may move hand from mouth to mother's breast, may protrude tongue, may look at father, may massage breast 8. suckling: newborn self attaches to nipple & suckles (usually begins ~60 min, anywhere from 49-90 min after birth) 9. sleeping: newborn & often the mother fall asleep (about 1.5-2 hours after birth)

Stages of Making Human Milk (Lactogenesis)

Lactogenesis 1: Lactogenesis 2: Lactogenesis 3:

Reflux

may be due to: mechanics of feeding (laying down certain way); nature of the food itself; physiologic immaturity -73% of newborns spit up daily the first month of life, decreasing to 50% by the 5th month -during first 2 months, 20% of babies spit up more tan 4x a day -EBF babies spit up less than formula babies -may be associated w/ cow milk allergy in infants less than one year of age