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Breastfeeding Success. Kirsten E. Crowley, MD Edited May, 2005. The big push. American Academy of Pediatrics “Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth.” WHO and UNICEF
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Breastfeeding Success Kirsten E. Crowley, MD Edited May, 2005
The big push • American Academy of Pediatrics • “Exclusive breastfeeding is ideal nutrition and sufficient to support optimal growth and development for approximately the first 6 months after birth.” • WHO and UNICEF • Infants should be breastfed for at least the first four months of life, and if possible 6 months • Healthy People 2010 Objective • Increase the number of mothers breastfeeding postpartum to 75%, at 6 months to 50%, and at 1 year to 25%
Benefits to the Baby • Protects against • Infection • Illness • allergies • Provides species-specific nutrition and hormones • May enhance development and intelligence • Confers long term benefits
Protection against infection • The studies • In first year of life, incidence of diarrheal illness among breastfed infants was half that of formula-fed infants • Infants who were exclusively formula-fed had a 70% increase in their risk of developing an ear infection • Formula-fed infants were 17 times more likely to be admitted for pneumonia
More infection studies • Associated with a lower incidence of RSV infection during the first year of life • Relative risk of developing a UTI of 0.38 compared to formula-fed infants • In the NICU • Among babies born at more than 30 weeks, confirmed NEC was 20 times more common in formula-fed babies • The incidence of sepsis/meningitis are significantly reduced in human milk fed VLBW infants
Other illness • There is an inverse relationship between breastfeeding and morbidity • Breastfed infants have gastroesophageal reflux episodes of significantly shorter duration • Breastfeeding is protective against SIDS • Toddlers who were breastfed appear to be healthier
Protection against allergies • In allergic families, formula introduction in the first week of life and weaning at less than 4 months were associated with increased allergies later in life • Eczema was less common and milder • Breastmilk = 22% • Soymilk formula = 63% • cow’s milk formula = 70%
Enhances development and intelligence • Controversial of course • Some studies have shown higher IQ and improved cognitive development in breastfed children • Psychomotor and social development may be improved as well
Long term benefits • Lower incidence of • diabetes • childhood cancer and breast cancer • May influence LDL concentration and mortality from ischemic heart disease • Decreased cavities • Better response to vaccines
Benefits to mom • Delays fertility due to lactational amenorrhea • Reduces risk of breast, uterine, ovarian, and endometrial cancer • Enhances emotional health • Decreases insulin requirements • Decreases osteoporosis • Promotes postpartum weight loss
Societal benefits • Encourages optimum child spacing • Improves vaccine effectiveness • Decreased expense of food (formula for one year is between $1160 and $3915) • Decreased medical expenses • 1000 bottle-fed infants had 2033 excess office visits, 212 excess days in the hospital, and 609 more prescriptions = $459-$808 per family per year • Reduced absenteeism due to child illness • Protects the environment (bottles, packages, etc.)
So, how are we doing? • In 1998 • 64% of women initiated breastfeeding • 29% were still breastfeeding at 6 months • 16% were breastfeeding at one year • highest rates in several generations • Rates still fall short of the Healthy People goals of 75% initiation, 50% at 6 months, and 25% at one year • U.S. breastfeeding rates are the second lowest of all industrialized nations
Who tends to breastfeed? • Most common among women who are • college educated • white • married • older than 30 years • middle or higher income levels • More prevalent in the western regions of the country
What affects success? • Maternity hospital routines • accuracy and timeliness of breastfeeding assistance are the most important • Birth weight and health of the newborn • Peer attitudes • Length of maternity leave • Employer’s willingness to make accommodations • Opinion of the child’s father • Aggressive marketing of formula
Promoting success • Women who are better informed regarding the benefits of breastfeeding and the breastfeeding process are more likely to initiate (and probably maintain) breastfeeding
An interesting study • Kistin et al. • First controlled trial of prenatal maternal counseling by MDs • Counseling increased the rate of initiation and duration of breastfeeding in a predominantly low-income, urban, African American population
National Assessment of Physicians’ Breast-feeding Knowledge, Attitudes, Training, and ExperienceFreed, et al. JAMA.. 1995; 273(6): 472-476 • Residents and practitioners in peds, FP, and OB/gyn were lacking in • Breastfeeding knowledge base • Ability to give appropriate advice
The role of the pediatrician • Promote and support • Become knowledgeable and skilled in physiology and clinical management • Provide education • Parents, Colleagues, Nurses, Residents • Become familiar with local resources • Develop and promote policy • Encourage insurance coverage • Promote breastfeeding friendly workplaces
Assessing for success • The input (milk transfer) • The output (urine & stool) • The ultimate (weight)
The intake • Goal is 8-12 feedings per day • Feedings should last 10-15 minutes when the baby is a newborn • Understand the cues • Sleep arousal • Increased alertness • Hand to mouth • Tongue or mouth movements • Crying (late stage of hunger)
The output • Urine • Before the milk is in: one void for each day of age • After the milk arrives: 6-8 times per day • Stool • Days 1-4: meconium • Day 4-4 weeks: 4 yellow, seedy BM per day • 1-4 months: varies from one per feed to once a week
The ultimate judge: The Weight • Initial loss • 8-10% of birthweight • Return to birthweight • 10-14 days • Aggressive intervention if not by 2 weeks • Rate of gain for full term babies • First 2 months = 30 grams per day • > 2 months = 20-30 grams per day
Assess the Latch! • Incorrect latch is one of the most common etiologies for poor weight gain • Observation of the mother - infant dyad is extremely important!
