EPIC® Breastfeeding

2015 Program

“Breastfeeding Fundamentals”

Copyright © 2007 Georgia Chapter, American Academy of Pediatrics. All rights reserved.

Breastfeeding education

Faculty Disclosure Information

• In accordance with ACCME* Standards for commercial support, all faculty members are required to disclose to the program audience any real or apparent conflict(s) of interest to the content of their presentation. I would like to disclose the following:

* Accreditation Council for Continuing Medical Education

Program Objectives• Describe two risk factors of mothers choosing

not to breastfeed

• Discuss why physicians play critical roles in a woman’s decision to breastfeed

• Demonstrate how to assist with effective breastfeeding techniques

• Review access to lactation support services in the community

EPIC BreastfeedingProgram Partners

• Georgia Chapter - American Academy of Pediatrics

• Georgia OB/GYN Society

• Academy of Family Physicians

• Georgia Department of Public Health

• Centers for Disease Control & Prevention (CDC)

AAP Breastfeeding Policy Statement

“The American Academy of Pediatrics reaffirms its recommendation of exclusive breastfeeding for about 6 months, followed by continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.

AAP Policy Statement: Breastfeeding and the Use of Human Milk, Feb. 13, 2013,

Healthy People 2020

Number Objective2020 Target

%

MICH-21 Increase the proportion of infants who are breastfed:  

MICH-21.1      Ever 81.9

MICH-21.2      At 6 months 60.6

MICH-21.3      At 1 year 34.1

MICH-21.4      Exclusively through 3 months 46.2

MICH-21.5      Exclusively through 6 months 25.5

MICH-22Increase the proportion of employers that have

worksite lactation support programs38.0

MICH-23Reduce the proportion of breastfed newborns who

receive formula supplementation within the first 2 days of life

14.2

MICH-24Increase the proportion of live births that occur in

facilities that provide recommended care for lactating mothers and their babies

8.1

Georgia’s Breastfeeding RatesCDC’s Breastfeeding Report Card 2014

Ever Breastfed 70.3%

Breastfed for 6 months 40.1%

Breastfed for 12 months 20.7%

Exclusively breastfed for 6 months

14.5%

Support for Minorities

• It’s All Natural• Launched by the Office of Women's Health• Discuss benefits, myths, and challenges• www.womenshealth.gov/itsonlynatural

• Reaching our Sisters Everywhere (ROSE)• Support and information for women of color• Started here Atlanta• Breastfeedingrose.org• BLINKS – a support club

AAP’s data

Disease and Risk Reduction in Breastfed Infants and Children

Acute Otitis Media 50%

Atopic Dermatitis 42%

Gastrointestinal Infections 64%

Lower respiratory infections, hospital rate

72-77%

Asthma 26-40%

Obesity 24%

Type I Diabetes 30%

Type II Diabetes 40%

Childhood Leukemia 20%

AAP ‘s data

Maternal Disease Risk Reduction from Breastfeeding

Diabetes 12%

Metabolic syndrome 8.4%

Ovarian Cancer 21%

Breast Cancer 4.3%

Coronary Artery Disease 23%

Aortic Calcifications 22%

Coronary Calcifications 15%

Challenges for Physicians• Lack of breastfeeding knowledge

and training

• Discomfort examining and discussing breasts

• Discomfort treating mother and baby

• Lack of time

• Concerns about reimbursement and coding

•Copyright © 2003, Rev 2005 American Academy of Pediatrics

The Three “B’s” of Breastfeeding

BREASTMILK PRODUCTION

BABY

MILK TRANSFER

BRAINMILK RELEASE

What are early infant feeding cues?

– Sucking sounds– Hand to mouth movements– Rapid eye movement– Soft cooing or sighing sounds– Restlessness– Yawning

Crying is a late hunger cue

What is a Good Latch?• Wide open mouth (check angle at corner)

• Mouth filled with breast tissue

• Flanged lips – “Fish lips”

Jack Newman, MD assisting a new mom with a good latch:

•

Cradle hold Football Side lying

Copyright © 2003, Rev 2005 American Academy of Pediatrics

Photo © Roni M. Chastain, RN

Laid Back Position

Cross Cradle

What are the signs of effective milk transfer?

• Audible swallowing• Appropriate output (i.e. urine/stools)• Weight gain of ½ to 1 oz. per day after day 4

What increases milk production?

Milk Removal!

Role of PhysiciansHelp Parents Develop Realistic Expectations

OB/Gyn Prenatal Visit

• Mothers need to hear from their OB that breastfeeding is important

• Encourage breastfeeding classes

• Discuss why her breasts are changing

• Educate the expectant mother and her partner

• Do not give out any formula coupons or freebies with formula branding to patients

Pediatric/FP Prenatal Visit

• Ask open ended questions– What are you thinking about breastfeeding?– What have your friends and family said about

breastfeeding?– What breastfeeding plans do you have when

returning to work?– What do you know about the benefits of breast

milk?• Help mom set realistic expectations• Discuss potential barriers and suggest

possible solutions

• Breast surgery or trauma• Breast or nipple abnormality• Absence of prenatal breast changes• Previous breastfeeding difficulty• Birth interventions• Separation from infant• Mother’s perception of insufficient milk

supply• Unrelieved fullness or engorgement

What are maternal risk factors for unsuccessful breastfeeding?

