1. Supporting Breastfeeding

2. 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.

3. 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
“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]

4. 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%) 

5. 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%) 

6. 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

7. 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)

8. 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

9. 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

10. 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:
View Breastfeeding Leaflet from UK Department of Health:

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

12. 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:

13. 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

14. 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

15. 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

16. Hand Expression View video demonstration of hand expression
Click the following link:

17. 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

18. 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

19. 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

20. 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 : 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

21. 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 – 5 cc
Day hours – 15 cc 
Day hours – 27 cc
* Academy of Breastfeeding Medicine, Protocol #3

22. Supplementing at the breast1 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!

23. 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

24. 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.)

25. 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

26. 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.

27. 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

28. 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

29. 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

30. 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