Correct latch • Mother • Mom holds breast back from areola and nipple with C-hold • Use manual stimulation to erect the nipple • Tickle the baby’s lips gently • Wait for baby to open mouth like a yawn • Center nipple quickly while pulling baby in close to the breast • Initial latch may be painful, but abates as nursing progresses
Correct latch • Baby • Tip of nose and chin touching breast • Tummy to tummy • Lips flanged over areola - fish lips • Gums bypass nipple and are over areola (where the milk sinuses are) • Movement of facial and jaw muscles, ear wiggling • Look for suck-swallow patterns
Assessment of suck • Tongue comes over the gumline • Cupping of tongue at the lip • Feel up and down motion of the posterior tongue • Strength of suck
Nursing positions • Cradle hold • Mom upright in comfortable chair with pillows in the lap and feet supported • Tummy to tummy • Head in straight line • Ear, shoulder, and hips in straight line • Baby’s body at breast level (boppy pillow) • Baby’s head in crook of elbow • Baby’s back supported with forearm • Cup breast with free hand
Nursing positions • Football hold • Mom in same position • Baby’s body and legs under mom’s arm • Head snugly in mom’s hand with neck grasped by thumb and pinky and head on palm and other fingers • Pillows under the baby (boppy) • Avoid flexing baby’s head too much
Nursing positions: Lying Down • Helpful after a cesarean section • Good for tired moms • Eases nighttime feedings early on if the dyad is co-sleeping
Sore nipples • Discomfort at the beginning is OK • Improper position is the main cause • Can also be caused by infection or inappropriate nipple care • Treatment • Position correctly • Begin feeding on least sore nipple • Frequent shorter feeds • Rub expressed milk onto nipple/areola • Air dry nipples • Pump if nipples are too painful
Engorgement • Occurs on the second to fourth days • Results from hormone changes that suddenly increase milk production • Temporary!!!: The supply becomes balanced within a few days • Treatment • Nurse frequently, around the clock • Heat and massage before feeding • Express some milk if baby can’t latch • May be harmful to supply if not relieved
Mastitis • Bacterial breast infection • caused by inadequate emptying of milk • Symptoms • achy, flu-like • breast pain, redness, tenderness • fever/chills • Treatment • Dicloxicillin 250 mg QID x 10 days • Keflex 500 mg QID x 10 days • Rest, fluids, pain meds, nurse often or pump after feeds, moist heat
Candidiasis • Rapid development of extremely sore nipples, burning or itching, shooting pain • Look for deep pink areas on mom and thrush or diaper candidiasis in baby • Treat both mom and baby • Topical antifungal for both, oral nystatin • Wash anything in contact with baby’s mouth or breast
Breastfeeding jaundice • Exaggerated physiologic jaundice due to lack of food in GI tract and increased enterohepatic circulation • Usually occurs in second to third day • Treatment • Increase feeding frequency • Mom should pump if baby is sleepy or poor feeder • Feed baby EMM or formula only • Use alternate feeding systems if necessary • Watch baby’s weight