Supporting Breastfeeding

Breastfeeding #1 Pam Jordan, PhD, RNC Winter 2014 Summarize interventions to support breastfeeding. Formulate interventions to support fathers/partners around infant feeding. Propose interventions to support fathers/partners over the perinatal period.

Breastfeeding Concerns & Nursing Interventions Wagner, E. A., Chantry, C. J., Dewey, K. G., & Nommsen-Rivers, L. A. (2013). Breastfeeding concerns at 3 and 7 days postpartum and feeding status at 2 months. Pediatrics, 132(4), e865-e875. doi:10:1542/peds.2013-0724 “What concerns, if any, do you have about being able to breastfeed?” [prenatal: 79% of mothers reported at least one concern] “Please describe any problems or concerns you have had since our last interview or are currently having about feeding your infant, including breastfeeding problems, concerns, or discomforts.” [postpartum at days 0,3,7,14,30,60] N=532 enrolled / n=447 eligible for postpartum FU/ n=418 with fdg status at 2 mos 92% reported at least one concern at day 3 [difficulty with infant feeding at breast (52%)/breastfeeding pain (44%)(peaked at day 7)/milk quantity (40%)(peaked at day 3] Concerns at any postpartum interview were significantly associated with increased risk of stopping breastfeeding and formula use Concerns most associated with stopping breastfeeding were day 7 ‘infant feeding difficulty’ and day 14 ‘milk quantity’ Of women who planned to breastfeed exclusively for >2 mos, 47% fed formula between 30 and 60 days Of women who planned prenatally to breastfeed >2 mos, 21 % stopped breastfeeding by 60 days 34 women reported NO breastfeeding concerns at day 3: 33 were stilll breastfeeding at 60 days[<30 yoa, Hispanic,strong prenatal BFg self-efficacy, unmedicated vaginal birth, strong BFg support]

Breastfeeding Concerns Prenatal n=278 (79%) Infant feeding difficulty (45%) Milk quantity concern (32%) Uncertainty about breastfeeding (29%) Breastfeeding pain (29%) Day 0 n=272 (77%) Infant feeding difficulty (44%) Milk quantity concern (28%) Uncertainty about breastfeeding (24%)  Breastfeeding pain (17%)  Sign of insufficient intake (1%) Day 03 n=324 (92%) Infant feeding difficulty (54%)  Milk quantity concern (42%)  Breastfeeding pain (42%)  Uncertainty about breastfeeding (29%)  Sign of insufficient intake (15%) 

Breastfeeding Concerns Day 7 n=285 (83%) Infant feeding difficulty (45%)  Breastfeeding pain (45%) Milk quantity concern (27%)  Uncertainty about breastfeeding (22%)  Sign of insufficient intake (17%) Day 14 n=244 (73%) Infant feeding difficulty (34%)  Breastfeeding pain (37%)  Milk quantity concern (19%)  Uncertainty about breastfeeding (15%)  Sign of insufficient intake (10%)  Day 30 n=223 (68%) Breastfeeding pain (34%) Infant feeding difficulty (27%)  Milk quantity concern (20%) Uncertainty about breastfeeding (13%) Sign of insufficient intake (5%) 

Breastfeeding Concern: Infant Feeding Difficulty Reported difficulties with how the infant is feeding at breast Problems with latch Infant sleepy or going too long between breastfeeds Infant refuses to breastfeed Infant fussy or frustrated at breast Problems with frequency or length of infant’s breastfeeds Infant not feeding well Other difficulty at breast

Breastfeeding Positions Cross-Cradle (Novice level skill) Cradle (Graduate level skill) Side-lying (Requires assistance initially) Twins (Tandem nursing – requires assistance initially) Football/Clutch Reverse Side-lying (Requires assistance initially)

Best Positions for Breastfeeding Newborns Cross-Cradle (Novice level skill) Keys to positioning Mother comfortable & in a well-supported position that allows unrestricted access to breast to manage latch (pillows, cushions, foot stool) Place baby at breast; remove barriers that might impede latch Baby’s body facing mother (tummy-to-tummy) with head straight and ears, shoulders & hips aligned Football/Clutch

