The Joys of Breastfeeding

1. The Joys of Breastfeeding New recommendations re: BREASTFEEDING from the American Academy of Pediatrics 7/2017

2. It’s a big commitment, but SO WORTH IT!! August is National Breastfeeding Month, and AWHONN has worked diligently to ‘spread the word’ to families in the Huffington Post and also in REUTER’s offering both education and statistics on where we need to go to advocate for babies’ optimum nutrition and health.

3. Nurses Role--encourage breastfeeding! • Nurse’s responsibility is to support the parents and promote the family’s sense of confidence and encourage breastfeeding per Healthy People 2020. • Recognize that cultural values influence infant feeding practices, be sensitive to ethnic background of minority populations, and understand that the dominant culture in any society defines “normal” maternal-infant feeding interaction. • Nurse’s responsibility to give new parents the knowledge, confidence, and support to do either. • Encourage early feedings of breast or bottle to stimulate peristalsis in the newborn, facilitating elimination of the by product of bilirubin conjugation which decreases the risk for jaundice and enhances maternal infant attachment. • Encourage feeding within one hour after birth.

4. History of Breastfeeding • The normal used to be breastfeeding until the 20th century when “modern mothers” began to want more freedom from their home and babies. • Formula became the norm by the 1950’s, and formula companies began to cash in. Infant formula is the only product mass-marketed through hospitals to the public. • Today the attitude has shifted. Many mothers believe that they can be a modern mother and still breastfeed. • Today the goal for Healthy People 2020 is to increase the breastfeeding rate to 75% of the population.

5. Anatomy of Breast • The breast is composed of glandular tissue that has a tree like structure that is surrounded by supportive, nutritive, and protective tissue including connective tissue, fat, and lymphatic tissue and blood vessels. • The nipple has ten to twenty large branches lobes. • Lobes  lobulesalveoli. • The alveoli are where milk is produced. • The alveoli are lined with secretory cells called acini which produce and secrete the milk. • Myoepithelial cells around the acini eject milk from the sac through small ductules into larger lactiferous ducts. • The ducts widen toward the nipple the lactiferous sinuses. The infant extracts the milk through the mammary papilla (nipple).

6. Anatomy of the Breast • The nipple located slightly below the middle of the breast contains the openings of the milk ducts. • Surrounding the nipple is a dark pigmented area called the areola. • The areola contains the Montgomery glands, sebaceous glands that secrete a substance for nipple lubrication and antisepsis.

7. Anatomy of the Breast

8. Physiology of Lactation • Preparation during pregnancy. • Teach mothers to wear supportive bras. • Even during pregnancy, mothers may practice rolling the nipple between their fingers to promote everted nipples. • Encourage the use of shells –worn inside the bra, for mothers with inverted nipples prior to delivery. • Promote breastfeeding classes and support groups.

9. Physiology of Lactation • Postpartum • Hormonal pathways • Birth results in a rapid  in estrogen and progesterone and an  in the secretion of prolactin. Prolactinpromotes milk production by stimulating the alveolar cells of the breast. Prolactin levels rise in response to suckling. • Let-down reflex • Suckling also stimulates the release of oxytocin from the pituitary gland. • Oxytocin increases the contractility of the myoepithelial cells lining the walls of the mammary ducts, and a flow of milk results this is called the letdown reflex. • Often described as a tingling, prickling sensation as milk comes down, mothers may feel increased cramping, increased lochia, leaking from other breast, and a sense of relaxation. Letdown reflex is stimulated by infants cry, infants presence, suckling, mothers thoughts of infant, and sexual orgasm.

10. Physiology of Lactation • Postpartum(Continued) • Once lactation is established • Prolactin decreases, and oxytocin and suckling facilitate milk production. • Production can be decreased • if breast are not emptied regularly and completely milk backs up in breasts and increases pressure in alveoli which causes milk secretion to decrease • “supply and demand”--if baby doesn’t suck adequately or effectively, makes amount of milk produced less.

