1. Breastfeeding Pearls
August 17th, 2017
Jamie Boudreau MD,IBCLC

2. Objectives
Understand the normal pattern of human lactation and infant feeding
Understand the 10 principles of a Baby Friendly Hospital
Troubleshoot common lactation problems/concerns
Counsel a lactating mother on risk of medication use
Learn techniques to teach mothers manual (hand) expression

3. Breastfeeding is the biological norm for infant feeding

4. During Pregnancy Colostrum is present as early as 16 weeks.
There is already colostrum in the breast when the mother delivers (mothers always concerned about not enough milk)
The lack of any breast changes during pregnancy is concerning (normal pattern is soreness followed by an increase in breast size, change in consistency (more lumpy), dilation of veins on the chest and darkening of the areola)
Very important to identify any potential risks of breastfeeding problems/supplementation including previous failure of breastfeeding, breast surgery, obesity, diabetes and medications
Counsel mother using recreational drugs on risk while breastfeeding (yes this means THC)

5. Breast Surgery
In cases on unilateral mastectomy the remaining breast can usually produce sufficient milk for the baby
Incisions closer to the nipple carry greater risk of affecting breastfeeding (innervation and interrupting ducts)
Implants not a contraindication to breastfeeding but need careful monitoring (more at risk of engorgement, decreased milk supply, problems related to incisions near the nipple) 5

6. Breast Exam during the Third Trimester
Excellent time to do another breast exam
Can evaluate for breast changes or potential barriers to successful breastfeeding-document any abnormal findings
Consider carefully how you counsel a mother
However the best thing to say to every mother is “Your breasts are perfect for feeding your baby!”
Great time to teach manual expression!
If a mother is committed to bottle-feeding good time to document and advise her how to handle engorgement 6

7. During Labor
Excess IV fluids can cause breast edema which negatively impacts breastfeeding
Can teach a mother hand expression before baby is born (collect any colostrum to give to baby afterwards)
Explain that the baby only needs a small amount of colostrum in the first couple days, breasts will not feel full
Document clearly mother’s feeding plan
Make breastfeeding the goal in the first hour of life before any unnecessary interventions

10. First 24 hours
Infants commonly are very sleepy which is the reason to get the first breastfeed in the first hour
If mother and infant are separated very important to start manual expression to collect colostrum to give or save for infant
Consider early pumping if suspected long separation of mother and infant but hand expression is much better for removing colostrum and less traumatic to the breast
Infant should remain skin to skin with mother as much as possible
So important that correct latching happens at this time to prevent nipple trauma!

11. Second 24 hours
Some babies will want to nurse continuously. Does not mean the mother doesn’t have enough milk.
Correcting latch issues is imperative to prevent nipple trauma
A frenotomy is a simple procedure done by the pediatricians to improve tongue movement (if already discharged can refer to dentist)
Breasts still will not feel full as they are still producing colostrum

12. Day 3-4 (can be longer) Mature milk comes in
Engorgement-despite the breast being full of milk the swelling prevents the milk from emptying
Reverse pressure softening reduces the edema in the nipples
Massage
Cold compress then heat
Accessory breast tissue

13. Ice Diaper Take a clean newborn diaper and get it wet
Then put in the freezer with a gentle c shape
Fits perfectly over the breast, isn’t too cold.
Can be reused

14. Key concepts Any empty breast makes milk faster
A full breast sends signals to slow down milk production
Frequent removal of colostrum/milk in the first days leads to a greater milk supply later on
Even one formula supplementation can affect milk supply and infant’s gut health
Formula should be considered as a medication/last resort

15. Formula
First 24 hours only medical indication for supplementation is hypoglycemia (can consider doing IVF instead of formula)
If a mother concerned about milk supply can instruct on hand expression and emphasize frequent removal of colostrum
If mother concerned about infant being fussy encourage skin to skin contact to calm infant
Follow age specific guidelines for amounts
Encourage paced bottle feeding (or more ideal give via syringe)

