Breastfeeding Success

1. Breastfeeding Success Kirsten E. Crowley, MD Edited May, 2005

2. 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%

3. Benefits to the Baby • Protects against • Infection • Illness • allergies • Provides species-specific nutrition and hormones • May enhance development and intelligence • Confers long term benefits

4. 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

5. 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

6. 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

7. 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%

8. 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

9. 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

10. 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

11. 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.)

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. Assessing for success • The input (milk transfer) • The output (urine & stool) • The ultimate (weight)

20. 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)

21. 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

22. 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

23. 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!

24. 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

25. 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

26. 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

27. 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

28. Cradle hold

29. Boppy pillow

30. 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

31. Football hold

32. Nursing positions: Lying Down • Helpful after a cesarean section • Good for tired moms • Eases nighttime feedings early on if the dyad is co-sleeping

33. Common problems(and how to fix them)

34. 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

35. 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

36. 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

37. 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

38. 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