12. Milk Stages • Colostrum yellow colored fluid present from end of pregnancy until 2 days after birth, • has  in protein and •  in fats and lactose than mature milk. • Rich in antibodies and has a laxative effect for baby. • Transitional milk is produced from the end of colostrum production until approx 2 weeks postpartum. This is where engorgement occurs. • consists of  fat, lactose, and water soluble vitamins • Mature milk has a •  in concentration of immunoglobulins, • in total protein • in lactose, fat, and total calories. • 10% solids, rest is water for maintaining hydration.

13. Initiating Breastfeeding • Timing • Initiate breastfeeding within the first hour after birth in the quiet alert stage—first stage of reactivity. • promotes bonding between mom and baby early • increases oxytocin levels to reduce maternal bleeding and • helps maintain baby’s glucose level. • Assess effectiveness of newborns suck, swallow, and gag reflex • Watch for circumoral cyanosis, rapid respirations, diaphoresis which may indicate cardiovascular complications. • Assess for tracheoesphageal fistula and esophageal atresia (look for increased oral mucus or hx of maternal polyhydramnios.

14. Positioning • Tummy to tummy is best, cradle hold, cross chest, side lying, football hold great for c-sections,

16. Initiation of Breastfeeding • Rooting • Reflex stimulated when the cheek or lip is touched and baby automatically turns the face toward the stimulus and makes sucking (rooting) motions with the mouth • Alternate breasts Try to get infant to nurse on both sides of breast. Always start with the one infant nursed on last, unless babe only nurses on one breast. Then start with breast infant has not nursed on.

17. Implications for nurses. • Objectives for successful breastfeeding • Provide adequate nutrition for baby • Facilitate maternal-infant attachment, • Prevent trauma to the nipples. • Create comfortable space: • Arrange for privacy, • Assist in finding a comfortable position, • Use additional pillows for support, evaluate baby’s mouth position, • Provide reassurance. Allow time to learn. • Pumping and Expression: start after 24 hours if nursing is not well established is recommended.

18. Breastpumps are available!

19. Problems with Breastfeeding • Engorgement painful firmness as milk comes, hard to touch, skin is shiny and taut. Usually disappears within 24-48 h wear support bras, empty breasts fully, frequent feedings. • To treat: keep nursing, use ice bags b/t feedings, hot shower and manual expression to soften nipples, pumping to soften nipples, increase feedings to 20 minutes. Apply warm compresses, cabbage leaves on inside of bra (reduces edema). Analgesics shortly before feeding. • Sore Nipples: common causes are poor positioning and improper latch, • To treat: warm compresses, air dry, lanonolin, breast milk on areola a natural emollient, frequently change positions, • Refer to experts: La Leche League, IBCLC lactation consultants, and breastfeeding support groups.

20. Problems with Breastfeeding • Breastfeeding contraindications • DISEASES: Mothers with known HIV/AIDS status, women diagnosed with breast cancer so they can begin treatment, chronic carriers of Hep B, herpes simplex virus only if active lesions on breast, TB, Cytomegalovirus Infection (CMV). • Galactosemia-baby’s intolerance of lactose, • Certain DRUGS: • Anticonvulsants: carbamazepine (Tegretol) and phenytoin (Dilantin), or • Antibiotics: metronidazole (Flagyl) which may be toxic to infant • Mastectomy

21. Getting started • Timing • Positioning • Assessment • mom-motivation and desire, knowledge, physical exam of nipple shape, inverted, everted, flat, level of anxiety, modesty • infant assess alignment, areolar grasp, areoloar compression, audible swallowing. Observation is imperative for support, trouble shooting and teaching. • The key to success is making sure a proper latch is established • Great resource from Stanford

23. Nursing Diagnosis • Knowledge Deficit about breastfeeding • Altered comfort (mom), • Altered nutrition less than body requirement (baby). • Interventions • a. positions for mom • b. relaxed environment • c. teach signs engorgement etc. • d. latching on –c-hold, asymmetric latch • e. breaking suction • f. frequency and length of feedings • Evaluation successes and support.

24. Other Resources • Babycenter.org • CDC Guidelines to Support Breastfeeding • Women’s Health.gov • Breastfeeding Resource Center