16. Common Problems Baby not gaining weight
Either milk supply or milk transfer issue
Milk transfer-eval for tongue tie, poor tone, nipple anomaly
Milk supply-work to increase supply, supplement via SNS, syringe feeding or cup.
Engorgement
Jaundice

17. Discharge from the hospital
Newborns require frequent follow up as they often have not reached their weight nadir at discharge
Mother’s often have not had their mature milk come in and haven’t had to deal with engorgement yet
New medications are prescribed (pharmacists are often counseling mothers not to breastfeed when taking common medications 17

18. Weight Gain
Goal is to regain birthweight by 2 weeks of age but normally sooner
Weight loss >9% needs careful feeding plan but not necessarily automatic formula supplementation
Follow up infant until clear weight gain (term 30gm/day) on a sustainable feeding plan
Failure to gain weight with adequate milk supply/intake needs further workup

19. Engorgement Reverse Pressure softening Cold compress
Heat to stimulate flow
Baby is the best pump but need to sometime relieve some of the pressure to soften breast so infant can latch
Consider hospital grade pump (CCHP vs MediCal)

20. Tongue Tie as an Outpatient
Can call Peds on call to see if appropriate to do in the nursery
Call dentist to schedule frenotomy

21. Jaundice Does not need formula * Encourage frequent feeds
Follow infant until trending down
* difference between breastfeeding jaundice and breast milk jaundice

22. Baby Friendly Hospital Initiative
1. Have a written breastfeeding policy
2. Train all health care staff
3. Inform all pregnant women
4. Help mother initiate breastfeeding in the first hour of life
5. Show mothers how to breastfeed
6. Given infants no food or drink other than breastmilk unless medically indicated
Practice rooming in
Encourage breastfeeding on demand
Given no pacifiers or artificial nipples
Foster establishment of breastfeeding support groups

23. Several different areas
Prenatal providers-discuss feeding plan with mother, give teaching, identify any potential barriers to successful breastfeeding (breast surgery, previous failure, medications etc)
Intrapartum-limit unnecessary interventions, protect that first breastfeeding session
Postpartum-encourage skin to skin, prevent problems (good latch good latch good latch!)
Clinic-support breastfeeding, ask for assistance before rec formula

24. Medications while Breastfeeding
Majority of Medications are safe
Use LactMed to see relevant studies
Very helpful to document discussion with mother about breastfeeding with her current medications while before coming so there is not confusion
Be aware that some pharmacists counsel patients erroneously that the medication is not safe while breastfeeding leading either to medication noncompliance or an unnecessary break if breastfeeding

25. Example: Dilantin
Because of the low levels of phenytoin in breastmilk, amounts ingested by the infant are small and usually cause no difficulties in breastfed infants when used alone except for rare idiosyncratic reactions. Breastfeeding during phenytoin monotherapy does not appear to adversely affect infant growth or development, and breastfed infants had slightly higher IQs and enhanced verbal abilities than nonbreastfed infants at 6 years of age in one study.[1] Combination therapy with sedating anticonvulsants or psychotropics may result in infant sedation or withdrawal reactions. In one case report, maternal phenytoin dosage requirements decreased as breastfeeding was discontinued.[2]

26. Absolute contraindications to Breastfeeding
HIV in the developed world
Active HSV of the breast
HTLV
Radioisotopes
Chemotherapy drugs
Infant galactosemia
Active untreated TB
Active drug use (Meth, Cocaine, Heroin THC controversial)

27. Skills Lab for Manual Expression
Every mother should know how to do hand expression
Increase milk supply when pumping (Hands on Pumping)
Better than pump for removing colostrum
Can be done antenatally

28. Practice Time!

29. Questions? 29

30. Mammary Line? Groin to axilla and inner arm?
Below umbilicus to upper outer breast?
Nipples to tail of Spence?
Below the breast out to the axilla? 30

31. 31

32. Fun Lactation topics Antenatal Expression of Colostrum Milk banking
Induced Lactation 32