• Birth interventions and/or trauma• Prematurity• Acute or chronic disease• Oral anomalies• Hyperbilirubinemia or hypoglycemia• SGA, LGA or IUGR• Persistent sleepiness or irritability• Inability to maintain an effective latch

What are infant risk factors for unsuccessful breastfeeding?

After Birth

Skin to skin Breastfeeding

In the Hospital

– Practice skin to skin – Limit procedures– Avoid separation– Rooming in – limiting visitors– Exclusive breastfeeding is encouraged

– Avoid use of supplements and pacifiers

Exclusive Breastfeeding

• No food or drink other than breastmilk• Mothers own milk is the first choice• No promotion of breast milk

substitutes, bottles or pacifiers given to parents.

• If supplementation is necessary staff have specific protocols/policies to follow

Separation of mother and baby

• Start pumping ASAP– Pump and hand express every 2-3 hours– Use a hospital grade pump– Pump at baby’s bedside if possible

• Hand expression– Increases volume collected– Can be used while single pumping

• Encourage Skin to skin

Baby’s First Office Visit• What to Do…

– Schedule visit within 1-2 days of hospital discharge

– Evaluate weight loss / gain

– Evaluate breastfeeding frequency / duration

– Evaluate outputs i.e. urine / stool

– Observe for jaundice

Breast Problems to Avoid

• Engorgement

• Plugged milk ducts

• Nipple Pain / Trauma

• Mastitis

• Candidiasis / Thrush

Engorgement

The Breastfeeding Atlas, 3rd Edition

Nipple Pain and Trauma

The Breastfeeding Atlas, 3rd Edition

Bilateral Mastitis

The Breastfeeding Atlas, 3rd Edition

Plugged Duct

• Presents as a hard, red, tender area on the breast

• May progress into mastitis• Have the patient

– Feed frequently on infected side– Massage area during breastfeeding– Change positioning at the breast– Check bra’s for correct fit and avoid

underwire bras

Yeast Infection

Treat Mom and Baby

Maternal Emotions

• Perinatal Mood Disorders

• Every provider has responsibility to assess mother’s mood

• Acknowledge and validate feelings of frustration, anxiety, inadequacy, etc.

• Project Healthy Moms Warmline in GA is 1.800.933.9896(x234)

Medications

Medications

• Most medications are compatible with breastfeeding

• The amount of medication that the infant receives via breastmilk is usually very low

• Usually the risk of NOT breastfeeding is greater than the risk of exposure through breastmilk

• Some medications can be changed or dosage altered to prevent exposure to the medication

• Refer to Hale’s “Medication and Mothers Milk” • LactMed @

http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT They have a free app for your smart phone

• Poison control’s number is 404.616.9000 or 1.800.222.1222

Maternal MedicationsShort list of contraindicated medications:

PhenindioneRetinoids

LithiumAmiodaroneChemotherapy agentsChloramphenicolDrugs of AbuseErgotamineGold saltsTetracyclines (chronic use >3 weeks)Radioactive Compounds

Hot Topics

• Bed Sharing vs Co-sleeping

• Pacifiers

• Supplementation

• Starting solids

• Returning to work

• Contraception

• Milk Sharing

• Vitamin D

Codes for diagnosis of the infant779.31 Feeding problems, newborn

783.3 Feeding problems, infant>28DOL

780.91 Fussy baby/infant

774.39 Jaundice (breastmilk)

774.6 Jaundice (neonatal)

779.34 Slow weight gain (<28DOL)

783.41 Slow weight gain (>28DOL)

750.0 Ankyloglossia

Codes for diagnosis of the mother

676.44 Disorders of lactation

676.84 Delayed lactation

780.79 Disrupted sleep pattern/fatigue

V24.1 Supervision of lactation/breast exam

676.34 Sore nipples

676.24 Breast engorgement

The Breastfeeding Friendly Physician Office

• Have a written breastfeeding policy• Train staff on cultural practices• Start educating mothers early• Use open ended questions when discussing

breastfeeding• Orders: no supplementing w/o a medical reason• Encourage exclusive breastfeeding• Eliminate distribution of free formula or formula

advertisement in the office• Track breastfeeding initiation and duration rates in

your office• Provide patient with community resources

Community resources

• Hospitals– Support groups

– Lactation clinics• WIC

– Breastfeeding food packages

– Breast pumps

– Lactation assistance

– Peer counselors• La Leche League• Georgia Breastfeeding Coalition • ZIPMilk

“While breastfeeding may not seem

the right choice for every parent, it is the best choice for every baby.”

Breastfeeding: Your Guide to a Healthy, Happy Baby, 2005