Pointers for Professionals: The 5 ‘M’s” for Breastfeeding Success

1. Pointers for Professionals: The 5 ‘M’s” for Breastfeeding Success 1) Mammals 2) Milk Production 3) Magic Numbers 5) Matching counsel 6) Money!! (last but not least) by Deanne Francis, RNC, IBCLC, LCCE

2. We are Expected to be the Experts “Have concerns? How the breast works? How much? How often? Is this normal? How to fix it? Does your counsel match mammalian physiology? Will it result in eventual successful breastfeeding or sabotage it? How to fit my lifestyle?

3. “M” #1: We are Mammals!

4. We are “carry” mammals-- like apes and kangaroos. We are not “cache” mammals or “follow” mammals or “nest” mammals. “There is a reason behind everything in nature.” Aristotle

5. Composition of Milk from Different Mammals

6. Growth Rate of Different Mammals’ Offspring

7. Normal Mammalian Behavior after Birth • Mom and baby stay together • Humans should act like ‘carry’ mammals • Lots of skin 2 skin contact • Baby controls the feedings • Non-essential intervention is postponed • Supplement ONLY if medically necessary

8. Skin-to-Skin Contact is Associated with: • Babies who are skin with the mother for 1-2 hours after birth: • Are more likely to latch on • Are more likely to latch on well • Will cry less • Have higher blood sugars • Have higher skin temperatures • Will breastfeed longer and more exclusively

9. Seven Natural Laws for Nursing Mothers 1. Babies are hardwired to breastfeed. 2. Mother’s body is baby’s natural habitat. 3. Better feel and flow happen in the comfort zone. 4. More breastfeeding at first means more milk later. 5. Every breastfeeding couple has its own rhythm. 6. More milk out equals more milk made. 7. Children wean naturally. (Mohrbacher/Kendall-Tackett 05)

10. Recommended Reading: Breastfeeding Made Simple: Seven Natural Laws for Nursing Mothers By: Mohrbacher, N & Kendall-Tackett, K. New Harbinger Publications. 2005

11. “M” # 2: Milk Production

12. What can each of these breasts actually DO? A new breast drawing for the anatomy books. (Hartmann and Ramsay)

13. Old Anatomical Model (Sir Astley Cooper 1840)Dissection: ducts full of colored wax and straightened out into lobes

14. Lactiferous Sinuses (Reservoirs) Do Not Exist

15. Normal Milk Volumes • First 3 days = drops to 15 mls/feed • 5 days PP = 500 mls/day • 10 days PP = 750 mls/day • 14 days PP = 750 – 1000 mls/day • Average = 24 ozs/24 hrs • Twins = 32 ozs/24 hrs

16. Supply Saboteurs • Poor or NO advice • Some meds • Some herbs • Visitors • Separation • Delayed BF • Pacifiers • Hormones • Alcohol • Feeding by the clock • Abnormal breast configuration • Breast surgery • Cigarettes (25% less milk with 20% less fat) • Infant oral abnormalities • OBD • Poor supplementation plan • Late preterm-no pump

17. The Perfect Mouth and Nipple Match-up

18. Chin Touches First

19. Importance of a Good Latch -Mom

20. Importance of a Good Latch- Baby

21. Evaluate this Latch

22. On the other hand…….

23. “M” #3 : MagicNumbers • Breasts are designed to PRODUCE milk, and ducts to TRANSPORT milk (both directions) but neither are designed to STORE milk for any length of time. Breasts must be drained before reaching “capacity” to maintain production. • Capacity of breasts is variable. • Size is not the main issue. • Overall production capacity has nothing to do with “full” capacity • Breasts produce milk fastest when DRAINED. • Question: Should we really counsel all mothers the same?

24. Defining Magic Numbers • Breast fulness: When storage capacity is reached in an individual mother’s breasts, milk production slows. NOTE: Drained breasts make milk fastest! • Breast storage capacity: Maximum volume of milk available to her baby when an individual mother’s breast is full. Capacity affects time it takes for breast to fill.

25. Counsel using Averages 24 hour AVERAGE Production in gms/mls: Total = 572 – 1016/day (750 av.) AVERAGE Capacity in gms/mls (when “full”) Total = 350 gms/mls (combined breasts) Assuming two given babies each require 750 mls/day, what counsel would you give the mother whose capacity is 150 mls total vs the one whose capacity is 400 mls total?

26. Individualizing Counsel • Two studies found that breast storage capacity in a range of mothers is 74 – 606 gms. • Largest capacity = 90% of baby’s daily needs at any one time in both breasts. • Smallest capacity = 20% of baby’s daily needs at any one time in both breasts.

27. Recommendations: How to figure it out? BF mothers = pump test. Decide if problem is something MOM is doing or something BABY is doing. Pump-dependent mothers – 1/wk keep track of the 24 hr milk volumes with DOUBLE pumping. Mohrbacher, N (2011) “The Magic Number and Long-Term Milk Production.” Clinical Lactation. Vol 2-1. (USLCA jnl) (Online free at ClinicalLactation.org)

28. The “4-hour” test How much milk is mom making? • Remove milk with a hosp-grade pump every hour for 4 hours. • 3rd + 4th pumping X2 = MP/hr • MP/hr X 24 = Daily milk production (Hartmann, Hale and Lai)

29. Test Weights • How effective is the baby at milk extraction? • Using a gm scale, weigh the baby before the feeding. • Leave the scale on. • Weigh immediately after the feeding without changing anything. • Increased gms = volume consumed

30. Recommendations cont. • First morning pumping: Mothers who expressed 10 oz of milk or more at the first morning pumping can maintain their milk production with as little as 5 expressions/d. • Employed mothers: think back to maternity leave. How many feedings/d did baby need? That number of expressions/d will keep milk production stable. How many is baby taking? How many pumpings to add? • Copy the baby!

