Breastfeeding Issues & Updates

Presented by Susan Howard, RN, MSN, IBCLCsusan@arlingtonlactation.com

About me

• RN and International Board Certified Lactation Consultant

• Owner of Arlington Lactation• Special interest in tethered oral

tissues and the breastfeeding dyads• Former L&D nurse• Clinical Research Coordinator in

pharmaceuticals• Clinical faculty at Georgetown Univ.

Disclosures & Conflicts

• I have nothing to disclose and no conflicts

Who is here?

Take home messages

1. Breastfeeding was simple before we started making it complicated2. The ability to breastfeed is innate and dependent upon

uninterrupted mother-baby interactions3. Birth practices influence breastfeeding outcomes4. What we say and what we do MATTERS

To move forward, we have to look back

Breastfeeding was simple before we made it complicated

Public Domain; Wikimedia Commons Raja Ravi Varma The Suckling ChildPublic Domain; Wikimedia commons

Breastfeeding was simple before we made it complicated

We modernized. Separated from babies

Workday ruled by the clock

Railroad cars and factory buildings in Lawrence, Mass

Shift from births at home to hospital birth

By McTaggart, James, Photographer (NARA record:

) i l hi

Forgot what is normal.

•Human milk is the biological norm

•Breastfeeding is normal feeding

•Normal breastfeeding begins with normal birth

Normal sequence of behaviors at birth

• Birth• Skin to skin on mother’s chest• Rest• Kick & schooch• Salivate• Mouthing movement• Seeks areola• Opens mouth wide• Latches

•Show Global Health Media video (free)•Early Initiation of Breastfeeding –Breastfeeding Series

•Begin at 4:26 •Found at https://globalhealthmedia.org/portfolio-

items/early-initiation-of-breastfeeding/?portfolioID=10861

Normal feeding instincts at birth

Normal newborn behaviors (start @4:26)

http://med.stanford.edu/newborns/professional-education/breastfeeding/early-initiation-of-breastfeeding.html#t=06:24

•Show Global Health Media video (free)•Early Initiation of Breastfeeding –Breastfeeding Series

•Begin at 6:16 •Found at https://globalhealthmedia.org/portfolio-

items/early-initiation-of-breastfeeding/?portfolioID=10861

More newborn behaviors (start 6:19)

Maternal expectations

• Most mothers are not prepared to experience any difficulties or problems when breastfeeding their first baby (Colin, 2002)

• New mothers assume it will work

• Little preparation for breastfeeding.

• Expect they will learn it in the hospital

Maternal expectations

• When problems arise mothers blame themselves for lactation failure rather than the hospital system that may have contributed to it.

• Birth impacts breastfeeding

• What we say and do can change outcomes

Labor practices undermine breastfeeding

• Bedrest and continuous EFM• Supine positioning• IV fluids• Induction/augmentation• Analgesics• Instrument birth• Cesarean birth

By JennaRich (Own work) Wikimedia Commons</a>

Epidurals

• Lower suckling scores are linked to epidural use• Delayed first feeding at breast• Disorganized sucking coordination leads to encouragement to use

formula• Infant weight loss impacts BF Mom hears “she’s not making enough

milk” vs my baby isn't sucking well.• Formula use in the early weeks are associated with early

breastfeeding cessation

Pitocin

• Oxytocin increases parasympathetic system and serotonin

• Natural benzodiazepine• Decreases pain• Synthetic pitocin (IV or IM) interferes

with natural oxytocin• Lower circulating oxytocin levels• Higher cortisol levels = stress Highest

among group receiving pitocin and epidural

• Encourages fluid retention

IV fluids

• Postpartum edema• Delays lactogenesis• Latch on difficulties

and milk expressionby Day 2

Breast edema

Vacuum assisted births

• Exerts excess mechanical forces on the infant’s head

• Disrupts bony structures• Vacuum elevate the palate• Affects suck coordination

Cesarean birth and breastfeeding

• Increased risk for insufficient milk

• Delayed milk • Risk early termination (Dewey

2003).• Mother infant separation• Delayed suckling• AAP recommends initiating

preventative measures within first 3 hours to reduce risks

Steps to support breastfeeding Recognize the impact of common labor and birth practices on newborn skillsEncourage frequent feedingsHand express after each feeding to stimulate milk supply or “phone in your order for Day 3”

"Hand expression will help ensure that by the time you go home, your production will be higher.”

