1. The NP’s Role in Lactation Nsg.485 DePaul University Department of Nursing Linda A. Graf, RNC, CNM, APN Former IBCLC

2. In The Beginning… Women didn’t have a choice Agrarian cultures had few technological options Universal “Reverence” for pregnancy & lactation Few interferences (war, famine, disease) Everyone ‘knew’ breastfeeding… –Who, what, where, when, how, what to do if this- then that

3. In the 20 th Century… Revolution in automation/mechanization and biochemical knowledge Fierce protection of individualism and personal freedoms Western cultural ‘worship’ of technology, choice, & convenience “Americans aren’t supposed to ‘suffer’” De-mystification of pregnancy, birth, & lactation

4. Current ‘Crisis’… US. Ranks 22-24 Internationally in Infant Mortality Poor over-all longevity and longer end of life “disability zone” Healthy People 2010 Goals not met Crisis in Health care Costs & Coverage High Cost of tertiary care vs. low cost of “Healthy Start” primary prevention

5. So Where Do NP’s Fit In??

6. The Role of the NP… Most women make their infant feeding decisions by the end of their first trimester Women tend to be heavily influenced by their partner and mother Cultural void of accurate information Lack of social, political, business, economic, and medical support

7. The Role of the NP… Approach the client AND her partner early and via multiple venues Empower your clients into their choice Childbirth & lactation classes REQUIRED for all!! (Do not forget return to work classes for those breastfeeding women who work outside the home)

8. “Disaster-proofing” Your Client - Breastfeeding supports/champions clearly identified (not merely lip-service!) –Accurate/reliable, readily accessible breastfeeding information on hand in the home (KNOW your sources!) –Early follow-up assessments/interventions: e.g. 24 & 72 hour post discharge call backs from you; 2 wk PP check-up in office with the baby

9. The “GOLD” Standards: Breastfeeding as the ABSOLUTE first thing that happens following the birth of the baby Minimize disruptions beginning with clamping of the cord… Continuous & unlimited access to baby and partner while in-patient Ongoing inpatient assessment by RN & LC Warm-line for questions/ problem triage Planned follow-up calls/office visits

10. The First Two Weeks… No Bottles No Pacifiers (Fingers are OK!) No Visitors (within strict guidelines) NO FORMULA “GIFT” PACKS Q Two Hour Feeds 24/7 Excellent Nutrition/Prenatal Vits Care of Self and Baby Only!! Hospital-grade Breast pump available in the home! (discuss pump issues here)

11. The Third Week Postpartum… Continue with previous guidelines May begin to resume a few limited household tasks May go out with baby alone for brief trips/walks May begin with limited (healthy) outside visitors

12. Starting the Fourth Week… May introduce ONE bottle of pumped breast milk/day given by partner (discuss types of bottles/nipples here) May introduce pacifier if desired by baby Begin storing milk for emergencies/return to work Finalize plans for childcare/return to work (who, what, where, when, how, timing issues with travel/pumping breaks, etc.)

13. Intermission…

14. Lactation Trouble-shooting 101: Nipple Soreness Positioning problems –Improper placement, infrequent change of position Poor Latch-on Nipple confusion/sucking problems Thrush Herpes

15. Sore Nipple Treatments… Correct the problem first and foremost “Soothies”, Medical-grade Lanolin, & time Nystatin Oral Suspension combined therapy- be specific with tx instructions! May need oral Diflucan if ductal infection is suspected Herpes? Pump and Dump/feed other side- EXSQUISITE hygiene hands & pump!

16. “Lost” Milk Supply… Assess cause(s): frequency of feeds; duration; supplements; pumping-brand, single/double, frequency/duration; medications; stressors; Correction of causes/give much encouragement Empower client with assessment tools Means for follow-up

17. Rx for low-supply: Galactagogues: “Mother’s Milk Tea”, fennugreek tea, slippery elm bark Double-pumping after feeds (remind moms that amount pumped is not a reflection of her actual ‘supply’) Rx for Reglan-10-14 day course Rx for Domperidone from a compounding pharmacy for as long as needed

18. “Plugged Ducts” vs. Mastitis… Differential Dx of each Plugged Duct management: Go to BED, continuous warm packs, massage of duct,frequent feeds, NSAIDS, fluids, nutrition, multi vits Mastitis non-pharmacological tx Dicloxicillin 500mg po QID x 10-14 days –Undertreatment is cause for reoccurence –Erythromycin for PCN sensitive clients

19. Mastitis Prevention Frequent feeds with sufficient breast emptying-to comfort Good fitting bra Excellent Hygiene (hands/pump, bra pads) Baby’s mouth only Sufficient sleep and nutrition (anemia) More frequent/common in first timers More frequent with cracked nipples

20. Lactation Resources… Get to know your local LC’s (they will refer patients to YOU!) Get to know the truly breastfeeding-friendly Pediatricians/Family physicians in your area (they will refer clients too!) Consider becoming IBCLC certified yourself! NP’s have the answer-We can make a difference!!