31. Establish and Maintain Mother’s Milk Supply until BF is Possible Pump or express milk regularly with a hospital grade electric pump every3 hours, or anytime infant feeding is inadequate or absent. 8X/day minimum to begin. Start soon! • Delay negatively impacts milk volumes at 6 wks • Double pumping is most effective • Hand-expression imperative

32. http://newborns.stanford.eduGo to Breastfeeding then Hand expression. • The best way to assure that babies get enough milk in the first few days (especially colostrum), or are able to establish a milk supply with a pump, is to teach the mother’s to use their hands effectively. • This website has fabulous information for professionals

33. Frequency and Duration of Expression – Beginning Counsel Should imitate a healthy newborn. Will affect volume changes. Frequency more important than duration. 100 min/day minimum (average) 15 minutes each time (average) 8 expressions per day (average) Depends on mother’s “magic numbers” Simultaneous pumping produces higher prolactin levels.

34. Does Pumping Work When Breastfeeding Doesn’t? “Mothers who express milk are more likely to breastfeed to 6 months….the appropriate use of expressed breast milk may be a means to help mothers to achieve six months of full breastfeeding while giving more lifestyle options.”(Win, 2006 Int’l BF Jnl) “2/3 of all women return to work after having a baby. “Company-sponsored lactation programs can enable employed mothers to provide breast milk for their infants as long as they wish, thus helping the nation attain the Healthy People 2010 goals of 50% of mothers breastfeeding until their infants are 6 mos. old.”(Ortiz, 2004 Ped Nurs)) “Extraordinary efforts should be made to use mother’s own milk.” (Heiman & Schanler, 2006 Early Hum Dev.

35. Don’t all breast pumps do the same thing?

36. Make sure the pump flange is not a tourniquet! Correct flange fit Too tight!

37. Develop a Milk-Management Strategy • Rule 1 = Feed the baby! (well-fed babies breastfeed better) • Rule 2 = Protect the Milk Supply! • Rule 3 = Find and FIX the problem.

38. More Than One Way to Provide Medically Necessary Supplement

39. “M” # 4: Matching Counsel to Natural Laws • Must agree with normal and individual mammalian physiology/behavior. • Must conform to natural laws. • Interventions should be medically indicated and appropriate. • Interventions should be designed to result in eventual successful BF. • Professionals must see the value of both breastfeeding and breast milk. Help mother match natural laws to her individual situation to succeed.

40. Keep mom and baby together! Rooming-In Mothers who room in and care for their babies 24 hours/day have babies that are better breastfeeders, are less disorganized, cry and startle less frequently, and feed more frequently than babies cared for in central nurseries.

41. Ten Steps to Successful Breastfeeding • Encourage breastfeeding on demand. Whose demand?

42. Feeding Cues • The baby may exhibit these cues several times in 20 to 30 minutes. • If no response may go back to sleep-which equals a missed feeding opportunity • Infants who have had delayed feedsdue to missed feeding cues often have difficulty latchingon subsequent feeds

43. Crying is a late feeding cue Early cues have been missed. Infant now in disorganized state. Tongue retracts with crying. Important to teach parent feeding cues as often they think crying is the feeding cue When do nurses notice feeding cues in the nursery?

44. Nipple Confusion vs Preference • Several theories on why some infants have difficulty with breastfeeding after bottles/pacifiers • Flow preference • Palatal super/stimulation by nipple • Confusion in tongue movement • Reduced milk supplyfrom pacifier vs breast sucking. • Difference between shape of mom’s nipple and bottle nipple.

45. Practice on the right piece of equipment

46. Nutritive vs Non-Nutritive Suckling. • Non-nutritive (pretending) • Rapid, choppy. • Vertical motion (chewing/munching) • Little swallowing • Nutritive (drinking) • Slow, rhythmic, Suck/pause • Wide jaw angle • Swallowing

47. You Can’t MAKE a Baby Breastfeed. COAX! • Promote flexion. • Pay attention to cues/maturity. • Oral stimulation – encourage rooting. • Skin to skin. • Rooming in. • Minimize distractions. (JOGNN Nov/Dec ’06) • Stabilize both breast and head. • Appropriate supplementation while learning. • Be patient. Don’t push or pull jaw down.

48. “M” #5: Money!! • If 90% of US families could comply with medical breastfeeding recommendations for 6 months, the US would save $13 billion/yr and prevent an excess of 911 deaths. $10.5 billion with 80% compliance. Bartick, and Reinhold. 2010 The burden of suboptimal breastfeeding in the United States: A Pediatric Cost Analysis Pediatrics.

49. Human Milk is VALUABLE STUFF

50. Laws are Becoming More BF Friendly • 17-15-25.Right to breast feed.     The county legislative body may not prohibit a woman's breast feeding in any location where she otherwise may rightfully be, irrespective of whether the breast is uncovered during or incidental to the breast feeding. Enacted by Chapter 131, 1995 General Session • 76-10-1229.5.Breast feeding is not violation of this part.     A woman's breast feeding, including breast feeding in any location where the woman otherwise may rightfully be, does not under any circumstance constitute a violation of this part, irrespective of whether or not the breast is covered during or incidental to feeding. Enacted by Chapter 131, 1995 General Session