This will make it easier for your baby to learn just how to breastfeed and get a full feeding.

Encouragement is key. Early intervention makes a difference

A few gems to support breastfeeding

• Avoid labeling “lazy feeder”• Avoid labels “Whimpy White

Boy”• No Smush & Push• Don’t assume that flat nipples =

latching difficulties• Always ask before touching

mother’s breasts

Normal is uninterrupted skin to skin contact• Cry less (less exertion)• More stable temperature• Higher blood glucose• Feed better• When positioned prone,

stimulates feeding behaviors and opening wide

Skin to skin in the first hour

• Perform initial physical assessment and Apgar with baby skin to skin

• Weight should be done after first breastfeeding

• Eyes & Thighs performed while feeding

• Breastfeeding is natural pain reliever (oxytocin)

Hand expression at first feeding video clip

•Show Dr. Jane Morton’s video (free)•Successful Breastfeeding Begins Right at Brith•Begin at 8:50 •Found at http://med.stanford.edu/newborns/professional-education/breastfeeding/breastfeeding-in-the-first-hour.html#t=8:50

http://med.stanford.edu/newborns/professional-education/breastfeeding/breastfeeding-in-the-first-hour.html#t=8:50

Steps to ensure solid start to breastfeeding

• Encourage & compliment mother• You have exactly the right

amount of colostrum for you baby right now

• Keep your baby with you day and night

• Feed frequently skin to skin• Hand express

Spoon feeding video clip

•Show Dr. Jane Morton’s video (free)•Successful Breastfeeding Begins Right at Brith•Begin at 5:29•Found at http://med.stanford.edu/newborns/professional-education/breastfeeding/breastfeeding-in-the-first-hour.html#t=5:29

Encourage hand expression (video)spoon feed

Cascade of missed opportunities

Case study

• G3 NSVD term baby• Skin to skin; infant temperature 97.6• Blood sugar was 37; No other symptoms of hypoglycemia• Baby remained skin to skin• Nurse assisted with hand expression, collected approx. 2-3ml into a

spoon and fed baby• Re-latched baby; covered with warm bath blanket• Blood sugar was 56; temperature 98.8

Practice implications

Breastfeed in the first hour

• Combine with hand expression• Consume more milk on day 4

Breastfeeding is a natural pain reliever

• Perform painful procedures while baby is skin to skin or latched

• Best practice is to have baby latched or feeding for at least 5 minutes

• They will not cry• Have you ever noticed that

during a perineal repair mom is less aware if breastfeeding?

Hand expression for engorgement

• Swelling and distention of the breasts in the early days caused by vascular dilation as well as the arrival of early milk

• Alveolar distension • Compression of surrounding ducts• Vascular and lymphatic compressions

• Peak 4-6 days postpartum• Second time mothers experience

engorgement sooner but resolve faster

Lymphatic system• Fluid tends to accumulate • Tight fitting bra may constrict

lymphatics and trigger fluid collection

• Maya bolman, Theory and practice of lymph drainiagetherapy: an osteopathic lymphatic technique B. Chickley 2011

Hand expression relieve breast engorgement

• Managing engorgement important for longer term breastfeeding success

• Severe engorgement associated with early weaning.

• Soften the nipple with revere pressure softening and “dancing finger”

• And breast massage AWAY from the nipple

https://goo.gl/q9LhJk

•Show Maya Bolman’s video•The Basics of Breast Massage and Hand Expression

•Begin at 2:50•Found at https://vimeo.com/user17150498

The basics of Breast Massage and Hand Expression

Breast massage tips and tricks

• For periareolar edema, soften the nipple/areolae with “dancing fingers”

• Start with gently fingertip massage within the areola to reduce swelling. Alternate RPS and fingertip massage

• Gentle stroking breast massage from the areola to the armpit

• Oil can reduce friction• Swelling reduced and breasts are softened

• Hand expression

Successful breastfeedingbegins with you

How new mother feels

Challenge you to thoughtfully consider how you impact breastfeeding