Breast support Breast may be gently compressed to form a ridge of tissue positioned parallel to baby’s mouth Thumb and fingers are placed opposite baby’s nose and chin Thumb lines up with nose Fingers line up with chin

Deep Latch Technique Mother holds baby close to her body Mother’s hand surrounds the nape of baby’s neck with her fingers below ear level Mother’s palm firmly supports baby’s shoulders & back Baby’s nose positioned opposite mother’s nipple Baby’s chin is brought to breast first Wait for baby’s wide, open mouth (like a yawn) Infant brought to the breast, not the breast to the infant Avoid pushing on the back of the infant’s head. It can cause the infant to arch away from the breast. View Latch-on Video Clip: http://www.ameda.com/breastfeeding/elibrary/videos.aspx View Breastfeeding Leaflet from UK Department of Health: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4135412.pdf

Animated video version: www.breastfeedingmadesimple.com Latch progression 1 2 3 4 6 7 5 Animated video version: www.breastfeedingmadesimple.com

Latch Assessment Indications of a deep latch Baby Mother Sustained attachment well behind nipple Wide-angled mouth Chin indents the breast Lips flanged out Mother Feels strong, rhythmic tugging sensation Pain-free (after first several seconds) Nipple elongated and symmetrical upon release No evidence of nipple skin damage Video demonstration on how to help a mother with latch-on. To view click the following link: http://newborns.stanford.edu/Breastfeeding/FifteenMinuteHelper.html

Latch Assessment Indications of a poor latch Mother Baby Inability to maintain attachment Narrow-angled mouth Lips rolled in Mother Misshapen nipple upon release (compressed, creased, pinched, blanched) Nipple pain Skin damage

Breastfeeding Concern: Milk Quantity Concerns that the mother is not producing or the infant is not getting sufficient breast milk Inadequate maternal production or milk supply Infant not getting enough milk or unsure if getting enough milk Infant shows signs of hunger Milk not in

Breast Preparation Why & How? To achieve best results when you: Evaluate for evidence of colostrum Teach mother hand expression Express colostrum to entice reluctant baby to latch How? Provide a warm, moist compress for mother to place over her breasts Demonstrate breast massage using the depth recommended for self-breast exam Begin at the outer edge of the breast using a circular, finger-walking or stroking motion Repeat all the way around the breast Explain how this brings colostrum from deep in the breast, along the ducts and down toward the nipple

Hand Expression View video demonstration of hand expression Click the following link: http://newborns.stanford.edu/Breastfeeding/HandExpression.html

When to Start Breast Pumping? Indicators: Maternal-infant separation Delay of initial breastfeeding longer than 6 hours Formula given to breastfed infant Ineffective breastfeeding Prior to hand expression to increase milk yields Sore nipples when pain too severe for breastfeeding Infrequent breastfeeding

Initiation of Breast Pumping Have mother prepare her breasts as previously described to improve milk yields (heat, massage, etc.) Demonstrate breast pump set up to mother & family Review pumping guidelines (frequency, duration) Turn the pump on Begin on the lowest suction setting Observe for proper flange fit Increase suction strength after a couple minutes Goal: Highest suction comfortable without causing pain Instruct mother to pump for a full 10 minutes (up to 20 minutes maximum if milk is still flowing) Inform mother that milk collection may be minimal to none in the beginning and explain that breast stimulation promotes production Failure to Take = Failure to Make

Formula Supplementation Rationale for giving formula to a breastfed infant Provider order Medical condition Mother unavailable Parent request, after informed consent Baby unable to latch & mother unable to express colostrum or milk for her baby

Acceptable Medical Reasons to Supplement a Breastfed Infant “… Supplementation in hospital is largely a nurse’s decision based on characteristics and preferences of the mother, unit practice, and his or her own understanding and beliefs about breastfeeding.” (In-Hospital Formula Supplementation of Healthy Breastfeeding Newborns; Anita J. Gagnon, Guylaine Leduc, Kathy Waghorn, Hong Yang and Robert W. Platt; J Hum Lact 2005 21: 397) Hypoglycemia that does not respond to breastfeeding Severe maternal illness Inborn errors of metabolism Acute dehydration not responsive to routine breastfeeding or Excessive weight loss that does not respond to breastfeeding management Maternal – infant separation Hypoglycemia unresponsive to breastfeeding and confirmed by laboratory result; not determined by bedside screening test HIV+ mother Maternal medications incompatible with BF

