Breastfeeding Nutrition 526

1. BreastfeedingNutrition 526 Ginna Wall, RN, MN, IBCLC gwall@u.washington.edu University of Washington Medical Center Lactation Services

3. University of Washington Medical CenterLactation Services Nancy Estill, Louise Peterson, Ginna Wall, Christy Shaw, Barb Lautman RNs, International Board Certified Lactation Consultants

4. Objectives • Describe the function of placental hormones, oxytocin, and prolactin in the breastfeeding process • Describe the let down reflex and list factors that may interfere or enhance this reflex • Recognize major contraindications to breastfeeding • Recognize factors that contribute to successful initiation and maintenance of breastfeeding • Describe correct positioning and latch on for successful early breastfeeding

5. The Most Important Factors For Good Milk Supply: • Prepared mammary epithelium • Progesterone withdrawal • Maintained plasma prolactin • Removal of milk within an undefined interval after birth

7. Prolactin Levels rise in pregnancy

8. Prolactin Hormone • Helps women respond to stress of perinatal period • Suckling is the most effective stimulus for prolactin release • Direct stimulation of the nipple is necessary for prolactin release • Prolactin levels rise as long as stimulation continues

11. Prolactin = for milk production Prolactin

12. Oxytocin

13. Electron micrograph of alveoli

14. Each alveolus opens into a ductule that leads to one main lactiferous duct

16. Let Down orMilk Ejection Reflex • Effective milk removal depends on the ejection reflex • Duct diameter increases 50%

17. Milk duct before letdown

18. Milk duct after letdown

19. Early Post-birth Events • Baby crawls to breast • Opens and closes hands • Massages the breast • Hand movements cause as high an oxytocin rise as sucking

20. Keep baby in skin contact with mother

21. Skin-to-skin contact encourages oxytocin release • Oxytocin: • Promotes milk • Promotes mothering behaviors • Alleviates pain

22. Oxytocin in the bloodstream • Released with nipple stimulation • Released in surges, lasting about 1-2 minutes • Contracts muscle cells • Causes uterine contractions, causing involution • Causes contractions of the muscle cells surrounding alveoli and ducts in the breast, causing milk “let down” or “milk ejection reflex”

23. Oxytocin Effects: Opposite of “Fight or Flight” Response • Lowers heart rate • Lowers blood pressure • Lowers blood cortisol • Stimulates endorphins • Affects metabolic actions • Contracts pyloric sphincter • Releases insulin and cholecystokinin

24. Oxytocin In The Brain Affects Social Behavior • Women who have high levels of oxytocin • Produce more milk • Breastfeed longer • Are more tolerant of repetitious, boring tasks • Demonstrate more “social” behavior – better listeners • Women become more social and retain those traits if they continue breastfeeding

25. The Let Down Reflex • List factors that interfere with this reflex • List factors that enhance this reflex

26. Cholecystokinin stimulates oxytocin • Food for mother

27. Is it ever NOT a good idea to breastfeed? Contraindications to Breastfeeding: • Maternal: HIV, HTLV-1, Herpes lesion on the nipple, Some drugs (cocaine, methamphetamine, radioactive drugs) • Infant: Galactosemia, PKU (partial breastfeeding may be possible)

28. Factors that contribute to successful initiation and maintenance of breastfeeding • 1991 WHO/UNICEF: Baby Friendly Hospital Initiative, “Ten steps to successful breastfeeding” • Certified 14,500 hospitals in 125 countries • 40+ US hospitals • In WA State: • Evergreen • St Mary’s • Okanogan • Tacoma General • And in 2008: UWMC! • And Group Health!

29. Baby Friendly Hospital:What are the “Ten Steps?” • Have a written breastfeeding policy that is routinely communicated to all health care staff. • Train all health care staff in skills necessary to implement this policy. • Inform all pregnant women about the benefits and management of breastfeeding. • Help mothers initiate breastfeeding within an hour of birth. • Show mothers how to breastfeed and how to maintain lactation, even if they should be separated from their infants.

30. “Ten Steps,” continued… • Give newborn infants no food or drink other than breastmilk, unless medically indicated. • Practice "rooming in" by allowing mothers and infants to remain together 24 hours a day. • Encourage breastfeeding on demand. • Give no artificial teats, pacifiers, dummies, or soothers to breastfeeding infants. • Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or birthing center.

31. Does “Baby Friendly”Make a Difference? • Promotion of Breastfeeding Intervention Trial • 30 hospitals, randomized to receive Baby-Friendly training, or continue routine practices • 17,000 mother-baby pairs • Followed for 1 year

32. “PROBIT” ResultsKramer, JAMA, Jan 2001

33. Baby-Friendly Hospital Initiative: Reduction in GI Infections and AllergiesKramer, JAMA, Jan 2001

34. “Maternity Care Practices:Implications for Breastfeeding” • Surveyed 1085 women who intended to breastfeed for more than 2 months • Assessed 5 Baby-Friendly practices: • Breastfeeding initiation • Supplements • Rooming-in • Breastfeeding on demand • Pacifiers DiGirolamo, Grummer-Strawn, and Fein, BIRTH 28:2, 94, June 2001

35. Percentage of women who stopped breastfeeding before 6 weeks, by specific hospital practices DiGirolamo, BIRTH, June 2001

36. Percentage of women who stopped breastfeeding before 6 weeks, by number of Baby-Friendly Hospital Initiative practices they experienced DiGirolamo, BIRTH, June 2001 % STOPPED BF Number of Baby-Friendly Practices Reported

37. “BFHI Improves Breastfeeding Initiation Rates in a US Hospital Setting” • Boston Medical Center • inner-city teaching hospital • 1800 births per year • 15-bed Level III NICU • primarily poor, minority, immigrant families • Implemented Baby-Friendly policies over a 3-year period • Reviewed 200 randomly selected medical records from each of the 3 years Philipp, PEDIATRICS, Sep 2001

38. BFHI IMPLEMENTATION:EFFECTS ON BREASTFEEDING TRENDS Philipp, PEDIATRICS, Sep 2001

40. ABCs of Helping Mothers to Breastfeed • A is for Attachment of baby’s mouth to mother’s breast (“latch”) • B is for Breastmilk (transfer of milk from breast to baby, and how to establish a good supply) • C is for Confidence (tell her what a good mother she is!)

41. A Good Latch • Nipple completely disappears • Lips are flanged out • Angle of baby’s lips is about 120 degrees

43. Latch Scoring Practicewith video: Jane Morton MD: “15 minutes of breastfeeding help”

45. How parents can tell that baby is getting enough • Stooling and urination patterns • Meconium first day (one or more)

46. Stooling and urination patterns • Transitional stool day 2-4 (usually one or more each day)

47. Stools when milk is "in” • By day 4: 4 stools each day (not just a stain in the diaper) • Frequent bowel movements for the first 4-6 weeks

48. Common Problems • Sore nipples • Engorgement • Low milk supply • Preterm and “late preterm” infants • Questions about drugs • Working outside the home • Infant sleep, crying, temperament issues • Relationships, social isolation

49. Test Weighing • Use “integrating” digital scale • Reweigh promptly in exactly the same way • 1 gram = 1 ml milk

50. Double-Pumping Single-Handedly