Supplementation Type, Method and Amount What Type? What Method? Order of preference: Mother’s expressed colostrum/breastmilk Donor breastmilk from human milk bank Commercial cow’s milk formula Commercial soy formula At breast Tube & syringe device Starter SNS Away from breast Spoon, cup, syringe Finger-feed Bottle How much? Average Intake of Colostrum* Day 1 Birth-24 hours 2 – 5 cc Day 2 24-48 hours 5 – 15 cc  Day 3 48-72 hours 15 – 27 cc * Academy of Breastfeeding Medicine, Protocol #3

Supplementing at the breast 1 2 3 Tube placement variations: Slide in after baby is well latched; photo 1 (doesn’t work as well with Starter SNS tubing – too flexible) Tape along breast just either above; photo 2, or below; photo 3 (taping along the length of the tubing provides better stability) Can be placed inside or outside of Nipple Shield; may not have to be taped Whatever works best!

Finger-feeding Rationale for use Baby unable to latch Mother too sore to nurse Avoids free flow of milk Allows paced feeding session Stroking palate with finger stimulates baby to participate in feeding Parent preference to avoid bottles and artificial nipples Easy for parents to manage compared to some of the other alternative feeding devices

Finger-feeding Directions Place the feeding tube along the palm side of index finger. The tube should end at the tip of the finger. Tape tube to finger to stabilize Gently stroke baby’s lower lip or chin until mouth is open wide. As the baby sucks, your finger should slide to the roof of baby’s mouth. Do not push the plunger. As baby sucks, he will pull the milk from the syringe. (A baby with a weak suck, such as a premature baby may need some counter pressure on the plunger or need you to deliver small amounts of milk to stimulate sucking.)

Bottle-feeding Rationale Method is most familiar to healthcare staff and parents Easiest to manage Alternative feeding options too overwhelming for parents Parent preference Staff preference

Bottle-feeding Method: Avoid “Free” Lunch Protect skills needed for breastfeeding Effective breastfeeding requires infant participation Minimize infant preference toward bottle flow Hold baby upright and keep bottle parallel to the floor Prompt baby to suck the milk out, don’t pour the milk in Intermittently tug on the bottle to coax baby to increase suction making it difficult to withdraw the nipple Remove the bottle nipple or lower the level to slow or stop the milk flow; and to pace the rate of feeding Follow the steps used for latch. The goal is to have baby contribute effort during the feeding process & utilize skills required for breastfeeding.

Breastfeeding Concern: Uncertainty with own Breastfeeding Ability Mother questions her own breastfeeding skills or perseverance Breastfeeding technique, positioning, or getting used to breastfeeding Not sure about breastfeeding frequency or duration Breast anatomy adequacy Milk quality or nutritional adequacy of exclusive breast milk diet Breastfeeding too difficult or time-consuming Wanting someone else to feed the infant Tired or exhausted Uncomfortable with the act or connotations of breastfeeding Not meeting breastfeeding goals Other uncertainty with breastfeeding ability

Breastfeeding Concern: Pain while Breastfeeding Includes nipple pain or other pain associated with breastfeeding Painful nipples General or unspecified breastfeeding pain Sore breasts, engorgement, or breast pain Cesarean birth or other pain not related to breasts or nipples Mastitis Thrush or yeast infection Biting

Sore Nipples Assess positioning and latch; correct as needed Comfort measures for: Irritated, intact nipple skin Apply colostrum or breastmilk after nursing Apply vegetable oil Medical grade lanolin product-specific for breastfeeding Moist compresses either cool or warm Anything that provides comfort and no harm Skin breakdown Saline rinse after each nursing to flush away any exudate or debris from open wound Moist wound healing treatments Gel dressings (when combined with lanolin will degrade the gel) Medical grade lanolin Prescription nipple ointment

Breastfeeding Concern: Signs of Inadequate Intake Includes references to signs in the infant of inadequate intake Weight loss Jaundice Urine and stool output or signs of dehydration Hypoglycemia